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The Itch Game
NonSteroid Alternatives (NSAs)
www.itchnot.com
Keith A. Hnilica DVM, MS
Diplomate ACVD
The University of Tennessee
www.UTSkinVet.org
Atopica is the NSAID for Allergies!
% of itchy dogs treated with steroids:
% of arthritic dogs treated with steroids:
% of itchy dogs that you offer steroids:
% of arthritic dogs that you offer
steroids:
Reason for treatment:
Reason for treatment:
1
„
Do you treat arthritis with
steroids?
„
„
„
Most vets would not even
offer steroids for arthritis.
„
„
Why not?
„
„
The answers should be
the same for allergies:
„
Better medications are
available: Rimadyl,
Deramaxx, etc
Too many side effects with
steroids.
Young age of onset
Steroids have too many
adverse effects.
There are better
treatments available:
„
„
„
„
Atopica
Allergy testing
Antihistamines, topicals,
EFAs
Referral
Allergies should be managed exactly like arthritis regarding steroid usage.
If you do not offer steroids for arthritis patient; do not offer it for allergies…
When would you consider steroids for arthritis:
that is exactly when you should consider steroids for allergies!!
„
NSAIDs
„
Replaced steroids
„
Arthritis
„
Atopica
„
„
First in category
Will replace steroids
„
„
„
„
„
„
„
Works better
Fewer adverse effects
Moderately expensive
„
„
„
Allergies
Lupus
Pemphigus
IMHA/ITP
Works better
Fewer adverse effects
Same price as NSAIDs
„
Once past induction and
on EOD
Allergies should be managed exactly like arthritis regarding steroid usage.
If you do not offer steroids for arthritis patient; do not offer it for allergies…
When would you consider steroids for arthritis:
that is exactly when you should consider steroids for allergies!!
2
3 Most Common Disorders
„
Musculoskeletal
„
Dental
„
Dermatitis
3
Treating Allergy in 10 Steps
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Selective Breeding
Start Early
Treat the Secondary Infections
Avoid Allergens
Bathe
Flea Control
Diet Change
Symptomatic Therapies
Allergy Testing and Vaccines
Cyclosporine
Ears, Pinnae,
Elbows, &
PP reflexes
Face& Feet
Scabies
Treatment
German
Breed
< 1 year
year around
Change
Diet
Lumbar
Anti histamines
Essential
Fatty Acids
Flea Control
Treat
Pyoderma
Topicals
Ste
roid
s
Treat Yeast
Allergy
Vaccine
Treat Yeast
Treat
Pyoderma
Atopica
Treat Yeast
Treat
Pyoderma
Change Diet
Treat Scabies
Referral
4
Amino-Acid shifts in
KDR and RDL1
Guanine
Flea Resistance
120
100
80
60
40
20
0
Reduced
completely
Reduced to 7-14 days
30 days
5
Flea Resistance Solutions
7 Great Uses of Capstar
1)
2)
3)
4)
5)
6)
7)
Diagnose FAD in cats: Capstar qod for 30 days gives
you a yes or no answer regardless of the adulticide
use.
Speed resolution of FAD in dogs: qod for 30 days
greatly reduces the symptoms!
Prevent hitchhike fleas that infest homes and
clinics
Treats owner “Fleanial”: give Capstar and let the
pet and owner sit in the exam room, they can count
the fleas falling off.
Kill fleas jumping into your surgical site – rectally
does the trick
Prevent transmission of resistant fleas from
Florida, Texas, Georgia, etc (any traveling pet
should use protection).
Kills maggots.
6
A Pattern Approach
2o Infections
‰
‰
‰
‰
‰
‰
Pyoderma
Demodex
Dermatophyte
Yeast Dermatitis
Otitis
Pododermatitis
Allergies
Atopy
Food
Scabies
Endocrine
Hypothyroid
Cushing’s
What are the
INFECTIONS?
Pyoderma
Yeast
Otitis
Ears,
Pinnae,
Elbows, &
PP reflexes
Face& Feet
Scabies
Treatment
German
Breed
< 1 year
year around
Antihistamines
EFAs
1. Referral
Topicals
2. Revolution
3. Food Trial
Change
Diet
Steroids
Lumbar
Flea Control
3 injections
90 days
lbs X 15 =
MYD pred
4. Atopica
5. Allergy
Testing
6. Steroids
7
FQ Induced
Promoter
FQ Resistance
Marbo
Cipro
Enro
Orbo
Methicillin
resistance
„ mecA gene
„ Inducible
„ Transfer
able
„ Oxacillin
„ Cephalexin
„ Clavamox
+
http://dbtbs.hgc.jp/test/prom/mecA.png
Staphylococcus
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Otitis Treatment
4 steps : 6 products
1. Control the primary disease
3. Use high volume, frequent
application therapies
2. Use high antibiotic concentration
4. Don’t just stop but taper therapy
www.itchnot.com
1.
2.
3.
4.
5.
6.
Vet Solutions – swimmers
Epiotic – otitis
Otomax
T8 Solution with
1% Baytril
Steroids
Recurrent
Otitis
T8 solution with
Baytril
10mg/ml fill
the canal bid
9
2006 Immunotherapy Retrospective
2006 Meta-analysis of Cyclosporine Studies
Methods:
117 dogs in a multiple group retrospective
study.
Dogs followed for at least 1 year
Methods:
799 dogs followed for 2 -24 weeks in a metaanalysis of data from the 10 studies.
Results and Conclusions:
Results and Conclusions:
64.5% excellent to good efficacy.
“Up to 85% of dogs could experience” excellent
to good efficacy.
Most dogs responded between 2-5 months after
starting immunotherapy.
Response at 1 month is predictive; high responders
go on to do very well. Maximum response
occurs at 3 months.
Skin testing was equivalent to serum allergy
testing.
Approximately 55% tapered to every other day and
30% tapered to twice each week dosing.
The number of allergens (1 vial or 2 vials) did
not impact efficacy.
Severity, weight, and administration with food did
not affect efficacy.
Molds were administered separately (in a
separate, additional vial).
Cyclosporine was equivalent to prednisone
therapy.
Results of Allergen-Specific Immunotherapy in 117 dogs with Atopic
Dermatitis. Schnabl B. et al. Vet Record Jan. 2006
A Systematic Review and Meta-Analysis of the Efficacy and safety of cyclosporine
for the treatment of Atopic Dermatitis.
Steffan j. et al. Vet Derm Feb. 2006
It is NOT Expensive – Dammit!
Dog
10lbs
20lbs
40lbs
80lbs
Atopica
Vet cost
25mg
19.05
50mg
38.10
100mg
76.20
200mg
152.40
40% markup
QOD
26.67
53.34
106.68
213.36
and rebates
21.67
40.84
81.68
175.86
40.84
87.93
and Keto
50% Atopica dose
10
Cyclosporine Therapy
„
If the patient demonstrated GI symptoms
„
Give Reglan (metoclopramide)
„
Give food
„
Give Atopica
Atopica Candidates
ines
Antihistam
s
A
EF
Topicals
11
The Treatment is like transportation
for your teenager!
http://www.negotin.co.yu/vilig/slike/Jeca%20und%
20Milena%20am%20Kawasaki%20Ninja%20ZX10.JPG== www.bfranker.badz28.com/ zx6.htm
Cyclosporins/Tacrolimus
Allergic Dermatitis
Discoid Lupus
Pemphigus
Bullous pemphigoid
Systemic Lupus
Sebaceous Adenitis
Granulomatous
dermatoses
Psoriasis
Actinic dermatitis
Dermatomyositis
Alopecia X
Vasculitis
Urticaria
Rheumatoid arthritis
Sweet’s syndrome
Panniculitis
Erythema multiforme
Hypereosinophilic
syndrome
Eosinophilic granulomas
Scleroderma
Senile pruritus
VKH
Vitiligo
Poison Ivy
AIHA
Colitis
Organ Transplants
Perianal fistulas
Interdigital pyogranuloma
Persian Facial Dermatitis
Feline Stomatitis
12
Dr. Itchy’s “Best in Class” Derm List
Pfizer
Novartis
Antibiotics
Antifungals
Simplicef
Primor
Lamisil
Antiparasitics
Revolution
Cats
Capstar
Intercepter
Sentinel
Antipruritic
Temaril-P
Medrol
Atopica
Bayer
www.itchnot.com
Merial
Schering
DVM
Virbac
Vetiquinol
Cephalexin
Clindamycin
Stridex al free wipes
ketoconazole (dogs)
fluconazole (cats)
LymDyp
Chlorhexiderm
Max
Malaseb
Otics
Other
Frontline
plus
Baytril
LA Inj
100mg/
ml
Otomax
Domitor
Antisedan
Generics/other
Preventic
Collars
Knockout
premise
spray
Benzoyl
Plus
Ivermectin
3V HP EFA
Genesis
ResiCort
Synotic
Dermal
Soothe
condition
er
Clemastine
Diphenhydramine
Amitriptyline
Dextromethorphan
Dex Na Phos inj
T8 Solution
Epi Otic Adv
Epi Otic
Adv
Vet Solutions
alcohol swimmers
ear flush
SebaHex
Royal Canin - IVD
Duck/rabbit
Vitamin A
Septicane
Acral Dermatitis
Primary Disease
Allergy
Neuropathy
Hypothyroidism
Blasto
Neoplasia
Secondary
Bacterial
infection
Amitriptyline
Allergy,
Behavior
Pain
Behavior
Hydrocodone
Pain
Endorphins
Antibiotics
2nd infection
Use ALL 3 for 1 month
then taper or DC 1 by 1
13
Agenda:
„
Wal-Mart and Macy’s
„
„
Typewriters and Laptops
„
„
How to make money!
Progress
Excorts and Camerys
„
Trading up
Wal-mart
And
Macy’s
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Walmart - Ford
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Price
Focus on cost
Walk-in Appts
Volume
Fast paced
Discount products
No frills
Long hours
Walmart - Ford
„
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„
„
TMS
Mitaban
Griseofulvin
Panalog
Iodine
Allergy
„
„
Macy’s - Toyota
„
„
„
„
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Quality – value
Focus on customer
Conference room
Treatment Protocols
Consolidated
pharmacy
Web page
Fun
Macy’s - Toyota
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Depo Medrol
Prednisone
Simplicef
Ivermectin
Fluconazole
Otomax
Chlorhexidine
Allergy
„
„
„
„
Temaril-P
Immunotherapy Vax
Atopica
Referral
15
Lessons from my MBA year: #1
„
Begin using “Practice Protocols”
„
„
„
„
55 common GP disorders
Clinic doc negotiated
Not written in stone
Improves customer service
„
„
„
Consistent education from front desk to kennel
Everyone knows what to expect
Everyone recognizes when exceptions have been
made
Lessons from my MBA year: #2
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„
„
Owners want convenience
www.VetInternetPharmacies.com
Give them what they want
BUT from your clinic
If you do not provide it: someone will
Streamline pharmacy
Based on agreed upon Practice Protocols
“Best in Class” drugs
Use Vet Centric for non-protocol drugs
16
Lessons from my MBA year: #4
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
All staff members are motivated to solve specific client problems with
practice specific protocols formulated to implement the “Best in Class”
treatment options.
The mission statement includes a commitment to the highest quality of
practice (not the cheapest).
Staff rounds are conducted to educate everyone in the clinic on the most
common diseases and the practice’s protocols treatment.
All staff provides consistent client education and treatment
recommendations: the same message from the front to the back of the
practice.
The doctors are removed from all treatment cost discussions: decisions
are made based on medical appropriateness not negotiated based on cost.
Follow up counts.
Technicians are used to their full potential: great knowledge, tremendous
ability, and enthusiasm produce an effective patient advocate that
functions like a physician’s assistant.
The receptions are recognized as the store front window of the practice.
Great emphasis is placed on disease prevention not just finding and fixing
problems.
All employees play and hug the patients.
Practice Considerations
Some of the simplest issues can have dramatic impact.
The following are a few estimations of your client’s experience.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Sight:
Initial impression:
1
2
3
4
5
wow
Educational materials:
1
2
3
4
5
impressiv
Clutter:
1
2
3
4
5
contained
Cleanliness:
1
2
3
4
5
immacula
Noise level:
1
2
3
4
5
quite
Phones:
1
2
3
4
5
absent
Ability to eavesdrop:
1
2
3
4
5
limited
Animal odor:
1
2
3
4
5
none
Fragrance level:
1
2
3
4
5
pleasant
1
2
3
4
5
professio
Sounds:
Smell:
Confidence Inspiring:
Attire:
Lobby:
1
2
3
4
5
impressiv
Exam rooms:
1
2
3
4
5
functiona
KA Hnilica DVM, MS, DACVD
www.itchnot.com
17