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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 8 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 14 Walmart - Ford Price Focus on cost Walk-in Appts Volume Fast paced Discount products No frills Long hours Walmart - Ford TMS Mitaban Griseofulvin Panalog Iodine Allergy Macy’s - Toyota Quality – value Focus on customer Conference room Treatment Protocols Consolidated pharmacy Web page Fun Macy’s - Toyota 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 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