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Cortisone For Dogs with Atopy

By Dr. Jeff LaCroix 


"You're not going to use cortisone, are you?", "Cortisone is bad for the kidneys, isn't it?", "Won't cortisone damage the liver?" These are only a small sample of the questions presented when I inform a client that the use of a glucocorticoid (also referred to as corticosteroids) may be part of the treatment for a pet's medical condition.

Fifteen or twenty years ago, I could avoid some of these questions by not using the word "cortisone" and using, instead, the less offensive and less recognized word "steroid". Steroids are now widely known as drugs abused by athletes and bodybuilders, so this ruse is no longer effective. I've tried "glucocorticoid", but the client invariably sees through this and knows I mean "cortisone".

If you haven't guessed by now, this will be the other side of the story - a defense of the use of cortisone in the treatment of medical conditions in the dog, especially allergy.

First, what is "cortisone"? Adrenal corticosteroids are produced by the adrenal glands. They are often simply called steroid hormones. Although the mammalian adrenal gland produces numerous steroids, only a few have significant biological activity. The significant hormones are classified into 3 groups: glucocorticoids, mineralocorticoids and androgens. They may be thought of as the sugar, salt and sex hormones, respectively.

It is the glucocorticoids that are most often used therapeutically in both human and veterinary medicine. Glucocorticoids can affect the body in many ways. The suppression of hypersensitivity and the anti-inflammatory properties of glucocorticoids are utilized in the treatment of allergy, or more specifically, Atopy.

These beneficial effects must be balanced against other effects that occur to some degree with all glucocorticoids, both natural and synthetic. These include, but are not limited to, increased glucose production, facilitation of free water excretion, the loss of both potassium and sodium, protein wasting, and the general suppression of the immune mechanism (especially at higher doses).

I'm sure some of you are already thinking "All these side effects just to reap the anti-inflammatory and hypersensitivity moderating benefits?" I haven't yet mentioned the most serious side effect of prolonged steroid use - the suppression of the natural function of the dog's own adrenal gland.

So why are we going to use glucocorticoids to treat Atopy? The answer is because nothing else works as well or as consistently.

Yes, some dogs can be helped with hypoallergenic diets, i.e. those with novel proteins or proteins of altered molecular size. However, few cases of Atopy are complicated by food allergies, because with Atopy, the majority of allergens are inhaled.

For the most part, chemicals other than antihistamines mediate allergies in dogs. Thus, antihistamines are of limited value unless the sedation they produce as a side effect is considered beneficial. The antihistamine hydroxyzine may be an exception, and may have some direct beneficial effect, in addition to decreasing the amount of glucocorticoid necessary if both are used together. Vitamin E may also have this same cortisone-sparing effect to some degree.

Recently, essential fatty acids in various forms and combinations have been found to have a beneficial effect in modifying the immune response in allergic states.

Finally, topical treatments, such as oatmeal shampoos and rinses, can be helpful and soothing, but their duration is short-lived. The same is true for "leave-on" shampoos containing both hydrocortisone and antihistamines.

So, when you're faced with an atopic dog who has not been helped through allergy testing and desensitization, and is unable to be managed by dietary manipulation, antihistamines, fatty acids, shampoos and rinses, and if you are unwilling to move to a mountain top in Arizona for the sake of your dog's health, what are you going to do?

Back to the point of this article, which is the rational use of corticosteroids to manage the allergic dog. In many cases, this will be the only way to control the condition and assure some level of comfort for the dog.

What do we do to attain the beneficial effects of glucocorticoids without harming the patient?

Most of the significant side effects occur with long term, higher and steady doses. With the exception of increased urination and thirst, nearly all side effects can be avoided by using an appropriate product and dose.

I mentioned previously that the most serious long-term side effect is the suppression of the dog's own adrenal gland. This occurs through a "feedback" mechanism. The pituitary gland (master gland at the base of the brain) can't tell one glucocorticoid from another. Thus, when cortisone is constantly delivered in the form of a pill or injection, the pituitary gland no longer feels the necessity to tell the adrenal glands to make more hormones. It stops producing the messenger ACTH (adrenocorticotropic hormone), and the adrenal glands respond by ceasing production. The resulting adrenal atrophy can potentially be a problem if cortisone therapy is suddenly stopped, or if working adrenal glands are required for other metabolic functions.

Obviously, one way to minimize the side effects is to use the lowest dose possible. The simultaneous use of essential fatty acids and hydroxyzine may be helpful in making this low dose more effective.

Secondly, it's necessary to use the right product. Depo injections (long lasting injections) with products such as depomedrol have no place in the management of the allergic dog. Unintended overdosing can happen easily, and, if so, the side effects will persist for the duration of the drug (several weeks). Also, adrenal suppression is most likely with this form of therapy.

Other shorter acting injections may have a place, but only for their immediate effect as a loading dose.

Oral forms of glucocorticoids are the safest and most effective for the long-term management of the allergic patient, because dose and duration of activity can be easily controlled. The products available include hydrocortisone (the natural hormone), prednisone, prednisolone, triamcinolone, dexamethasone and flumethasone. The duration of action of hydrocortisone is less than 12 hours. Prednisone, prednisolone and triamcinolone are of intermediate duration, lasting 12 to 18 hours. Dexamethasone and flumethasone are long acting, lasting 36 to 72 hours.

In most cases, the duration of action with hydrocortisone is too short to be effective. The long duration of dexamethasone and flumethasone makes adrenal suppression more likely to occur.

Drug levels are most easily controlled with prednisone, prednisolone or triamcinolone. Additionally, if it is possible to control the pruritus (itching) with a dose administered on alternate days, significant side effects (especially adrenal suppression) are unlikely to occur.

Alternate day therapy described above is always the goal in long term management of the allergic patient - although it is not always achievable.

With long-term steroid therapy, it is wise to monitor liver function and electrolyte levels (especially potassium) at regular intervals.

There is as yet no "cure" for Atopy. Management is through avoidance, desensitization or medication. In the real world, avoidance is usually impossible, and desensitization has inconsistent results. Thus, most cases will be managed medically. Done properly, the dog can be made much more comfortable, and serious side effects can be avoided nearly 100% of the time. 






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