Veterinary Medicine - May 2008 - (Page 273) and mucopurulent discharge from the perineum. Increasing evidence exists that an immune-mediated cause may be involved in the disease’s pathogenesis. For many years, surgery was the treatment of choice for affected dogs, even though relapse was common. Patients treated medically with traditional antiin ammatory and immunosuppressive drugs (e.g. prednisolone, azathioprine) responded inconsistently. Cyclosporine was rst explored as an alternative treatment in a small number of dogs and then in a larger case series.17-19 Cyclosporine is effective as a sole therapy or in combination with surgery in which it is used to decrease lesion size before surgical correction. The ideal dosage of cyclosporine to treat perianal stula is unknown; the dosing regimens in studies vary from 1 to 10 mg/kg once or twice a day. It is difcult to make direct comparisons between the studies because the cyclosporine formulation varied between unmodied and modi ed, the treatment period varied from four to > 20 weeks, and some studies used ketoconazole concurrently to increase serum cyclosporine concentrations while other studies did not. The following medical treatment protocol for perianal stulas is used by the soft tissue surgeons at the University of Wisconsin’s School of Veterinary Medicine20: • Induce remission of clinical signs by using cyclosporine alone (5 mg/kg orally twice daily) or combined with ketoconazole (cyclosporine: 5 mg/kg orally once daily; ketoconazole: 8 mg/ kg orally once daily). • Monitor the dog for signs of clinical improvement. Most dogs show some bene t within two to four weeks, but complete remission of clinical signs can take 16 to 20 weeks. • Once clinical remission has been established, treat for an additional four weeks and then discontinue therapy. • If a relapse occurs, repeat the above treatment protocol and then establish a maintenance dose that keeps the lesions in clinical remission. Some dogs have needed a dose as low as 25 mg daily or every other day. One study of dogs with perianal stulas found that serum cyclosporine concentrations did not correlate with clinical response; dogs responded to therapy even though they had serum concentrations below the therapeutic target range.19 Often the rst clinical sign of treatment success owners note is a decrease in licking. If a patient is not responding as expected, serum trough cyclosporine concentrations are measured to ensure adequate absorption. CONCLUSION Although cyclosporine was once thought of as only a transplant drug, we now know it can be used to treat dermatologic diseases such as atopic dermatitis, sebaceous adenitis, and canine perianal stula. With few side effects at therapeutic doses, cyclosporine should be added to your list of possible therapies for these diseases. REFERENCES 1. Marsella R. Calcineurin inhibitors: a novel approach to canine atopic dermatitis. J Am Anim Hosp Assoc 2005;41(2):92-97. 2. Robson D. Review of the properties and mechanisms of action of cyclosporine with an emphasis on dermatological therapy in dogs, cats and people. Vet Rec 2003;152(25):768-772. 3. Brazis P, Barandica L, Garcia F, et al. Dermal microdialysis in the dog: in vivo assessment of the effect of cyclosporine A on cutaneous histamine and prostaglandin D2 release. Vet Dermatol 2006;17(3):169-174. 4. Robson D. Review of the pharmacokinetics, interactions and adverse reactions of cyclosporine in people, dogs and cats. Vet Rec 2003;152(24):739-748. 5. Steffan J, Strehlau G, Maurer M, et al. Cyclosporin A pharmacokinetics and ef cacy in the treatment of atopic dermatitis in dogs. J Vet Pharmacol Ther 2004;27(4):231-238. 6. Robson DC, Burton GG. Cyclosporin: applications in small animal dermatology. Vet Dermatol 2003;14(1):1-9. 7. Bloom P. Symptomatic management of pruritus. In: Campbell KL ed. Small animal dermatology secrets. Philadelphia, Pa: Hanley & Belfus, imprint of Elsevier, 2004;53. 8. Radowicz SN, Power HT. Long-term use of cyclosporine in the treatment of canine atopic dermatitis. Vet Dermatol 2005;16(2):81-86. 9. Atopica [product insert]. New York, NY: Novartis Animal Health, 2007. 10. Parks SC. Observations on the incidence of cystitis in a population of dogs diagnosed with atopic dermatitis (poster). 18th Proc Am Acad Vet Dermatol Am Coll Vet Dermatol 2003;243. 11. Steffan J, Favrot C, Mueller R. A systematic review and meta-analysis of the ef cacy and safety of cyclosporin for the treatment of atopic dermatitis in dogs. Vet Dermatol 2006;17(1):3-16. 12. Steffan J, Alexander D, Brovedani F, et al. Comparison of cyclosporine A with methylprednisolone for treatment of canine atopic dermatitis: a parallel, blinded, randomized, controlled trial. Vet Dermatol 2003;14(1):11-22. 13. Olivry T, Mueller RS, the International Task Force on Canine Atopic Dermatitis. Evidence-based veterinary dermatology: a systematic review of the pharmacotherapy of canine atopic dermatitis. Vet Dermatol 2003;14(3):121-146. 14. Carothers MA, Kwochka KW, Rojko JL. Cyclosporineresponsive granulomatous sebaceous adenitis in a dog. J Am Vet Med Assoc 1991;198(9):1645-1648. 15. Linek M, Boss C, Haemmerling R, et al. Effects of cyclosporine A on clinical and histologic abnormalities in dogs with sebaceous adenitis. J Am Vet Med Assoc 2005;226(1):59-64. 16. Noli C, Toma A. Three cases of immune-mediated adnexal skin disease treated with cyclosporin. Vet Dermatol 2006;17(1):85-92. 17. Mathews KA, Sukhiani HR. Randomized controlled trial of cyclosporine for treatment of perianal stulas in dogs. J Am Vet Med Assoc 1997;211(10):1249-1253. 18. Mouatt JG. Cyclosporin and ketoconazole interaction for treatment of perianal stulas in the dog. Aust Vet J 2002;80(4):207-211. 19. House AK, Guitian J, Gregory SP, et al. Evaluation of the effect of two dose rates of cyclosporine and the severity of perianal fistulae lesions and associated clinical signs in dogs. Vet Surg 2006;35(6):543-549. 20. Hardie R, Bjorling D. University of Wisconsin School of Veterinary Medicine, Madison, Wis: Personal communication, 2007. 21. Last RD, Suzuki Y, Manning T, et al. A case of fatal systemic toxoplasmosis in a cat being treated with cyclosporin A for feline atopy. Vet Dermatol 2004;15(3):194-198. 22. Callan MB, Preziosi D, Mauldin E. Multiple papillomavirus-associated epidermal hamartomas and squamous cell carcinomas in situ in a dog following chronic treatment with prednisone and cyclosporine. Vet Dermatol 2005;16(5):338-345. 23. Werner AH Psoriasiform-lichenoid-like dermatosis in three dogs treated with microemulsi ed cyclosporine A. J Am Vet Med Assoc 2003;223(7):1013-1016. EXTRAS See for information on otitis externa in dogs. VETERINARY MEDICINE May 2008 273 http://www.vetstreamcanis.com/ACI/MAy08/VMD1/dis02565.asp
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