Vet360 Vet360 Vol 05 Issue 04 - Page 18

DERMATOLOGY FELINE MEDICINE Modifications of the standard SCIT protocol are emerging and include rush immunotherapy and intra- lymphatic immunotherapy. Rush immunotherapy has the advantage of limiting the number of injections that an owner must apply during the initiation phase of ASIT as maintenance levels are achieved rapidly. Dogs must be hospitalised and increasing doses of allergen extract or injected subcutaneously every 30 minutes for 7 hours. Animals are then discharged and continue on maintenance therapy. Therefore, with rush immunotherapy maintenance doses are achieved within one day compared with weeks or months with conventional immunotherapy. Intra-lymphatic immunotherapy is a recent modification of ASIT vaccine application, is reported to be associated with fewer and less severe adverse reactions then encountered with SCIT and to be effective for several years after only 3 intra-lymphatic injections. Alum precipitated ASIT vaccines are administered monthly into 1 of the popliteal nodes (alternating sides with each subsequent injection), under ultrasound guidance over 3 to 5 months. The number of intra-lymphatic injections (4 to 6) is based on the clinical improvement of the individual dog. In most instances, no sedation is required. In various studies complete remission was documented in 13% to 24% of dogs. Trouble shooting allergen specific immunotherapy (ASIT). Subcutaneous immunotherapy (SCIT) • • • • Be alert to anaphylactic reactions, most likely during the initial loading phase. Monitor for increase in pruritis and flare ups of otitis or pyoderma. If pruritis initially decreases after each injection but then slowly increases prior to the next injection, the interval between injections should be decreased. If pruritis initially increases after each injection, followed by improvement prior to the next injection, the allergen dose is too high. Decrease the dose by 25%. If pruritis still spikes after injection, reduce dose by a further 25%. Sublingual immunotherapy (SLIT) • • A few dogs rub or scratch at their mouth following application and individual dogs will vomit. However, these effects are short lived and usually disappear after a few applications. If signs persist or worsen, lowering of the allergen dose may be required. Article sponsored by: vet360 Issue 04 | SEPTEMBER 2018 | 18 • Monitor for increase in pruritis and flare ups of otitis or pyoderma. Some highly effective drugs such as cyclosporin (Atopico®, Elanco) and oclacitinib (Apoquel®, Zoetis) and biologicals (anti-IL-31 therapeutic monoclonal antibody), control clinical signs over a long period of time and may obviate some of the “need” for ASIT. However, these drugs and biologicals still require lifelong treatment and they only reduce clinical signs rather than reversing the pathogenesis of the condition as observed with ASIT. Long-term safety of these agents is not always known, and they carry no hope of permanent cure that can sometimes be achieved with ASIT. Use of these drugs and biologicals in conjunction with ASIT provides a template effective disease control in many instances. Historically, allergen specific immunotherapy has been viewed in general clinical practice as a last resort treatment option. With the growing knowledge of how and when to use ASIT, it has taken its place as a foundation treatment for the long-term management of canine atopic dermatitis. REFERENCES 1. De Boer D J. The future of immunotherapy for canine atopic dermatitis: a review. Veterinary Dermatology 2017; 28:25 – 30. 2. DeBoer D J. Sublingual Immunotherapy in Veterinary Dermatology. NAVDF 2013. 3. DeBoer & Morris – Multicentre open trial demonstrates efficacy of sublingual immunotherapy in canine atopic dermatitis World Congress of Veterinary Dermatology 2012 Vancouver, Canada. 4. Hensel P, Santoro D, Favrot C, Hill P & Griffin C. Canine atopic dermatitis: detailed guidelines for diagnosis and allergen identification. BMC Veterinary Research 2015; 11: DOI 10.1186/S12917–015–0515–5. 5. Hobi S & Mueller R.S. efficacy and safety of rush immuno- therapy with alum precipitated allergens in canine atopic dermatitis. Tierarztl Prax Ausg K Klieintiere Heimtiere 2014;42:167-173. 6. International Task Force on Canine Atopic Dermatitis - Vet- erinary Dermatology 2010; 21:233-248. 7. Moingeon & Mascarell – Induction of tolerance via the sub- lingual route: mechanisms and are applications. Clinical and Developmental Immunology 2012 8. Morris & DeBoer – Sublingual immunotherapy for pets: A Guide for Veterinary Dermatologists. White paper on SLIT therapy, Heska Corporation. 9. Nuttal, Uri & Halliwell - Canine atopic dermatitis – what have we learned? Veterinary Record 2013 172:201-207. 10. Olivry T, DeBoer D J, Favrot C, Jackson H A, Mueller R S, Nuttal T & Prelaud P. Treatment of canine atopic dermatitis: 2015 updated guidelines from the International Committee on Allergic Diseases of Animals (ICADA). BMC Veterinary Research 2015:11: D01 10.1186/S12917–015–0514–6. 11. Olivry T & Saridomichelakis M. Evidence-based guidelines for anti-allergic drug withdrawal times before allergen specific intradermal and IgE serological tests in dogs. Veterinary Dermatology 2013; 24:225 – 232. 12. Timm K, Mueller R S & Nett-Mettler C S. Long-term effects of intralymphatic immunotherapy (ILIT) on canine atopic dermatitis. Veterinary Dermatology 2018; 29:123 – 127. Shaping the future of animal health