scott@vtx-cpd.com
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Hey Laura!
This is a brilliant question! Balancing the urgency of treating immune-mediated diseases with the potential risks of combining NSAIDs and steroids is indeed challenging.
Ideally, I aim for a 72-hour washout when feasible, although the urgency of some immune-mediated conditions (like IMHA, IMTP, or polyarthritis) often necessitates quicker action with steroids. In certain severe cases, using alternatives like tranexamic acid or vincristine as bridging measures can help delay steroid administration slightly. However, most often, we weigh the risks and proceed with steroid therapy, acknowledging the potential for complications.
Regarding gastroprotection, the evidence supporting prophylactic omeprazole use in preventing GI bleeding in concurrent NSAID-steroid therapy remains limited. A study in the Journal of Veterinary Internal Medicine found that adding omeprazole to prednisone didn’t significantly reduce GI bleeding risk compared to prednisone alone. The study can be accessed here: https://onlinelibrary.wiley.com/doi/pdf/10.1111/jvim.16672. In human medicine, corticosteroid-NSAID combinations are associated with increased GI risk, as shown in a systematic review in BMJ Open available here: https://bmjopen.bmj.com/content/4/5/e004587. Although this data is from human studies, it may indicate similar risks in veterinary patients.
Given the lack of robust veterinary-specific evidence, I reserve omeprazole for cases with GI symptoms rather than routine prophylactic use. Instead, I prioritize hydration, good nutrition, and sometimes probiotics to support the GI tract. For washout, a minimum of 24 hours is often my baseline, extending up to 72 hours when the patient’s condition allows.
Sometimes you just have to hold your nose and give the steroids, I just make sure to carefully council the owners.
Does that make sense?
Scott 🙂
Replying to Anna H. 05/11/2024 - 19:34
Hey Anna!
No problem. I hope you are well!
Scott 🙂
Replying to Anna H. 05/11/2024 - 20:44
Hello!
I hope you are well.
It sounds like you made a great call, especially since inpatient care was feasible for the owner. Given the potential for severe AKI, inpatient care with IV fluids is definitely the most secure approach when it’s an option, and it’s great to hear your patient did so well without any signs of AKI.
I agree; it’s difficult to assess how a patient might have done without IV fluids, especially since subcutaneous fluids might not offer the same level of renal support. It’s a relief knowing that 48 hours of fluids provided such a positive outcome, and you’re absolutely right—there’s something reassuring about the continuous monitoring inpatient care allows, both for us and the owners.
Scott 🙂
Replying to Leyla T. 30/10/2024 - 22:00
No problem Leyla!
Hope you find them helpful. I hope you are enjoying the course! Any feedback is always welcome.
Happy Halloween!
Scott 🙂
Hello Rachel!
Great questions. Chatting about omeprazole might be on of my favourite things… I might chip in too.
Looking forward to Felipe’s thoughts.
Scott 🙂
Replying to Susana S. 25/10/2024 - 17:25
Welcome Susana!
Thank you so much for being part of the course!
Scott 🙂
Replying to Megan S. 24/10/2024 - 12:28
No problem.
Have a great week.
Scott 🙂
Replying to Yvonne McGrotty 23/10/2024 - 17:14
Welcome pal!
Great to have you here!
Scott 🙂
Replying to Rachel R. 22/10/2024 - 16:35
Hello again!
We were chatting about them on one of the other courses and this was another interesting comment regarding securing them:
“Mostly just glue, though I do find that these guys get more skin irritation the more glue you add.
I find that clipping really close to the skin and giving it a good alcohol prep to remove as much oils etc helps a lot too.
In some patients I have also used the human over-sensor plasters (https://www.amazon.co.uk/Type-Strong-Adhesive-Freestyle-Medtronic/) and these work well!”
I had never heard of the plasters before!
Scott 🙂
Replying to Talia C. 21/10/2024 - 12:17
Hi Talia,
Thank you for your kind words and for sharing your thoughts on Molly’s case!
Your approach is quite thorough, especially with your inclusion of ionized calcium (iCa) in Pu/Pd evaluations, which can be pivotal in differentiating primary causes. I agree that an abdominal ultrasound can be helpful, both for ruling out other potential causes and for adrenal evaluation, particularly given the mild ALP increase and hypercholesterolemia in Molly’s case.
I would tend to use the Urine Cortisol
Ratio (UCCR) in cases where the index of suspicion for hyperadrenocorticism is lower, as it serves well as a rule-out test. When suspicion is higher, a more definitive test like the Low-Dose Dexamethasone Suppression Test (LDDST) or the ACTH Stimulation Test would be considered, though as we know, no test is perfect.Regarding urine culture, I align with your approach. I often reserve it for cases with sediment abnormalities or a clinical suspicion of infection, using cystocentesis as needed to ensure accuracy.
The paper you referenced is indeed interesting. The persistence of subclinical bacteriuria in older dogs without progression raises questions about the necessity of aggressive intervention in such cases. We will chat lots more about this in the UTI lesson. I find urinary tract infections and the significance of bacteria in the urinary tract fascinating!
Looking forward to catching up more on these topics.
Warm regards,
Scott
Hey.
Really interesting. Absolutely, the calcium issue can definitely feel like a “chicken and egg” situation! It’s often tricky to figure out whether hypercalcemia is driving the problem or a consequence of early diet changes. I completely agree—having more diet options these days makes it so much easier to tailor plans to each patient’s specific needs while keeping an eye on potential complications.
It’s great to have the flexibility to adjust diets based on individual responses rather than a one-size-fits-all approach. Curious to hear if you have any go-to diets?
Scott 🙂
Replying to Laura Jones 21/10/2024 - 09:10
Hi Laura,
Thanks for the detailed response!
I recently came across a study titled “Comparison of Unilateral versus Bilateral Nasal Catheters for Oxygen Administration in Dogs” by Dunphy et al. (2002), which found that FiO2 and PaO2 significantly increased with higher total oxygen flow rates, regardless of whether it was through one or two nasal catheters. The study also highlighted that bilateral catheters could achieve up to 60% FiO2 with minimal patient discomfort, suggesting they might be particularly useful for achieving higher flows while keeping the patient comfortable.
I know that there is more and more literature on high-flow oxygen, but I am not always clear on what you need to actually do it! What special equipment do you use to deliver high-flow oxygen? Is it straightforward to administer, or does it require additional training or setup?
Looking forward to hearing your thoughts!
Best,
Scott 🙂
Hey.
I agree regarding the skin irritation. I had one Labrador that got quite bad pyoderma!
I have never seen those covers before! That is really helpful, thank you for sharing.
Scott 🙂
Replying to Harry S. 22/10/2024 - 08:17
Thank you Harry.
Really great to have you join us.
Thank you for all of your brilliant contribution to the course.
Scott 🙂
Replying to Harry S. 22/10/2024 - 08:20
Hey.
My only first hand experience is with the SediVue. It definitely helps guide, but we obviously always follow up with a culture.
Scott 🙂
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