October 14, 2020

Protocol vs. Protocol

Sometimes I’m asked, “Caroline, how does your SARDS treatment protocol different from Dr. Plechner’s protocol?”  

Before I reply, let me say that Dr. Plechner’s work was important to me, both personally and professionally. And despite some significant differences in our work, his work influenced mine. 

Dr. Plechner’s work was unconventional. And because of this — rightly or wrongly— he endured professional attacks from other veterinarians.  Some of these endocrinologists are still in practice today and maintain their opposition to Dr. Plechner’s practices.  This might explain why veterinary endocrinology still ignores the concept of cortisol replacement as the treatment for elevated adrenal sex hormones. 

For humans, cortisol replacement has been the standard medical treatment for elevated adrenal sex hormones for 65 years.  Sixty-five years.  That’s a stunning difference between the two fields. Countless other treatments have been adapted from human medicine to veterinary medicine, but this one remains ignored. 

Readers, you might find the following two articles helpful before you continue. Click here and here.

Difference in Dosing

There are several distinctions between my SARDS protocol and Dr. Plechner’s protocol. The first distinction is in the dosing.  Dr. Plechner’s protocol recommends higher doses and more potent forms of cortisol replacement as compared to my SARDS protocol.

Dr. Plechner felt pressure to lower sex hormone levels quickly and show rapid results in his cases. Consequently, his doses supply more than a dog requires as a daily replacement dose. His doses are closer to anti-inflammatory or immunosuppressant levels. It’s not uncommon for dogs on his protocol to experience clinical signs/symptoms from the prescriptions in addition to the signs/symptoms they already experience from the elevated sex hormone steroids. 

In my dealings with general practice veterinarians across the country these past 15 years, it’s become clear that most are not comfortable giving the Depo-Medrol injections recommended in Dr. Plechner’s protocol. That’s not a judgement, merely an observation.

Their main complaint is this. Depo-Medrol is a long-acting injectable that persist for several weeks.  So, if the Depo-Medrol injection delivers an excess of cortisol, there is no way to mitigate the effects of that injection, no way to lower the dosage. Both dog and owner must “ride it out”.

On the other hand, my protocol stems from the work of Dr. Simpson, my general practice veterinarian. He ran a holistic practice and understood cortisol deficiency. Between 1999 and 2005, two of my dogs were diagnosed with elevated adrenal sex hormones. One was a Dachshund, the other a Boxer.

Sophie and Milo

Dr. Simpson practiced a milder version of Dr. Plechner’s program. Dr. Simpson felt that his clients were troubled by the effects of Dr. Plechner’s dosing just as much as they were troubled by the original hormone problem — endless panting, accidents in the house, etc.  Consequently, Dr. Simpson endeavored to replace only what the dog needed on a daily basis and no more.

This gentler approach is the basis for my SARDS protocol. It describes the methods holistic veterinarians use to replace only what cortisol the dog is missing, no more.  It’s easier to get a dog’s general practice veterinarian on board with this dosing. After all, if you’re making the argument that, “We’re just replacing what the dog would normally make,” then low-dose treatment is understandable.

One can’t make the same argument, however, when discussing doses that are closer to anti-inflammatory levels (Dr. Plechner’s). It can’t be both ways. This is either seen as a hormone replacement issue requiring a low daily replacement dose or it’s seen as an inflammatory problem requiring a larger, anti-inflammatory dose. And this leads us to the second distinction between my work and Dr. Plechner’s.

Retinal Seizure or Auto-immune Disease?

In 2006 I recognized the connection between SARDS and adrenal exhaustion. When my SARDS research was published at the 2007 meeting of the American College of Veterinary Ophthalmologists (ACVO) I contacted Dr. Plechner. I sent him my papers and informed him that SARDS-affected dogs were testing positive for elevated sex-hormones, including elevated estrogen. And I further explained that they responded brilliantly to low-dose cortisol replacement therapy. This was Dr. Plechner’s introduction to SARDS. 

One of my poster presentations at the 2007 ACVO meeting

2007 was also about the time that some veterinary ophthalmologists were investigating autoimmunity as a possible cause of SARDS.  Dr. Plechner latched on to that theory.  To this day his website asserts that SARDS is an autoimmune disease despite growing evidence to the contrary. 

And therein lies the problem. If one claims SARDS is an autoimmune disease, one would expect that 40 years of high-dose, short-term prednisone (the standard in ophthalmic veterinary care) to have had some positive effect on vision. Furthermore, one would also expect that mycophenolate mofetil, a powerful immunosuppressant recently studied, would also have had some positive results. Neither has. 

So when Dr. Plechner backed the autoimmune theory of SARDS, and since he was already recommending higher doses of Depo-Medrol and prednisone, he did himself a disservice. Ophthalmologists had been prescribing anti-inflammatory levels of prednisone since the 1980’s with no success.  The way other practitioners saw it, Dr. Plechner was simply prescribing more of the same anti-inflammatories. His underlying principle —the idea of repairing a cortisol deficiency—was lost.

I’m unclear as to why Dr. Plechner embraced the autoimmune model so adamantly. In one of our conversations I made a strong case for a retinal seizure or “excitotoxicity” as the cause of SARDS. Both concepts (excitotoxicity versus autoimmunity) are explained by elevated estrogen. Both concepts are explained by a disruption in cortisol synthesis.  Perhaps he wished to align himself with the university researchers at the time. I don’t know. But with respect, I think he was wrong on this point.

If elevated estrogen causes a seizure in the retina, it explains the sudden nature of vision loss and the reason vision can be restored. Ophthalmologists have long reported that retinal cells are not destroyed at the time of vision loss. Degeneration occurs in the weeks and months after vision loss.  If retinal cells can be spared from destruction, and the seizure halted, vision often returns.

To that end, my SARDS protocol is divided into two parts. Part 1 addresses the elevated sex hormone production using the milder hormone replacement approach.  Part 2 protects the retinal cells from destruction until sex-hormone levels decline. 

Dr. Plechner dismissed the idea of retinal protection therapies and advised his clients to ignore them. His protocol addresses only the adrenal piece.

Dietary Sources of Estrogen

Some dog owners ask me to comment on Dr. Plechner’s dietary recommendations, specifically the recommendation to eliminate foods that contain phytoestrogens. He felt these contributed to the dog’s estrogen load.   

It’s my opinion that vegetables did not contribute to the adrenal problem and eliminating them from the dog’s diet also deprives the animal of valuable anti-oxidants.  Flax seed and soy are by far and away the leading sources of dietary phytoestrogens, and since dog owners typically do not feed these, this issue is of little concern. 

Instead, my protocol recommends a diet that provides a variety of nutrients over time. This mimics the way animals eat in the wild. It’s good for the dog and easier for the dog’s owner.

Success Rates of the Protocols

In 2008 I reported that 23% of dogs following my protocol regained some vision. Functional vision was confirmed by general practice veterinary examination or by ophthalmic veterinary examination. I have always been careful not to overstate this figure, in fact, I typically describe it as 20%. Dr. Plechner reported that 80% of dogs on his protocol regained vision. 

In 2019, a survey was conducted by a large online support group for the owners of SARDS dogs, a group with which I have no affiliation. 352 dog owners who had tried some type of treatment for their dogs were asked if treatment restored any vision. Respondents replied that the Levin protocol was successful 55% of the time and the Plechner protocol was successful 43% of the time.

Undeniably, this was an informal poll with no method of verification. Taken at face value, however, it suggests a significant increase in the success rate of my SARDS protocol —of which I was unaware— and a decline in that of Dr. Plechner’s. 

Over time my SARDS protocol has been modified slightly. This may have improved outcomes. Furthermore, client compliance may have improved. Evidently, some dog owners implemented only bits and pieces of my protocol in the early years.

Here’s a quick review

LEVIN’S SARDS PROTOCOL

  • Based on the seizure/excitotoxity model                   
  • Low doses aim to replace daily needs, no more
  • General practice vets more likely to implement
  • Addresses both retinal and adrenal issues
  • Diet is more relaxed

PLECHNER’S PROTOCOL

  • Based on the autoimmune model
  • Higher doses often exceed daily needs
  • General practice vets less likely to implement
  • Addresses only adrenal issue
  • Diet is more restrictive