Treatment Simplified: A Guide to Comfort for the Itchy Dog (Sponsored by Novartis Animal Health)

Atopic dermatitis, a pruritic and inflammatory disease, has no cure. One estimate indicates that one in 10 dogs in the United States has atopic dermatitis, which makes it one of the most common chronic conditions that veterinarians encounter.1 Although practitioners are growing more adept at diagnosing atopic dermatitis, the real challenge comes with providing immediate relief of patients' clinical signs while addressing their underlying allergic disease. This article illustrates how managing atopic dermatitis in dogs may be simplified and will help you provide comfort for these pruritic canine patients.

Treatment Simplified: Start early, address flares, and assess progress

Atopic dermatitis can start with acute, seasonal flare-ups and if the underlying disease process is not managed, it progresses, over several months to years, to a nonseasonal, chronic condition.2 Thus, managing the disease earlier should be beneficial. Every dog that suffers from atopic dermatitis has its individual allergic threshold — the point at which the environmental allergen load triggers the dog's immune system to react. Once the allergic threshold is exceeded, the dog develops inflammation, pruritus, and pain, which usually results in skin damage. Therefore, treatment of the clinical signs and long-term management are always aimed at returning to a point below the dog's allergic threshold. This, in turn, reduces the number and severity of allergy flare-ups that the patient experiences.

Even in well-managed patients, occasional flare-ups are inevitable and should not be deemed a long-term treatment failure. Jerry Wilson, DVM, owner of Animal Hospital of Collin County in Allen, Texas, says, "Having a plan that will decrease the frequency and severity of these flare-ups is in the best interest of the patient and client. Long-term success is achievable with the correct diagnosis and medication regimen."

Once atopic dermatitis has been diagnosed, this three-month "Treatment Simplified" protocol (Figure 1) may be implemented to help control patients' clinical signs and monitor their response.

Figure 1

For more information about the Treatment Simplified protocol, visit us.atopica.com/treatmentsimplified.

Treatment Simplified: MONTH ONE — Long-term solution, immediate relief

Start long-term therapy early

Since atopic dermatitis is progressive, beginning a long-term management plan as early as possible should make it easier to control the disease. In the first month of treatment, ATOPICA® (Cyclosporine capsules, USP) MODIFIED should be initiated at a dose of 5 mg/kg/day (range 3.3 to 6.7 mg/kg/day). ATOPICA is the first and only approved nonsteroidal prescription medication for the control of atopic dermatitis in dogs. Dr. Wilson agrees, saying, "Having had success with ATOPICA, I now make the recommendation much earlier in the course of therapy." As with all drugs, side effects may occur. In a field study, the most common side effects were gastrointestinal signs. Gingival hyperplasia and papillomas may also occur during the initial dosing phase. ATOPICA is a systemic immunosuppressant that may increase the susceptibility to infection. ATOPICA is not for use in reproducing dogs or dogs with a history of neoplasia. Please see the included product insert "Atopica" for more information.

ATOPICA Product Insert

Treat secondary infections

Patients with allergic skin disease have alterations to the normal protective function of the skin, which increases the likelihood of infection. Secondary bacterial and yeast infections of the skin and ears, caused by Staphylococcus and Malassezia species, commonly exacerbate a dog's clinical signs, such as pruritus. In dogs with clinical signs of atopic dermatitis, positive cytologic examination results indicate the need for antimicrobial agents.3 Antimicrobial therapy should be continued for four to six weeks and be discontinued only when cytologic examination results are negative. More chronic infections may require prolonged antimicrobial therapy. If fungal infections are present, antifungal treatment (e.g., ketoconazole) may be indicated. Simultaneous administration of ATOPICA and drugs that suppress the P-450 enzyme system, such as ketoconazole, may lead to increased plasma levels of cyclosporine. ATOPICA should be used with caution with drugs that affect the P-450 enzyme system.

Client Communication Simplified

According to Keith Hnilica, DVM, MS, DACVD, of the Allergy and Dermatology Clinic of the Pet Wellness Center in Louisville, Tenn., "Bacterial and yeast infections and the accompanying pruritus are the most common reasons for apparent failure of most allergy treatments." It is imperative to resolve any secondary infections to successfully manage patients with atopic dermatitis in the long term.

Case Study: Prissy

Provide immediate relief

Short-term concurrent topical or systemic corticosteroid therapy may be indicated for immediate relief in a dog that is suffering from pruritus and pain. As Steven Milden, VMD, of Delaware Valley Veterinary Hospital in Mullica Hill, N.J., explains, "All atopic pets have some degree of discomfort. While ATOPICA® (Cyclosporine capsules, USP) MODIFIED is the long-term solution to treat the underlying disease to minimize and prevent flare-ups, corticosteroids may be needed in the most severe cases to bring the pet relief."

Case Study: Matty

Unlike ATOPICA, corticosteroids do not treat the underlying atopic disease and should be used only in the short term to treat the clinical signs. Anti-inflammatory doses of corticosteroids provide quick relief, but also can cause numerous side effects, especially with long-term use. There have been reports of convulsions in human adult and pediatric patients receiving cyclosporine, particularly in combination with high-dose methylprednisolone. (See the Animal Safety section of the product insert — "Methylprednisolone combination: Twenty-four dogs were administered 1 mg/kg/day methylprednisolone alone for 14 days followed by 20 mg/kg/day cyclosporine either alone or in combination with methylprednisolone, or placebo for 14 days. There was no evidence of seizures/convulsions or neurological signs.")

Treatment Simplified: MONTH TWO — The turning point

After four weeks of treating secondary infections, initiating ATOPICA, and managing the patient's clinical signs, a progress examination should be performed to assess the patient's response to therapy.

If the patient shows a 50% reduction in skin lesions and pruritus, the ATOPICA dose can be tapered to once every other day.4 Conversely, if a dog is only showing slight improvement, the patient's ATOPICA dose should be evaluated to ensure it falls within the dose range (3.3 to 6.7 mg/kg/day). If the patient's dose is at the lower end of the range, it may need to be increased or once-daily treatment may need to continue. If no improvement in skin lesions or pruritus has occurred, a thorough re-evaluation of the patient may be warranted, and referral to a veterinary dermatologist should be considered.

A cytologic examination should also be included, as failure to adequately address infections may lead practitioners and owners to declare ATOPICA a failure. If the cytologic examination results are negative, antimicrobials can be discontinued. If the secondary infections are chronic, a longer course of antimicrobials may be indicated.

By this point in treatment, corticosteroids may no longer be indicated. Dr. Milden offers this perspective based on his clinical experience: "I try to discontinue corticosteroids before the second month re-evaluation so I can assess the dog's true level of pruritus. If the dog is still receiving corticosteroids at the end of the first month, veterinarians may prematurely reduce the ATOPICA dose and then see a rapid return of pruritus, leading them (and the owners) to believe (and rightly so) that ATOPICA wasn't responsible for the decrease in pruritis and that 'only steroids will help this dog.'"

Treatment Simplified: MONTH THREE — Entering the comfort zone

The dog's clinical signs and response to treatment and the results of physical and cytologic examinations should be assessed at this evaluation. ATOPICA® (Cyclosporine capsules, USP) MODIFIED dosage adjustments may be made if needed. By this point, ATOPICA may be indicated as the sole therapeutic agent for long-term management of atopic dermatitis. However, according to many dermatologists, even in the most well-managed patients, practitioners and owners should expect occasional flare-ups, and clients must be prepared to address these. Possible flare factors include an increased allergen load, secondary infections, fleas, and concurrent disease (e.g., food allergy). Some options for managing the short-term flares include increasing the frequency of ATOPICA administration (e.g., back to once-daily dosing), controlling secondary infections, and adding a topical corticosteroid.

Conclusion

Once atopic dermatitis is confirmed, practitioners need a reliable, repeatable, and customizable treatment protocol providing both long-term comfort and short-term relief for the atopic patient. Utilizing the "Treatment Simplified" approach may help practitioners achieve success in atopic dermatitis patients sooner rather than later. According to Dr. Milden, "Many clients come to me frustrated. Either the dog has been keeping them awake or they have been dealing with chronic disease. When ATOPICA prevents the return of their dog's clinical signs, they bring me presents!" In addition, Dr. Wilson points out, "Through long-term use of ATOPICA and control of clinical signs and flare-ups, we are able to integrate the pet back into the family — the pet and the people all benefit."

Initiating treatment with ATOPICA as the first-line medication for the primary disease can result in successful, long-term management of atopic patients. The following two case summaries for Prissy and Matty will demonstrate how the "Treatment Simplified" protocol has helped Drs. Jerry Wilson and Steven Milden manage their canine atopic dermatitis patients, describe what they've learned along the way, and illustrate how the protocol can help in your practice.

REFERENCES

1. Hillier A. Definitively diagnosing atopic dermatitis in dogs. Vet Med 2002;97(3):198-208.

2. Griffin CE, DeBoer DJ. The ACVD task force on canine atopic dermatitis (XIV); clinical manifestations of canine atopic dermatitis. Vet Immunol 2001; 81:255-269.

3. Olivry T, DeBoer DJ, Favrot C, et al. Treatment of canine atopic dermatitis. 2010 clinical practice guidelines from the International Task Force on Canine Atopic Dermatitis. Vet Derm 2010:21(3);233-248. doi: 10.1111/j.1365-3164.2010.00889.x.

4. ATOPICA Freedom of Information Summary. NADA 141-218, 2003.

Simplify allergy treatment by starting earlier

Keith A. Hnilica, DVM, MS, MBA, DACVD

The earlier an allergic patient is started on a management program designed with aggressive allergen avoidance practices and targeted treatment of the underlying disease, the easier the allergic condition will be to control. Patients with chronic allergic disease or recurrent skin or ear infections have immune system changes as well as alteration in normal skin function, which can make it more difficult to treat dermatitis. By starting targeted allergy treatment early in the disease course, simpler, less expensive adjunct therapies are likely to help improve the patient's condition.

The most common allergens in the home environment are house dust mites, molds, and cigarette smoke. These, as well as other allergens (e.g., wool, fleas, certain foods), can often be reduced or avoided with several simple techniques. Bathing the pet with a mild antimicrobial shampoo every three to seven days removes allergens and helps resolve and prevent secondary bacterial or yeast infections. Administering a monthly insect growth regulator and a flea adulticide is the best combination for flea control and prevention. In my experience, feeding a diet without beef or dairy ingredients but with high levels of essential fatty acids is beneficial.

Allergic disease changes the normal protective function of the skin, which increases susceptibility to skin infections. These infections can cause severe pruritus and further inflammation. In my clinical experience, up to 80% of allergic patients develop secondary infections, and typically any dog that has a pruritus score above 5 on a scale of 0 to 10 has a secondary bacterial or yeast infection. Additionally, bacterial and yeast infections and the accompanying pruritus are the most common reasons for apparent failure of most allergy treatments.

Antibiotic administration is needed for at least 21 days for each pyoderma episode. Yeast infections require topical or systemic antifungal treatment for at least one month. Ear infections usually require ear cleaning every three to seven days and daily administration of a topical antibacterial or antifungal. Often a topical corticosteroid is used to decrease the associated inflammation. Pododermatitis is often treated with topical antimicrobial wipes, shampoos, or rinses used frequently.

For patients with atopic dermatitis, the only targeted treatments that modulate the immune system are ATOPICA® (Cyclosporine capsules, USP) MODIFIED and allergy desensitization vaccination. Skin or serum allergy testing can be used to identify the offending allergens, and the results can be used to formulate an allergy vaccine that may desensitize the immune system to those allergens. Desensitization therapy has few side effects and various authors have rated response as good to excellent in 60% to 70% of atopic dogs.1,2 ATOPICA is an oral capsule that is administered every day until the patient's clinical signs markedly improve. Then the dosing frequency can usually be reduced to every other day. In clinical trials, ATOPICA was proven to be effective in 74% of dogs with atopic dermatitis.3

Dr. Hnilica is the author of Small Animal Dermatology: A Color Atlas and Therapeutic Guide, 3rd ed. He is the founder of the Allergy and Dermatology Clinic of the Pet Wellness Center in Louisville, Tenn.

REFERENCES

1. Griffin CE, Hillier A. The ACVD task force on canine atopic dermatitis (XXIV): Allergen-specific immunotherapy. Vet Immunol Immunopathol 2001;81:363-383.

2. Nuttall TJ, Thoday KI, van den Broek AH, et al. Retrospective survey of allergen immunotherapy in canine atopy. Vet Rec 1998;143(5):139-142.

3. ATOPICA Freedom of Information Summary. NADA 141-218, 2003.

Simplify allergy treatment by addressing flare-ups

Ian Brett Spiegel, VMD, MHS, DACVD

A multimodal approach is often required when initially treating atopic dermatitis in dogs. Secondary bacterial and yeast (Malassezia species) infections must be identified and managed in order to successfully treat these patients. Preventing flea infestations, ruling out mite infestations, and addressing potential adverse food reactions are important components as well.

Corticosteroids are often indicated at some point in allergy management, but ideally they are used infrequently and administered orally and only when necessary. If injectable corticosteroids are used, consider short-acting options such as dexamethasone sodium phosphate. In my opinion, injectable corticosteroids are rarely indicated. The modified formulation of cyclosporine (ATOPICA®) is an excellent option for managing canine atopic dermatitis. This drug lacks the adverse effects frequently associated with corticosteroids. A corticosteroid may be needed in conjunction with ATOPICA when therapy is initiated, and even in a well-managed atopic patient, the therapeutic plan will need to be adapted to address occasional flare-ups of clinical signs.

Intermittent application of topical treatments may also be effective in helping manage flare-ups of atopic dermatitis. Topical antimicrobials may target the secondary infections, and some topicals may help maintain barrier function. Many topical anti-inflammatory and antipruritic preparations (e.g., corticosteroid sprays or analgesic sprays containing pramoxine) are also available.

Keep in mind that every patient is different, and every client's situation is unique. It is important to remember that, even in the most well-managed cases, flare-ups are inevitable. Flare-ups can be caused by anything from a flea infestation or a change in season to the development of a concurrent disease, such as a food allergy. The art of managing the allergic patient requires good communication with the client as well as patience and perseverance on the part of both the clinician and the client.

Dr. Spiegel is affiliated with the following clinics: Veterinary Specialty and Emergency Center, Levittown, Pa.; Animerge 24/7 Animal Emergency and Specialty Care, Raritan, N.J.; and Garden State Veterinary Specialists, Tinton Falls, N.J.

For more information about the Treatment Simplified protocol, visit us.atopica.com/treatmentsimplified.