Flea Allergy Resurgence

Due to Frontline Breaks

Fleas and Flea Allergy is increasing

Patients MUST be treated with

and IGR and an Adulticide

The best IGRs are lufenuron (oral) or pyriproxifen (topical)

these will handle 90% of the flea control during the year

even when used alone.

Adulticides should be used when

1. fleas are observed

2. known exposure is predicted

3. lumbar itching increases

Make Atopica work better and Cheaper

1/2 Dose Protocol seems to be the way to go...

2.5mg/kg of Atopica with 5mg/kg ketoconazole

Freeze the Atopica and give after a meal

Administer every day for 4-6 weeks or until :)

then taper to QOD

Both drugs must be given on the same day

Half dose seems to be very well tolerated

even over long durations

Atopica for Cats

Feline Atopica was finally approved in September!!!

Liquid formulation

Most cats can be tapered to every 3 days

Don't need to test for Toxo according to the FDA

Minimal GI adverse effects

Treats all allergies except Fleas

Rule out fleas with Capstar QOD

or Revolution q 14 days

Temaril-P vs Atopica/Keto combo therapy

Interesting observation:
Calculate the price of Temaril-P
and
the price of 1/2 dose
Atopica/Keto combination therapy

They are much closer than you think...

Finally a TRUE NSAID for allergy for the SAME price???

Atopica 2.5mg/kg with 5mg/kg ketoconazole on the same day

Flea and Tick Revolution

The Flea and Tick product category is undergoing a revolution.

The Market Place Game (available on itchnot.com)
is designed to help vets and clinics
BE decisive in their product selection
to better prepare for the changes ahead.
LOTS of good products - BE DECISIVE!

MALASEB is BACK!!!!!

Malaseb Shampoo is finally back
woot woot

FreForm EFA too

Promeris

To the best of my ability to determine, Promeris causes about 1 in 1000 cases of SEVERE skin drug reactions like PEMPHIGUS or EM or TEN.

This risk is too high if using the product for routine flea and tick control; resulting in about 2 cases each year; BAD!

For treating Demodex (every 2 weeks), this adverse event rate is more acceptable; resulting in about 1 case every few years.

Pseudomonas Otic Therapy

The consistently best treatment option for otitis caused by rods on cytology is a topical solution of trisEDTA mixed with enrofloxacin (4oz of trisEDTA with 12 cc of LA Baytril) filling the ear every 12 hours for 2 weeks.
NO ORAL antibiotics as they provide no benefit.
Oral high dose pred if the canal is extremely swollen and painful (for only 1 week).

Recheck in 2 weeks with cytology and if still severely infected based on cytology, anesthetize and flush the deep canal and bullae using an 8 fr red rubber catheter and LOTS of fluid.
then repeat the 2 weeks to TrisEDTA and Baytril treatment.

If still not improving on cytology, then culture and chase the results with concentrated antibiotic topicals.

DVM product alternatives

Chlorhexiderm >> Duoxo PS chlorhex
Malaseb Shampoo >> Ketochlor shampoo
Malaseb wipes >> Duoxo Pledgets
T8 Keto >> Dermapet TrizEDTA Keto
Relief HC spray >> Genesis
Relief Conditioner >> ResiCort Conditioner
OxyDex Shampoo >> Pyoben Shampoo

When the DVM products are available again, I would strongly recommend switching back to
T8 Keto and Malaseb Shampoo.

For God's sakes, Stop using pred!!!

If you do not frequently use steroids for arthritis, find a way to stop using them for itch.
Our profession has made great medical progress in the treatment of arthritis; limiting steroids use.
We need to do the same for allergies for the EXACT SAME reasons.
What are you really treating with the steroids?
Lets stop the slow, insidious destruction of our patients with steroids; PLEASE!

Helpful hints:
Treat LUMBAR itch with flea control!
Treat FOOT itch with allergy testing or Atopica!
Treat BUTT itch with a food trial!
Treat LEATHERY skin with antiyeast shampoo and ketoconazole!
Treat RASH with antibiotics!

Best Antibiotics for Skin

Convenience Improves Compliance which decreases Resistance.

Primor
Simplicef
Convenia

Use more for best medicine!!

5 Best Flea and Tick Products

The Shining Star Products ARE:

Capstar - Fastest way to diagnose flea allergy dermatitis in dogs and cats.
Sentinel - Prevention and reduces the amount of adulticides needed.
Comfortis - Best long term adulticide, veterinary only, no resistance yet.
Preventic - Collars are safest, longest acting tick product.
Frontline - Every 2 week application is safe and effective.

Every patient and family situation requires combinations of the above products.

Good luck.

Sterilize Your Cones!!!

At least once each week, through all of your otoscope cones into the autoclave. This is a minimal prevention for resistent infections.

DON'T USE FQs for SKIN

UpGrade to BEST MEDICINE

Use MORE Sentinel
Use MORE Adequan
Use MORE Simplicef
EVERY cat NEEDS Revolution
Do MORE skin cytology
Use MORE Slentrol

These Products represent the VERY BEST medicine for the most common diseases in dogs.

Steroid Challenge as a Diagnostic Tool

Many vets use response to steroids as a predictor of response to Atopica or allergy vaccine. This can be useful in that dogs that respond very well to steroid therapy are likely infection free and atopic; however, patients that do not respond may have severe infections masking any benefit from the steroids. Alternatively dogs may respond well but still have food allergy which can be variably responsive to steroids in which case allergy vaccine would be useless.

I believe that a pattern approach is more accurate and useful.

MRSI and MRSS and MRSA

All 3 bacteria are potentially zoonotic.
FQ antibiotics increase the risk.
All patients should be identified to limit contagion.
Daily bathing can eliminate the infections.
Dual antibiotic therapy is ideal (based on cultures).
Identify and treat the underlying allergy or endocrine diseases.
Wash hand after touching the infected patient.
Where gloves when possible.

Cyclosporine Monitoring Program

Based on the most recent adverse event data, there are only 4 consistent adverse effects occurring in 1% or more of treated patients.

1. Vomiting
2. Loose stool
3. Lethargy
4. Anorexia

Generic Cyclosporine

During Western States Veterinary Conference, 7 Veterinary Dermatologists met to discuss cyclosporine uses.
There was general agreement regarding generic alternatives to Atopica:
1. Generics lose 10-50% of the efficacy compared to Atopica.
2. The cheapest generic with good efficacy only saved the owner $15/month at 100mg daily dosing. (based on Feb. 2009 web research)
3. Several derms had their prescriptions changed by the pharmacist to less effective generics without the dermatologist's knowledge or consent.
4. The use of compounded cyclosporine is likely useless.
5. Using a nonFDA veterinary approved product is less than ideal and loses all drug surveillance and pharmacovigilance required by the approved product.

Atopica use for Cats

Atopica is currently the only veterinary approved FDA cyclosporine and its use in cats is off label. Saying that, there is consensus among Veterinary Dermatologists that Atopica in cats is effective for multiple, steroid-responsive diseases and is "Beautifully Tolerated" in cats. Uses included; miliary dermatitis, eosonophilic granulomas, indolent ulcers, "Fat Chin" syndrome, Atopy, food allergy, insect hypersensitivity, chronic otitis, Lupus, Pemphigus, IBD, Stomatitis, chronic asthma, etc...

The dose ranges from 5-10mg/kg with higher doses being used to treat more serious disorders. Most cats need daily therapy for 30-60 days or until good control of the symptoms is reached, then the administration frequency can be reduced to every other day for 2 weeks and usually every 3rd day.

Cyclosporine is very well tolerated with cats demonstrating fewer adverse effects than dogs. Most cats do not vomit and thus do not need Reglan.

The most concerning issues are Toxo and FeLV, FIV.
Cats with FeLV and FIV should not be treated; however, cyclosporine is almost always safer than steroids.

The current consensus is that some cats are "Super" absorbers of cyclosporine which results in a greater immunosuppression. If the cat then encounters an infectious agent (Toxo) it is at a greater risk. Toxo negative cats that are "super" absorbers seem to be at greatest risk. The incidence of Toxo in treated cats is very low but several reports are in the literature.

To limit the Toxo risk, keep cats inside during daily cyclosporine therapy. Post administration peak blood levels may identify "super" absorbers.

Atopica Off Label

Usually at a double dose of 10mg/kg
administered daily for 60 days or until
good response; then taper to every other day.

Pemphigus
Lupus
Sterile panniculitis
Chronic Otitis
Perianal fistulas
Food allergy

IMHA
ITP
IBD
Encephalopathy
Arthritits
Immunemediated blepheritits

Stomatitis
Asthma
Eosinophilic granuloma
Miliary dermatitis
indolent ulcers
linear granulomas
insect hypersensitivity

When a dog is 10 out of 10 itchy

When a dog is SEVERELY itchy
a 10 out of 10 on the Visual Analog itch scale
consider:

Yeast dermatitis
Fleas
Scabies.

What's in My Pharmacy

Antibiotics
Simplicef
Primor
Clindamycin

Shampoos - you only need 5 topicals + a wipe
Antibcterial - Duoxo PS 2% chlorhexidene
AntiYeast - Malaseb
AntiItch Conditioner - ResiCort Conditioner
Demodex - Pyoben
NonMedicated - Etiderm
Wipes - Malaseb
and Genesis Spray for SPOT treatment

Ear Therapies
Yeast, Cocci, Allergy - Mometomax
Swimming dogs - VetSolutions Swimmers Tx
Pseudomonas - T8keto with Baytril (4oz + 12cc LA Baytril)
Cleaner - EpiOtic ADVANCED
Ear Mites - Milbemite

FQs increase MRSI, MRSS, and MRSA

Mounting evidence in the human and veterinary literature is revealing a connection with a patients exposure to FQ therapy and the increased risk for developing an Methicillin Resistent Staph infection.

Don't use FQs for pyoderma.

Kill Pseudomonas

Topical therapy alone is the best way to eliminate Pseudomonas infections.

4oz of a trisEDTA solution (I prefer T8) combined with 12cc of LA Baytril overwhelms the Pseudomonas's resistant mechanisms and kills the bacteria.

Fill the ear canal or lavage the wound BID for 2 weeks the reassess via cytology and organism counts. If ineffective for otitis media, lavage the bullae to remove inspisated pus and retreat for 2 more weeks.

Oral FQs only lead to resistance since the MIC of Pseudomonas is SO high and the oral dosing is ineffective/incapable of achieving high enough tissue levels.

Use the BEST steroid

Stop the oral and long acting injectable steroids - they are BAAAD!!!!!!!!!

Use Dexamethazone NA Pos (1cc/10-20lbs) IM (4mg/ml)
Repeated as needed; every 2-3 weeks.

The ultrashort acting steroids causes almost NO PU/PD and other adverse effects
but
the allergy reaction is suppressed for weeks.

Try it; You WILL like it . . . . .

Stop Steroid Abuse

Chronic steroids even if at a very low every other day dose prematurely age our patients.
Joint breakdown
Immune System weakening
Muscle weakness
UTI
Thin hair
Thin skin
Loss of stamina

Magic Force Field for Fleas

Capstar administered everyother day seemingly blocks flea spit.

Flea allergy dermatitis can be blocked by the everyother day capstar.

This is especially useful to diagnose any cat with skin disease since most are
flea allergic AND most have no obvious fleas.

Additionally, in dogs, if the owner is in FLEANIAL, the Capstar qod can
result in dramatic - OBVIOUS - improvement.

I use Capstar to diagnose flea allergy dermatitis in all dogs with lumbar dermatitis and all cat with skin disease; especially if I can't find fleas.

Other flea adulticides require ALL pets to be treated and take months to reduce the flea population enough to improve the flea allergic patient.
The Capstar protects the individual animal enough to make an obvious diagnosis.

Convenience improves compliance

Once a day treatments are easier for owners to remember and result in better outcomes.
Try to convert medications to daily protocols if possible:
Simplicef
Primor
Ketoconazole
Fluconazole
Otic Treatments

Convenience improves compliance

Diagnosis by exclusion is ILLOGICAL

We were taught Dermatology backwards . . .

Diagnosis by exclusion is illogical.

A Pattern Approach is Better!!!
Footlicking, periAnal dermatitis, lumbar dermatitis, and a positive ear scratch test are 85% accurate.

Appointments: Derm like Diarrhea

Dermatology appointments should flow like Diarrhea appointments. The 3 Slide technique for dermatitis should be used like fecals for diarrhea. The 3 Slides will demonstrate treatable organisms more often than the fecals. Technicians do it better....

Free CE Online 8 hours

There is over 8 hours of free online CE at CEforVets.com
This is a Novartis sponsored site but the content is pretty
free of bias product materials.

Welcome to itchnot.com's Blog

Since the University shut-down my archive site, I am replacing some of the most useful features with EVEN MORE useful features.

This Blog replaces the "What's New" page and will contain a contemporaneous listing of the best ideas that I run across in my search for better medicine and good business practices.

I hope you find this useful :)