Pongo is a pretty healthy dog. He has only had to go to the vet a few times, mainly for itchy ears or an infected cut or such things. Pretty much every time we go, we end up with the same prescription - a hefty course of both steroids and antibiotics in pill form. This time it was for an inflamed nail bed - he was licking and licking at his foot. He is now on steroids and antibiotics and the course won't be finished for another ten days. Now, I'm not a vet (not even a doctor or pharmacist) but I would be surprised if this was the pattern of prescribing in human medicine. I know there are issues about over-prescribing antibiotics; and with steroids I would imagine the issues are even greater - as I understand it, steroids are pretty strong drugs with a systemic action - in other words, they affect all parts of the body, not just the area being treated, so it is not surprising there are side-effects. I hate watching the side-effects of drugs on Pongo. Steroids, in particular, change his character (he becomes jumpy and wound-up, not my normal happy relaxed boy) and they make him both drink and urinate more (especially the latter - we had a huge "accident" in the house yesterday when he couldn't get to the door quick enough). I did query the necessity of the steroid pills with the vet this time, but was assured they were essential for the treatment to work. Is it just my vet that is so quick to prescribe? Or is this really the state of the art with veterinary medicine - is everyone else's vet the same? Rosie
A tricky one to comment on. The key to mimimal drug use in dogs is an accurate diagnosis and for any long-term problem then a full workup is mandatory to give an accurate diagnosis, prognosis and specific course of treatment. For an acute, short term problem then your vet is being pragmatic. To fully diagnose exactly why Pongo was frantically licking at his nail bed he would need samples taken for cytology to examine under the microscope, and if bacteria are seen a swab taken for culture and sensitivity testing. He might also need a general anaesthetic and biopsy of the nail bed, which is a tricky technique to get right so that you don't damage the nail bed and make the claws grow in abnormally afterwards. The results for all this to come back would take 7-10 days during which time Pongo is frantically licking at his nail bed and ensuring that if it wasn't bacterial at the start, it certainly would be by the time he'd had a good 10 days having a go at it.He would almost certainly have to wear the cone of shame during this time. So, to avoid a large (and for a one-off problem pretty unnecessary) bill and to minimise suffering for Pongo, your vet is taking a bet on the likeliest cause (bacterial infection of the nail bed with subsequent frantic licking due to the inflammation) and prescribing on that basis. The steroids are simply to reduce the inflammation and stop him licking and making it worse. So whilst prescribing antibiotics and steroids for a nail bed infection is not state of the art, it is a pragmatic, sensible and cost-effective method of giving Pongo relief as fast as is possible. However, if this became a recurrent problem then a full workup as outlined above would become important. Hope this helps.
Very interesting to read . Millie is on long term steroids plus another drug, for neurological problems , the steroids being given to keep swelling around her brain reduced . I do think the effects of steroids can vary, dog to dog , in her case , they have given her to feel good factor as well as reducing the swelling , she remains calm and very happy .When she first started on them, she also urinated more often but has settled onto a lower therapeutic dose , so for her, they are a wonder drug . I hope that Pongo soon feels some real relief , and that the infection soon heals up .
Thanks Lochan and Kate - really helpful as always. I think I just needed reassurance that this really is necessary. Pongo is pacing the room today - he can't settle, he desperately wants to play, goes crazy for a few minutes with a toy and then loses interest, he is panting as though he has run a mile, and whining quietly and constantly. It is so very different from his usual behaviour (i.e. flat out and snoring) and I can't seem to do anything to make him feel better..... As usual I'm sure the problem is more with me than him (over-anxious lab parent!) but it's good to share at least. Thanks. Rosie
My vet tends to do the same, unless it's recurring. Then they will investigate further. Hope Pongo feels better soon. Harley sends healing licks x
Rosie , I know how you feel. Lochan has given a very reasonable and rational answer. In human medicine the overuse of antibiotics is becoming a real problem, and not only are GPs having their prescribing monitored (not just for antibiotics, but it is regarded as a marker of good practice, both total number of antibiotics and type of antibiotics prescribed) but there is a huge campaign to reduce the public expectation that they need an antibiotic for self-limiting illnesses, most of which are probably viral. I find it tricky to reconcile this with the veterinary approach. We also try to limit steroid use - oral steroids can make you hyper, make you pee more, cause thinning of the bones , diabetes, suppress your natural steroid production............yep, not something to use lightly. Yet, that said, we use an awful lot of it, for asthma, COPD, rheumatic conditions. Anything where you need to reduce inflammation quickly and effectively. I am guessing that just as with humans, vets know how much to give before needing to address these other issues. To reduce inflammation we are more likely to give a NSAID (a Non-Steroidal Anti-Inflammatory Drug) than a steroid because risks may be less. However, we are prescribing less of these as we know more about how they affect kidney, guts, hearts etc. If a human has a strong allergic response they get anti-histamines, steroids, and possibly adrenaline too. The differences and similarities in veterinary and human medicine I find fascinating. The biggest one I find, is that with human medicine we are more likely to take an "expectant approach" expecting something to get better with a bit of time, allowing our own natural immune system to take care of it. Not so easy to explain to an animal that if they keep picking a scab it will get worse though. I guess that makes a big difference. That and the fact that animals are pretty stoical and hide a lot! I think that was an excellent question Rosie. Sorry to hijack it a bit. I really appreciate Lochans response, really helpful.
Thank you, Harley! The infection itself seems to have cleared up now (no paw licking going on any more), so the treatment has certainly worked. But he needs to finish the whole course of ABs and have a very gradual weaning off the steroids (which will take another 10 days)..... Pongo says he feels like a complete woos because I'm making such a fuss over a little sore nail when his poor darling Harley has got two cracked paws. He wants me to ask you to tell Harley it wasn't his idea to go to the vet, and that he thinks she is very brave, and that if he could he would come over and look after her.
We do use NSAID's in dogs all the time to reduce the inflammation associated with arthritic conditions, etc. NSAID's simply do not work to reduce the inflammation associated with skin disease, and they do not reduce itch at all hence they would be of no benefit to Pongo. As a dermatologist muself, I'm quite a fan of topical steroid sprays for focal itchy skins - they tend to work quickly and well with few if any systemic side effects. It depends on the site though - very difficult to use a spray over a large area of hairy skin without a fairly major haircut! And if you have a dog that is frantically licking at an area, you need to keep the tongue off the treated area for a good while to allow the spray to penetrate the skin so this has fairly major practical problems. In terms of skin or ear disease in dogs, viral infection as a cause is as common as hen's teeth. Bacterial infection is incredibly common though, and in dogs it is frequently a staphylococcus which is the causal agent. Staphs produce an immunospuppressive agent themselves, disabling the canine immune system from clearing them up hence bacterial skin disease in dogs is far from self-limiting and is much more likely to be self-perpetuating, therefore the use of systemic antibiotics in cases of bacterial skin disease is indicated. For a variety of immunological reasons (for those interested staphs produce a super-antigen) staph infections in dogs may in fact drive the immune system in the direction of allergy, something we wish to avoid with skin problems. I agree though that I wish more vets would use cytology to assess if a pustule is truly bacterial or not before using antibiotics but I guess that is the dermatologist in me and for GP vets well in excess of 90% of pustular skin conditions/nail infections are going to have a significant bacterial component which needs to be treated. drjs@5 I also find the similarities and differences between human and veterinary medicine fascinating. A good friend of mine is a consultant paediatrician and we find more similarities than differences between paediatrics and vet medicine - we both deal with non-verbal and frequently uncooperative patients with worried owners/parents......
Lochan - thank you SO much for all this explanation. Very much appreciated, and very clear. (Now if I could just get Pongo to understand, all would be well...) (He has now finally conked out asleep. His steroids are taken with his breakfast so I guess that's why the morning was a bit fraught! Hopefully we've got calm now til tomorrow.) drjs@5 - and thanks for the sympathy and the input! I do find it all very interesting.
Human infections are probably much the same - viral tops the urti list, staph tops the skin list, though I guess viral causes of skin rash are going to be higher in paediatric practice than veterinary practice Apart from respiratory infections (aka "Kennel cough") I am guessing you have a higher proportion of bacterial infections in dogs generally. One of the interesting things for me is eye infections - most vets seem to give antibiotic drops for gunky eyes, whereas medical evidence seems to support the use of emollients and hygeine as first line unless there is a high index of suspicion for a bacterial infection. Mind you, most docs still end up giving the antibiotic ones if the pharmacist hasn't already done so!
