I have the privilege of evaluating patients and conversing with their families every day I’m in the hospital. Although I rarely meet healthy patients, I find tremendous satisfaction sitting on the floor with them in my consultation room, examining (and cuddling) them and chatting with their parents. As my patients are invariably ill, I have to devise both diagnostic and therapeutic plans for them.
Unquestionably my recommendations come with financial implications for families. The pet parents with whom I partner are rarely the proverbial 1%, and accordingly the price tag associated with testing and treatments is a legitimate consideration. Understandably some parents can’t heed my recommendations due to fiscal constraints, but they want to do what they can within their respective budgets. A typical conversation is as follows:
Family: I understand what your saying and recommending, but that plan just isn’t in the cards for us right now. Is there a medicine we can just try?
Me: The simple answer is yes. A more thorough answer is yes BUT you have to understand and accept the limitations of such an approach.
At this point in our discussion the family and I spend time reviewing what is medically termed empirical therapy. Using the term empirical is just a swankier way of saying best guess, and such an approach is used every day in veterinary medicine. But is empirical therapy effective and safe?
Empirical Therapy: Do best guess treatments actually work?
Empirical therapy for some diseases thankfully does result in clinical improvement for many patients. If it didn’t, veterinarians wouldn’t even discuss such a course of action with pet parents. Nevertheless families must acknowledge there is absolutely no guarantee best guess interventions will succeed. If a fur baby responds the way for which we hope, that’s fantastic. Indeed that’s exactly what we want! However if a pet doesn’t respond positively, we won’t know why because we haven’t determined a definitive diagnosis. Are we not treating the correct disease process? Are we using the wrong drug(s)? In other words, are we barking up the wrong tree? We just won’t know!
There are other major limitations and risks to empirical therapy besides an inability to guarantee treatment success, particularly:
All medications have potential side effects: Any drug can cause problems, for example gastrointestinal upset, bone marrow issues, or liver damage. Accordingly when veterinarians prescribe medications, we always want to be able to justify and rationalize our choice. However such justification and rationalization is not truly possible without a definitive diagnosis; thus empirical use of drugs is potentially more precarious. Furthermore some veterinarians will not prescribe certain pharmaceuticals without a definitive diagnosis. The first tenet of medicine is:
Primum non nocere
The English translation of this Latin phrase is “first, do no harm.” Using a drug without evidence-based justification could potentially cause a veterinarian to violate this chief principle. Accordingly for some veterinarians, certain medications are simply off limits when a definitive diagnosis is not available. Families must accept this possible restriction with empirical therapy.
Some drugs can change test results and affect healing: A classic example to illustrate these points is a dog or cat with chronic vomiting and diarrhea. You’ve allowed your pet’s healthcare team to run appropriate blood, urine, and fecal tests. You’ve been told your fur baby most likely has inflammatory bowel disease (IBD), but a cancerous process can’t be ruled out without biopsies of the gastrointestinal tract. You know the veterinarian’s recommendation is to obtain biopsies, and s/he reviewed the common methods for procuring them. You ultimately decide you don’t want to ask your pet to go through any type of biopsy procedure, but would like the doctor to prescribe something to help. In other words, you want the veterinarian to empirically treat your fur kid for IBD.
In this common situation a veterinarian may prescribe a special diet. An anti-nausea medication can be used to control vomiting. An anti-diarrheal drug can be tried to help resolve diarrhea. Most IBD patients benefit from treatment with a steroid like prednisone/prednisolone, budesonide, or dexamethasone. As I discussed earlier, if your pet responds positively to these best guess treatments, we will be very happy! However if you choose to administer a steroid to your pet, you can’t really come back to the veterinarian a few weeks or months down the road, change your mind about biopsies, and expect to be able to pursue the recommended testing immediately. It just isn’t that simple! Medications like steroids need to be weaned slowly, and then a patient needs to be not receiving them for a period of time (called a washout period) before pursuing most biopsy procedures. Why?
Steroids are anti-inflammatory drugs, and they can change the appearance of tissue under the microscope. This class of drugs may also affect tissue’s ability to heal properly. This means we rarely, if ever, recommend performing surgical gastrointestinal biopsies for patients currently receiving a steroid. If we, as veterinarians, are going to ask your pet to go through a procedure and ask you to invest in such a course of action, we want to ensure the biopsies will accurately reflect our patient’s disease process and be entirely comfortable with your pet’s ability to heal properly and thoroughly.
The take-away about empirical therapy…
In an ideal world, finances would have no impact on a family’s veterinary healthcare decisions. A veterinarian would make recommendations for testing and/or treatments, and well-informed and educated pet parents would always be able to heed them. Alas we don’t live in an ideal world. We live in the real world, one where the vast majority of us live within a (often tight) budget. Your budget may not always allow you to do everything your pet’s veterinarian recommends. In these situations, empirical therapy may be a viable alternative as long as you understand and accept the risks and limitations of best guess interventions.
To find a board-certified veterinary emergency and critical care specialist, please visit the American College of Veterinary Emergency and Critical Care.
To find a board-certified veterinary internal medicine specialist, please visit the American College of Veterinary Internal Medicine.
Wishing you wet-nosed kisses,