2019 Fall Derm Dialogue

DERM DIALOGUE

FALL 2019

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Editor: Norma White-Weithers, MS, DVM, DACVD • Veterinary Allergy & Dematology Consultant, Baldwin, NY 11510 Work: 646-329-4719 • Fax: 631-694-3401 • E-mail: nweithers@yahoo.com Assistant Editor: Tim Strauss, DVM • Frederick,CO 80516 | E-mail: drtim@comcast.net

FROM THE PRESIDENT

Dr. Outerbridge

Dear Colleagues, It was great to see so many familiar faces in Austin. Thanks to everyone on the NAVDF Organizing Committee and the Program Committee for all of your hard work in planning another successful meeting. Before you look over this edition of the Derm Dialogue, I want to remind everyone that this is the only source where you can read about what was discussed at the roundtables at the NAVDF meetings and that would not be possible without the volunteer efforts of Norma White Weithers and everyone who helps get Derm Dialogue to your inbox. If you want to check out past issues, go to the members’ section of the website at AAVD.org.

At the 2019 AAVD members’ business meeting on Saturday April 13, it was my distinct honor to award Dr. Sheila Torres with the Frank Kral Award. Dr. Torres, as most of you know, is a well deserving recipient and she joins other past recipients Dr. Valerie Fadok, Dr. Phil Roudebush, Dr. Jimmy Noxon, Dr. Wayne Rosenkrantz, Dr. Peter Ihrke and Dr. Danny Scott; all are true representatives of what the Frank Kral award recognizes in our specialty.

NAVDF will not take place in 2020, as hopefully all of you are planning to attend the 9th World Congress of Veterinary Dermatology in Sydney, Australia. There is an updated flyer within Derm Dialogue for the 9th World Congress of Veterinary Dermatology. This is going to be an amazing meeting with six different themes that have state-of-the-art and Supporting Review speakers that are all world experts in their fields. There are numerous different tracks: 24 hours of CME lectures for Dermatology in General Practice, 24 CME lectures for Advanced Dermatology in Clinical Practice, 2 days of feline dermatology, exotics and equine dermatology tracks, workshops and wet labs. There really is something of interest for everyone. Registration will include Congress attendance at the Sydney International Convention Center right on the beautiful iconic Sydney Harbor, daily box lunches and two evening events including the Opening Ceremonies and the local evening at Luna Park. If you have ever wanted to visit Australia now you have an incredible reason to do so. Check out the web page https://www.vetdermsydney.com/ The next NAVDF meeting will be in New Orleans in 2021. Save the dates of April 21 to 24, 2021 to attend another great meeting in an amazing location. The AAVD board is making special plans to organize and sponsor a speaker for this meeting.

This year the AAVD again donated $15,000 to the ACVD Research Fund to provide grant funding for the AAVD/ACVD research grant.

We all also funded more student awards, bringing the total to over 90 student recipients since 2014 when we started funding the AAVD veterinary senior student award in Veterinary Dermatology. This monetary award accompanies 2 years of membership in the AAVD, which hopefully fosters a lifelong interest in veterinary dermatology, and ongoing membership in the Academy.

I wanted to thank the AAVD leadership team: Drs. Rod Rosychuk, Klaus Loft, Rose Miller, Andrew Mills, Verena Affolter, Norma White Weithers, and Jeanne Budgin. Also thanks to our Executive Secretary Jason Harbonic.

Warmest regards and I hope to see many of you in Sydney.

Catherine

AAVD Executive Board

Administrative Team

President Dr. Catherine Outerbridge West Sacramento, CA

Members-at-large Dr. Andrew Mills Shoreview, MN

Co-Executive Secretary Jason Harbonic AAVD JHarbonic@pamedsoc.org

Immediate Past-President Dr. Rod A. Rosychuk Ft. Collins, CO

Dr. Verena Affolter Davis, CA

Co-Executive Secretary Alexis Borich itchypet@aol.com

Meeting Planner Jill Senior JSenior@pamedsoc.org

WAVD Representative Dr. Jeanne Budgin Riverdale, NJ

Vice President Dr. Klaus Loft Cohasset, MA

Meeting Planner Asst. Tracy Mitchell TMitchell@pamedsoc.org Administrative Assistant Travis Haines, THaines@pamedsoc.org

Editor, Derm Dialogue Dr. Norma White-Weithers

Treasurer Dr. Rosemarie Miller Ardmore, PA

ACVD

Baldwin, NY

NAVDF Program committee

Executive Secretary Mr. Jason Harbonic 1.877.SKINVET (7546838) info@aavd.org

Program Chair Sandra Koch

Co-Chair Marcy Murphy

Petra Bizikova Alberto Cordero Brian Scott Klaus Loft

WAVD Committee AAVD Representative to the WAVD, Jeanne Budgin

NAVDF-OC Committee Positions Term Name Affiliation Email Chair 2019-2021 Dana Liska ACVD Danaliskadermvet@gmail.com Co-Chair 2019-2021 Rose Miller AAVD RMillerdvm@gmail.com Treasurer 2019-2021 Kristin Holm ACVD Kshdvm@yahoo.com Sponsorship Liaison

2018-2020

Klaus Loft

AAVD

klausloft@gmail.com

Sponsorship Co-Liaison 2019-2021

Jeanne Budgin

AAVD

dermgirl02@yahoo.com

OC Mbr ACVD

2017-2021

Allison Kirby

ACVD

alliekirby@yahoo.com

OC Mbr ACVD

2018-2022

Kristin Holm

ACVD

kshdvm@yahoo.com

OC Mbr AAVD

2019-2023

Norma White-Weithers

AAVD

nweithers@yahoo.com

OC Mbr AAVD

2019-2023

Rose Miller

AAVD

rmillerdvm@gmail.com

CONGRATULATIONS STUDENT AWARD WINNERS! Katherine Anderson, DVM

Natalie Gregory, DVM

Alysha McGrath, DVM

Abigail Romano, DVM

Lindsey Citron, DVM

Greyshawn Kelly, DVM

Desmond Muther, DVM

MaryKate Tully, DVM

Hannah Clark, DVM

Sarah Lewis, DVM

James Oldeschulte, DVM

Nehemiah Washington-Ball, DVM

Drew Fleischman, DVM

William McClean, DVM

Leslie Prescott, DVM

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ROUNDTABLE SUMMARIES

ROUNDTABLE SUMMARIES Adverse Effects of Apoquel Moderator: Dr. Jennifer Bentley 1. Opening Question: What adverse effects have you seen with Apoquel?

• The consensus from attendees was that Apoquel at the labeled dosage causes very little side effects.

Some of the side effects that attendees have observed include: Gastrointestinal • Most attendees believed this was a very rare occurrence.

• Two attendees discontinued Apoquel for a patient due to gastrointestinal side effects (vomiting).

Behavioral • Several attendees (~40%) noted aggressive behavior while on Apoquel. This was not common and for most attendees the behavior was seen only in a couple of patients.

Weight gain • One attendee mainly saw weight gain in Labrador Retrievers.

• Some attendees believed that weight gain may be due to a reduction in itch level.

• There was a brief discussion about oclacitinib impacting adipocyte metabolism and altering leptin levels.

Leukopenia • Several attendees have seen leukopenia, but not severe enough to require discontinuation of the medication.

• One attendee observed a white blood cell count of 700/µL requiring discontinuation of the medication.

Demodex • The consensus of the group was that Apoquel rarely causes demodicosis. Two attendees have observed patients develop demodicosis while on Apoquel, but these dogs appeared to have poor immune systems in general and were manifesting other systemic diseases.

Pneumonia • A couple of attendees have observed pneumonia in adult dogs.

• Most had predisposing factors – brachycephalic.

2. What should we be monitoring while on Apoquel long term?

• The consensus of the attendees would be to monitor CBC/Chem + urinalysis every 6 months to 1 year.

• Few attendees are performing regular urine cultures while on Apoquel.

• All attendees agreed that owners were not observing symptoms of urinary tract infections.

• One brief discussion regarding the controversy of treating subclinical bacteriuria occurred.

3.

What side effects are being seen at increased dosages of Apoquel?

• Many attendees (~60%) are using the twice daily dosage long term.

• Attendees that monitor bloodwork did not observe more severe or frequent leukopenia.

• The consensus of the attendees was that they did not encounter more severe or frequent side effects at an increased dose. However, the group agreed that monitoring bloodwork more frequently would be recommended.

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4. Discussion Point: Using Apoquel in cats – efficacy and adverse side effects.

• Discussed efficacy of Apoquel in cats and many attendees reported low efficacy. However, some attendees are using increased dosages 1.3mg/kg/day and reporting substantially better efficacy with the increased dose. Of those using the higher dosage no side effects have been seen clinically or on bloodwork (including leukopenia). One attendee saw pneumonia in one cat who was on Apoquel.

• Several attendees agreed that it is extremely easy to give Apoquel to a cat as it dissolves easily in wet food.

5. Discussion Point: Apoquel and cancer.

• Most of the attendees were not concerned about Apoquel causing cancer. However, most attendees were concerned about exacerbating neoplasia by placing dogs who have cancer on Apoquel. Many would switch to Cytopoint, but also consider quality of life and let the owner decide.

• A brief discussion was started about Apoquel’s label. The label for Apoquel has a warning for exacerbation of cancer. One attendee pointed out that this warning is required by the FDA for all immunomodulatory drugs.

• It was also pointed out that in humans the cancer risk may be higher for JAK inhibitor as many viral diseases are the cause of cancer. Since there are fewer viral induced cancers in dogs this may be less of a concern.

6. Discussion Point: Apoquel efficacy with ear infections.

• The attendee consensus was that Apoquel does not have enough anti-inflammatory effect to be successful at treating Otitis.

• A brief discussion occurred about the following publication: Fukuyama, T. “Topically Administered Janus Kinase Inhibitors Tofacitinib and Oclacitinib Display Impression Antipruritic and AntiInflammatory Responses in a Model of Allergic Dermatitis” J. Pharmacol Exp Ther. Sep:354(3) (2015): 394-405.

• One conclusion from this article was that ear thickness was reduced when oclacitinib and tofacitinib were applied topically.

7. Discussion Point: Apoquel efficacy with pododermatitis.

• The consensus of attendees was that Apoquel is not very effective for pododermatitis.

• A few attendees reported seeing an increase in number of cases of pododermatitis with furunculosis.

These attendees believed that general practitioners are using less steroids and cyclosporine and thus these cases are getting referred more frequently because they are not responding to Apoquel.

8. Discussion Point: Using Apoquel with other immunosuppressive medications.

• Most attendees are not using Apoquel with concurrent immunosuppressive medications.

• One attendee noted severe immunosuppression with Apoquel and chloramphenicol when given together.

9. Discussion Point: Apoquel induction of tolerance.

• Most attendees believed that cases of suspected tolerance were usually not tolerance, but rather due to secondary infections - particularly malassezia hypersensitivity.

10. Discussion Point: Using Apoquel for treatment of auto-immune disease.

• Most of the attendees are not trying this because we do not know what dose would be safe and effective.

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Technician Roundtable– Defining the roles and responsibilities of the veterinary technician in dermatology practice Moderator: Juliann London Summary: Technicians that attended the roundtable had a variety of years of experience in dermatology practice; we were able to have views from technicians who have been in the dermatology practices for only a few years (2-3) to up to 20 plus years.

Do you notice any differences between general and specialty practice? Different types of clientel, much more microscope work in specialty practice. Also, discussed was the increase of client communication in specialty practice compared to general practice.

Dermatology has the “special clients,” as stated by multiple attendees. Most of the clinics have very heavy client communication and not as much focus on procedures, surgery, anesthesia, etc. Some clinics do have heavy procedure days, and sometimes will often try to schedule procedures the same days as initial consultations. A few technicians mentioned that have all new patients fast just in case they need to be sedated or have general anesthesia performed the same day. A lot of the clinics have clients driving from multiple hours away and try to limit the amount of times a client must drive to the clinic.

When thinking of the dermatology technician as an appointment and break down from getting the client in the door to discharging a patient. First step, getting a client in the door – multiple private practice technicians act as receptionist as well and schedule appointments. There was one technician who works at a private practice and they specifically were by referral only (up until recently when that policy changed). All other technicians work for private practices and universities that do not require referrals and clients can be self-referred. Length of appointment time was also discussed that initial appointments were often 1 hour in length (there was one clinic that sees initial consultations in 30 minutes), compared to general practice where appointments often are only around 20 minutes.

Who obtains the history and collects cytology samples from the patients? A few technicians do go into the room with the doctors, however they are finding that when they do this, they are not having enough time to get their other daily tasks done, so are attempting to find a happy medium. Technicians at the universities are evaluating cytology samples. One of the technicians at a university stated her doctors “have not looked a sample in years.” The technicians at the universities are teaching students how to obtain samples, how to use a microscope and review skin samples. Many technicians stated that it really depends on what work best for the practice on who is collecting samples and reading samples.

A place the dermatology technician can be very beneficial is obtaining a thorough history and being able to anticipate what will need to be done and set the doctors up for what they are walking into the exam room.

Complex procedures in the clinic: Multiple technicians perform intradermal allergy testing, none of the technicians are reading the allergy tests. Some of the doctors will pick out the biopsy sites and the technician will perform the skin biopsy and suture (one of the technicians helps students at the university select biopsy sites). Having technicians assist/perform more complex procedures allows the doctors to get other things that are piling up on their desk done.

Handout and client communications. All the technicians (at private practice and universities) have handouts to go home with the clients. The handouts range from atopic dermatitis treatment options, elimination diet trial handouts, MRSP handouts, dermatophytosis handouts, etc.

How as technicians do, we make sure clients come back in the door to the clinic? Try to schedule the client prior to them leaving the clinic. One participant mentioned they follow up with the client a week after the appointment to make sure the patient is doing okay and schedule a recheck exam if not already scheduled. One of the technicians who works at a large university has a specialty coordinator who calls 1-2 days after the appointment and schedules a recheck exam at that time.

Some of the technicians can give input on products that are carried in their practice. In the universities it is more difficult to bring in new products, as they must work within the pharmacy and a lot of times it comes down to space and they will often have to stop carrying one product, to bring in another product.

Immunotherapy is prepared in house by some of the clinics and some clinics perform IDATs and then order all their immunotherapy from the laboratories.

Ways that the doctors can help technicians to make our jobs go easier/smoother. Many technicians agreed that sometimes when the technicians call the owners, there are some owners that just need to speak directly to the doctors, and it would really help the technicians when this is done.

There were multiple VTS dermatology members at the round table and it was disused that some of the VTS members had some incentives to becoming VTS. Unfortunately, a few of the technicians do not receive any extra compensation, even though their department was very pleased with their participation in VTS. VTS members benefits of additional PTO (some even get extra days paid off to study for their VTS exam), increased salary, etc. varied among the VTS members. It was interesting to hear the difference of VTS benefits among both universities and corporate clinics who have VTS members, and private practice. Overall it seems that universities and private practices are very supportive of VTS specialty members.

As a group we also discussed what becoming a VTS dermatology member entails.

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Sublingual Immunotherapy (SLIT) Roundtable Moderator: Dr. Douglas DeBoer 1. Introduction and general experience with SLIT The participants introduced themselves and discussed their experiences with SLIT, specific questions they had, and what they hoped to gain from the roundtable. The experiences ranged from good to poor and the participants were relatively evenly split between self-prepared (“homemade”) SLIT therapy and SLIT therapy ordered from companies providing the product.

2. Success rates Opinions on success of SLIT therapy varied, with 60-70% success reported by some participants but poor success by others. The group speculated that variable experiences might be related to many factors that appear to vary by clinician: the allergen extracts that are used (i.e. the company producing them), the diluent, the schedule, the dose, and the frequency of administration – as well as individual pet response.

There are currently no agreed-upon standards for how to prepare SLIT prescriptions if they are done at the practice. There may be variability of allergen extracts from company to company as well as from batch to batch within a company, and aqueous extracts may differ from glycerinated extracts. Thus, many factors could influence success rates, and which of these are most important is not known.

T here was brief discussion regarding success rates in cats and horses; SLIT has been used by some participants with anecdotal benefit. SLIT dosing appears to be well tolerated by these patients.

3. Why the differences in experience – could it be dosing?

Some companies that supply SLIT allergen prescriptions use their own standard formulation.

Others formulate the product based on the instructions from the clinician, creating further variability, especially if different clinicians are asking for different concentrations in the prescription. The general recommendation from the allergen extract manufacturers is that the higher the concentration the better, and that using the highest tolerated dosage is often the goal. SLIT therapy concentrations in people are sometimes decided based on skin test reactivity to a series of dilutions of each allergen which is not a practice done in veterinary dermatology. In addition to the actual dose of allergen, there is evidence that dosing frequency is important (i.e. more frequent = better). This has been shown in people and in mouse models. Within the group, some dermatologists use SLIT with twice-daily dosing, and some only once-daily.

Some participants indicated that if allergen injections fail, they think that SLIT may work in around 50% of these patients.

T here was discussion regarding combining SCIT/SLIT (IE both injections and sublingual concurrently). In theory this may increase the total dosage and the different routes of exposure could be beneficial. There is one human study in the literature that suggests in that SLIT+SCIT is better than either alone. No veterinary studies have evaluated this.

4. Company-provided prescriptions vs. “homemade” (made at the practice) SLIT Another topic that was discussed involved the potential benefit of company-provided SLIT prescriptions over “homemade” SLIT therapy. One participant felt that “homemade” SLIT treatments are not very effective, but again, there is great variability in how those prescriptions might be formulated by the dermatology practice. What might be the main differences? One difference is that SLIT prescriptions

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provided by companies are often made from glycerinated allergen extracts. With glycerinated extracts, the glycerin is added immediately when each extract is first manufactured, which may help protect the antigenic protein structure. “Homemade” prescriptions made at practices are nearly always made using aqueous allergen extracts as starting material, then adding glycerin to the final product. The use of glycerinated extracts as starting material may be important, but this is only speculation.

5. Is variability in administration a factor?

There is also variability as to the route of delivery into the oral cavity with many or most participants instructing owners to apply the drops in the “cheek pouch” as opposed to a truly sublingual route. Since there are dendritic cells that are present throughout the oral cavity, the effects of delivery to different sites within the mouth may or may not matter. There was also the question as to the ability to deliver SLIT therapy appropriately depending on the shape of the jaw and dental arcades of certain breeds including bulldogs.

Recommendations for human SLIT involve no drinking or eating for 5-10 minutes after each dose, and the same is true for pets. People are advised to hold the allergen dose in their oral cavity, under the tongue, for 30 seconds. Of course, this is not feasible in animals. Some registered products for people use a tablet dosing form that slowly dissolves under the tongue, leading to prolonged contact time. There is some experimental work with gel vehicles, mucoadhesive polymers, etc. that may provide increased contact time of the allergens in the mouth, but this has never been studied in veterinary medicine.

In summary, the group found that there are a large number of variables in the way SLIT is currently being used in animals. This may explain variation in practitioner experience with success. Unfortunately, at this time we have very few studies to help guide us in many of these variables.

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Extra-label Apoquel Use Roundtable Summary Moderator: Dr. Falk The Roundtable was broken up into 4 main sections: Extra-label Apoquel use in non-canines, Extra-label Apoquel dosing in canines, Extra-label use of Apoquel for diseases other than allergic dermatitis, and topical formulations of Apoquel.

Part 1: Extra-label use of Apoquel in non-canines a. Horses: A participant asked if others present had experience with Apoquel in horses. She has treated one case (a head shaker with hives) with 0.1 mg/kg SID (no loading dose), with efficacy too early to tell.

Another participant said that he had heard reports of much different pharmacokinetics in horses vs. dogs in that they seem to need 0.2-0.3 mg/kg (which works out to seven to eight 16 mg tablets per day), with some efficacy. It is unclear what type of allergy these horses had (insect bite vs atopic). The absorption appears independent of whether crushed or with food. That participant reminded the others present that all of what was about to be discussed was extra-label, meaning that there have not been marginal safety studies or dosing protocols established. b. C ats: Several participants mentioned using Apoquel in cats with allergic disease that had failed other conventional treatments (corticosteroids, Atopica). Those using the drug in cats agreed with the recent paper by Noli, et al, which suggested reasonable efficacy at a higher dose than previously reported, 0.8-1.2 mg/kg, with several individuals reporting starting it at 0.8-1 mg/kg BID then slowly tapering. A participant reported that she can maintain at 0.5 mg/kg BID after this initial loading period. A separate individual reported using it in several allergic cats at 0.6-0.8 mg/kg BID, with an estimated response rate of 60-80%. One individual had used it effectively at 1 mg/kg SID in 2 cats with eosinophilic granulomas that were non-steroid responsive. Others reported using it for severe asthma at 1 mg/kg SID with good success. In regards to the administration of Apoquel in cats, the consensus was that it seems to dissolve well/ water soluble and not too bitter, such that it is reasonably well-tolerated. Another individual reminded us that it’s unclear what dissolving it in water does to its bioavailability. One participant brought up monitoring in cats on Apoquel. Several individuals say that they screen for FIV/FeLV prior to starting, but no one reported seeing increased incidence of herpes virus/other viruses or toxoplasmosis while being treated with Apoquel. One individual recommended monitoring UA/UPC regularly while on it, while another participant recommended always getting bloodwork prior to starting any extra-label treatment, so that any abnormalities can be compared to a baseline. c. Human: A participant mentioned a single case report of an atopic human male self-treating with Apoquel, with good success. Another participant said that there’d been other similar anecdotal reports but wondered why these people did not use tofacitinib (Xeljanz) instead, which is a very similar drug approved for people (though it is predominantly a JAK3/JAK1 inhibitor). That individual mentioned that Xeljanz has a black box warning for SERIOUS infections. He mentioned that, at the labeled dose of Apoquel, dogs may have a slightly increased risk of papillomavirus, but this is well recognized and does not appear to be common or of serious concern.

Part 2: Extra-label dosing in canines a. Long-term BID dosing: Several individuals use Apoquel at 0.4-0.6 mg/kg BID long-term with a feeling that it is quite well-tolerated, though some monitor bloodwork more regularly than SID dosing, i.e., every 3 months versus every 6 months. A few reported a feeling that they see increased incidence of papillomaviruses and demodicosis on the BID dosing. Several agreed that switching these patients to

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regular flea/tick prevention with an isoxazoline was helpful at preventing demodicosis. There did not appear to be any increase in incidence of bacterial skin infections or any increased difficulty resolving them. Others reported loading at the BID dose, and then advising the owner to use the medication between SID and BID, with the goal of the owner using their judgement to give the medication at the lowest possible frequency of administration. Some patients were able to be maintained at BID/SID, alternating every other day. Some maintain on SID but then increase to BID with any flares. Another individual mentioned that re-starting at BID to control a flare is most effective, but that perhaps not every dog needs BID for 2 weeks. A participant asked about when it was safe to reload at BID when a pet had been off the medication; another participant suggested that, according to the label, you could reload at BID dosing after 24 hours off the medication given Apoquel’s short half-life. b. C oncurrent administration of Apoquel with other immunomodulatory drugs, such as prednisone or cyclosporine: Most participants were not combining Apoquel with these other medications for allergic dermatitis, though several reported that they will administer a brief course of Temaril-p to help control flares, even for just a few days. They reported that this was particularly helpful for dogs having a flare of allergic otitis externa. A short discussion of Apoquel and otitis externa followed, with individuals agreeing that for dogs with severe chronic, recurrent otitis externa or proliferative otitis externa, they will discontinue Apoquel and treat those patients with prednisone/cyclosporine. A brief discussion of Apoquel’s limitations at managing interdigital folliculitis/furunculosis then followed, with several participants agreeing that corticosteroids and cyclosporine were more effective for this allergy manifestation.

Part 3: Extra-label use of Apoquel in non-allergic disease diseases a. Pemphigus foliaceus: A participant mentioned that Apoquel has been helpful in combination therapy for PF, as a steroid-sparing agent. It seems to be well-tolerated in these individuals, who are also on azathioprine or cyclosporine, in addition to a small amount of prednisone. Another individual mentioned that he has mild cases of PF managed on doxycycline/niacinamide whose mild flares might be helped by Apoquel, though this hasn’t been tried yet. b. Vasculitis: Another participant reported that she’d heard reports of good efficacy of Apoquel at 1 mg/kg orally BID in combination with cyclosporine. c. DLE: A participant mentioned that, in treating an atopic patient who had concurrent DLE with Apoquel, he noticed good improvement of the DLE. This was at the standard allergy dose. d. Ear margin vasculitis: One participant mentioned no real improvement of concurrent ear margin vasculitis in an atopic patient who was on Apoquel for the atopic dermatitis. This patient markedly improved when switched to cyclosporine. That participant mentioned that they’d tried this drug based on a published case report suggesting efficacy. e. Ischemic dermatopathy: An individual mentioned reading 2 case reports suggesting some efficacy of Apoquel for this disease, including an abstract from ECVD Lausanne. In that abstract, the normal allergy dose was used. f. Generalized cutaneous lupus: An individual reported a case that was well-managed on Apoquel/ Cyclosporine.

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g. Perianal fistulas: One participant reported no efficacy in 1 case of perianal fistulas. Another individual reported some mixed reports anecdotally. h. Angiomatosis: One individual reported a case of a patient with angiomatosis affecting 1 leg and causing significant pruritus and discomfort, such that amputation was being considered. The patient was started on a BID allergy dose, and the patient did very well in regard to decreased swelling and pruritus. i. Allergic rhinitis/conjunctivitis in dogs: Contributors reported a hit-or-miss, 50:50 mix of responsiveness.

Another individual mentioned an abstract being presented at this conference regarding the CSU internal medicine service, where they had 6 dogs included in a retrospective study on Apoquel for allergic rhinitis – 5/6 had shown improvement. j. Lymphoma—a participant mentioned that a pruritic patient with nodules on the ear was put on Apoquel while she awaited biopsy results. The nodules disappeared with the Apoquel. The biopsies were consistent with B cell lymphoma. A participant mentioned that JAK inhibitors are being considered for future treatment of lymphoma, leukemias, and even solid tumors. k. IBD/ulcerative colitis: No participants reported using Apoquel for IBD or ulcerative colitis. One participant pointed out that Xeljanz is labeled for ulcerative colitis. Given the similarities of tofacitinib to Apoquel, this may be something to consider in the future l. Overall use as an immunosuppressant medication: There was a discussion about whether Apoquel is immunosuppressive. A participant noted that it is currently classified as immunosuppressive by the FDA but that the FDA tends to categorize anything that has an effect on the immune system as immunosuppressive. A better understanding of Apoquel is that it is immunomodulatory, or that it can cause dose-dependent immunosuppression. A vaccine response study in young dogs supports that B and T-cell responses were maintained, even at exaggerated (3x label) doses, and provides evidence against immunosuppression. JAK inhibitors are targeted and are not designed to be broad acting immunosuppressives for autoimmune diseases.

Part 4: Future topical applications of Apoquel a. A participant mentioned a recent paper on intraocular application of oclacitinib for KCS, which was not found to be helpful. b. I n addition, she mentioned papers on topical tofacitinib and oclatinib in mice, which look promising.

Another participant mentioned that there have been Phase 2 and Phase 3 studies on tofacitinib and baricitinib for AD and psoarisis in humans. They have passed phase 2 and the phase 3 trials are quite promising, so perhaps a topical oclacitinib would be helpful for focal atopic lesions in the future.

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MANAGEMENT OF EQUINE ALLERGIES Moderator: Dr. Sandra Koch OBJECTIVE: Discuss the different therapies used to manage horse allergies, including environmental allergies and insect hypersensitivities, and individuals’ experiences.

Participants: There were a total of 12 people - private practice (6), universities (5) and industry (1).

ALLERGY TESTING AND ALLERGEN-SPECIFIC IMMUNOTHERAPY Allergy testing Most individuals perform only intradermal test (IDT) and some will also perform allergy serum test, mainly when IDT results are not rewarding, and most include insect panel in the tests. Usually most individuals do not perform allergy testing during a specific allergy season, testing whenever they are able to test. Withdrawal times prior to testing for antihistamines and glucocorticoids seem variable, but usually only 3 days and 2 weeks maximum is needed, respectively. One person reported that if the horse is coming from far away sometimes test without discontinuing medications. Many individuals work with internal medicine and they usually decide the sedative to be used, usually dexmedetomidine. Some will go to their farms and perform tests in the horses in their barns. Usually owners are asked to take pictures 24 and 48 hours after the testing to help evaluate for any delayed reactions. Most individuals do not measure the reactions; usually use subjective reading. One individual reported that some primary veterinarians think that IgE serology works, and they will refer for IDT when they see poor response to immunotherapy.

Immunotherapy Everyone agrees that what is included in the allergen specific immunotherapy (ASIT) depends on history and clinical signs of individual horses. As far as efficacy, most feel like it works for 70-80% of allergic horses and that usually takes 3-6 months to work. As far as efficacy differences between sublingual/oral (SLIT) and subcutaneous immunotherapy, the general agreement is that it seems too soon to tell and that studies are needed to investigate responses to the different modalities. Some individuals have noted response to SLIT while one person expressed concern with possibly more side effects with SLIT. Some individuals feel that acute cases respond better to immunotherapy, not age related, but chronicity may influence the response negatively perhaps. Horses with RAO (recurrent airway obstructions) usually respond well to ASIT, with SLIT possibly working better for these coughing wheezing horses. Anecdotally, 15% of the horses that have discontinued ASIT therapy did not relapse. Many were lost to follow up as they continue care with their primary veterinarians. One individual believes that cold-blooded horses are more sensitive to ASIT and need lower concentration to prevent adverse reactions. One individual reported having severely allergic and reactive horses observed by primary veterinarian for several hours when starting ASIT due to concerns with adverse reactions.

SYSTEMIC THERAPIES Antihistamines There are only a few published studies on the efficacy of antihistamines for allergic horses. Most individuals use hydroxyzine as first choice, while some also use doxepin. Efficacy is variable but most horses seem to respond. Efficacy is usually expected within 2 weeks. Unusually one would see drowsiness or nervousness.

Glucocorticoids Glucocorticoids are commonly used in allergic horses. Prednisolone and dexamethasone are the preferred ones. One individual reported using the injectable formulation orally due to better absorption. Side effects are not commonly seen but idiosyncratic laminitis can be seen. Dosage is reduced to the lowest efficacious dose for maintenance.

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Pentoxifylline Most reported lack of efficacy with pentoxifylline in allergic horses.

Oclacitinib maleate (Apoquel) - extra-label use No one present had experience. One anecdotal report (book chapter) in horses using 0.25 mg/kg q12h for 14 days, with dosage reduction to q24h but with rebound effect reported.

Cyclosporine – extra-label use A few individuals reported experience with cyclosporine. Dosage is unknown for horses and response may be variable and unpredictable. Treatment is quite expensive for horses.

PREVENTION AND CONTROL OF INSECT EXPOSURE/BITES Everyone agreed that insect prevention and management is important in the allergic horse since insect allergies is such a common problem in rural areas. Besides protection with masks/sheets and coverings, various insect repellents are used, including Advantage multi (needs many pipettes: 5-6/horse), permethrin (be careful with barn cats), picaridin (usually recommended for children) and Skin So Soft (Avon). In very hot parts of the country, it might be better to recommend water-based products due to possible burns. It seems like most individuals include insect allergens in the immunotherapy formulation.

TOPICAL THERAPIES Bathing horses with medicated shampoo is generally recommended, whenever possible, mainly when owners have proper facilities for baths. Dermal-Soothe shampoo (Vetoquinol), labeled for horses, was mentioned as a good antipruritic shampoo for horses. Other effective products mentioned were TrizChlor4 HC shampoo and spray (Dechra), also labeled for horses.

GENERAL COMMENTS A few individuals reported concerns regarding dealing with horse clients, as they tend to be more “needy”, and they tend to use many of their own remedies and often have unrealistic expectations.

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13

Treatment of Cutaneous and Oral PapillomatosisModerator: Dr. Carine Laporte How often do you see papilloma in practice?

• Multiple people feel they have seen a recent increase of severe cases

• Patients covered in papilloma from ‘head to toe ‘with hundreds in the mouth.

• Many of these patients are not on immunosuppressive medications I ndividual case as reported by participant

• Older boxer (around 8 years), went through full work up (thoracic radiographs, AUS) and nothing was found for cause of papilloma

• Biopsy of the skin revealed papilloma, which was submitted to Georgetown University

and typed as papilloma type 10

• Later (unsure time line) the Boxer ended up with kidney failure and passed due to this disease

• Treatment for this case included surgical removal (relapse/grew back) and a combination of azithromycin, cimetidine, and lysine Breeds seen most frequently

• Great Danes, Boxers, French bulldogs

• Typically, these are the worst cases people have encountered Treatments being used Surgery

CO2 laser, which is referred over cryotherapy

Some recommend amputation for solitary lesion on toes

Crushing technique

If there are only a few papillomas, crushing some has been performed.

Otherwise not often used as treatment

Cryotherapy

Responds well, especially in the oral cavity

Recommend surgical debulking of large papillomas with scalpel, tie off at bottom of papilloma

with suture to prevent hemorrhage, then perform cryotherapy on the base of the remaining mass

5% Imiquimod cream-topical application

Individual anecdotal reports: usage in one patient with control sites (untreated)

and treated sites resulted in variable response

Recommended for cutaneous papilloma, not oral papilloma

A few participants highly recommended it for inverted papillomas Oral medications

Combination azithromycin, cimetidine, and lysine • Cimetidine: (dosage used as stated in Plumb’s pharmacology book)

• Lysine: 500mg BID per dog

• Success with this combination after surgical removal, did seems to prevent recurrence

Azithromycin • Many do not feel that this medication works for papilloma • Though in combination with cimetidine and lysine (see above), few feel this is more successful • Azithromycin 10-15mg/kg BID

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ROUNDTABLE SUMMARIES

Interferon alpha

• Intron A

500-5000 IU daily

1.5-2 million/m2 twice weekly

• Compounded medications

Unsure if this is effective

• Must register in order to obtain the “real stuff”

• Expensive to the client Melatonin

• Shown in humans to enhanced cell mediate immunity In multi-specialty hospital it was reported that internal medicine department will use as adjunctive therapy for immune mediate thrombocytopenia

• Melatonin implants (Dermatonin) Given subcutaneously

Doses: small dog-8mg; medium dog-12mg; large dog-18mg

Can potentially be used for cyclical flank alopecia, alopecia X, and Microsporum canis

(individual reported use in Persian cats with severe infections) Clinical impression: as an adjunctive therapy, it can beneficial

• An average effective duration is 2-3 months

• Side effects of implant

Injection site reaction (sterile nodular disease) this occurred twice (individual report) Benign neglect

• Some will choose this route of treatment, though depends on the client’s preference

• Will wait 3 months to see if it will resolve Immunoregulin

• Has been used and appears to keep papilloma at a status quo

• Individual reports that in one patient it did not cause remission, but did get worse when stopped

• Individual reports have used it once with no success

Concerns for reactions Papilloma Vaccines

• Recommend typing with Georgetown University then obtaining a vaccine for the particular type

you are treating

• Vaccines are recommended for young dogs

• Vaccine success

Not many people use this treatment modality; best used as a preventative

Some success, yet not very much

Individual reported using it in 6-8 patients with no response

At a multi-specialty hospital, individual reports the oncology department uses the vaccine

quite frequently. Is unsure of the success rate

• Georgetown University/Vaccine protocol

Sample is sent dry within a sterile blood collection tube

Typing and vaccine for about $350 (?)

Not recommended for treatment, but as a preventative medicine

BIG QUESTION: How do you really know that the vaccine is preventing?

Would it stay resolved/in remission without the vaccine?

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• Recombinant vaccine

5 doses every 2 weeks NOT autologous

If it is autologous, there are concerns for the vaccine to induce papilloma at the site

where the vaccine is administered Immune suppressive medications and Papilloma

• Apoquel and/or steroids

Many are not as worrisome, since once the medications are stopped, the papilloma seems to

resolve on its own.

• Recommend substitute treatment for allergic disease

IDAT and subsequent immunotherapy Cytopoint

• Not seeing as many cases of this kind vs. natural occurrence with no immune suppressive

medications on board

• Most individuals that encounter papilloma virus in older patients not receiving immune suppressive medications, have stopped looking for underlying disease process or cause of suppression as they do not often find much on investigation

Transformation of Papilloma

• Many are seeing this more increasingly with canine papilloma

• Individual report (same case mentioned above with Boxer) saw transformation with

Papilloma virus type 10

Question: If we typed more of them would we identify transformation for certain types?

Typically, oral papilloma is type 1, and have seen transformation for oral lesions

• Many find that oral and digital papilloma are more likely to transform to SCC

Multiple people have diagnosed this clinically

• Best way to diagnose transformation

Biopsy initially confirms papilloma then biopsy later (after no response or progressive lesions)

confirms squamous cell carcinoma

• Individual report; traumatized papilloma seems to transform more frequently

If the lesion is large on the paw or in the mouth that is being chewed on by the dog

• Few incidences have been seen ‘Corns’ in greyhounds

• Could this be Papilloma?

Typically, on biopsy there are no consistent cytopathic changes, but papilloma is often suspected

• Treatment

Recommend to core them out with biopsy punch

• Often see reduction or resolution of limping (paw) Individual report

• Will try to identify if the corn is causing the limping vs. other disease

• One case: corn was removed, patient continued to limp, on radiographs an osteosarcoma

was identified

• Recommend performing a ring block on the affected toe

• If the patient stops limping, then the corn is the cause of limping and recommend moving forward with surgical removal

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ROUNDTABLE SUMMARIES

• Low dose interferon

• Silver nitrate used on the lesion after removal • Azithromycin

Inverted papilloma

• Good response to imiquimod

• Individual reported using topical Imiquimod on inverted papilloma for initial treatment; worked

very well after one relapse.

At third relapse, did not seem to be responding well therefore toe was amputated and con

firmed squamous cell carcinoma (transformation) Environmental cleaning and contagious nature

Even when the papilloma lesions are resolved, the virus is still in the

skin therefore relapse is possible

• Most feel once the papilloma lesions are resolved, the virus is not active and would be less likely to

be transferred

Though if there is a low grade shedding, transmission to other dogs is still possible

• Oral papilloma in young dogs appear to be more transmissible

Many recommend isolation/reduced contact in these cases

Avoid dog parks, groomers, etc. until no visible lesion

• There is still a small risk even when lesions are not visible – Carriers can be seen in cases where

relapses have occurred after papillomas had been completely resolved

• Hard to rely on the owner to make sure they are all gone, recommend patient is evaluated

by veterinarian

• Some feel the virus is ubiquitous anyway, therefore most animals are likely to be in contact

with the virus

• Doggy day care outbreaks

When multiple dogs come down with this virus, usually these patients have a

decrease in immunity

Oral papilloma outbreaks in doggy daycare is threatening and scary for the clients, daycare

providers and patients

Some feel they see more cases of papilloma due to the use of doggy day care facilities

• Cleaning the facilities

Recommended bleach or Rescue for cleaning of the hospital

Room used should be shut room down “for a bit”

• When there is a relapse, is it the same type/strain of virus?? Or is it different?

Two types 1 and 10 in that Boxer above

• Clinically they looked the same everywhere except the mouth; the only ones that looked different

were the ones that appeared to be transformed

• Individual participants story of sister’s papilloma virus disease (human)

• Located on sister’s lip when she was very young

• Treatment consisted of blister beetle juice (cantharidin)

Her skin was eroded, but the lesion resolved

Relapsed 30 years later in the same spot

Question: Could we consider using cantharidin for Greyhound corns or other possible

papilloma virus treatment?

Bowens (squamous cell carcinoma in situ)

• Most feel treatment with imiquimod is partially helpful

16

15 ROUNDTABLE SUMMARIES

• Many recommended CO2 laser as a treatment modality

• Few will refer to oncology department

Unsure of the treatments of these referred patients, but individual reports indicated they

seem to do well

Some oncology departments will use Palladia

• Seem to have a longer time of recurrence

Treatments

• Imiquimod

• Recommend using topically until the lesions resolved (in owners’ eyes), this typically

will take about 4 weeks

• Often will see improvement within the first week

• Dosing

• Recommend daily to every other day to three times weekly

• Inflammation at application site seems to be a good prognostic indicator for beneficial response

• Appears to be less expensive now Side effects

• Vomiting

• Liver value increase

• Are side effects more related to ingestion vs. topical absorption?

Unknown at this time

Many will not use if the animal can ingest /lick the imiquimod

Concern for possible inflammatory reaction in the esophagus

Horses and Sarcoids

• Imiquimod

Recommended for treatment

Individual report of one case with continual application, created large ulceration in the area,

treatment was discontinued, though once healed the sarcoid was gone

• Based on this, recommend continual application until 80% resolved and then stop (have stimulated

the immune system to take care of the rest)

• Treatment recommendations depend on type of sarcoid

Most are only clinically diagnosed and not biopsied Feline sarcoid

• Immiquimod

Recommended for small lesions, will not work on big lesions

• Must wear a cone to prevent ingestion

INITIAL TX/GO TO FOR TREATMENT

• Depends on severity

• Biopsy if want to know dx 100%

• Oral Medications

Cimetidine, Lysine, Azithromycin combination

• CO2 Laser for surgery

• Make sure patient is not receiving immune suppressive drugs

Discontinue Apoquel or other immune suppressive medications

Report them to Zoetis if on Apoquel

• Cytopoint seems to do ok without causing papilloma viral infections

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ROUNDTABLE SUMMARIES

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ROUNDTABLE SUMMARIES

Immunosuppressive Therapies Moderator: Dr. Elizabeth Layne Article: Review of Immunosuppressive Therapies in Dogs and Cats, Veterinary Clinics of North America, Viviano, 2013 Most of the therapies were discussed in the context of treating pemphigus foliaceus(PF), though other autoimmune diseases were mentioned, noted below.

Glucocorticoids: • It was discussed that a number of participants work with internists who have an upper limit on the amount of prednisone they give to dogs. This ranged from 40mg to 80mg per dog per day, regardless of the dog’s body size. Generally, the dermatologists said they do not adhere to this limit. One participant said she never gives more than 40mg per dog per day, mainly due to concerns about side-effects; this participant adds azathioprine often for control of PF.

• Nobody has been able to obtain a reference for this limit. Some hypothesized that this might be due to internal medicine specialists needing to use higher doses for longer duration for systemic autoimmune disease.

• The preferred long-term dose of prednisone in the group is 0.5mg/kg every other day.

• High-dose prednisone induction therapy: a few participants have used this therapy. One uses it regularly for dogs with PF that are severely affected; 10mg/kg is given daily for 3 days then 1mg/kg is given daily with a few weeks between cycles. Gastroprotectants/anti-ulcer therapies are not routinely used.

• PredniSOLone in dogs instead of prednisone: some people have made this change with the impression that some dogs respond more quickly; there are some internists who advocate this also.

• Dexamethasone and triamcinolone were discussed as alternatives to prednisone. Fewer hepatic side effects were cited as a reasoning, also better/quicker response in some animals that are refractory to prednisone.

Nobody has seen increased incidence of calcinosis cutis.

• Dexamethasone sodium phosphate injectable solution is being used per os in cats.

• Dose of triamcinolone for induction of PF remission: 0.2mg/kg dogs, 0.2-0.6mg/kg cats.

• Dexamethasone is tapered to every other or every third day.

• Triamcinolone cream was discussed as an affordable/easily accessible option for focal treatment of persistent PF lesions.

• Betamethasone dipropionate ointment was also discussed for focal lesions; it is currently on back order.

Azathioprine • Some participants limit to 1mg/kg every other day, some to 2mg/kg, some never use it daily, some start daily and taper to alternate-day.

• Hepatic adverse effects were discussed; experience was varied.

• It was mentioned that some had experienced severe adverse effects combining doxycycline and azathioprine.

Mycophenolate mofetil • Not many in the group have used it; those who have report variable effectiveness, almost always as sole therapy. Concerns included cost, gastrointestinal adverse effects (primarily diarrhea). Those who have used it did so on the recommendation of internists.

• Monitoring has consisted of complete blood count and serum chemistry after the first month; keeping in mind this was combined with corticosteroids.

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ROUNDTABLE SUMMARIES

Cyclosporine/Tacrolimus • There was minimal discussion of cyclosporine. It was mentioned as having been used in combination with other therapies for various refractory cases of PF with no dramatic improvement.

• It was reported that some internal medicine specialists are using it at 10mg/kg per day or twice daily (20 mg/kg total per day).

• Tacrolimus ointment was reported as effective as sole initial therapy for perianal fistulas; it has been used effectively as a compounded spray.

• It was reported that Protopic has been discontinued so generic tacrolimus is being used.

• Tacrolimus is not available in Australia so pimecrolimus is used.

Chlorambucil • One participant reported successful use of compounded chlorambucil as a steroid-sparing agent in large dogs with PF, alternate-day dosing with prednisone.

Oclacitinib • Some participants reported the addition of oclacitinib at label dosing to treatment regimens for PF appeared to reduce pruritus and lesion severity.

• One participant reported using it for a case of uncategorized vasculitis in addition to other therapies, and having positive response in cases of rhinitis.

• One participant reported that the addition of oclacitinib for treatment of atopic pruritus appeared to provide resolution of DLE lesions.

• There was discussion of using oclacitinib in cats, primarily for treating allergic signs, at 0.8- 1.3mg/kg twice daily; one participant has owners dissolve the tablet in water and mix with canned food. This appears effective.

Doxycycline: • There was brief discussion of doxycycline-associated photosensitivity; two participants had had cases where they believe this occurred.

Hydroxychloroquine • There was also brief discussion of hydroxychloroquine; very few participants had used it.

• One reported no evident adverse effects, but no therapeutic benefit, for ECLE (exfoliative cutaneous lupus erythematosus).

• One reported no effect for DLE. • One reported good response when used in combination for ECLE. Leflunomide • One reported good response in cutaneous histiocytosis; monitoring of blood levels was not performed.

It was started at 3mg/kg every other day with cyclosporine. Lab work remained normal • Some experience with positive response for PF, IMPA (immune-mediated polyarthritis).

IVIG (intravenous immunoglobulin G) • Very few participants had experience with it, primarily due to high costs ($600 for a small-sized dog). While PF lesions responded, they returned within 10 days or so. One participant had experience with it in humans for an autoimmune neuropathy; there was rapid remission but rapid recurrence so it was administered every few weeks. The concern was expressed that dogs would likely develop hypersensitivity because it is a human product.

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ROUNDTABLE SUMMARIES

Rituximab (monoclonal anti-CD20 [B cell] antibody: One experience using it for PF, similar rapid remission of lesions but rapid recurrence.

Dapsone: one historical experience with PF, no recent use.

Infectious disease: It was asked if anybody in the group routinely screens for regionally important infectious diseases prior to or during immunosuppressive therapy. The response was generally no. PCR for infectious agents was discussed; there is a new commercial lab offering this. It was discussed that various university pathologists or microbiologists have varying opinions on the utility due to possibility for detecting environmental contaminants and false-positive results.

Allergy Testing Roundtable Moderator: Dr. Jon Plant Attendees agreed that allergy testing is mainly useful for choosing allergens for allergen immunotherapy (AIT) and should not be used to make the diagnosis of atopic dermatitis. Attendees gave examples of clinical situations in which allergy testing guided successful avoidance of allergens. Examples included sensitivity to storage mite (dry food), cedar (cedar bedding), and house dust mite (old couch, dog beds, stuffed toys, car upholstery).

November and March allergy peaks were said to correlate with HD mite sensitivity on the U.S. west coast.

Allergy testing for foods is not generally recommended by the attendees. Examples of poor repeatability were given. Some stated that clients request serum allergy test panels including foods because they are familiar with them being used in human medicine. A few attendees provided examples of positive allergy testing to foods which did correlate with the clinical findings. It was pointed out that this may happen by chance.

Intradermal testing (IDT) was generally preferred over serum allergy testing (SAT) for dogs, but many in attendance preferred SAT for cats due to the subtle reactions observed with IDT. When initially setting up IDT panels, allergens are selected based on the local prevalence of plants, cross reactivity of allergens, allergen manufacturer resources, SAT laboratories’ panels, human allergists’ panels, and experience of other veterinary dermatologists practicing in the area. Some revise their tests every 5-7 years.

Most in attendance test for both dust mite species separately and see about 50% cross reactivity. Dilute allergens for testing are replaced every 4-6 weeks. Most attendees use new syringes and needles for each patient; one re-uses IDT testing syringes on multiple dogs. Most of the attendees use dexmedetomidine sedation for IDT in dogs and add ketamine and butorphanol in cats. Most of the attendees interpret IDT reactivity on a subjective 0-4 scale, based on size, turgor, and erythema. 2+ reactions are considered positive by most.

Most attendees interpret SAT reactivity of each allergen relative to the overall reactivity of the test, rather than strictly following the laboratory cutoff values. In a young dog or cat, waiting for all 4 allergy seasons to pass is preferred by most for SAT and IDT. Attendees generally considered tests with fewer positive reactions more meaningful than those with mostly positive reactions. If clients ask about the accuracy of allergy testing, most attendees preferred to move the discussion to the outcome of the therapy. Attendees discussed the reported false negative rate of IDT being 15-25%. A mention was made that we may need to pay more attention to latephase reactions and ask clients to send photos 24-48 hours after testing.

None of the veterinarians in attendance routinely recommend both IDT and SAT, but many use SAT as a backup to IDT when it is negative. Most attendees perform IDT year around, without regard to the patient’s seasonality. Some will take previously performed SAT results into account when formulating AIT. Attendees recognized that there are differences between SAT laboratories in terms of the proportion of allergens that are reported as positive, in general.

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ROUNDTABLE SUMMARIES

Open forum to discuss business related topics Moderator: Dr. Rosenberg As business topics were discussed and people requested anonymity, full names will not be included in the summary.

Introductions: Everyone introduced themselves and their affiliation Moderator: Does anyone have any opening thoughts?

Attendee #5 worries that as groups like VCA buy more specialty companies, will it get to a point where Mars general practitioners only refer to Mars specialty practice and only use certain labs. Will HMOs be started?

Attendee #1 works for a corporation and feels that GPs will still refer to the specialists they select and prefer aside from the affiliated corporations. If she were to leave and open up her own business would they refer to her or not?

Attendee #6 says that corporations do not think they are missing out on a lot of income by not employing a dermatologist.

Moderator: What we can do to combat the increased buying power of corporations.

Attendee #1 feels that dermatologists need to market directly to the public.

Attendee #3 is navigating between corporations like Blue Pearl and GPs. Attendee #3’s feeling is that if they pull a Blue Pearl dermatologist to her area, that it would be hard for her patients to jump ship.

Attendee #6 believes that as a dermatologist you can go to any region of the country to open a practice.

That makes recruiting to a region that is not that desirable much harder. She feels that dermatologists are also very independent individuals and more likely to start their own businesses.

Attendee #5 and group feels that this is refreshing to hear.

Attendee #6 feels that dermatologists should do what they want to do with regards to independent business and not be concerned about corporations providing serious competition.

Attendee #7 is concerned about independent dermatologists competing with each other. Important to be as good as we can to each other.

Attendee #1 feels that dermatologists should market directly to the public.

Attendee #5 says that he markets to the public online.

Attendee #3 feels that it is very important to have a big sign outside so people can see it and come in directly. The sign on the road grew her business by 2 - 3 times.

Attendee #7 says he painted his sign a bright green which significantly helped to attract clients.

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ROUNDTABLE SUMMARIES

Attendee #6 says that her marketing dollars went a long way when she was part of a group but now as an independent dermatologist she cannot advertise as much. She feels that Facebook and social media is very important to attract business. Attendee #5 agrees.

Attendee #3 wants to know if you have to get permission from the owners to post pictures of their pets.

Attendee #5 has owners sign off on their intake forms an approval for posting pictures. You need a signed authorization to treat in some states Attendee #7 puts in his authorization a note that not all of the medications he uses are FDA approved.

In California, there is a new law that you have to give a consult on drugs as if you are a pharmacy.

Attendee #3 wants to know what to do about online pharmacies. Should dermatologists stop selling drugs and mark up the exams? There is no way to compete with chewy.com.

Attendee #6 says that VIP and Pet IQ have merged in rural areas and they are going to be opening practices in WalMarts where the vet won’t carry any prescriptions. Companies cannot refuse to sell a drug because the WalMarts have vet practices now. Attendee #6 says that Zoetis has promised not to sell cytopoint to online pharmacies. She will sell Cytopoint to her good clients who can give it at home or else they will go to the vet across the street.

Moderator: What should we do as independent small practice owners to increase our buying power and counteract those things?

Attendee #3 believes having a veterinary dermatology business group to decide how to combat the corporate takeover would be appropriate. Attendee #3: As a college, we need to decide what our stance on many things are. What about telemedicine? It is happening whether we like it or not and we need to be ready. As a college, do we need to focus only on services and no longer rely on pharmacy. We need to shift away from selling drugs. We will have to sell our brains because that is all we really have.

Attendee #1 will tell her clients that selling drugs are our living and people understand. She also tells owners about situations in which pharmacies make mistakes with the prescriptions and patients have died.

Attendee #6 feels that we have become a strictly service profession. She has kept her mark-ups reasonable because she cannot compete with chewy but she is reasonable. She recently opened her own online pharmacy. She mails a lot of medications to clients.

Attendee #5 uses “Vet’s First Choice” but just for food and sells it at a reasonable price- he does not make much money off of selling food. His thought process was that he does not want people to buy food from chewy and see that they can buy drugs and shampoos for less money.

Attendee #5 wonders whether the College could make a position statement on how we do not support the online pharmacies. Dr. Sargent feels that making a stance like that would make the ACVD look bad given the pet owner’s fairness act.

Attendee #6 is very excited and happy with her e-commerce site. Attendee #3 wants to know how to start an e-commerce site. Attendee #6’s practice manager started it for her.

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ROUNDTABLE SUMMARIES

Attendee #6 reiterates the point that Facebook is free advertising and very important. Facebook provides a free marketing platform. Attendee #6 knows what gets the most hits- personal pictures, before/after pictures, cute kids- people love those kind of pictures. Intersperse that with educational things. Have a link for learning about otoscopy.

Attendee #7 wants to know where we are these days with compensation.

Attendee #3 is the medical director of her practice. She said doctors fight with each other over the procedures and money. “Off the record” discussion ensued.

Attendee #6 wants to know if anyone has read the Mayo Clinic book- they have a completely different way of compensating their physicians and it makes a better culture. GPs have it even worse in that they are often involved in negative accrual.

Attendee #6 does not see the corporate model working.

Attendee #3 says that there is a good book called “Profit First.” The book recommends making four separate accounts. Helps with a budgeting.

Meeting adjourned.

Kral Award Nominations Now Being Accepted The AAVD Board is inviting nominations for the 2020 Frank Král Award for Achievements in Veterinary Dermatology. Deadline for submission is December 2, 2019.

In January 1964, Drs. Frank Král, George Muller, James Conroy and Robert Schwartzman met in Philadelphia, Pennsylvania to discuss the possibility of establishing an organization dedicated to the practice of veterinary dermatology. The outcome of the meeting was the founding of the American Academy of Veterinary Dermatology (AAVD) with Dr. Král assuming the first presidency. Dr. Král was elected as the first AAVD Life Member in 1971. He also received the first AAVD Dermatology Achievement Award for outstanding contributions to veterinary and comparative dermatology, given at the Dermatology and Allergy session of the American Veterinary Medical Association meeting in 1973. Unfortunately, the achievement award was not continued. The AAVD Board has re-established an annual achievement award in veterinary dermatology, named in honor of Dr. Král.

Eligibility and selection criteria for the Frank Král Award for Achievements in Veterinary Dermatology are described on the Call for Nominations. You are invited to nominate one or more deserving individuals by submitting a nomination form for each nominee along with their curriculum vitae or résumé, and three (3) supporting letters from other colleagues. Please give this matter careful consideration and help us develop a slate of outstanding nominees for this important award. Contact info@aavd.org with any questions.

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ROUNDTABLE SUMMARIES

Cytopoint Updates Moderator: Dr. Ben Tham

Question and Answer Session

What is your biggest challenge concerning Cytopoint usage in your practice?

Majority of the participants stated that in spite of Cytopoint treatment, many of the dogs still developed a secondary skin infection (bacterial and/or yeast), which later leads to pruritus and gives the owners the wrong impression that Cytopoint is not effective. A few participants were concerned with the incidence of immune-mediated diseases which was alleged to occur after Cytopoint injection.

How familiar are you with the mechanism of action of Cytopoint?

All participants were familiar with the mechanism of action of Cytopoint.

How many of you have used Cytopoint in your practice?

Majority have used or have access to Cytopoint at their practice. A participant from Sweden stated that Cytopoint was only recently available in her country and although she has used them in some of her patients, she hoped that she would gain more knowledge and tips on Cytopoint therapy from this discussion.

When presented with a pruritic dog, what makes you use Cytopoint over other treatments?

Two participants prefer using Cytopoint in young dogs (less than 12 months old) because it is not contraindicated for dogs in this age group, unlike other antipruritic drugs such as oclacitinib (Apoquel) which is labeled to be safe only for dogs 12 months old and above. The side effects of glucocorticoids and possible immunosuppression when used in puppies also influenced their decision to use Cytopoint in young dogs.

Other participants stated that the decision to use Cytopoint depends on the skin disease status of the dog when presented: if there is a secondary skin infection, this would be treated first prior to Cytopoint injection.

How many of you will select Cytopoint as the first-line therapy for canine atopic dermatitis?

All participants stated that their decision is on a case-by-case basis. One participant uses Cytopoint if allergen-specific immunotherapy (ASIT) was declined. Another participant recommends Cytopoint in geriatric atopic dogs where the long onset of ASIT makes it not practical as a treatment option.

What is the success rate of Cytopoint injection in eliminating or reducing pruritus to a satisfactory level?

All participants agreed that it is effective for at least 70% of cases. However, some of the participants noted that in spite of the remission or reduction of pruritus, some patients continue to develop secondary bacterial and/or yeast infection. One participant stated that one should interpret the efficacy of Cytopoint in the light that most general practitioners (GPs) do not assess the reduction in pruritus based on any validated pruritus scale (i.e., PVAS, CADLI) and therefore the comparison of pruritus pre- and post-Cytopoint injection may be under- or over-appreciated.

How fast does Cytopoint work?

Majority stated that the antipruritic effect of Cytopint can be appreciated within 24-72 hours of administration. One participant stated that in one dog, the pedal pruritus resolved but the dog was still scratching on the flanks.

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ROUNDTABLE SUMMARIES

How long does the antipruritic effect of Cytopoint last? (i.e., How frequently do you need to administer Cytopoint?)

Majority of the participants administer every 4-6 weeks, but many agreed that the frequency of administration depends on the seasonality and the allergic status of the dog. During the allergy season, some dogs required more frequent injections.

If the first Cytopoint injection appeared to be ineffective and there is no secondary skin infection, do you increase the dose of Cytopoint or start another anti-pruritic therapy?

All of the participants would increase to the maximum dose before recommending other therapies.

Do you select the dose based on the dosing chart or calculate based on mg/kg? If the latter, what is the dosage?

Almost all participants calculate the dosage based on mg/kg. It was pointed out that in Europe, the recommended dosage is 1mg/kg. One participant asked about the reason for the differences in the recommended dosage in USA versus Europe and another participant (who is affiliated with Zoetis) replied that the discrepancy is due to local requirements of the regulatory body involved in approval of the drug dosage. One participant from Sweden said the antipruritic effect of 1mg/kg dosage does not last as long as the higher dosages.

Do any of you dispense Cytopoint to owner for them to administer at home?

Majority of the participants do not dispense Cytopoint for the owners to administer at home. The reasons include concerns about stability of the drug (due to the need to refrigerate) and the possibility of owner misusing it (i.e., administering it to another dog). However, one participant argued that dispensing Cytopoint for owners to take home is no different from dispensing other oral drugs (i.e., oclacitinib and prednisone), and therefore there should not be any issue of the owners misusing it. One participant from Vancouver reports that on one occasion, there was a sudden surge in the numbers of injection failure reported; further investigation revealed that the perceived lack of effectiveness was due to the failure of veterinary technicians (that administered the injections without the presence of a veterinarian) to identify the presence of a secondary skin infection at the time of injection.

What are the adverse effects of Cytopoint? How soon did it develop? Did it develop after the first injection or only after subsequent injections?

The most common adverse reaction seen (or reported by the referring veterinarian) after the first dose of Cytopoint was hives (2 participants), angioedema (2 participants) and nausea-vomiting-fever (1 participant).

These adverse effects developed within 24 hours for the former two, and within 3 days for the latter. Some participants have seen dogs that only developed adverse reaction when receiving the 2nd or subsequent dose(s). Several participants reported a cutaneous adverse reaction (erythema) in a few dogs, whereas at least 3 participants have experienced or heard from an Internist about some dogs that developed immune-mediated hemolytic anemia (IMHA) subsequent to Cytopoint injections. One participant said that the IMHA developed one week after the Cytopoint injection. Another participant who is a general practitioner with special interest in dermatology, have not seen IMHA in dogs that were given Cytopoint but have seen more incidence of IMHA due to vaccination.

All of these adverse reaction cases were reported to Zoetis.

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ROUNDTABLE SUMMARIES

All participants agreed that the incidence of immune-mediated diseases after treatment with Cytopoint could be multifactorial (genetic, interaction with other concurrent drugs i.e., epitope spreading) but collectively agreed that everyone must continue to be vigilant in detecting the adverse reaction (i.e., owner should be educated to report any possible adverse reaction immediately, technician should be trained to get good history and detect the “red flags” before administering subsequent Cytopoint injections) and report them to Zoetis.

Does the efficacy of Cytopoint reduces after repeated injections?

All participants have observed that in some patients, the effectiveness of Cytopoint reduces over time and in most cases, the perceived lack of efficacy (e.g., increase in pruritus) was due to a secondary skin infection.

Another reason for the presumed treatment failure is when it was given during a seasonal flare. One participant affiliated with Zoetis stated that each molecule of lokivetmab can only bind to 2 or 3 molecules of interleukin (IL)-31, and during a seasonal flare, there could be an “overload” of IL-31.

Have you ever treated a non-atopic pruritic dog with Cytopoint? (i.e., cutaneous adverse food reaction, scabies, flea allergy dermatitis, cutaneous mastocytosis, cutaneous lymphoma).

How effective was it?

A few participants stated that Cytopoint is effective for scabies and flea allergy dermatitis. One participant had a dog presented with periauricular pruritus without skin lesions and was treated with Cytopoint injection. On a recheck appointment 4 weeks later, the pruritus had resolved but the pinnal margins were crusty; sarcoptes scabies was subsequently diagnosed via skin scrapes.

Some participants reported that pruritus in dogs with cutaneous adverse food reaction (CAFR) responded to Cytopoint injection but majority agreed that it is difficult to make any conclusion because a dog with a CAFR that supposedly responded to Cytopoint, may also have concurrent canine atopic dermatitis (AD).

Do you use Cytopoint as an antipruritic treatment during the initiation of an elimination diet trial?

Majority of the participants have no issue using Cytopoint at the beginning of the elimination diet trial because the dogs were kept on the elimination diet trial for 12 weeks and by then, the antipruritic effect of Cytopoint would have worn off. However, one participant was concerned that Cytopoint may affect the outcome of an 8-week elimination diet trial. Finally, one participant shared her experience that Cytopoint injection was effective in controlling the pruritus associated with mast cell tumor in one dog.

What is your main takeaway from this roundtable session?

All participants agreed that client education is the most important factor and stated that Cytopoint is not the cure for canine AD but just another antipruritic therapy. It is important to monitor secondary skin infection while on Cytopoint therapy and listen to owner’s feedback on the possible adverse reaction especially with technician appointments.

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ROUNDTABLE SUMMARIES