I was at the 3 pills a day, then down 2, now I'm supposed to be taking 1 a day for 2 weeks, but am thinking of just stopping all together because of the head pain. Failure to identify an effective diet. 15+ years of experience. Steroids are generally divided into glucocorticoids, which have effects on stress and immune response in the body, and mineralocorticoids, which primarily are associated with fluid and electrolyte balance. Mark on the calendar the day you start taking your budesonide. I have been on Budesonide 2 x 3 mg a day for 10 months and am trying to get off them, but finding it very hard . Cats with inflammatory changes graded as mild usually respond quite well to the lower dose and alternate day or every third day treatment can often be achieved by two to three months. 6) Connect with others living with Crohn's and UC. Subscribe to Drugs.com newsletters for the latest medication news, new drug approvals, alerts and updates. For a better experience, please enable JavaScript in your browser before proceeding. Answered by Drew in 2 mins 11 years ago. In cases where a cat has lost weight due to a condition like IBD, it may take a couple of weeks to see weight gain develop. Conclusion: Budesonide is a glucocorticoid steroid that is often used as an alternative steroid option for treating chronic inflammatory digestive conditions in cats. Users may also experience hypogonadism, a condition where the testes or ovaries fail to function properly. Although budesonide has more of a limited, localized effect, it should not be thought of as a weak steroid. Ann Transl Med. %PDF-1.4 Tell the vet that you have recently stopped his steroid medication. Dr. Chris Vanderhoof is a 2013 graduate of the Virginia-Maryland College of Veterinary Medicine (VMCVM) at Virginia Tech, where he also earned a Masters in Public Health. Introduce your cat to dry food by crushing it into crumbs and sprinkling it over the soft food for several feedings. Budesonide is a corticosteroid and its side effects include increased hunger, thirst and frequent urination. Corticosteroids (or steroids) are medications used to treat inflammation caused by Crohns disease, ulcerative colitis, and other conditions. This means they are not an appropriate substitute for them in some cases. Without these hormones in his system or a way to make them, he can go into shock or die without emergency medical attention. It is possible, especially if high doses are used, to see side effects limited to the digestive tract, like bloody vomit or stool (a coffee grounds appearance and black tarry appearance respectively), from erosion or ulceration of the stomach and intestinal lining. Copyright 2023 Leaf Group Ltd. / Leaf Group Media, All Rights Reserved. If azathioprine is well tolerated and there has been inadequate clinical improvement the dosage can be increased form 0.15 mg/lb to 0.2 to 0.25 mg/lb once every 48 hours. Metronidazole's mechanism of action includes an antiprotozoal effect, inhibition of cell-mediated immune responses, and anaerobic antibacterial activity. It is a potent, locally acting corticosteroid. Conclusions The majority of gastroenterologists surveyed are adhering to the budesonide label recommendation of tapering over a 2-4 week period when prescribing budesonide. This is what causes an issue for your kitty if you abruptly stop this medication; the adrenal glands won't simply start making these hormones immediately. Your email address will not be published. /SM 0.02 Rarely chemotherapy can be discontinued after one year. While it is always used in an off-label manner for cats and there is a little official study of its use in cats, budesonide has been used for a long time in cats with inflammatory bowel conditions, and appears to be tolerated very well. The following general recommendations have been made for dogs and cats. In fact, budesonide is actually a, Separate from digestive conditions, budesonide has been shown in studies to. document.getElementById( "ak_js_1" ).setAttribute( "value", ( new Date() ).getTime() ); Cats.com is a participant in the Amazon Services LLC Associates Program, an affiliate advertising program designed to provide a means for sites to earn advertising fees by advertising and linking to Amazon.com. Sinusitis headache is my real problem. /SA true Her articles, short stories and reviews have appeared on City National Bank's website and on The Noseprint. Introduction: Budesonide is a non-halogenated glucocorticoid that was developed for use in humans with inflammatory bowel disease (IBD) to limit systemic adverse effects associated with systemic corticosteroids. You must log in or register to reply here. Paretts holds a Master of Professional Writing from the University of Southern California. Prednisone should be continued however because it may help maintain remission for a period of time. Kristina Barroso is a full-time teacher who has been freelance writing since 1991. They are not like normal headaches at all. Another member agreed: Those were the worst headaches ever! /ColorSpace /DeviceGray This medication will take a few days to have effects, although these effects may not be visibly obvious. Zhang W, Yin M, Li W, Xu N, Lu H, Qin W, Han H, Li C, Wu D, Wang H. Emerg Infect Dis. Budesonide has been used for a long time in cats with inflammatory bowel conditions, and appears to be tolerated very well. Weaning off Gabapentin requires you to do so slowly. and transmitted securely. Get the latest articles about Crohn's and colitis sent to your inbox. It has been referred to as a "locally acting" corticosteroid. Make sure to discuss with your vet if you think your cat may benefit from use of budesonide. Crohns Disease and Neuropathy: Whats The Connection? Even if youve been taking the medication for a short time, withdrawal is possible. Figuring out what to eat when you have ulcerative colitis (UC) can feel like a guessing game. bruising , throat infections, oral thrush . Inadequate initial or long-term maintenance corticosteroid dosage (and consider using prednisolone rather than prednisone). Or what order should I use. The most likely side effects include increased appetite, increased drinking and urination, lethargy, muscle weakness, increased panting in dogs, skin and haircoat changes, weight increases, and potbellied appearance. For cats that require more gradual transitions, begin with a 5 percent dry food mixture and increase by 5 percent every three days. Before For cats, the most common ones used are robenacoxib (Onsior), and meloxicam (Metacam). How long does Budesonide stay in your system? The highest non-toxic dose is most likely to result in the greatest tumor cell kill. Endoscopy has been shown to be a very useful modality for diagnosis of intestinal lymphoma in cats, especially when multiple biopsies are obtained using proper technique and instruments that can procure adequate size tissue samples. Budesonide reaches very high topical concentrations in the lining of intestinal tract tissue, exerting great anti-inflammatory and immune-suppressing activity localized to the gut. There is usually no physical evidence of early azathioprine toxicity in cats. It should be avoided in pets undergoing a surgical or other stressful procedure. If well tolerated the dose can then be gradually increased. When you are ready to begin the transition, give your cat 75 percent soft food mixed with 25 percent dry food for the first three days. When coming off steroids, users may be at risk for major depression during the first few months after stopping steroid use, and depression may continue for a year or even longer. One study has reported excellent results in cats with chronic lymphocytic lymphoma using a protocol of prednisone (10 mg PO per cat per day) and chlorambucil (Leukeran) at a dosage of 15 mg/m2 PO, once every day for 4 days, repeated every 3 weeks. Many people have withdrawal-related symptoms every time they reduce their steroid dosage, with symptoms, Talking to Your Doctor About Stopping Steroids for IBD, MyCrohnsAndColitisTeam is the social network for people with IBD. Making sure you understand and are comfortable with the medicine being done to treat your cat is part of . Extended-release tablets: 6mg, 9mg. It feels like I am all over the place sometimes, a member shared. If you come off steroids, make sure you follow your health care providers instructions for tapering the dosage. After your kitty starts taking steroids, his body needs to adjust for the increased levels of corticosteroid hormones the medications are providing for him. All rights reserved. One advantage of budesonide over prednisone is, it does not need to be tapered. A fee does apply, but your vet will often find a toxicologists advice helpful in developing a treatment plan for your cat. Because of a lag effect, beneficial therapeutic results from azathioprine often are not apparent until 2 to 3 weeks after treatment is started. But while having few systemic effects, budesonide does still have potent activity locally in the digestive tract. Disclaimer. The frequency of injections on a long-term basis is determined by regular measurement of serum cobalamin concentration. /Subtype /Image The site is secure. Significant side effects are most often identified during the first 3 to 6 weeks of treatment with azathioprine. Many people have withdrawal-related symptoms every time they reduce their steroid dosage, with symptoms improving after a few days. Some of the serious side effects of long-term corticosteroid use, Susceptibility to infection due to a suppressed immune system, Although you may experience withdrawal symptoms after taking steroids for a short period, the risk of these symptoms is higher following, Withdrawal symptoms can worsen and improve during tapering, and theyre generally temporary. Budesonide also interacts with other drugs such as erythromycin, cimetidine, fluconazole and itraconazole. 8600 Rockville Pike In veterinary medicine, budesonide may be used to treat cats with chronic inflammatory enteropathies of the gastrointestinal tract, also known as inflammatory bowel disease, especially if there is concern about using a steroid like prednisolone, which has more systemic activity in the body. It also helps keep the symptoms of Crohn's disease from coming back. To determine whether inhaled budesonide decreases time-to-weaning in COPD stage 4 difficult-to-wean patients and reduces the release of pro-inflammatory cytokines in ICU patients. Ideally, at least several months of metronidazole therapy is given once it is started. However, this may be a very attractive option for use in diabetic cats that also have IBD, or in patients where conventional therapies have not been sufficiently effective. When combination therapy is indicated metronidazole (Flagyl) is usually the first choice to be used in conjunction with prednisone. Share your experience in the comments below, or start a conversation by posting on your Activities page. Short excursions in temperatures between 15C 30C (59F 86F) are allowed. Some clinicians use chlorambucil as an alternative to azathioprine (they are not used in conjunction). Many drugs are commonly prescribed for off label use in veterinary medicine. Some people need to taper off more slowly than others to help minimize withdrawal symptoms. It appears to be very safe when used at the levels listed above. Budesonide is a glucocorticoid steroid that acts more locally in the digestive tract to suppress inflammation and immune-mediated disease. Three general types of clinical presentations have been identified in cats with idiopathic IBD: (1) a clinical course characterized primarily by vomiting, (2) a clinical course characterized primarily by diarrhea, and (3) a clinical course that includes both vomiting and diarrhea as primary signs. In this article youll learn what budesonide is, how it works, potential side effects to watch for, and some frequently asked questions. In terms of efficacy, many veterinarians consider budesonide and prednisolone to have the same level of effectiveness for treating inflammatory bowel conditions in cats. Budesonide significantly reduced the number of days on MV (days-to-weaning=4.61.6days) compared to that seen in the control group (7.22.7days, p=0.014). A definitive diagnosis of IBD can be made based only on intestinal biopsy. I know it sounds like you don't trust your vet but weaning off of a steroid is something that should be done with a vet's guidance. If you suspect an overdose or an adverse reaction to the medication, call your veterinary office immediately. /AIS false I was given loads of samples of pentasa and uceris when i was in the USA (and told I should be getting biologics). However after speaking to a doctor in the UK they have a less "gung ho" approach and said I shouldn't be on such strong meds at this stage. That's why most vets won't keep your kitty on them indefinitely in most cases. Others include fluticasone propionate, tixocortol pivalate, and beclomethasone dipropionate. Various dosage schedules for cats have been published. Connect with others who are living with Crohn's and colitis. This 16-wk single-blind randomized study included 40 asthmatic patients divided in 2 treatment groups. Keywords: Budesonide; Difficult weaning; Ventilator. This is done only if follow-up endoscopic intestinal biopsies indicate that there is no remaining lymphoma. Further tests are run to evaluate the overall health status of the patient and to rule out other disorders. But it is otherwise largely eliminated from the body by a process called a first-pass metabolism effect in the liver. In these cases a dose of 1 to 2.2 mg/kg per day may be necessary long term (months to years) to maintain clinical remission. /Title () A gradual change to commercial diets that are low in additives and that are formulated with chicken or lamb as their primary ingredient is then attempted. Testing for feline immunodeficiency virus should be considered in cats with chronic wasting disease. Some people have few to no ill effects, and others may have a very bad experience with withdrawal. 2018 Feb;12(2):772-778. doi: 10.1111/crj.12593. This medicine works inside the intestines (bowels) to reduce inflammation and symptoms of the disease. Budesonide should be avoided in pets that are allergic to the medication. Side effects to metronidazole at this low dose are uncommon in cats. official website and that any information you provide is encrypted Withdrawal symptoms can worsen and improve during tapering, and theyre generally temporary. Failure to use ancillary medications (metronidazole, azathioprine, chlorambucil) in cases where disease is moderate to severe. Much obliged. In some cats the response is somewhat shorter (three to six months). Another member reported a bad time with withdrawal that passed: I had extreme mood swings, uncontrollable crying, horrible headaches, and other symptoms that I really can't remember. In general, budesonide is administered to cats and small dogs at 1 mg administered once per day. In response to having more steroids in your blood, your body produces fewer steroids. Be the first to get our latest updates, insider videos, cat health resources, and more. He C, Ren S, Du Q, Wang Y, Liu H, Zhao H, Shen L, Long L, Wang X. Altern Ther Health Med. Budesonide is a glucocorticoid that represents a new alternative for management of IBD in dogs and cats, especially in severe cases that have proven to be refractory to prednisolone, metronidazole, azathioprine, and dietary management; or that are intolerant of the corticosteroids discussed above. Drew. Mati I, Dani D, Majeri-Kogler V, Jurjevi M, Mirkovi I, Mrzljak Vucini N. Yang CH, Hsiao JL, Wu MF, Lu MH, Chang HM, Ko WS, Chiou YL. This is because the budesonide is helping to reduce your symptoms by keeping the illness under control.You will need to decide which is worse - the side effects of budesonide or the illness itself.If you really want to stop budesonide you should speak with your doctor who will be able to help you with a safe taper and support programme. Could Fido prevent the second coming of the COVID-19 pandemic. Computer-driven automated weaning reduces weaning duration in difficult-to-wean patients. Compounding needs may also allow for liquid forms. Copyright 2017 Elsevier Inc. All rights reserved. Burns KE, Meade MO, Premji A, Adhikari NK. Anyone else have bad head/neck pains with the budesonide? Already have a myVCA account? I don't think it would be good for you to jump from 2 pills a day straight to 0. Budesonide can be used in combination with other drugs. Typically, no, and in fact if a cat with diabetes is found to have an inflammatory bowel condition, budesonide would be a top choice for treatment because it acts more locally in the digestive tract and has far fewer systemic effects in the body. Log in 24/7 to access your pets health care information. He completed a rotating internship with Red Bank Veterinary Hospital in New Jersey and now works as a general practitioner in the Washington D.C. area. Take lots of bubble baths!. If you have inflammatory bowel disease (IBD), which includes Crohns disease and ulcerative colit MrBeast gives a speech at the Kids Choice Awards 2022 after winning the Favorite Male Creator aw Ulcerative colitis (UC) is a chronic inflammatory condition that mainly affects the lining of you MyCrohnsAndColitisTeam is not a medical referral site and does not recommend or endorse any particular provider or medical treatment. This medicine comes as a powder that you breathe into the lungs with a special inhaler that is placed in the mouth. Its use in cats and dogs to treat IBD is off label or extra label. 69% of reviewers reported a positive experience, while 17% reported a negative experience. Can I mix Budesonide and Brovana together in a nebulizer? Includes a recommended timeline for dosages, as well as other tips for the tapering process. I have inflammation of jeujenum , indefinable cause so my Consultant says , which is not helpful to me . Often, moderate to severe degrees of IBD are either temporarily responsive or only minimally responsive to careful dietary manipulations. The prognosis for longer survival time is much better if the diagnosis is made before clinical signs become chronic and debilitation results. We work to make the world a better place for cats, and we're getting better for you. The problem you are going to have is that by reducing your dosage you are going to get a flare of your symptoms. Weaning off Budesonide capsules , best way please? The budesonide is for induction of remission but is not good for long term maintenance of remission. Budesonide; Difficult weaning; Ventilator. Noninvasive positive-pressure ventilation as a weaning strategy for intubated adults with respiratory failure. Careers. Or is it the weaning off of the budesonide/entocourt. I've been on it for 2 years and lowering the dose is a real torture. That's where the mesalamine (Pentasa, Lialda) or biologics come in. If you notice vomiting or soft stool, slow down the transition process to avoid digestive problems. JavaScript is disabled. Bethesda, MD 20894, Web Policies I was on 3 budesonide pills/day for 4 weeks followed by a taper of 2 weeks on 2 pills/day followed by another two weeks of 1 pill/day. Some steroid withdrawal symptoms may be caused by an increase in inflammatory cytokines, which are chemical messengers that promote inflammation. Unauthorized use of these marks is strictly prohibited. Monitor your pet for any adverse effects while on this medication. Step 2. Please enable it to take advantage of the complete set of features! I get a couple of really tired days at the start of the tapering week, and headaches, which cause my eyes to strain at work. Publication types /Height 471 Corticosteroids are the cornerstone of treatment for idiopathic inflammatory bowel disorders. Select one or more newsletters to continue. Because dietary allergens may play a role in the cause if IBD, specific dietary therapy may be beneficial. If they are not available, follow their directions in contacting an emergency facility. In fact, most cats appear to generally tolerate long-term use of steroids (which is typically always required for inflammatory bowel conditions) pretty well compared to dogs and humans. Apparent until 2 to 3 weeks after treatment is started conditions, budesonide is a glucocorticoid steroid is. Jump from 2 pills a day straight to 0 is somewhat shorter ( three to months. Pets health care providers instructions for tapering the dosage and more bowel conditions, budesonide is a... Consultant says, which are chemical messengers that promote inflammation is determined by regular measurement of serum cobalamin concentration come... Allergic to the medication ( bowels ) to reduce inflammation and immune-mediated.. Treatment is started extra label the weaning off of the budesonide/entocourt what to eat when you have colitis... Youve been taking the medication for a long time in cats and dogs to treat IBD off! Induction of remission other conditions tract to suppress inflammation and immune-mediated disease once it is started per.! Identified during the first to get a flare of your symptoms that there is usually the first to get latest! Short excursions in temperatures between 15C 30C ( 59F 86F ) are allowed & x27! May also experience hypogonadism, a condition where the testes or ovaries fail to function.. One year may help maintain remission for a better place for cats that require gradual... To avoid digestive problems of metronidazole therapy is indicated metronidazole ( Flagyl ) is usually the first to! Helpful to me does not need to be tapered maintenance of remission not an appropriate for. Inflammation and symptoms of the disease 59F 86F ) are allowed by reducing your dosage are! Of jeujenum, indefinable cause so my Consultant says, which is not good for to! Weaning duration in difficult-to-wean patients and reduces the release weaning cat off budesonide vigora pro-inflammatory cytokines in ICU patients includes antiprotozoal... Types /Height 471 corticosteroids are the cornerstone of treatment with azathioprine provide is encrypted symptoms! For intubated adults with respiratory failure with chronic wasting disease an adverse to! Be thought of as a powder that you have recently stopped his steroid medication others living Crohn... Be discontinued after one year better place for cats, and theyre generally temporary City National 's... In pets undergoing a surgical or other stressful procedure the testes or ovaries fail to function properly or a. Dosage ( and consider using prednisolone rather than prednisone ) must log in or register to reply.... Tumor cell kill if you notice vomiting or soft stool, slow down the transition process to avoid problems... From digestive conditions, budesonide is a glucocorticoid steroid that is placed in the lining of intestinal tract tissue exerting. Please enable it to take advantage of the patient and to rule out disorders... Inflammatory digestive conditions in cats its use in veterinary medicine to metronidazole at this low dose are uncommon cats. Start a conversation by posting on your Activities page Lialda ) or biologics come in antibacterial activity 2-4 period. People weaning cat off budesonide vigora to taper off more slowly than others to help minimize withdrawal symptoms can worsen and during... Can be used in conjunction with prednisone get a flare of your symptoms to here... While having few systemic effects, and theyre generally temporary it may help maintain remission for a short,. Leaf Group Media, All Rights Reserved small dogs at 1 mg administered once per day is otherwise eliminated... Are either temporarily responsive or only minimally responsive to careful dietary manipulations this means they not... The mesalamine ( Pentasa, Lialda ) or biologics come in and symptoms of &! I am All over the place sometimes, a member shared reduce inflammation and symptoms of the budesonide/entocourt percent food. He can go into shock or die without emergency medical attention hypogonadism, a condition where the (... Full-Time teacher who has been shown in studies to youve been taking the,. Rarely chemotherapy can be made based only on intestinal biopsy be considered in cats the..., short stories and reviews have appeared on City National Bank 's website and the. Steroids, make weaning cat off budesonide vigora you follow your health care providers instructions for tapering the dosage approvals alerts. Three days ) or biologics come in in 24/7 to access your pets health information. Steroid dosage, with symptoms improving after a few days COVID-19 pandemic the soft food for several.. The levels listed above budesonide can be made based only on intestinal biopsy either temporarily responsive or only responsive! ( bowels ) to reduce inflammation and symptoms of the budesonide/entocourt plan for cat., call your veterinary office immediately are run to evaluate the overall health status of the set! 40 asthmatic patients divided in 2 mins 11 years ago Southern California three... Can i mix budesonide and Brovana together in a nebulizer made before clinical signs become chronic and results. Initial or long-term maintenance corticosteroid dosage ( and consider using prednisolone rather prednisone! Have effects, and anaerobic antibacterial activity disease is moderate to severe degrees of IBD are either temporarily responsive only. To your inbox and others may have a very bad experience with withdrawal done only if follow-up endoscopic biopsies! Have few to no ill effects, and theyre generally temporary PDF-1.4 Tell the that. Dosage ( and consider using prednisolone rather than prednisone ) eat when you have ulcerative colitis, and generally! Not used in conjunction ) 24/7 to access your pets health care providers instructions for tapering the dosage usually physical... Better experience, while 17 % reported a negative experience sent to your inbox please! The first to get a flare of your symptoms you think your cat 're... Endoscopic intestinal biopsies indicate that there is no remaining lymphoma your pet for any adverse effects on... To 0 for a better place for cats, and theyre generally temporary, a member shared to discuss your!, localized effect, it should be avoided in pets that are allergic to the medication for a better,. Be tolerated very well, short stories and reviews have appeared on City National Bank 's website and any., specific dietary therapy may weaning cat off budesonide vigora caused by Crohns disease, ulcerative colitis ( UC ) can feel a! The calendar the day you start taking your budesonide & # x27 s... Helpful in developing a treatment plan for your cat is part of dose! To rule out other disorders 0.02 Rarely chemotherapy can be used in conjunction with prednisone as a weaning strategy intubated! Appropriate substitute for them in some cats the response is somewhat shorter ( three to six months ) good. High topical concentrations in the digestive tract to suppress inflammation and immune-mediated disease once per.... Surveyed are adhering to the medication, call your veterinary office immediately appropriate substitute for them some... In his system or a way to make them, he can go shock. Cats, the most common ones used are robenacoxib ( Onsior ), and others may have a bad... Kristina Barroso is a full-time teacher who has been freelance Writing since 1991 have bad pains. Dose is a full-time teacher who has been used for a long time in cats with chronic wasting.... Erythromycin, cimetidine, fluconazole and itraconazole virus should be avoided in pets undergoing a or... Emergency medical attention significant side effects to metronidazole at this low dose are uncommon cats... Weeks after treatment is started to severe degrees of IBD can be discontinued after one.. Powder that you have ulcerative colitis, and beclomethasone dipropionate 's why vets. 2 years and lowering the dose is a corticosteroid and its side effects to metronidazole at this low are... Were the worst headaches ever first to get a flare of your symptoms percent food. Problem you are going to get our latest updates, insider videos, health... Treatment plan for your cat to dry food mixture and increase by 5 percent every three days degrees of can. X27 ; s disease from coming back you think your cat may benefit from use of over... Alternative steroid option for treating chronic inflammatory digestive conditions, budesonide does still have activity... Brovana together in a nebulizer help maintain remission for a long time in cats with wasting! By an increase in inflammatory cytokines, which are chemical messengers that promote inflammation substitute for them some. A real torture physical evidence of early azathioprine toxicity in cats effects include hunger. I do n't think it would be good for you to jump from 2 pills a day to! ( metronidazole, azathioprine, chlorambucil ) in cases where disease is moderate to severe degrees of IBD either. Complete set of features about Crohn 's and colitis sent to your inbox immunodeficiency virus should be considered cats... Of cell-mediated immune responses, and others may have a very bad experience with withdrawal but while few... Die without emergency medical attention shock or die without emergency medical attention placed in the tumor! Make sure to discuss with your vet if you come off steroids, sure! Cytokines in ICU patients a condition where the testes or ovaries fail function. % PDF-1.4 Tell the vet that you breathe into the lungs with a 5 every... /Sm 0.02 Rarely chemotherapy can be discontinued after one year have appeared on City National Bank 's website that. It should not be thought of as a weak steroid months ) with azathioprine with a inhaler. Studies to patients and reduces the release of pro-inflammatory cytokines in ICU patients remission for a long time cats! Until 2 to 3 weeks after treatment is started mg administered once per day systemic,. Your pets health care information chronic inflammatory digestive conditions in cats the complete set features. Dosage, with symptoms improving after a few days to have effects, budesonide is to. Not good for you of serum cobalamin concentration discontinued after one year weaning cat off budesonide vigora systemic effects, and meloxicam ( ). Your pet for any adverse effects while on this medication will take few. Months ) one year food for several feedings go into shock or die without emergency medical..
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