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Thursday, December 22, 2011

Long-Term Steroid Use

Olivia sent me this question...

I would be very grateful if you could offer me an opinion on this if you can find the time. I've found it quite difficult to find proper information on.

My dog was diagnosed with lymphangiectasia back in October. It seemed to come out of nowhere, one minute he was well, the next he was barely able to breath and extremely unwell.  His diagnosis was followed by a 'but we're not 100% sure'.  This was all after a biopsy as the vet originally thought he had a growth in his abdomen.  To keep all unnecessary content out of this email, he was put on steroids and has been on a low fat diet since that. This has worked extremely well, in fact, he hasn't been this happy or healthy looking in a long time. However, we were told that the long term affects of steroids are damaging and we'll have to talk to our vet after Christmas about discontinuing them and figuring something else out.

Do you know of any other ways of controlling this or how long a dog can be left on steroids? I'm quite concerned as the only other option we were offered was a very expensive medicine that we'd have to pay almost 200 for a month (I wish I remembered what it was..), and even then the vet said he wasn't sure it could control the problem that it was trial and error at the moment.
For the readers who don't know what lymphagiectasia is, let me briefly explain, though the disease isn't really the main focus of the question. In essence this is a disorder that results from a dilation of the lymph vessels and most commonly affects the intestinal tract.  Chronic diarrhea results, and though that's bad enough it's not the main concern of the disease.  The diarrhea and loss of lymph fluid causes often severe loss of proteins from the blood stream, a process called "protein-losing enteropathy".  The low serum blood protein level causes fluid accumulation under the skin in the limbs, within the abdomen, or in the lungs.  Over time this can become a serious and life-threatening disease.  Though the only definitive diagnosis is through biopsy of the intestine, we can often get a very strong idea that we're dealing with lymphangiectasia based on symptoms and routine blood tests.

Treatment always involves switching to a diet low in fat and with high-quality protein.  It may also be necessary to provide supplemental fat-soluble vitamins (A, D, E, and K).  But one of the hallmarks of treatment is steroids to reduce the inflammation of the lymph vessels.  And that's where we get to the heart of Olivia's question.

There is often a lot of talk about the evil of steroid (glucocorticoid use).  And yes, it's not ideal.  Long-term steroid use has the potential of causing liver damage, affecting the immune system (though normally only when given at high levels), and inducing Cushing's disease.  These are all potentially serious issues, but the will NOT happen automatically or in every case.  Every patient is different and should be evaluated individually.  I also believe that long-term steroid use should never be a first option in most cases and other treatment options should be investigated and pursued.

But given all of that steroids are very effective in many diseases and disorders and should not be immediately eliminated from consideration, even long-term.  I have had many patients over the years that have had to stay on steroids for life and most of them have done quite well.  I have treated pets for lymphangiectasia, and I have always kept them on long-term steroids.  In my opinion you have to weigh the pros and cons of such medication use.  Ask whether or not the pet will be better off with the steroids or without.  It's really that simple.  No, long-term steroids are not ideal and can have side-effects.  However, in many cases they are better than the option of not treating.

If this were my case I would start the pet on steroids and recheck the blood proteins every few weeks until they stabilized.  Then I would check the liver enzymes and see if the steroids were causing significant effects.  If so, then I would investigate other treatment options.  If the chemistries were normal I would continue steroid therapy and recheck the blood every six months.  As long as the pet wasn't having significant clinical side-effects and the blood tests remain normal, stay on the medication.  So long-term steroids ARE an option and should be considered, weighing the decision against any potential harm.

Olivia, I hope this helps.  Remember that your vet knows the specifics of your pet's case better than I ever will and you should discuss all of these options with him.