Disclaimer: These questions were generated at a CE lecture of AVMA. There may be context provided in the lecture that is not addressed in the answer to these questions. Paper links have been provided where possible/applicable. I linked to the publisher’s site to avoid any copyright issues. Some papers may be behind paywalls, though I try to use mostly open-access journals. Finally, many of these comments are opinions or thoughts based on experience in my situation; your patient’s situation may not apply to all comments. I try to link sources to questions about doses. It is recommended that you consider rechecking all doses prior.

How do you treat idiopathic head tremors?

a. There are no true therapies that work to get rid of all tremors. Some people with very severe versions will try to see if they respond to antiseizure medications, but they often are non-responsive. The best thing to do is try to distract the animal out of it with saying their name, food, or a toy. Some dogs will experience spontaneous improvement or resolution over time.

If you do not have access to MRI/CT, what is the best way to diagnose the ischemic event?

a. For vascular events, they only show up on MRI scans. CT scan doesn’t show them well. If you have neither, it is based on a lack of evidence for other conditions and improvement over time. Now, I have had a few vascular cats that took a while to improve (compared to the dog fibrocartilaginous embolisms). So, the best thing to do is evaluate what you can systemically with blood work and other diagnostics to the best of your ability or that owner allows, then treat the treatable. Many times, vascular events will improve over time and often will appear to improve even if you are treating another condition. In cats, looking at the heart is a worthwhile play.

Washout periods for steroids vs NSAIDs. E.g dog on carprofen for pain and then develops MUO. When to start steroids.

a. Ideally, 5 to 7 days if you look at the literature, I typically shoot for five if I can; however, what will kill the animal first? If I need steroids now, then by golly I’m going to inform the owner of the risks, load up on gastroprotectants, and do what I need to do to save the animals life. I think it all depends on the situation and the condition. There are times I have waited to be safe and times I said please GI tract stay with me on this.

Dog on carprofen and develop IVDD and has no deep pain, declined referral. Do you start steroids or wait and just do gabapentin and methocarbamol +/- diazepam.

a. Deep pain negative, you bet I’m going to start on steroids. At this point, the pro/cons or risk/benefit leans towards the steroids. Not everyone agrees with this, but I have had many a deep pain negative dog leave with steroids and a prayer and eventually walk again. At this point I don’t know if I am fighting against myelomalacia or not so I’m going for the gun that I feel personally is better. There are no papers that really have proven steroids vs. NSAIDs vs. neither is better. Some that are suggestive (check out acvim consensus on back dogs), but I don’t think we have a consensus.

Steroids vs NSAID same situation but lack of superficial pain but has deep pain if on NSAIDs for other pain management and developed IVDD

a. If this dog is already on NSAID long term realistically I’m probably going to continue it. This is a situation where I would wash out if they have been on long term NSAIDS so might as well continue it. It isn’t wrong to wash out incase, but again without a true definitive answer of NSAIDS vs STEROIDS vs Neither not sure there is the proof to change over. No matter what the cage restriction and tough love is the most important aspect!!