Solving the Allergy Puzzle. Amy Haarstad DVM DACVD

Size: px

Start display at page:

Download "Solving the Allergy Puzzle. Amy Haarstad DVM DACVD"

Elijah Stevenson
5 years ago
Views:

1 Solving the Allergy Puzzle Amy Haarstad DVM DACVD

2 Diagnosis of Exclusion History Physical Exam Diagnostics

3 Other Causes of Itch Ectoparasites Fleas Sarcoptes Bacterial Staphylococcus Pseudintermedius Fungal Malassezia Dermatophytosis Allergic Dermatitis Atopy Food Allergy Flea Allergy

4 History Pruritus Recurrent pyoderma Recurrent otitis Response to steroids Seasonality

5 Physical Exam Pinnal pedal reflex German Shepherds Pattern of lesions Face, ears, paws, legs, ventrum, under tail Dorsal lumbar Fleas

6 Diagnostic Tests Skin scrape Flea comb Trichogram Ringworm culture Thyroid panel Drugs Skin biopsy

7 Skin Biopsy-Quick Tips Keep it DIRTY Keep it HAIRY Just say NO! Ulceration Normal Keep that CRUST! Get the FAT! Do you feel lucky? Well, do ya punk?

8 Diagnostic Tests Skin cytology Ear cytology

10 Food versus Environmental

11 Adverse Food Reactions Less than 10% of dogs have food allergy Non-seasonal Gastrointestinal signs Concurrent atopic dermatitis Serum food allergy tests Diet trials

12 Diet Trials

13 AVOID Over the Counter Grain free Limited ingredient

14 Diagnostic Diets Prescription Homecooked veterinary nutritionist Treats Prescription Marshmallows

15 Diet Trials Express food trials Rechallenge Realistic?

16 Therapy Puzzles Monotherapy versus Multimodal

17 Topical Therapy Glucocorticoids Essential fatty acids Antiseptics

18 My favorites Magic eraser Chlorhexidine/-Azole Shampoo Spray Betamethasone cream Ear cleaner

19 Systemic Therapy Antihistamines Omega-3 Fatty Acids 180 mg EPA per 10 lbs body weight Glucocorticoids Atopica Apoquel Cytopoint

20 Glucocorticoids Bind glucocorticoid receptors Effectiveness Side effects Chronic use

21 Atopica Modified cyclosporine Binds cyclophilin and inhibits calcineurin function Side effects Age Delay of action 80% respond Recurrent pyoderma

Atopica cost saving tips Worst case scenario Two month trial Give with 2.5-5.

22 Atopica cost saving tips Worst case scenario Two month trial Give with mg/kg ketoconazole Every other day or every 3 rd day Comfort Club Rebate for every 2 boxes 100 mg=$80, 50 mg=$60 Generic modified cyclosporine

23 Atopica for Cats 7mg/kg dose Indoor only Liquid Titrate dose up slowly Capsules BID if needed Injectable How low can you go?

24 Apoquel Oclacitinib Inhibits JAK enzyme function IL-31 IL-2, 4, 6 and 13 Over 1 year of age Quick onset of action Once vs twice daily

25 Apoquel Types of cases 2000 patients at MDC Side effects are uncommon Monitoring CBC/Chem/UA Cats Autoimmune diseases

26 Apoquel with Atopica Repeated oral dose tolerance in dogs treated concomitantly with cyclosporine and oclacitinib for three weeks Veterinary Dermatology 2016

27 Antibodies Produced by B-lymphocytes Secreted by plasma cells Foreign or self-proteins Each plasma cell produces one type Therapeutic mabs

28 Therapeutic mabs IgG class Mice immunized B-lymphocytes produce antibodies Antibodies isolated Recombinant DNA techniques Caninized

29 Therapeutic mabs Metabolism Human mabs Long half-life 21 days IgG more protected from degradation and rapid elimination Elimination

30 Human mabs Used for over a decade Omalizumab (Xolair) Targets IgE to treat asthma 25 clinical trials-rare local reactions, fewer side effects than placebo Rituximab (Rituxan) Targets B-lymphocytes (CD 20) in non-hodgkin s lymphoma

31 Cytopoint Canine Atopic Dermatitis Immunotherapeutic Antibody Anti-IL-31 monoclonal antibody Lokivetmab 200 cases Any age Concurrent therapies

32 Safety Most common side effects vomiting, diarrhea and lethargy Not metabolized in liver or excreted in the urine One study 6 laboratory beagles 1 mg/kg, 3mg/kg and 9mg/kg dosing SQ for 3 injections at two week intervals No hypersensitivity reactions were noted. Another study 12 laboratory beagles 3.3 mg/kg or 10 mg/kg monthly SQ injections for 7 months No adverse reactions.

33 Intradermal Allergy Testing Reasons NOT to allergy test Diagnose allergies Avoid allergens Age Dogs and Cats Serum tests

34 Bubble Therapy

35 Allergen Specific Immunotherapy Drug free Prevention Long term management Route of administration Hyposensitization injections Sublingual immunotherapy Ongoing cost Injection $35/month SLIT $50/month

36 Jazz 11 yr old FS Springer Spaniel First exam October 2012 History pruritus, chewing feet, licking groin and back end ear infections occur year round and have been progressively getting worse Diet changed several times with no improvement

37 Jazz Oral immunotherapy daily Apoquel 16mg: 1/4 tablet once daily Ketoconazole 200mg: Give 1/2 tablet by mouth once daily. T8+Keto: Clean both ears once weekly ongoing. Douxo Chlorhexidine Mousse: Apply to the groin, vulva, and under the tail weekly TriOtic Ointment: Apply to the nail beds, lip folds, and chin weekly, or as needed Clotrimazole/Dexamethasone in both ears once weekly

38 Coco 2 year old FS DSH Heart murmur First exam September 2016 History started 2.5 years ago winter is better, but needs prednisolone year round steroids do not seem to work as well anymore. Itchy ears Difficult to give oral medications Hill s D/D venison and pea diet

39 Coco Hyposensitization injections. Prednisolone 5 mg once daily for 1 week, then 2.5 mg once daily for 1 week, 2.5 mg every other day for 2 weeks, then stop. Atopica liquid (100mg/ml) - give the 2 pound dose by mouth once daily on day 1, then the 4 pound dose on day 2 and increase by 2 pounds each day up to the 10 pound dose once daily for 4-6 weeks, then as directed. Continue prescription diet.

40 Kirby 8 yr old MN Labrador First seen November 2015 History Acral lick granuloma 4 months duration Previously treated with cefpdoxime and amitriptyline. Acral lick granuloma in the same spot December Resolved after several months. Mild generalized pruritus. Hydroxyzine.

41 Kirby Synotic: Apply twice daily to lesion. Mupirocin Ointment: Apply a thin layer twice daily. Methylprednisolone 4mg: Give 4 tablets by mouth once daily for 1 week, then 4 tablets every other day for 2 weeks, then 2 tablets every other day for 2 weeks, then 2 tablets twice weekly for 2 weeks, then stop. Atopica 100mg: Give 1 capsule by mouth once daily with ketoconazole. Ketoconazole 200mg: Give 1/2 tablet by mouth with the Atopica. N-acetyl-cysteine 500mg: Give 1 capsule by mouth twice daily. Bathe Kirby up to once weekly.

42 Deja 3 yr old FS GSD First presented September 2014 History Non seasonal pruritus Atopica 50mg every other day Gentacalm used on itchy areas. Diet prescription duck and potato. Apoquel was tried and worked well

43 Deja Oral immunotherapy Hill s Z/D prescription diet Canine Atopic Dermatitis Immunotherapeutic every 6 weeks

44 Dash 7 yr. old MN Dalmatian First presented February 2012 Recurrent pyoderma Year round pruritus but worse in summer Ear infections

45 Dash Hyposensitization injections Staphage Lysate Atopica with ketoconazole TriOtic ointment on focal lesions Douxo chlorhexidine baths weekly

46 Questions? ICADA.info The ACVD task force on canine atopic dermatitis Mckeevervetderm.com Dermatohistopathology

47 Thank You!

Atopic dermatitis and the skin barrier

Atopic dermatitis and the skin barrier Dani Hoolahan BVSc BVMS DACVD Veterinary Dermatology Clinic: Sydney, Canberra, Newcastle, Tasmania, Kiama, Coffs Harbour Newcastle Animal Referral and Emergency Centre