Veterinary Medicine - May 2008 - (Page 270) Cyclosporine PEER-REVIEWED every other day, and in 20% to 26% of dogs, dosages could be reduced to twice weekly after 14 to 16 weeks of therapy. When cyclosporine was compared with placebo, a signi cant difference in ef cacy was noted; however, no signi cant difference was noted when cyclosporine was compared with glucocorticoids. There are several take-home points from this review. • Unlike with glucocorticoids, a lag exists between the start of cyclosporine therapy and the appearance of clinical bene ts. Clients should expect to see some indication of response between four and six weeks of cyclosporine therapy. • The best clinical response was seen in patients in which the cyclosporine dosage was not decreased after the initial four weeks (the package insert suggests tapering the dose after four weeks). • Less improvement was noted in dogs that were considered glucocorticoid failures or those that had unacceptable adverse effects from glucocorticoids. • Overall, cyclosporine had a good to excellent response in 65% to 76% of patients, with better responses noted in dogs receiving longer treatment regimens. • The most common adverse effects were vomiting, nausea, soft stools, or diarrhea. These side effects were noted in the rst month, and most dogs acclimated to the drug. In our experience, vomiting can often be avoided by starting with a lower dose and administering the drug with food during the induction period. • Secondary skin infections must be monitored and controlled while the patient is receiving cyclosporine. Even with good control of atopic dermatitis, breakthrough infections may still occur. Our experience. Our starting dose is 5 mg/kg orally once daily in both dogs and cats. Clients are advised to give the medication with food to decrease adverse Cyclosporine therapy: Things to consider before prescribing Ask yourself the following questions before treating atopic dermatitis with cyclosporine. And when choosing therapy for atopic dermatitis, also consider alternatives such as antihistamines, essential fatty acid supplementation, topical medications, and allergen-specific immunotherapy. than using cyclosporine. The clinical signs of atopy in many patients can be controlled with alternative drugs alone or in combination with essential fatty acids, pentoxifylline, antihistamines, oral glucocorticoids, or spray topical glucocorticoids. • How long is the offending season? It takes four to six weeks for cyclosporine’s benefits to take effect, so in some patients with seasonal allergies, alternative medical therapies might be better choices. of ketoconazole may decrease the total dose of cyclosporine needed by as much as 50% to 75%, making cyclosporine cost-effective.1 However, the cost of routine monitoring of liver enzyme activities needs to be included in the estimate. • Will client compliance with regular reexaminations be a problem? Atopic patients receiving immunotherapy or cyclosporine therapy still need to be examined at regular intervals. In our experience, atopic dogs with well-controlled pruritus can still develop bacterial pyoderma and yeast overgrowth. Often the dog is not as pruritic as it was before beginning therapy, and the client may be unaware of an infection. In addition, pets should be examined for other adverse effects of the medication (e.g. other skin lesions, gingival hyperplasia). • What is the alternative plan if cyclosporine therapy must be discontinued? Working out a contingency plan will be beneficial for all. REFERENCE 1. Patricelli AJ, Hardie RJ, McAnulty JF. Cyclosporine and ketoconazole for the treatment of perianal stulas in dogs. J Am Vet Med Assoc 2002;220(7);1009-1016. For all cases of atopy • Are there any contraindications for use in this patient? Cyclosporine is not for use in breeding, pregnant, and lactating animals or in animals with a history of malignant neoplasia, and its safety hasn’t been determined in animals < 6 months of age. • Can the owner afford the drug? The cost of cyclosporine can be prohibitive for some clients. • Will the pet tolerate the drug? In our practice, we dispense a 10-day supply of cyclosporine and follow up to ensure that if a pet develops vomiting or diarrhea, the problem gets resolved. For year-round atopy • Does the pet respond well to cyclosporine? If the pet responds well to this medication alone, it may be reasonable as a single-agent therapy for year-round atopic dermatitis. Also, in our clinical experience, the combination of cyclosporine and immunotherapy may provide marked benefit, especially during the induction of allergy injections. • Which is more cost-effective: cyclosporine therapy or immunotherapy? For small animals that respond well to cyclosporine, the cost of therapy may be equal to or less than that of immunotherapy. For large dogs, the concurrent use For seasonal atopy • Is this the most cost-effective medication for the patient? Shortterm use of oral or topical glucocorticoids may be less expensive 270 May 2008 VETERINARY MEDICINE
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