294. How to NOT feel guilty using steroids

Welcome to the Dernvet Podcast, where PET skin is always in. I'm Dr. Ashi Puzwa, board certified veterinary dermatologist, skin nerd, and your go-to guide for everything itchy, smelly, and inflamed. I'm here to take the itch out of your day and make Derm more fun than frustrating. Grab your microscope and let's focus in. Welcome, welcome back to the Dermvet Podcast. I am coming to you on a gloomy fall day here in the Pacific Northwest, and I wanted to go back to the basics of something, and that is to discuss steroids. I've spent a lot of time talking about alternative to steroids when it comes to managing allergies and other inflammatory diseases, but I just also want to take a step back and provide some relief. I want to provide a way to take away guilt and say this. I still use a lot of steroids as a dermatologist. I am so incredibly thankful for the advancements in my field. I practice in a world pre-apaquillocyte point, obviously, in release since it's newer. I have practiced where we had just immunotherapy, which I still love. Of course, you guys know that steroids and cyclosporin, as far as like the ways we really had to manage atopic dermatitis. I am just incredibly thankful that we have other options. I know other options are going to come along the pipeline as well, but sometimes I think we get so excited about those things that we don't recognize that there is still a time in place for these older modalities that we have had because of how complex the disease is that we manage. If you just look at keen on atopic dermatitis or just skin in general in ears. I wanted to provide, let's see, I've got six, different situations where I still use steroids. This can be for other things like we're going to talk about autoimmune diseases, but also just talking about real life everyday allergy too. I want to provide my two cents on when I use those just to provide some, like I said, to take away some of that guilt from you guys. Because when I lecture, sometimes people are like, "Why put them on steroids?" It's a big secret. Like, "I put them on steroids." I'm so sorry. I'm like, "Listen, I still use steroids. We need them, but I just want to go over." Maybe the certain situations that I tend to use them in when I'm managing cases in the clinic. Because I am, though I'm a specialist, I am in, again, a busy prior practice. I'm seeing lots of cases with lots of different situations as far as what the pet allows, the finances, the owner has, what that pet is actually responded to. So let's go over the reasons when I think it's totally appropriate to use corticosteroids in the clinic. Number one, really severe inflammation. Like, those German shepherds that come in and they're just draining lesions all over their bodies. They're like fire engine red. Now, I don't want to say every inflammatory case has to have steroids because I do think that the jack inhibitors, potentially cyclosporin, that that takes a while to work, can still help to control inflammation. But there are just cases when that inflammation is really severe and they're having the draining lesions and we need a quick way to provide relief for them to make them feel better. That steroids definitely will be the fastest, most effective way to do that. So when they are just super red, and of course you need to look for infection, all the things that we've talked about on the podcast before. But there are just situations where that pet, especially right cats, when we're limited on the options that we have, but even in certain situations of really severe inflammatory dermatitis and dogs, there is just a time in the place to say a couple weeks of steroids is going to reset you and do you some good. We're going to provide quick relief. We're going to control the inflammation. And then we can adjust to what makes sense for that pet in the future. You know, maybe two weeks of steroids really helps to clear that inflammatory process up. But maybe then we're going to switch to a jack inhibitor, or we need to figure out what the allergic workup is for that particular patient. So severe inflammation, you know, draining tracks, I think of really severe pododermatitis interdigital for umkylosis. I am not saying a jack inhibitor could it potentially help those cases. But when they are just erupted not dwells all over and really swollen paws and we've ruled out things like demodex. We know there's infection that we're going to manage with they just really need some quick inflammatory relief. Then doing a short course of steroids can do wonders for them. So number one, really severe inflammatory skin. Number two, using steroids in the clinic and feeling guilt-free about it. When we are waiting for a medication that's not as quick. And I'll tell you the most common time that I use this in my clinic is when I'm starting cyclosporin. So if I am starting cyclosporin, I think that's the right decision for that patient as far as the management of their long-term disease. We know cyclosporin can take four or six weeks to see that full effect. I don't want a patient to be miserable inflamed itchy whatever I'm using the cyclosporin for while I wait to see if that is an effective drug for them or not. So it's very common for us. I call it, I tell owners kind of like a bridge. Like it's very common for us to bridge over a short course of anti-inflammatory steroids just to provide some quick comfort, allow the cyclosporin time to have an effect and then slowly try to taper away from the steroid and see if that cyclosporin can take over for us. Another situation I think about this in the clinic. If I am starting a dog with an autoimmune disease on azithiaprine, azithiaprine is not a quick medication. It can take a couple of months to see the full effect. We have to watch for a lot of side effects with that medication. So if I'm managing say a pimpficus case and I need them on something while I see if I can get them on azithiaprine long term or maybe another med like microphenolate long term that's not fast, then we'll often use steroids to provide that relief or control even if we're having to stay up a little higher than we'd like and that's why we're trying to switch to another medication in the first place in cats with autoimmune diseases. This happens a lot for me when I'm switching them to lucoran. I don't have to use lucoran very often. Clarambusol being the drug name. I don't have to use that super often in things like pimpficus foliaceus but I do have a handful of cats I've had to use it in and I do use steroids usually while we're trying to get them started knowing that's a medication that can take a couple of months to work. So while waiting for a slower medication to have an effect, we'll often use some steroids just to provide some sort of relief even if it's not perfect while we wait to see if that's going to be a drug that works for them or not. Number three and this is probably one of the most common ways that you will see us in dermatology use steroids, stenotic ears. When those ears you ever heard me time and time it in talk about this on the podcast. When those ears are swollen shut, you can't even get an otoscope in them, you can barely get a swab down them and they're pliable, meaning they are not calcified and you have a chance to open them up medically. Then steroids are the way to go if it's not contraindicated. Putting them on insets, maybe it's going to help a little bit with the pain, but it's not going to open up that ear canal. We obviously can't use the two together. So putting them on steroids is going to make that ear canal open up. It's going to make them feel a lot more comfortable. Sometimes I even make them wait a few days of just starting oral steroids before we start topical ear drops, just to allow some of that inflammation to go down so that your drop actually goes in the canal and so that pet's not so uncomfortable when they try to put a topical in. So that's probably one of the biggest ways you will see us use steroids is when their ears are stenotic. Now I'm not saying every case of a tightest need steroids because it doesn't. There's topical steroids in a lot of our ear drops, you know, if they're just a standard allergy case doing pretty well, they get an ear infection. It's not like they're swollen shut. They just have, you know, mild and moderate inflammation and an infection just by treating that infection will probably feel better plus the topical steroid you're likely to put in that ear. But when they are swollen shut, stenotic, edemidis and you know you have a chance to medically help them and you don't have to send them in a surgery because it's calcified, then oral steroids are probably the best way to go to help open that ear up. Number four, and this is an obvious one, but for complete missiles, put it on there and that is management of autoimmune diseases. Now there are lots of cases that I have been able to get off steroids long term. You know, I have him biggest cases that I've successfully managed with cyclosporin or even off-label use of a jack inhibitor or some other combination. But to get them under control and oftentimes for some of these cases long term, they do need a little bit of steroid. But when they are coming in and they're in a full-blown, let's say, pimpigus flair, most of us are going to start a steroid to at least get a hold of that disease process and then start the steroid sparing medications to see if we can make our way off of steroids in a perfect world or at least be able to minimize the dose of steroids. Remember, everything was steroids very dose-dependent drug. You know, you kind of have cases on low-dose steroid long term and their lab work will look good, they'll tolerate it well. But if we're up in that autoimmune, you know, immunosuppressive dosing, like two minutes per gig of steroids a day, of course, you're going to maximize, you're going to increase the chance that you're getting a lot of those side effects. But if you can taper down to an effective dose, monitor their lab work, many will do fine on it long term, as long as you're being thoughtful. Because there are some that are really sensitive, right? We've all had the patient. We don't even put on that high of a steroid dose and they're just getting pupd all over the place. So they're all individual as far as the side effects they have. But we are very, very likely to be able to minimize those side effects if we can use lower dosing. So we'll often start higher as you guys are all probably used to get the inflammation under control, get the disease under control epiphygas and then try to reduce our dosing down to the lowest effective dose or transition them to another medication if we can. But when they are in that really full-blown autoimmune, you know, flare or you're just diagnosing them, then majority of the time we're going to use steroids because they're so effective. Number five, this is real life. I deal with this too. Cost concern, severe cost concerns of the client. Now, let me preface what's saying. There's a lot of times that if you manage our allergies appropriately, let's say you're going to put them on a jack inhibitor and maybe that cost seems like a lot to the owner. But then if you explain, hey, if we control your dog's disease better, you know, we might not have to see your dog as often for flares. So we're going to save on veterinary visits. We don't have to do say apologies all the time. We're going to save on that. We're going to save on antimicrobials. Like there are a lot of cases where if we can control their disease better with one of those medications and take away the other costs with it that is actually more cost effective for that owner. But of course, we have cases too that all the other therapies we have, monoclonal antibody, jack inhibitor, cyclosporin is just too much on a month-to-month basis. I would rather have that patient on hopefully a low effective dose or not having a lot of side effects with, monitor their lab work appropriately, which for me, an ongoing case of lab work looks okay. We try to check them a couple times a year, CBC, KMEA. But I would rather manage them with a load of steroid, if they're tolerating it well, then nothing at all in the quality of life for that pet and that owner is terrible. So we do have cases where they really can't afford anything else and we just find and we do the best we can, we find the lowest effective dose and that is okay. I would much, much rather have them have a good quality of life, monitor things, still educate owners of what to watch for like flares, but give a quality of life to them in their pets. And especially cats, right? Because we're so limited on what we have with cats. We have lots of cats who have to be on low dose steroids and we just do our best to monitor for the obvious side effects that we can see. Last one, this is a good one, maybe you're not thinking of, but this is real life and this is where I tend to use them a lot as a dermatologist right, a specialist where we do tend to get people who are really committed trying things. Nothing else works. Nothing else works. It just happens. These are complicated disease processes that we are dealing with. I have cases where it's not for lack of me trying. It's not for lack of the owner trying. It's not for lack of the pet trying because they'll actually take the meds. But we just get really tough cases where they fail at the quill. They fail in ralia. They fail cyclosporin. They fail immunotherapy. They fail the supportive stuff. And some steroids provides the best relief we can. You know, so sometimes it's not just they can't afford anything else that the owner is not compliant or not trying. Sometimes we just got tough cases. We just have tough cases. And that is what provides that quality of life. You know, sometimes it's not even perfect, but it's like the best we can get to. And that happens. So I just want to provide relief that even as a specialist, that happens to me too, where my owners do all the things that ask them to do, and they just have a dog or a cat with really tough disease process. You know, I have some right now. We're waiting for the next medication to release because they're just still not responding to all the tools that I have. So it happens to us. It's going to happen to you. Nothing else is working. You've tried all the things. And sometimes we just have to say, Hey, let's monitor steroids the best we can. Let's provide the quality of life the best that we can. And that's a tough situation to be in. None of us like to have to say you've tried everything and it's not working. But again, it's real life and it happens. So the top reasons I want you to understand even as a specialist, we use steroids to, you know, not be so afraid or feel guilty about using steroids when you're in these situations. Number one, very severe inflammatory dermatitis that you feel like that dose of steroids is going to provide a lot of relief and comfort for that pet. Number two, you're starting a medication that has a slow onset. So you need something to bridge over to that because you don't want the pet to be miserable while we wait to see if that helps. Big one, number three, really stenotic ears that are not calcified. And we think we can open them up medically. Number four, autoimmune cases, especially when we are in that induction phase of starting their treatment and they really need some relief. Number five, severe cost constraints. We want to still provide a quality of life for those pets and those owners. In the last one, nothing else works. You've done, you've done your due diligence, you have done the work up, you have done the appropriate things. This is a pet with complicated disease and they just need some steroids to have some stability in their lives. So I hope that's helpful because sometimes you get asked about steroids as I go to conferences and speak and it is really important and I want you guys to realize that even as specialists, we do use steroids. Now we have other medications if we're able to write that have less side effects that are better tolerated. So you always have to find the balance. You really want to try to practice the best quality medicine and offer the other things. But I also don't want you to be afraid to provide relief in these situations where it can make a big difference. So hopefully that provides some clarity, maybe some relief, maybe a little lift of burden from having to be in these situations because I face these all the time too as a clinical dermatologist.