Two Classes Of Anti-Inflammatory Drugs: Steroids and NSAIDs
- What to expect during the inflammation/swelling phase of a disc episode
- NSAIDs vs. steroids
- How long to stay on an anti-inflammatory drug to get the swelling down
- Why Pepcid AC
Answers about anti-inflammatory drug use
2. Washout NSAIDs <->steroids: Switching between the two classes or within the NSAID class requires a safety factor of 5-7 days of washout. Without the 5-7 day washout period, severe GI tract complications can occur. Warnings accompany each medication in the package insert. Look up your dog’s anti-inflammatory package insert.
3. Steroids are the most powerful of anti-inflammatories. Non-steroidal anti-inflammatory drugs (NSAIDs) are less powerful than steroids.
4. When there are solely pain symptoms with a disc episode and no neurological deterioration, many vets often choose an NSAID. Other vets choose to start with a steroid to avoid dealing with the washout issue should the NSAID end up not being enough to deal with the inflammation.
5. Mild episodes can have the possibility to progress to more severe cases when there is too much movement of the spine. Should neuro functions begin to deteriorate, then a vet has a very serious decision to make.
When nerve function is being lost, the spinal cord takes priority over days of anti-inflammatory washout. With an emergency, the GI tract is double protected with not only continued use of Pepcid AC, but also with the addition of sucralfate. This double stomach protection gives a safety factor to do the emergency switch between the two classes or within the NSAID class.
6. All anti-inflammatories, whether they be from the steroid class or the NSAID class, increase the chance of serious GI toxicity such as bleeding and ulceration. A stomach protector such as Pepcid AC (famotidine) suppresses acid production. Pepcid AC is generally considered a safe, over-the-counter stomach acid suppressor for a healthy dog and is good insurance. Dogs don’t speak up at the first signs of trouble like a person does. By the time we notice black or red blood in the stools, things can quickly go from bleeding ulcers to a life threatening perforated stomach.
How long to use an anti-inflammatory?
A vet must take an educated guess on how long it might take to resolve painful swelling. Often the first course will be a 7- or 14-day anti-inflammatory course. Additional course(s) are prescribed if there is still pain.
NSAIDS: At the end of a 7-day or 14-day NSAID course, pain meds are also either stopped or backed off. The owner’s job is to observe for surfacing pain and alert their vet for another course of the NSAID. Pain = another course of NSAID.
STEROIDS: The first steroid dose tapering down day give a window to see if pain is really gone.
- Taper days are no longer working on swelling.
- Pain meds are also stopped or backed down to enable the owner to quickly assess whether there is remaining pain and alert the vet right away.
- Pain = another course of steroid back up at the “anti inflammatory” level, all pain meds back on board, continued Pepcid AC
- NOTE: steroid hormones may not be full-stopped; they require tapering off under the supervision of a vet.
Prepare when NSAID stops - Steroid tapers
Your job at home will be to assess just how well reduction of swelling is going by observing for any hint of pain (▪︎shivering ▪︎trembling ▪︎yelping when picked up or moved ▪︎reluctant/slow to move head or body ▪︎tight hard tummy, ▪︎holding leg flamingo style not wanting to bear weight). And also alert your vet ASAP if seeing any new or increases loss of neuro function so that another anti-inflammatory course can be prescribed.
To avoid being blindfolded by pain meds, it is the vet’s decision if pain meds are also full stopped or backed off on the date NSAIDS stops or steroid tapers. Know ahead of time which your vet prefers: full stop of the pain meds or backing them off in mgs/frequency given.
Plan B
Rule of thumb :
pain = swelling = another anti-inflammatory course, pain meds and Pepcid AC
No Pain= (if on a steroid complete the taper to conclusion). Complete 8 weeks of crate rest for the disc to heal.
4 THINGS TO KNOW ABOUT ANTI- INFLAMMATORY DRUG USE
A range of anti-inflammatories specially formulated for canines with fewer side effects are now available. The metabolism and dosages of drugs for people are much different for dogs.
Aspirin should not be used with other medications due to its lengthy effect of prolonging bleeding (DO NOT use with other NSAIDS, steroid hormones, or joint supplements). At least a 7-14 day washout period is advisable when going from aspirin to another anti-inflammatory medication. Self-prescribing aspirin for your dog is dangerous, plus it can tie your vet’s hands in using the appropriate meds for a disc episode!
Depending on a dog’s metabolism, 5-7 days must be given for an NSAID to leave the body before it would be safe to move to the more powerful anti-inflammatory class of steroids.
When there is loss of neurological functions, the lesser of the anti-inflammatories (NSAIDs) are not usually continued. The most powerful of the anti-inflammatories (steroids) is considered. If the vet deems it an emergency to switch from an NSAID to a steroid due to deteriorating neurological functions, a switch can be made without a 5-7 day washout period with the addition of TWO stomach protectors:
- Pepcid AC (famotidine) to suppress acid production
- Sucralfate to neutralize existing acids and form a protective bandage gel coating to damaged areas of the stomach lining.
All NSAID package inserts carry a similar FDA required warning: “Should not be given with other NSAIDs (for example, aspirin, carprofen, etodolac, deracoxib, meloxicam, or tepoxalin) or corticosteroids (for example, prednisone, cortisone, dexamethasone, or triamcinolone).” Look up the package insert for your dog’s anti-inflammatory.
“The primary cause of adverse effects from NSAIDs is incorrect dosing (eg, concurrent use with corticosteroids or another NSAID, changing NSAID without a suitable washout).8 Washout period (dogs, 5–7 days)”2
2. Guidelines for safe and effective use of NSAIDs in dogs. Lascelles BD, McFarland JM, Swann H. Vet Ther 6:237-251, 2005.
8. Systematic review of nonsteroidal antiinflammatory drug-induced adverse effects in dogs. Monteiro-Steagall BP Steagall PV, Lascelles BD. JVIM 27:1011-1019, 2013.
“Let me be crystal clear right from the get-go. A steroid (aka: corticosteroid, glucocorticoid) should rarely be given at the same time as a non-steroidal anti-inflammatory drug (aka: NSAID) prescribed at an anti-inflammatory dose. This is a well-established pharmacologic principle, but for some reason, it is also one I see violated on an almost daily basis. With so many alternatives to help keep patients as comfortable as possible, I’m perpetually flummoxed by this choice of treatment. Thus I’m writing this blog post so pet parents are aware of this important issue and can be proactive advocates for their fur babies.”
Christopher G. Byers, DVM, DACVECC, DACVIM (SAIM), CVJ
Three reasons why Pepcid AC
Learn what your vet may not have had time to go over with you about Pepcid AC: Three reasons why Pepcid AC
Suppresses Acid Production-FAMOTIDINE
- Effective in 30 mins, lasts for 12 hrs
- H2 blocker: famotidine– Pepcid AC®, brand X products.
Used at the start of any anti inflammatory drugs (non-steroidal or a steroid) - Veterinary dosing information
Suppresses Acid Production: OMEPRAZOLE
- Peak effectiveness in 3-5 days, studies indicate with IVDD every 12 hrs dosing
- Veterinary dosing information
- Check with your vet for dose
Neutralizes existing acids: SUCRALFATE
SUCRALFATE– Carafate®; a prescription product. Any sign of GI tract damage, advocate for this to be added to Pepcid AC.