Concurrent short-term use of prednisolone with cyclosporine A accelerates pruritus reduction and improvement in clinical scoring in dogs with atopic dermatitis

Clinical Guidelines for the Use of Antipruritic Drugs in the Control of the Most Frequent Pruritic Skin Diseases in Dogs

Pruritus is a common clinical sign in many skin disorders and is currently the main complaint in canine dermatology. Pruritic skin diseases can affect the quality of life of dogs and their owners. Several families of antipruritic drugs are available to help control pruritus in dogs. The aim of this review is to help practitioners select the most appropriate symptomatic treatment in the most frequent situations of dermatological pruritus in dogs. The molecules reviewed here are systemic and topical glucocorticoids, antihistamines, ciclosporin, oclacitinib and lokivetmab. A level of evidence (1, 2 or 3) has been established according to a detailed algorithm for each individual study in the literature published between 1990 and March 2021. The guidelines result from evidence grading using the strength of recommendation taxonomy (SoRT) and clinical recommendations using a thorough methodology.

A proposed medication score for long-term trials of treatment of canine atopic dermatitis sensu lato

BACKGROUND

The use of concurrent medications is necessary in trials of treatment of canine atopic dermatitis. Our aim was to use the best available evidence to construct and then to validate a medication score (MS) formula that will estimate the impact of concurrent medications on trial outcomes.

METHODS

Trials of 15 interventions were scrutinized to find those that were consistent in terms of specific medication, administration route and dosage regimen. A MS was constructed in five steps, starting from assigning a score of 1 for each day on oral prednisone, prednisolone or methylprednisolone at 0.5-1.0 mg/kg. The MS score was validated using the clinical records of 35 dogs with atopic dermatitis that had been treated for a period of 12 ± 2 weeks with six of these medications and compared with a previously published non-validated MS.

RESULTS

A MS could be assigned to eight treatments, six of which had been administered to the 35 dogs. A positive correlation was seen with the previously published MS and a negative correlation with changes in lesional and pruritus scores.

CONCLUSION

This MS may be a useful tool in new studies evaluating the efficacy of treatments in canine atopic dermatitis.

The prevalence of bacterial infections during cyclosporine therapy in dogs: A critically appraised topic

Cyclosporine is used to treat immune-mediated and allergic conditions and to prevent transplant rejection. To determine the prevalence of bacterial infections during cyclosporine therapy in dogs, 2 databases were searched and 14 articles reporting usable data were identified. In 828 dogs with atopic dermatitis receiving anti-allergic dosages of cyclosporine, the prevalence of bacterial infections was 11%; these occurred most often in the integument and urinary systems and not in multiple systems. In 95 dogs receiving cyclosporine at higher dosages for other conditions, the prevalence of bacterial infection was 17%, and these infections occurred most often in the gastrointestinal, urinary, and respiratory systems, often occurring at more than one body site. The prevalence of bacterial infections in atopic dogs treated with cyclosporine is low and occurs most often in the skin. When given for immunosuppression, the prevalence of bacterial infections is higher and can affect one or more body systems.

Deep pemphigus (pemphigus vulgaris, pemphigus vegetans and paraneoplastic pemphigus) in dogs, cats and horses: a comprehensive review

Pemphigus is the term used to describe a group of rare mucocutaneous autoimmune bullous diseases characterized by flaccid blisters and erosions of the mucous membranes and/or skin. When the autoantibodies target desmosomes in the deep layers of the epidermis, deep pemphigus variants such as pemphigus vulgaris, pemphigus vegetans and paraneoplastic pemphigus develop. In this article, we will review the signalment, clinical signs, histopathology and treatment outcome of pemphigus vulgaris, pemphigus vegetans and paraneoplastic pemphigus in dogs, cats and horses; where pertinent, we compare the animal diseases to their human homologue. Canine, feline and equine pemphigus vulgaris, pemphigus vegetans and paraneoplastic pemphigus have many features similar to the human counterpart. These chronic and often relapsing autoimmune dermatoses require aggressive immunosuppressive therapy. In animals, the partial-to-complete remission of pemphigus vulgaris and pemphigus vegetans has been achieved with high dose glucocorticoid therapy, with or without adjunct immunosuppressants; the prognosis is grave for paraneoplastic pemphigus.

Multidose intramuscular allogeneic adipose stem cells decrease the severity of canine atopic dermatitis: A pilot study

Aim

The aim of this pilot study was to evaluate the therapeutic and safety performance of an intramuscular treatment protocol of multidose of allogeneic adipose stem cells (ASCs) isolated, characterized, and expanded ex vivo from a healthy canine donor.

Materials and Methods

Twelve dogs diagnosed with canine atopic dermatitis (CAD) were intramuscularly treated with 0.5×10⁶ of cryopreserved ASCs from a healthy immunized young canine Ehrlichia canis free donor weekly for 6 weeks. Treatment efficacy was evaluated by the pruritus index and the CAD Lesion Index (CADLI) test. Safety and adverse effects were determined by injection site reaction, weight, blood chemistry, liver function, and whole blood count.

Results

Canine ASCs obtained from a donor met the minimum qualities required for this type of cells and showed viability of 90% after thawing. The efficacy of the CADLI score and the pruritus index in 12 dogs with atopic dermatitis was statistically significant efficacy. No adverse reactions were observed at the intramuscular application site, or in relation to animal weight, blood cell populations, or liver and renal function.

Conclusion

These results suggest that intramuscular administration of cryopreserved ASCs to dogs with atopic dermatitis is a promising cellular therapeutic product for the relief of the symptoms of this disease; however, the duration of the effects obtained with this dose and with other doses should be evaluated, as well as possible immune reactions. As far as we know, this is the first report of the use of multiple intramuscular doses cryopreserved ASCs to treat atopic dermatitis.

Repeated oral dose tolerance in dogs treated concomitantly with ciclosporin and oclacitinib for three weeks

Background

Ciclosporin and oclacitinib are immunomodulators approved for the treatment of canine atopic dermatitis. The administration of a short course of prednisolone at the beginning of ciclosporin therapy hastens the efficacy of this drug; oclacitinib has a rapid antipruritic effect similar to that of prednisolone.

Objectives

To evaluate the oral tolerance of oclacitinib and ciclosporin given concurrently for three weeks.

Animals

Two groups of eight beagles.

Methods

Dogs were randomized to receive oclacitinib alone (0.4–0.6 mg/kg twice daily for 14 days then once daily for seven days) or in combination with ciclosporin (5 mg/kg once daily) for three weeks. They were examined every day and adverse events were recorded. Blood samples were collected during the acclimatization phase, weekly during treatment and at the end of the study for haematology, clinical chemistry and coagulation evaluation.

Results

There were no abnormal clinical observations following treatment with oclacitinib given alone or concomitantly with ciclosporin, with the exception of diarrhoea in two dogs receiving both drugs. Three dogs from each group experienced transient inappetence; three dogs treated with oclacitinib had mild weight loss. Clinical pathology parameters remained within the reference range for beagle dogs at that facility.

Conclusions and clinical importance

The concomitant administration of ciclosporin and oclacitinib for three weeks to beagles was well tolerated and was not associated with an increase in the number of adverse events or laboratory abnormalities beyond those associated with oclacitinib given alone.

Background – Ciclosporin and oclacitinib are immunomodulators approved for the treatment of canine atopic dermatitis. The administration of a short course of prednisolone at the beginning of ciclosporin therapy hastens the efficacy of this drug; oclacitinib has a rapid antipruritic effect similar to that of prednisolone. Objectives–To evaluate the oral tolerance of oclacitinib and ciclosporin given concurrently for 3 weeks. Conclusions and clinical importance–The concomitant administration of ciclosporin and oclacitinib for 3 weeks to beagles was well tolerated and was not associated with an increase in the number of adverse events or laboratory abnormalities beyond those associated with oclacitinib given alone.

An update on the treatment of canine atopic dermatitis

Canine atopic dermatitis is a common skin disease seen in veterinary clinical practice. Several factors appear to contribute to the cutaneous inflammation and pruritus. The therapeutic strategy should focus on control of those factors that can be identified and for which interventional measures are feasible; these include ectoparasites, bacterial/fungal infection and dietary hypersensitivity. Ectoparasites, particularly fleas, are not the cause of atopic dermatitis, but they are a confounding factor, which can exacerbate pruritus, and preventative measures are therefore indicated. Bacterial and yeast infections are frequently associated with atopic dermatitis and initial systemic and/or topical therapy should be considered, followed by regular topical treatment for preventing relapse. Concurrent dietary hypersensitivity should be investigated by undertaking an elimination/provocation trial, followed by feeding of a hypoallergenic diet where appropriate. Depending on the severity of the clinical signs of atopic dermatitis and the willingness and expectations of owners, symptomatic treatment and/or specific interventional therapy for environmental allergy (allergen avoidance, allergen-specific immunotherapy) may be implemented. Symptomatic treatment includes use of glucocorticoids (systemically or topically), ciclosporin and oclacitinib. Other treatment modalities of lower or less proven efficacy include antihistamines, dextromethorphan, fatty acids, feline interferon-omega, misoprostol, pentoxifylline, specific serotonin re-uptake inhibitors and tricyclic antidepressant drugs. The therapeutic approach should be reviewed at regular intervals and tailored to the individual's needs. A successful long-term outcome can usually be achieved by combining the various treatment approaches in a way that maximises their benefits and minimises their drawbacks.

Efficacy of ultra-micronized palmitoylethanolamide in canine atopic dermatitis: an open-label multi-centre study

BACKGROUND

Palmitoylethanolamide is a naturally occurring bioactive lipid, produced on-demand by damage-exposed cells. Palmitoylethanolamide is documented to counteract inflammation, itch and pain.

OBJECTIVE

The aim of this 8-week study was to evaluate the efficacy of oral ultra-micronized palmitoylethanolamide (PEA-um) in dogs with moderate atopic dermatitis.

ANIMALS

Clinicians from 39 veterinary clinics enrolled 160 dogs with nonseasonal atopic dermatitis and moderate pruritus.

METHODS

This was a multi-centre open-label study. On days 0 (D0) and 56 (D56), owners evaluated pruritus with a Visual Analog Scale (VAS) and completed a validated Quality of Life (QoL) questionnaire. Veterinarians assessed the severity of skin lesions using the Canine Atopic Dermatitis Lesion Index (CADLI).

RESULTS

Mean pruritus VAS score decreased from 5.7 ± 0.08 cm (range 3.8-7.9 cm) to 3.63 ± 0.19 cm (range 0.1-9.2 cm) (P < 0.0001). At D56, 58% of dogs showed a greater than 2 cm reduction from baseline and 30% showed an absent-to-very mild pruritus (VAS ≤ 2 cm). Mean total CADLI at D56 decreased significantly (P < 0.0001); in 62% of dogs this score reached a value in the remission range (≤5). Mean total QoL score was significantly decreased (P < 0.0001) with 45% of dogs reaching QoL values described for healthy animals. Tolerability was good-to-excellent with only four dogs reporting treatment associated reversible adverse events.

CONCLUSIONS AND CLINICAL IMPORTANCE

PEA-um appears to be effective and safe in reducing pruritus and skin lesions, and in improving QoL in dogs with moderate atopic dermatitis and moderate pruritus.

Treatment of canine atopic dermatitis: 2015 updated guidelines from the International Committee on Allergic Diseases of Animals (ICADA)

Background

In 2010, the International Task Force on Canine Atopic Dermatitis (now International Committee on Allergic Diseases of Animals, ICADA) published the first consensus guidelines for the treatment of atopic dermatitis (AD) in dogs. This is the first 5-year minor update of this document.

Results

The treatment of acute flares of AD should involve the search for, and then elimination of, the cause of the flares, bathing with mild shampoos, and controlling pruritus and skin lesions with interventions that include topical and/or oral glucocorticoids or oclacitinib. For chronic canine AD, the first steps in management are the identification and avoidance of flare factors, as well as ensuring that there is adequate skin and coat hygiene and care; this might include more frequent bathing and possibly increasing essential fatty acid intake. The medications currently most effective in reducing chronic pruritus and skin lesions are topical and oral glucocorticoids, oral ciclosporin, oral oclacitinib, and, where available, injectable recombinant interferons. Allergen-specific immunotherapy and proactive intermittent topical glucocorticoid applications are the only interventions likely to prevent or delay the recurrence of flares of AD.

Conclusions

This first 5-year minor update of the international consensus guidelines for treatment of AD in dogs further establishes that the treatment of this disease is multifaceted, and that interventions should be combined for a proven (or likely) optimal benefit. Importantly, treatment plans are likely to vary between dogs and, for the same dog, between times when the disease is at different stages.

Electronic supplementary material

The online version of this article (doi:10.1186/s12917-015-0514-6) contains supplementary material, which is available to authorized users.

Voluntary acceptance and consumption of two oral ciclosporin formulations in dogs: two randomised, controlled studies

Background

Atopic dermatitis (AD) is the most common canine allergic skin disease and can significantly affect the quality of life of affected dogs. Treating canine AD with ciclosporin has been a subject of great interest in recent years. Many studies have provided substantial evidence of ciclosporin efficacy and safety in canine AD management, and for several years ciclosporin has been recognised as a major component of canine AD multimodal therapy. As a chronic condition, canine AD requires life-long medical management and treatment success relies in large part on product ease of administration. Two studies were conducted to assess the comparative voluntary acceptance and consumption of Cyclavance® (Virbac), a new oral liquid formulation of ciclosporin, and Atopica® (Novartis) either added to a small quantity of kibbles (study 1) or administered directly into the dog’s mouth (study 2).

Results

Over the course of the two studies 70 dogs assessed each of the ciclosporin formulations and 320 individual tests were performed for each tested product. Immediate prehension (in less than 2 seconds) occurred significantly more often with Cyclavance® (90.6% of the tests) than with Atopica® (14.4% of the tests) when products were mixed with 30 grams of dry food (p < 0.001). Moreover, Cyclavance® was significantly more often easily accepted than Atopica® (99.3% vs 27.1% of the tests, respectively) when products were administered directly into the dogs’ mouth (p < 0.0001). Cyclavance® was also more often totally consumed (98.3% of the tests) than Atopica® (2.2% of the tests) when mixed with a small amount of food (p < 0.001). However, both products were totally consumed once administered directly into the dogs’ mouth.

Conclusions

By facilitating cicloporin administration and consumption, Cyclavance® liquid formulation offers an interesting alternative to capsules that may improve dosing compliance and therefore the ability to benefit from the therapeutic effects in the long-term treatment of canine AD.

Atopic itch in dogs: pharmacology and modeling

Itch is the most common clinical problem seen in dogs with skin diseases. Although an etiological classification of canine pruritus does not yet exist, most causes would likely fall into the IFSI class I (dermatological) itch. One of the most common causes of canine itch is that associated with atopic dermatitis, and there is randomized controlled trial grade evidence of the efficacy of several antipruritic interventions. At this time, the mainstay of treatment of canine atopic itch relies principally on the use of topical and/or oral glucocorticoids and oral cyclosporine. Type 1 receptor antihistamines are notorious in their inconsistency in reducing pruritus in atopic dogs. A new Janus kinase (JAK)-1 inhibitor has recently been approved for treatment of allergic itch in dogs, and its onset of efficacy is remarkably fast. Modeling itch in dogs can be achieved by allergen sensitization (fleas, house dust mites), and challenges that elicit pruritic manifestation can be used for mechanistic studies as well as for testing of novel anti-itch modalities.

A blinded, randomized, placebo-controlled trial of the efficacy and safety of the Janus kinase inhibitor oclacitinib (Apoquel®) in client-owned dogs with atopic dermatitis

Background

Pruritus is the hallmark clinical sign of atopic dermatitis (AD) in dogs. Preliminary study results suggest that oclacitinib, a selective Janus kinase inhibitor, could reduce pruritus and associated inflammatory skin lesions in dogs with AD.

Hypothesis/Objectives

The objective was to evaluate efficacy and safety of oclacitinib (Apoquel^®) for the control of AD in a randomized, double‐blind, placebo‐controlled trial.

Animals

Clinicians at 18 specialty clinics enrolled client‐owned dogs (n = 299) with a history of chronic AD.

Methods

Dogs were randomized to receive either oclacitinib (0.4–0.6 mg/kg twice daily for 14 days and then once daily for up to 112 days) or an excipient‐matched placebo. Owners assessed visual analog scale (VAS) scores of pruritus on days 0, 1, 2, 7, 14, 28, 56, 84 and 112. Clinicians assessed Canine AD Extent and Severity Index (CADESI‐02) scores on days 0, 14, 28, 56, 84 and 112.

Results

On days 1, 2, 7, 14 and 28, oclacitinib‐treated dogs had a 29.5, 42.3, 61.5, 66.7 and 47.4% reduction from baseline in owner‐assessed pruritus scores, respectively, compared with a 6.5, 9.1, 6.5, 3.9 and 10.4% reduction in placebo‐treated dogs. On days 14 and 28, dermatologists recorded a 48.4% reduction in CADESI‐02 scores in oclacitinib‐treated dogs compared with a 1.7% reduction and a 3.6% increase in placebo‐treated dogs. After day 28, >86% of all placebo‐treated dogs had moved to an open‐label study, making between‐group comparisons biased. Differences were significant at all time points assessed (P < 0.0001).

Conclusions and clinical importance

Oclacitinib provided rapid, effective and safe control of AD, with substantial improvement in VAS and CADESI‐02 scores.

Ciclosporin 10 years on: indications and efficacy

Ciclosporin is a lipophilic cyclic polypeptide with powerful immunosuppressive and immunomodulatory properties that has been used in veterinary medicine for two decades. It is a calcineurin inhibitor whose principal mode of action is to inhibit T cell activation. The drug is principally absorbed from the small intestine and is metabolised in the intestine and liver by the cytochrome P450 enzyme system. Ciclosporin is known to interact with a wide range of pharmacological agents. Numerous studies have demonstrated good efficacy for the management of canine atopic dermatitis and this has been a licensed indication since 2003. In addition to the treatment of atopic dermatitis, it has been used as an aid in the management of numerous other dermatological conditions in animals including perianal fistulation, sebaceous adenitis, pododermatitis, chronic otitis externa and pemphigus foliaceus. This article reviews the mode of action, pharmacokinetics, indications for use and efficacy of ciclosporin in veterinary dermatology.

Life-long diseases need life-long treatment: long-term safety of ciclosporin in canine atopic dermatitis

Ciclosporin (Atopica; Novartis Animal Health) has been licensed for canine atopic dermatitis (AD) since 2002. Adverse events (AEs) have been reported in 55 per cent of 759 dogs in 15 clinical trials, but are rare in pharmacovigilance data (71.81 AEs/million capsules sold). Gastrointestinal reactions were most common, but were mild and rarely required intervention. Other AEs were rare (≤1 per cent in clinical trials; <10/million capsules sold). Hirsutism, gingival hyperplasia and hyperplastic dermatitis were rarely significant and resolved on dose reduction. Ciclosporin decreases staphylococcal and Malassezia infections in AD, and at the recommended dose is not a risk factor for other infections, neoplasia, renal failure or hypertension. The impact on glucose and calcium metabolism is not clinically significant for normal dogs. Concomitant treatment with most drugs is safe. Effects on cytochrome P450 and MDR1 P-glycoprotein activity may elevate plasma ciclosporin concentrations, but short-term changes are not clinically significant. Monitoring of complete blood counts, urinalysis or ciclosporin levels is not justified except with higher than recommended doses and/or long-term concurrent immunosuppressive drugs. Ciclosporin is not a contraindication for killed (including rabies) vaccines, but the licensed recommendation is that live vaccination is avoided during treatment. In conclusion, ciclosporin has a positive risk-benefit profile for the long-term management of canine AD.