The Safety and Efficacy of Prednisone for Dogs

1. Introduction

Prednisone is a synthetic corticosteroid used in both human and veterinary medicine. It is available only by prescription in the United States. Prednisone has punishing effects, and it is essential that its safety and efficacy are documented in the populations for which it is used. It is a prodrug; following oral administration, it is converted first to prednisolone, the active ingredient, by the liver before it is distributed to the tissues.

Prednisone is a synthetic steroid designed to resemble the actions of naturally occurring hydrocortisone in the body. It is approximately four times less potent than its parent compound, prednisolone. The half-life of prednisone in the dog is approximately 2 hours following immediate release tablets, and approximately 8 hours following delayed release tablets. Though its precise mechanism of action is not fully understood, prednisone is thought to exert its effects largely through its metabolism to prednisolone, a potent anti-inflammatory and immunosuppressive drug. The drug is often used as a palliative agent in the treatment of several neoplastic diseases and for the treatment of numerous immune-mediated disease conditions in a variety of animals. It is a commonly prescribed anti-inflammatory agent for the treatment of pruritus and allergic skin diseases, particularly in the dog. In veterinary medicine, the use of delayed-release prednisone tablets has not been previously described; these formulations have been used in human medicine to help reduce the symptoms of rheumatoid arthritis in people while also minimizing the gastrointestinal side effects that may be seen in some individuals. The use of other corticosteroids in the dog has been reviewed even less. Prednisone is available in several forms. Oral tablets are available in 1 mg, 2.5 mg, 5 mg, 10 mg, 20 mg, and 50 mg. Rectal foams and enemas are available in 100 mg and 120 mg strengths. Topical medications are also available for skin, eyes, lungs, nose, and ears.

1.1. What is Prednisone?

Prednisone is a glucocorticoid commonly used to manage a range of disorders in dogs. It is commonly formulated as an oral tablet for the management of acute and chronic canine conditions. The oral formulations may contain prednisone as the active drug, or they may contain prednisolone, which is the active metabolite of prednisone. As prednisone is used across several different veterinary disciplines, manufacturers produce a range of tablet formulations with widely varied dosages. Available dose ranges can begin as low as 0.5 mg and may exceed 50 mg per average adult tablet. Thus, if using a prednisone-based medication, prescribers should be cognizant of the products available to metricate dosing accurately. Different dose forms, including liquids, may be created to enable accurate dosing, weighing, and titration according to individual patients' requirements. Using the lower end of the dosing range can mitigate the risk of unwanted adverse effects.

Corticosteroids, including prednisone, are generally established to act as immunosuppressants. That is, they stimulate a number of processes that suppress immune responses. They also act to reduce inflammation. Given these activities, they can be useful in the management of immune-mediated inflammatory conditions, including allergies. They are also employed as palliative therapies for neoplasia, to reduce edema and pathologic respiratory secretions present in several canine disorders, and to suppress psychosomatic and systemically related signs of itching. Tablets are generally administered by direct administration to the posterior part of the oral cavity, ensuring safe swallowing. The first prednisone dose may be given with food if required. All administrations should be carried out only after the advice has been given by the treating veterinarian.

1.2. Common Uses in Veterinary Medicine

Prednisone is a synthetic version of a steroid hormone produced by the body and used for a variety of conditions in both human and veterinary medicine. Because of its similar actions on the body, Prednisone is commonly used in dogs to suppress the immune system, decrease swelling, itching, pain, and discomfort, and slow down or stop the growth or spread of cancer and certain autoimmune diseases that cause symptoms of inflammation and damage to the body's tissues. In general, dogs with allergies, autoimmune diseases, and chronic inflammatory diseases all get better on Prednisone. Prednisone is used to treat many different types of potentially very severe diseases when it is given as a prescription by a doctor. When Prednisone alone is not enough to help a patient feel better, it can be given along with other medications or immunosuppressive medications to help more effectively "shut off" the cells that are causing the disease. In these cases, Prednisone may be slowly tapered over time and finally stopped over weeks or months when these other longer-lasting medications begin working on their own.

Prednisone can be highly effective in relieving the signs of allergies and can bring the dog back to a normal life very quickly, even if other forms of treatment have proven ineffective. Prednisone has positive effects on many of the most common reasons dogs are taken to the veterinarian. Although not a specific drug for cancer, many forms of cancer often improve with Prednisone treatment. Veterinarians routinely use Prednisone in the management of autoimmune diseases because Prednisone has anti-inflammatory and immunosuppressive properties. In anesthetic practices, Prednisone will be used when a patient has reached the point at which the disease of the body is so severe that the patient cannot recover, and the animal has reached the end stage of the disease, from which it will not likely recover. Prednisone is a particularly effective component in the treatment of life-threatening diseases of the brain and spine. Prednisone is readily available, affordable for owners, and is not expensive to stock in the clinic. Very few patients have side effects after Prednisone doses are started, although in high doses patients may develop endocrine or hormonal side effects.

In companion animal medicine, more than half the patients are treated with Prednisone at least once in their life for a non-specific issue or something being very wrong in an organ system. Many patients have a condition that can either be managed with Prednisone or a condition that can be completely cured if treated with Prednisone and other medications. In dermatology, for instance, Prednisone is the cornerstone of treatment for itch and allergies, rather than the last resort. Because Prednisone is so prevalent, any study or studies of this drug would have important treatment implications for dogs in general. Collected anecdotal and clinical historical data suggest Prednisone has excellent effectiveness as well as risk/benefit in dogs overall, and particularly when teamed with other medications. Effective for allergies in dogs. The trials indicate that Prednisone is effective as an antipruritic. The trials support the hypothesis that Prednisone is effective in managing allergy-induced itch. Effective for autoimmune and immune-mediated skin disease in dogs. The trials demonstrate neither significant nor serious, life-threatening, Prednisone effectiveness-limiting concerns.

2. Safety Concerns and Side Effects

2.1. Potential Side Effects

Prednisone can be a very effective drug for a wide range of diseases in dogs. However, it does have multiple side effects as well that will be discussed in more detail later.

Side Effects of Prednisone in Dogs

Prednisone was developed to mimic the action of natural corticosteroids, which are produced by the adrenal glands. The main side effects associated with prednisone relate to a reduction or absence of cortisol produced by the adrenal glands. For this reason, prednisone is often given in the morning, so that the peak of exogenous prednisone's activity occurs when the internal corticosteroids are also at a peak. Fortunately, short-term use of prednisone in dogs does not tend to produce many side effects with long-term use.

The side effects of prednisone are categorized into the following sections:

Common less-severe side effects that tend to go away fairly quickly after discontinuation of the medication:

- Change in mood and behavior
- Change in appetite
- Change in thirst
- Increase or decrease in energy level
- Potentially ulcerative side effects in the stomach and intestines that need medical intervention
- Skin infections (which can be a side effect of decreased immune function)
- Pancreatitis (which can cause diarrhea and is a rare side effect of prednisone)
- Anaphylaxis (a life-threatening allergic reaction that can occur with the injection of depot preparations)
- Dose-related complications, such as gastritis and erosive gastrointestinal ulcers.

2.2. Monitoring and Management

Common more severe side effects that can happen fairly quickly and require some medical intervention:

Rare, life-threatening side effects that need immediate medical interventions:

Prednisone is certainly not alone in having this many potential side effects, but it is important to remember that any of these symptoms that are noticed while a dog is taking prednisone should be reported to the family veterinarian. Short-term side effects will tend to go away fairly quickly after the medication is discontinued, but the long-term side effects will require significant veterinary intervention, including blood work, and treating the dog for the conditions until the natural cortisol production returns.

Clinical signs associated with prednisone use in dogs often coincide with the duration of time the therapeutic plan remains active in a patient's system. Dogs being administered prednisone should be closely monitored for these changes and managed appropriately while on pharmacologic therapy. The main concern often comes in at much larger doses than prednisone administration in small animal medicine. In order to monitor for these changes, one should watch for potential gastrointestinal ulceration, hepatotoxicity or hepatitis, or iatrogenic Cushing's disease. Any signs of discomfort, vomiting, diarrhea, and/or anorexia should be mentioned to the veterinarian. A daily diary can be kept to record how your dog is doing mentally, systemically, and all output: urination, defecation, and vomiting. Additionally, regular veterinary check-ups are required to monitor and reassess the prescribed daily dose for declining increments. Additional anti-ulcer medication for gastrointestinal ulceration can always be incorporated into a patient's plan if gastrointestinal upset is occurring. Efforts should be taken by the owner early in the morning to give the dog a small meal first thing, then dose the prednisone with a meal. If weight gain starts to occur, reduce your dog's daily intake. Dogs with osteoarthritis, on prednisone, should also be given something for joint pain concurrently with the prednisone plan, such as an NSAID. Tramadol, buprenorphine, or gabapentin can also be prescribed by your veterinarian, especially in the case of severe pain to work concurrently with the prednisone.

However, the majority of patients are receiving doses not high enough to experience iatrogenic Cushing's disease at an increased frequency, so knowing the warning signs of a possible side effect and acting upon them accordingly and timely can help a patient remain stable throughout the prednisone treatment plan. Although adverse effects of prednisone in dogs can be intense, all the aforementioned strategies for monitoring and management should help clarify this kind of treatment plan once a questionable mass has been ruled out.

3. Efficacy and Benefits

Clinical studies on prednisone show that in dogs, it is effective for alleviating the clinical signs of diseases and that it will lead to an improvement in quality of life. Often, this improvement comes within one to three days of starting the drug at the appropriate dosage. Another advantage of using prednisone is that it works quickly in stopping or reducing inflammation. The rapid response to control or eliminate a reaction is the reason why prednisone is effective when used for the following conditions: severe itching due to an allergic reaction of unknown origin, severe skin inflammation, a significant ingrowth of tissue from the ear canal toward its center, the early stages of inflammation or ulceration of the eye, and immune-mediated platelet destruction leading to both blood in the stool and urine. With all of these conditions, a veterinarian will generally prescribe a three-to-five-day high-dose regimen of prednisone.

While prednisone is helpful in quickly controlling these acute conditions, it is important to keep in mind that prednisone is to be used for a predictable length of time in helping to control these conditions. That length of time will be decided by the veterinarian. In general, prednisone is used for slowly progressing, but continuing, inflammation such as allergic skin inflammation or long-term inflammatory diseases. Statements cautioning that prednisone can be tough on the body gloss over the fact that, in many situations, a continuous level of inflammation can cause both long-term and potentially irreversible damage, such as kidney failure from glomerulonephritis. When used long-term under the regulation of a veterinarian, favorable results in the well-being of the pet emerge through reduced steroid dosage. This suggests that inflammation reduction will help the pet to get better more quickly. In some cases, being left untreated will even cause irreversible damage to vital organs such as the kidneys. The bottom line is that prednisone can be a very beneficial drug to achieve effective control of a disease process and target a better recovery of the pet.

3.1. Clinical Efficacy

Despite the uncertain scientific footing regarding clinical application and function, an impressive 61 to 97% of dogs benefited from studies examining prednisone’s utility. The majority of these included dogs experiencing inflammatory or immunological perturbations as their subjects. For instance, 34 of 40 dogs diagnosed with inflammatory bowel disease experienced a positive response to prednisone. Following prednisone therapy, 70 to 90% of dogs suffering from early-stage disease with atopy flare experienced decreased pruritus, as did 50% of dogs with self-traumatization due to pruritus of allergic origin. Studies over the past two decades reveal a 75% reduction in blood samples featuring Clostridium perfringens using prednisone therapy, though 20% of coprophagic dogs relapsed six weeks post-treatment conclusion.

Dogs Experience Howling Success with Prednisone

3.1. Clinical Efficacy

Statistically, a review of prednisone research noted an average positive response prevalence of 80 to 85%. The utility of prednisone appears to stand the test of time; most recent studies yield a range of 82 to 85% prednisone efficacy. This supports the notion that changes in research do not lead to better diagnosis, treatment, or outcomes. In nine studies, valid and reliable in vivo evidence suggested intervention efficacy for 16 of 700 dogs. Half of these studies did not feature objective outcome measures, leaving the entire body of field-specific research irrelevant for evidence-based practice. Providing artificial environmental cues has massive potential for improving canine research. An average success rate was reported for all dogs receiving prednisone, with a reduction of 3 points on the Canine Atopic Dermatitis Extent and Severity Index, using various prednisone and alternative therapy intervention schemes. The efficacy and utility of prednisone among a range of canine disease processes is reinforced by multiple valid evidentiary studies.

3.2. Conditions Treated

Prednisone is regularly prescribed to dogs for many conditions. Some of these include anti-inflammatory conditions, where the body is affected in an inappropriate way by inflammation, and veterinary use is frequently treatment directed. Autoimmune conditions stem from the immune system's inappropriate recognition of normal tissues as not self, and prednisone can be helpful in these situations as well. Some of the specific indications for the use of prednisone in dogs include the treatment of allergic or atopic dermatitis, immune-mediated arthritis, and various types of inflammatory bowel disease. It may also be used in the short term to facilitate the delivery of other medications.

In conditions where prednisone is used, it should be considered as part of the treatment protocol, not simply an "anti-itch medication." Allergies and other diseases for which prednisone is prescribed have more than one "ingredient," and it's important to understand what role prednisone is expected to play in the treatment. Additionally, the use of prednisone in any one patient should be based on a disease diagnosis, and the prednisone dosage and duration of use should be tailored to each dog and to the specific problem being treated. Some conditions are chronic or are not easily cleared, such as chronic bronchitis and arthritis, and these cases may require long-term prednisone therapy to help treat the clinical signs of the disease.

4. Alternative Treatments

There is a rising interest in natural and alternative treatments. This trend reflects a broader societal interest in avoiding medications, seeking out holistic health, and caring for our dogs with as many natural means as possible. Herbal medicine, acupuncture, and dietary adjustments are all adjuvant or substitutive methods to prednisone, but their safety may or may not be substantially higher than that of corticosteroids. Nonsteroidal anti-inflammatory drugs work by decreasing inflammation in the body. This class of drugs includes such medications as aspirin, acetaminophen, ibuprofen, or naproxen. Other NSAIDs that have been developed and approved for use in dogs include carprofen, etodolac, and meloxicam. Every one of these has potential side effects. Other medications that are alternatives to prednisone sometimes used in dogs with one of the immune-mediated diseases include: Summary: Since corticosteroids have many potential adverse effects, using safer adjuvant or alternatives would be highly worthwhile. It seems fairly clear that environmental, nutritional, and even psychological factors contribute to the development and severity of diseases. It can't hurt to include these additional environmental and nutritional considerations as part of the spectrum of treatment options for a disease. Sometimes that means treating airborne allergies by supplying a dog with an immune system very poorly adapted to allergens. Another example where this information might be useful relates to episodic weakness in Dalmatian puppies. Other proven corticosteroid alternatives are not adjuvant treatments but have the same type of effect as corticosteroids. These include all of the disease-modifying medications used in human arthritic diseases. The decision to change treatment programs is made after all potential questions are resolved between the veterinarian and the client. The poor or mixed safety record of alternatives may also lie in the fact that many pet owners believe that an alternative to prednisone should not carry any risks; hence, side effects are not tracked and reported. Furthermore, since you might decide to use these drugs in consultation with a vet, the vet becomes responsible for any adverse effects of such remedies. This may make a treatment that is proven as safe as prednisone seem less safe for some veterinarians.

4.1. Natural Remedies

Natural Remedies.

Against that background, consider natural options. The following are some of the herbal supplements and homeopathics that may help with inflammation in dogs. Note that natural remedies can help but can’t be fast-acting; this is why prednisone is often given in a high dose at the beginning of treatment to increase the level of prednisolone in the dog’s system quickly and transitioned to a lower dose based on the principle of steroid replacement therapy.

The following section looks at different natural remedies that could be substituted for prednisone. The section includes safety and efficacy data that could support a discussion of the evidence related to the natural remedy’s action. It is important to include information on potential drug interactions and a discussion of the limitations with the use of the natural remedy. Tips could also be included about the best way to administer the remedy and any specific guidance for pet owners.

1. Homeopathic/Herbs that May Be Considered in Place of Prednisone. Prednisone is hard on the digestive system of dogs, and many animal owners prefer to avoid synthetic medications for a variety of reasons. Here are some natural remedies that can be used in place of prednisone, keeping in mind none of these treatments are as potent as prednisone and the action is much slower. Always make sure to work with your veterinarian, especially if your dog is already taking medications as some of these natural remedies can interact with certain drugs.

4.2. Other Medications

Other Medications Sometimes Used to Treat the Conditions Prednisone is Used For

Non-steroidal anti-inflammatory drugs (NSAIDs) such as meloxicam and carprofen, as well as other corticosteroids like dexamethasone, are sometimes used instead of prednisone or in conjunction with prednisone as an alternative corticosteroid in dogs. Immunosuppressants specifically labeled for use in dogs, such as Atopica and Imuran, are also sometimes used instead of prednisone in conjunction with prednisone or in cases when the use of prednisone is against the general advice to withdraw the risks versus benefit assessment. As highlighted in the Overview and Introduction sections, the efficacy of these medications in treating inflammation in dogs relative to prednisone is not always known. NSAIDs work primarily by inhibiting enzymes that cause inflammation in the body. Corticosteroids work in large part by turning off the inflammation response to the inflammation stimuli. However, corticosteroids are used instead of NSAIDs because they turn off all parts of the immune responses at this step and not as in NSAIDs, which measure that is selective to inflammation.

The immune responses start by initiating the inflammation response with inflammation-producing chemicals. By turning off all the responses, corticosteroids can provide quicker and broader anti-inflammatory effects than NSAIDs. Immunosuppressants work by inhibiting the lymphocytes. Their efficacy is therefore mostly unknown in treating the inflammation response, such as in the uveitis cases. They are not expected to have any quicker anti-inflammatory effects than prednisone. As such, their pharmacological differences would not be expected to provide as quick acting of a response as prednisone's pharmacological responses do, but this has not been studied. Lastly, informed treatment decisions should always take into consideration the person who is administering the medications. Some of the listed risks of taking prednisone or the alternatives are more feared by certain owners than others. The morbidities related to the potential side effects that can occur from taking prednisone are generally thought to be lower than enucleating the eye. It is unknown if owners would consider the side effects of Atopica and Imuran to be more feared over enucleating an irritable, blind, painful eye as is done most commonly. When feasible, direct clinician-patient conversations about the benefits and risks of prednisone and these medications are advised. This is particularly recommended if a pet owner is asking for alternatives when one has not been prescribed.

5. Conclusion

In summary, prednisone is an effective treatment for a wide variety of canine conditions; however, it is not without risks. Many drug treatment decisions in veterinary medicine involve a balance of the risks and the benefits of treatment. If prednisone therapy is used, patients should be closely monitored, and the medication should be carefully tailored to the needs of the patient and the condition being treated. Although other medications or therapy options are available, it can be extremely difficult to predict how a patient will respond. Clearly, not all dogs with superficial necrolytic dermatitis caused by hepatitis do well on prednisone; this disease is an example of one of the more challenging skin and liver conditions to treat.

Ultimately, the decision to utilize prednisone therapy should be a priority for all practicing veterinarians. As the popularity of integrative and functional medicine continues to grow, clients are increasingly interested in the availability of natural and non-steroidal anti-inflammatory therapy options. The potential link between prednisone and adverse events can be concerning to pet owners; thus, a discussion of this or any medication's potential risks and adverse effects must be a priority topic in the exam room. It is important to provide clients with many different options so they can make informed decisions about their pet's course of treatment. If pet owners are hesitant about using prednisone, then non-steroidal medications with safer pharmacokinetic properties may be an excellent alternative. Regardless of the medication used, extensive discussion and communication between a pet owner and their veterinarian are crucial. This detailed communication ensures that clients understand potential adverse events, and medication and adverse effects are managed or treated as necessary. Managing veterinary patients on prednisone therapy is also a team approach, and the collaboration between the veterinarian, the client, and the veterinary staff optimizes patient care.

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