Derm Dialogue - Spring 2019

DERM DIALOGUE Editor: Norma White-Weithers, MS, DVM, DACVD m 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

SPRING 2019

FROM THE PRESIDENT Dear Colleagues, I hope to see many of you at the NAVDF meeting in Austin. Please include in your plans to attend the AAVD members’ business meeting on Saturday, April 13th, over the lunch hour. A boxed lunch will be provided for members attending the AAVD business meeting.

Dr. Outerbridge

I want to take a moment to update you that we have a new AAVD Executive Secretary, Jason Harbonic. Please be sure to welcome Jason when you see him at NAVDF. I also want to thank on behalf of all AAVD members Libby Dietrich, who has served as the AAVD executive secretary the past few years. We are grateful for all Libby has done for the AAVD and wish her every success in her new endeavors.

As you look over this edition of the Derm Dialogue, and read the insights shared from the last of the NAVDF roundtables that occurred in Maui, I know that the AAVD membership can look forward to reading about what was discussed at roundtables in Austin in future editions of Derm Dialogue.

This year the AAVD funded 24 student awards, bringing the total to 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. It is our hope that these awards will foster a lifelong interest in veterinary dermatolContinued on page 8

ROUNDTABLE SUMMARIES Isoxazolines

Moderator: Paulo Gomes DVM Participants Paulo Gomes, DVM, DACVD (Moderator); Brooke Simon, DVM (Secretary); Ms. Heather Carmine, Michael Charach, DVM, DACVD; Angela Everett, DVM; Valerie Fadok, DVM, DACVD, PhD; Katrina Frost, DVM; Michael Hannigan, BVMS; Janet Littlewood, BVSc, MA, PhD, CertVD, DVD, DVR, MRCVS; Linda Messinger DVM, DACVD; Lynn Schmeitzel, DVM, DACVD; Sheryl Scolnick, DVM; Mimi Seo, BA; Liora Waldman, BVM&S, CertSAD, MRCVS; Rebekah Westermeyer, DVM; Caitlin Wright, DVM; Lerpen Duangkaew, DVM; Janet Wojciechowski, DVM, DACVD; Robin Baldwin; Thitirat Chaimee, DVM; Maturawan Tunhikorn, DVM; Teresa Koebke, DVM. Discussion Points i. Quick Background on Isoxazolines: Isoxazolines were originally developed for agricultural use. However, when investigators tested them in the field (literally in the field), they were not as effective as initially expected. Then, companies started synthesizing isoxazolines for flea/tick control in pets. ii. Isoxazolines and the modern flea/tick control: Speed of kill and residual speed of kill are a huge draw for most doctors. Broad spectrum of control is helpful as well as most doctors are dealing with not just fleas or tick, but rather a combination of the both. Isoxazolines are appreciated to have helped dramatically in flea endemic areas. Some doctors have found that dogs tolerate the oral formulations very well (in terms of palatability) whereas others suspect up to 1/3 do not eat it readily. iii. Regarding appeal to owners: topically applied products tend to show obvious wetting of the hairs, which can be inconvenient for some clients. The orals might help them to overcome this issue. In some instances, the lack of need for monthly application/re-application in addition the easy oral administration of the chews may be contributing for owner compliance and adherence to isoxazolines.

1. Tick efficacy with Isoxazolines: • Participants agree that there is a current need for products that help with tick control, especially as the Amblioma americanum (lone star tick) is making its way across the US. It was noted that not every tick is equally susceptible to isoxazolines. For instance, treatment efficacy for A. americanum may be not be same at the end of the treatment period. Also, this tick has been the limiting factor for product efficacy. An example given was with Fluralaner that has a product label of 8 weeks for A. americanum and 12 weeks for the other tick species this product covers. Good success has been seen with the use of isoxazolines in dogs housed in premises infested with Rhipcephalus sanguineus (brown dog tick) after treatment failures with topical products, as ticks located in the interdigital spaces and ears are exposed to therapeutic concentration of isoxazolines after a blood meal. According to most participants it seems that the oral isoxazolines are doing a good job on tick management and prevention of tick-borne diseases due to their rapid killing effect. • Internationally, both in the UK and Thailand have a similar emergence/prevalence of ticks with concern for tick-born disease as well.

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2. Isoxazolines phamacokinetics: • A participate questioned. Do we know if it is incorporated into the hairs? Or the epithelial cells?

It was commented that after oral administration there is a strong correlation between isoxazolines plasma concentration and product efficacy, and that the parasites have to feed on the host for it to work. Though it is possible that the medication is going to work its way through the dermis/layers of the epidermis and eventually to the surface, apparently it has not been investigated yet. This may be a potential source of future studies in order to assess concentrations/presence of isoxazolines within the layers of the skin.

3. Off label use of isoxazolines in dogs and cats: • It was mentioned that most products containing isoxazolines have studies showing efficacy of treating canine demodicosis, sarcoptic mange, and otocariasis caused by Otodectes cynotis in cats at the product label dose. One study used afoxalaner product every 2 weeks instead of monthly for generalized demodicosis with success.

• It was asked if anyone has experienced treatment failures for common parasitic mites using isoxazolines. One doctor in New England USA finds that it may not work fully in scabies cases. She had to use ivermectin additionally in one case to help to treat it as lesions persisted. Another doctor consulted on a case that seemed refractory demodicosis to fluralaner. Another participant mentioned in growing puppies before declaring treatment failure it needs to be taken into consideration that fluralaner product may not last as long as their body mass is changing.

• Another case presented was a dog being treated for Cushing’s disease that required fluralaner every 3 months or demodicosis would recur. It was pointed out that in the UK it is advised fluralaner treatment every 12 weeks, not of every 3 months, as the treatment interval is not necessarily the same and it is more accurate for dosing according to the manufacturer.

• When using isoxazolines for demodex (esp. fluralaner) how often the present clinicians have been monitoring their patients with skin scrapings after initiating therapy? Most participants answered monthly skin scrapings in the absence of complicating factors. Some doctors will recheck skin scrapings 6 weeks after dosing fluralaner product.

4. Off label use of Isoxazolines for demodicosis in feline medicine: • There is a report regarding the use of a single oral dose of 28mg/kg of fluralaner that was effective to treat feline demodicosis (Demodex cati). Negative skin scrapings were obtained in 30 days. (Matricoti et al, 2017).

• One of the participants presented a case of shelter cats successfully treated with fluralaner for D. gatoi. The infection was diagnosed by fecal flotation and superficial skin scrapings. After treatment failure with topical parasiticides, the cats were treated once with doses that ranged from 26 to 34mg/kg orally.

The clinician noted that at the time of the treatment, topical fluralaner for cats was not available, therefore she has used the oral chewable product for dogs. Skin scrapings repeated at two and three months were negative. At six months follow-up the cats were still lesion free. No adverse effects were noted. This case was recently published in the veterinary dermatology journal as a letter to the editor.

• Regarding the use of fluralaner to treat D. gatoi many participants mentioned that a single oral dose seems to be all that is required. On the other hand, one participate mentioned that some cases may require every 2 months dosing.

5. Off label use of isoxazolines for cheyletiellosis and lice infestations: • Sarolaner has been used monthly by many participants to successfully treat cheyletiellosis. It was mentioned that in the listserv there are a few reports of Fluralaner used successfully in several canine patients with cheyletiellosis. A single dose with environmental treatment. No treatment failures reported.

• Doctors in Colorado US also have used Sarolaner monthly to successfully treat sucking/biting lice infestations. Lice at dog daycare seems to be making a comeback per many doctors present.

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6. Question posed by participate: What is the experience with harvest mites (Neotrombicula autumnalis) and use of isoxazolines?

• A colleague from the UK mentioned that in Huntington harvest mites are seen on a seasonal basis, and clinicians in the UK believe that they had less cases due to perceived increased use of Afoxalaner.

7. Efficacy on the treatment of maggot infestation with isoxazolines?

• Afoxalaner has worked very well for maggots in canine and feline patients by some participants.

• Additionally it was asked if isoxazolines in rabbits would be an option as a preventative/treatment of maggots. No participate in this roundtable have used isoxazolines in rabbits. However, it was brought the discussion that there is a paper on the use of isoxazolines in rabbits. Sheinberg, G et al. “Use of oral fluralaner for the treatment of Psoroptes cuniculi in 15 naturally infested rabbits” Vet Dermatol March 2017. In this report fluralaner at 25 mg/kg was effective to treat Psoroptes cuniculi over a 90 day period.

8. Use of isoxazolines for sarcoptes in pigs: • One of the participants mentioned that there are anecdotal reports of the use of Afoxalaner (2 doses, 30 days apart) in Vietnamese pigs with sarcoptic mange without adverse effects and the use of Fluralaner in a porcupine with great success.

9. Use of isoxazolines for chickens: • It was noted that it would be great to assess the efficacy in treating Dermanyssus gallinae in birds. It was brought to the group’s attention about a study by Thomas, E. et al. “Field efficacy and safety of fluralaner solution for administration in drinking water for the treatment of poultry red mite (Dermanyssus gallinae) infestations in commercial flocks in Europe”, 2017. It was found to be very effective and safe in chickens.

10. Other papers regarding fluralaner: • 15 mg/kg fluralaner was found to be effective for the treatment of Caparina tripilis in pygmi hedgehog (Romero et al, 2017).

11. The use of Isoxazoline products during food trials/in food allergic animals?

• One participant will use afoxalaner product through a food trial, which contains soy protein. Others will use fluralaner product at the start of the diet trial, and therefore the patient will not require another until after the diet trial is completed. It was mentioned that fluralaner product is the only isoxazolines chewable that is hydrolyzed pork flavored, however the molecular weight of the protein is unknown. It was noted that lotilaner and sarolaner products contain non hydrolyzed pork liver.

12. Side effects experienced with isoxazolines: • Some participants noted gastrointestinal upset, however giving with a meal may help to avoid vomiting. Seizures have been listed as a possible side effects for some of the isoxazolines products, but none of the participants have had any increase in seizures with patients who had previously diagnosed epilepsy.

• One participant reported a cat that had vomiting, lethargy with topical isoxazolines product. The same cat had previous reactions to other topical products. When the dermatologist saw the cat she had excoriations and alopecia surrounding the site. Biopsy of the cat returned as “allergy”. Also non-pruritic alopecias have been noted after applying the topical versions of isoxazolines. Drug-induced pemphigus attributed to isoxazolines have not been seen or any anecdotal report heard by any participant.

• Overall participants find isoxazoline products very safe.

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Multidrug resistance in the Dermatology Clinic Moderator: Amanda Friedeck BS, LVT

Multidrug resistance is becoming a serious problem in veterinary medicine. Many times these patients are not diagnosed as resistant until after the first appointment with the dermatologist. The round table discussion among technicians covered many aspects of dealing with this type of patient. From the causes that have been noticed, how it is diagnosed, different treatment options that are currently being used and care of the hospital with known and unknown resistant infections.

Reasons for resistance

The first topic was causes of resistance that have been noticed in the dermatology patient. Most attendees agreed that short courses of antibiotic therapy at low doses were seen most regularly. The short course was identified as 14 days or less. Many were seeing doses below the recommended therapeutic range. One attendee has also seen multiple cases of pulse therapy for chronic skin infections. These cases are usually prescribed cephalexin to be given on the weekends. No other hospital at the roundtable has noticed this trend.

The reports of fluoroquinolones setting patients up for resistance was brought up. Many of the attendees had heard of this phenomenon but have not witnessed it for themselves. A few have seen cases that were started on a fluoroquinolone based off culture results that within a few weeks cultured resistant to the drug.

The discussion went on to the correct dosing for antibiotics and all agreed that they use the upper end of dosing ranges when treating bacterial infections.

When resistance is suspected

Resistant infections were considered in all patients that have been exposed to many antibiotics over a short period of time by all attendees. Some hospitals treated patients as resistant if their records show more than two rounds of antibiotics over a three month period. Others based the decision on the chronicity of antibiotic therapy over a longer period of time. The discussion went on about referring veterinary records, some hospitals would only use them if they were available, and others would request them from every patient. Many agreed that the referring hospital’s medical records were very difficult to read and many times were not helpful. The consensus was that the records were either incomplete, itemized, or illegible. To combat this a few hospitals, have a referral questionnaire that referring veterinarians are supposed to fill out prior to the appointment. There was mixed reviews if these were beneficial. Some referring veterinarians do not take the time to fill these out correctly, will not do them at all or they are illegible. When filled out correctly these forms were very helpful in preparing for the patient’s appointment. Culturing patient’s lesions was the primary diagnostic tool used. Most of the labs used by the attendees would automatically speciate the organism. One lab that is used by the attendees does not unless requested. This discussion did not cover the exact species of resistant organisms that were seen by the attending hospitals.

Patient treatment options

Treatments varied depending on the type of infection. Systemic therapy is still used based off culture results. Most hospitals tried to avoid rifampin, amikacin and gentamycin if at all possible. Rifampin was avoided due to the extreme likelihood of severe hepatotoxicity and death. Amikacin and gentamycin are known to be nephrotoxic and these patients are monitored during therapy. One hospital used rifampin with success and only a few patients having side effects. Another used rifampin with a few cases but had most patients experience extreme side effects of hepatotoxicity. Now they limit the use to a drug of last resort. It was brought up that there is a retrospective case study out now about rifampin and it not causing hepatotoxicity as often as many think. It was questioned about which cases were chosen for the study and if ROUNDTABLE SUMMARIES

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they only picked the cases with a good outcome as none of the cases had severe side effects.

Topical therapy seems to be the mainstay for many dermatology hospitals. Most of the attendees used chlorhexidine 4% as a spray or shampoo. The recommended bathing regimen was split between once to twice a week for some and two to three times a week for others. One clinic did appreciate a reaction to the spray version of chlorhexidine in the form of erythema. The spray was discontinued and the erythema went away without treatment. One clinic brought up Command shampoo from VetriMAX. This shampoo contains bleach and salicylic acid, it suds well and owners do not seem to mind the smell. Many clinics are using a dilute bleach solution that they have a recipe for. There are different concentrations depending on the severity of the infection. VetBioTec’s chlorhexidine shampoo was also brought up. There was a new study that was posted in the exhibitor’s hall about how well the shampoo did compared to other shampoos due to the silver it contains. Only a few of the attendees carry that shampoo or have any experience with it.

Some attendees will start using it soon.

Staff personal protective equipment

Personal protection equipment (PPE) is very important to all the hospitals in attendance. At minimum all staff must wear gloves then wash hands when handling any patient. When it came to known or suspected resistant patients the protocols varied between the different hospitals. All required gloves, a few required a gown or lab coat where another used disposable bunny suits. Many had additional sets of scrubs available to be worn after the patient left. The only time a mask or face shield was required was if there was any possibility the exudate could be splashed such as hydrotherapy on draining tracts.

Every hospital in attendance had either a separate room to house only MDR cases or at least an isolation room to keep them away from other healthy patients. The only time a resistant patient could be housed in the general wards was if it was a contained resistant infection such as a middle ear infection. Some of the hospitals require full PPE to enter these wards. The cleaning for the wards also differed. One hospital would reserve two kennels for each patient. One kennel would be decontaminated once a day while the other was in use. Others would decontaminate the cage while the patient was outside and be placed back in the same cage.

The decontamination process was very similar between the attendees. Bleach is a common disinfectant usually in combination with steam. Some of the hospitals are using the new product Rescue.

It is used in human hospitals and can be used without gloves. Those who use it are happy with the results.

One attendee said they rotate between three different disinfectants; Opticide, Rescue and Misty BioDet weekly then follow those with bleach and steam for the resistant patients. All attendees would leave the cages vacant for 24 hours after the resistant patient was discharged.

Handling requirements varied by the number of available staff. Those with larger staff had one person assigned to the infectious ward, others wore PPE and went back to other cases after. Allowing these resistant patients to relieve themselves can be tricky as to not expose healthy patients. One attendee has a designated fenced off area for resistant patients, another would use the far end of the patient yard. Many agree there should be separation but some do not have the space to accommodate this.

Hospital environmental cleaning protocols

Standard cleaning protocols for everyday patients is equivocal throughout all the attendees. The lobby floors are mopped twice a day unless needed otherwise. Most of the hospitals are using Rescue, a few are using dilute bleach and a few using steam. The furniture in the lobby ranges from vinyl or plastic to wood. But all agree it needs to be easily cleanable. The exam rooms are cleaned once a day and after each patient with either Rescue or bleach. Cleaning the exams rooms include not only the exam table and floor but the wall up to the chair railing. It is agreed that the bleach solution for the mop is changed at least once a day or when it gets contaminated.

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ROUNDTABLE SUMMARIES

If it is a known resistant patient some hospitals have designated infectious room for these patients, others use a regular exam room and decontaminate after use. Decontamination of known or suspected resistant patients includes bleach or Rescue followed by steam in most hospitals.

The discussion continued on to other items that are cleaned on a regular basis. The scale is cleaned after each use and thermometers and pens between each patient. Some attendees mentioned cleaning their stethoscope after each patient as well. Many disinfect glass or plastic storage containers on a weekly to biweekly schedule. Stain containers seem to be changed and disinfected weekly.

Conclusion

Overall the attendees seem to agree on how to handle a resistant patient. Most of the time everyone is doing the same thing, but with a different protocol. It’s agreed that antibiotics should be given at the higher end for two weeks past clinical remission. Appropriate cultures should be obtained when the patient has been exposed to multiple rounds of antibiotics. There are many different options when it comes to treatment with either systemic or topical therapy. The hospital should be protected from even a suspected resistant patient by appropriate cleaning protocols and staff hygiene.

AAVD Executive Board President Dr. Catherine Outerbridge Davis, CA Immediate Past-President Dr. Rod A. Rosychuk Ft. Collins, CO Vice President Dr. Leonard Jonas Wheat Ridge, CO Treasurer Dr. Klaus Loft Weymouth, MA Members-at-large Dr. Rose Miller Salt Lake City, UT Andrew Mills Shoreview, MN

NAVDF OC Members: (Two year term 2017 - 2019): Jeanne Budgin, Chair Dana Liska, Co-Chair Marcia Schwassmann, Treasurer Klaus Loft, Social/Sponsor Liaison Chair Christina Restrepo, Past Chair and Social/Sponsorship Liaison Assistant

Catherine Outerbridge, OC Member (AAVD) ​Rose Miller, OC Member (AAVD) Kristin Holm, OC Member (ACVD) Allison Kirby, OC Member (ACVD)

2019 Program Committee: Mitch Song, Program Chair Sandra Koch, Program Co-Chair Petra Bizikova Paulo Gomes Marcy Murphy ​

Administrative Team:

Alexis Borich, ACVD NAVDF Executive Secretary Jason Harbonic, AAVD NAVDF Executive Secretary Jill Senior, NAVDF Meeting Planner

Dr. Verena Affolter Davis, CA WAVD Representative Dr. Jeanne Budgin Riverdale, NJ Editor, Derm Dialogue Dr. Norma White-Weithers

Baldwin, NY Executive Secretary Mr. Jason Harbonic 1.877.SKINVET (754-6838) info@aavd.org

WELCOME NEW AAVD MEMBERS! Brandi Sandstrom DVM Carly Glinski Cecilia Leatham Dr Christoph J Klinger DVM, Resident ACVD Jinwon Lee DVM John Fleming, MS, DVM

McKenna Snidow Meredith R Stevens RVT Molly J Patterson DVM, MSc Robert M Ward BVM&S Tiffany Sheldon DVM

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FROM THE PRESIDENT Continued from page 1 ogy and that they will continue to be members of the AAVD. The AAVD also donated $15,000 to the ACVD Research Fund to provide grant funding for the AAVD/ACVD research grant.

While at the meeting, please thank your colleagues on the NAVDF Program Committee and Organizing Committee who have worked hard to plan this meeting. Those who volunteer to put Derm Dialogue together under the leadership of Dr. Norma White-Weithers are also deserving of our gratitude. These are all busy individuals who volunteer their time to make the NAVDF and Derm Dialogue a success for our benefit. Also, be sure to say hello and thank you to our wonderful professional staff from PAMED and the amazing Alexis Borich. Working on behalf of the AAVD are a number of individuals I would like to thank: Dr. Jeanne Budgin as the AAVD representative to the World Association for Veterinary Dermatology and the AAVD executive board for all of their hard work and efforts; Dr. Rod Rosychuk (Past-President), Dr. Klaus Loft (Treasurer), Dr. Rose Miller, Dr. Andrew Mills, and Dr. Verena Affolter.

Warmest regards and I hope to see you in Austin, Catherine

NEW ORLEANS A P R I L 21 - 24 S H E R ATO N N E W O R L E A N S H OT E L

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Refractory Pruritus in Dogs and Cats Moderator: Rendina McFadden, DVM, DACVD Participants included: boarded dermatologists, general practitioners, and industry veterinarians When is pruritus considered refractory to treatment?

• Depends on the owner’s perception of pruritus • When the pet’s scratching is keeping the owners awake at nights Are dogs or cats more likely to have refractory pruritus? Are there breeds that are more likely to be refractory to treatment?

• Cats can be challenging • Bichon frise • French bulldogs and other bulldogs • Cats may not be as responsive to prednisolone as other steroids (triamcinolone, dexamethasone) • Food allergic animals may not be as steroid-responsive as other patients

• Some practitioners have found that food allergic patients might be very steroid responsive Are there diseases other than allergy that can cause refractory pruritus?

• Cutaneous lymphoma

• Some practitioners have had success managing pruritus of cutaneous lymphoma with

Cytopoint (lokivetmab) • Contact dermatitis if the patient is still being exposed to the offending agent What therapies do you find to be helpful for refractory pruritus?

• Cats

• Apoquel (oclacitinib) 0.6mg/kg PO q 12 hr

• Apoquel 1mg/kg PO q 12 hr • Checking bloodwork every 3 months • No observed adverse events so far

• It works well in some cases

• Apoquel also was found to be helpful in severe pemphigus-like disease

• One person said Apoquel has no taste which facilitates dosing cats with this medication

• Injectable cyclosporine for cats • 5mg/kg SQ q 2 days then q 3 days • Painful as medication is thick, viscous • Local injection site reactions are possible • May be helpful in some cats

• Transdermal cyclosporine • May or may not work

• Daily Cerenia • Approximately 1mg/lb PO per day is helpful for some cats • Effect occurs within a few days • Question about if cats should be prescribed a Cerenia holiday or not (a day or more off

medication at regular intervals)

• Doxepin 1mg/kg PO SID (never BID due to ALT elevations that could occur)

• Tacrolimus 0.1% (as a compounded spray) for eosinophilic granulomas ROUNDTABLE SUMMARIES

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• Idiopathic ulcerative dermatitis in cats • Maxi pads placed around neck sticky side out, t-shirts • Experiences range from simple and easy success with silver sulfadiazine cream to completely

refractory and all experiences in between • Apoquel may be helpful • Topiramate may be helpful at 5mg/kg PO SID or BID

• Consider injectable Benadryl (diphenhydramine) in cats • Experience that it was helpful in one cat • Dogs

• Apoquel used off label at BID dosing long-term

• Apoquel combined with Cytopoint

• Some practitioners do not ever start Apoquel at BID dosing so as not to set unrealistic

expectations for owners • Once daily Apoquel dosing from the start is effective for many moderately pruritic dogs • Is twice daily Apoquel long term harmful?

• Concern for excessive immunosuppression

• Perhaps less immunosuppression when ½ dose Apoquel BID is used

• Consider using isoxazoline concurrently with BID dosing of Apoquel to reduce risk of

demodicosis

• Concern for inducing neoplasia with BID dosing of Apoquel

• Antihistamines are still helpful for a small subset of atopic dogs

• Combining antihistamines may be helpful • Hydroxyzine and Amitriptyline

• The question was raised if moving an atopic patient out of state is helpful

• Gabapentin in dogs • 10mg/kg PO SID in evening, then possibly increasing to BID • Others start BID dosing due to concern of a short half-life • Higher dosing may be needed

• Mycophenolate mofetil (low end of dose) was used in one dog and reduced pruritus by 50% • The idea of combining Atopica and mycophenolate mofetil was raised • Mycophenolate mofetil can cause hemorrhagic diarrhea but is helpful with some cases of

pemphigus Topical therapeutics • Large jar of triamcinolone cream • Betamethasone cream • Douxo calm spray • Combination DMSO, Dexamethasone and Baytril topically

• 96mL DMSO + 12mL 4mg/ml Dexamethasone SP + 12mL Large animal Baytril • Baratone topical is missed (no longer available) • Genesis spray is missed • Tar bathing or whirlpool

• Prescription strength tar shampoo Miscellaneous discussion: • Temaril-P is surprisingly helpful in many cases

• Lower than label doses are helpful

• Cyproheptadine or hydroxyzine combined with prednisone does not seem as effective as

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Temaril-P • Different breeds react differently • Speculation as to how gene receptors may work • Speculation as to how much pyoderma and yeast may contribute to pruritus • Immunotherapy is helpful in many dogs

• Discussion about if dogs can continue to be sensitized to new allergens if they are receiving

immunotherapy or if they are receiving Apoquel • Multimodal therapy is important • Cytopoint may induce months of allergy remission in a small subset of cases • Perhaps size of dog is related to how long Cytopoint works • Variable experience with how Cytopoint works over time (decreasing time interval between injections) • Increased frequency of label dose flea control or using 2 flea control products • Possible isooxazoline-induced acute blindness at label dosing (anecdotally reported on ophthalmology

list serve) • Topical tacrolimus on regional refractory pruritus • NeoPredef powder • Occlusive or partially occlusive coverings

• Thunder shirts or other t-shirts

• Itchy cats can wear backward Onesies

• T-shirts for pets who have received an intradermal allergy test • Capsaicin cream 4 times per day, prevent licking, avoid applying to an ulcer: is considered helpful by

some, and not helpful by others

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Apoquel, Beyond allergies Moderator: Andrea Meyer DVM We started the conversation with reviewing the literature.

1.Frank et al. published on a colony of cats that developed cutaneous mastocytosis that was nonresponse to prednisone therapy. A 2cm area of oozing lesion was on the ear. Diagnosis was based on biopsy. The cat was prescribed Apoquel. This was effective at resolving the lesion at 1mg/kg bid, and within 2.5months the lesion was resolved.

2017 publication in Veterinary Dermatology: 2. A 5 yr old German shepherd mix breed dog was diagnosed with subepidermal blistering dermatosis. The dog was started on Apoquel so that the prednisone could be tapered because pet was not tolerating it well.

The dog was in remission within 2 weeks and was kept on Apoquel twice daily to maintain remission. There would be a flare-up if the dose was lowered.

A poster presentation in Nashville: 3. Dr. Klaus used Apoquel for a cat with idiopathic ulcerative dermatosis. The cat went into remission on 1-1.5mg/kg/day of Apoquel in 4-6 weeks, after having no response to several other therapies.

Use in dogs with immune mediated disease!

One participant had a 5yr old FS bulldog. She was started on triamcinolone and azathioprine. To facilitate the reduction of the triamcinolone mycophenolate was added. This was not successful and so the mycophenolate was discontinued and apoquel 0.6mg/kg bid was added. This owner lives hours away so they were monitoring and adjusting therapy via text messaging. With proper monitoring of blood work and adjustment of medication, pet was able to tolerate the therapy of triamcinolone, azathioprine, and Apoquel.

Another participant with special interest in Shar pei medicine had used it for Shar pei fever. His dose was 0.5mg/kg bid with some dogs responding better than others. These cases were rechecked every few months and with annual blood work. At recheck presentation he was not having any problems with the above mentioned cases. Hematuria with negative urine culture were encountered which resolved when medication was withdrawn.

Is this a first line drug?

Many would use it if the other accepted drugs are not working or there are side effects What do you suspect the MOA is since it is not supposed to be immune suppressive?

It works on pro-inflammatory cytokines other than just IL-31, and these could play a role in these diseases.

We do not know why this drug works for these diseases.

How do we monitor since these may have co-morbidities? They would monitor like other drugs and examine for masses and monitoring blood tests.

What are Internists using it for?

Some have used it for rhinitis in both feline and canine cases. Some dogs with IBD get better as reported on the list serve. One case of a dog with Immune mediated polyarthropathy got better on apoquel. The lupoid/crusting diseases seem to respond to Apoquel such as DLE (discoid lupus erythematosus) and PE (pemphigus erythematosus) respectively. One participant has a geriatric dog with DLE that did not tolerate azathioprine well and would be interested to see if Apoquel would work for this pet.

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Anyone using it for Acral Lick Dermatosis?

One participant has used it, but feels it did not help much as sometimes it becomes behavioral. Response will depend on if it is allergic, OCD/behavior, or pain related. One participant has used it with and extended course of antibiotics.

Is anyone using it for feline asthma?

Good response in some cases but has not been tried in a large number of cases. The dose used was 0.5mg/ kg bid.

What conversation do you have with clients on side effects?

Conversation with owners usually about demodex and the need to have pet checked with skin scrapings and to check for skin infection as well. It is important for those on multimodal therapy. Many have put the dogs on Bravecto, Simparica, or Nexgard as prevention for demodex. One participant doubles the label dose of these preventatives.

Has anyone seen an outbreak of demodex while on one of these preventative and on Apoquel?

No one has seen outbreak of demodex while on these preventatives in combination with Apoquel.

If you had a dog with a mast cell tumor with complete remission, would you use it?

With mast cell tumors, they often develop more. So do we use cytopoint instead, since it does not have these risks? Also do we choose not to use it in older dogs that could have cancer.

Do we do radiographs and ultrasound as baseline before prescribing for all dogs?

No one does. It is also important that we talk to these owners.

Who would be willing to use it after this conversation?

Many would use it and do the on label dosing with bid x14d then taper to SID if possible.

Would you use it as a first line therapy? One participate would, especially for a DLE. They would use it before using doxycycline and niacinamide.

Are there any diseases for which you would not use it?

Panniculitis, perianal fistulas.

Has it been used for symmetric lupoid onychodystrophy? No one has used it.

How about cats?

One participant used it in idiopathic ulcerative dermatosis. It has been used in treating feline asthma with good success. Cat has been on inhalers, and owners had a difficult time in giving it. Apoquel was started BID then reduced to SID due to easier administration. It was difficult to give cats oral therapy twice daily after a few weeks. It was used at 1mg/kg and monitor with blood work every 3-4 months long term with no changes.

Anyone using for plasma cell pododermatitis or eosinophilic granuloma?

One participant had used it for EGC as part of a multimodal therapy but was not a first line therapy. Some cats did well, while others did not do well. A dose of 0.8-1mg/kg was used. Animals that had only a 50-60% response on other therapies, did response to Apoquel.

Is it easy to give to cats?

It depends on the client and the cats. Of the cats on it, he sees far fewer abnormalities. It does not have a ROUNDTABLE SUMMARIES

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flavor. Some compounding pharmacy will compound the medication if you should take it to them. It is not known if crushing and adding to food affects stability.

One person had stated that it was only good for 42 days after it is opened. Zoetis was not aware of this concern, but if you feel uncomfortable you can request a return and Zoetis will replace it.

Does halving the tablets affect its effectiveness? If they are kept in the container after they are cut, they will crumble. However, they do not loose its efficacy.

Seems to be very effective for mucinosis.

Many dermatologists would say that it does not work for otitis. Nothing does otitis better than steroids especially oral steroid. It can work for pinnal pruritus, but it will not open a stenotic ear canal. One participant has used it in Shar peis and the owners noticed it open the canals although it was not prescribed for that purpose. Zoetis did a study with otitis. Topical baytril and trizEDTA with no steroid had reduced inflammation with apoquel. It can help if there are no proliferative changes or stenosis.

Is it helpful for perianal pruritus? These are often food allergy. Pet with anal sacculitis that have been on apoquel when referred, did not respond. You can try it but only for short time before trying something else.

Tacrolimus does work for these cases but people do not always want to do that. You can have it made into a spray.

Food allergy hypersensitivity can be an indication for use.

Anecdotally, some people will say it may not work as well for food allergy. One participant used it during food trials due to its short duration and at the end you can still do allergy testing. Cytopoint effect may last longer so need to do a longer food trial.

Has it been used for Idiopathic ulcerative dermatosis?

Many have not seen it but would try it. Would likely try something else first, but others would try it as a first line drug.

With blood monitoring, is anyone seeing changes in blood values?

When it happens, most have seen it in the first month. Many would do monitory blood work every 6-12 months thereafter. Elevation in liver values in both ALT and ALP are often observed. Others would have to stop therapy as the values would increase after restarting. Neutropenia has been observed. If quality of life the main goal, then therapy will be retried and closely monitored.

Is Zoetis recommending GPs to do lab work?

They recommend that they treat it like any dog on chronic medications. Get baseline and maybe once yearly is enough. If they are an older dog with comorbidities, recommend they do it every 6 months.

If the owner declines blood tests, do you refuse medication refills?

One person mentioned that it depends on the client and would have them go see their regular veterinarian.

Others will not refill without blood work since monitoring is needed due to its effect on the liver. Another take into consideration the quality of life of the pet. Apoquel is not cheap, and so it is often a choice for them to either purchase the apoquel or do blood tests. Others would explain to owners and document risks but still refill.

Should you have them sign a waiver to protect against state boards? It depends on your state and your medical records. One participant explains that they care about lumps and bumps while pets are on these medications. The micromanagement of these patients is why they do better. It is uncommon to see a dermatology patient only annually so these cases will likely be monitored closer for risks.

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