Cyclosporin and ketoconazole interaction for treatment of perianal fistulas in the dog

Longitudinal evaluation of the cutaneous and rectal microbiota of German shepherd dogs with perianal fistulas undergoing therapy with ciclosporin and ketoconazole

BACKGROUND

Perianal fistulas are painful ulcers or sinus tracts that disproportionately affect German shepherd dogs and are proposed as a spontaneous animal model of fistulising Crohn's disease.

OBJECTIVES

To characterise the rectal and cutaneous microbiota in German shepherd dogs with perianal fistulas and to investigate longitudinal shifts with lesion resolution during immunomodulatory therapy.

ANIMALS

Eleven German shepherd dogs with perianal fistulas and 15 healthy German shepherd dogs.

MATERIALS AND METHODS

Affected dogs were evaluated and swabbed at three visits, 30 days apart, while undergoing treatment with ciclosporin and ketoconazole. Healthy German shepherd dogs were contemporaneously sampled. Sites included the rectum, perianal skin and axilla. The microbiome was evaluated following sequencing of the V4 hypervariable region of the 16S ribosomal RNA (rRNA) gene.

RESULTS

Alpha diversity was not significantly different between healthy and affected dogs at each of the three body sites (p > 0.5), yet rectal and perianal beta diversities from affected dogs differed significantly from those of healthy dogs at Day 0 (p = 0.004). Rectal and perianal relative abundance of Prevotella spp. increased and perianal Staphylococcus spp. relative abundance decreased in affected dogs over time, coincident with lesion resolution.

CONCLUSIONS AND CLINICAL RELEVANCE

Changes in lesional cutaneous and rectal microbiota occur in German shepherd dogs with perianal fistulas and shift over time with lesion resolution during immunomodulatory therapy. Further investigations of the role of cutaneous and enteric microbiota in the pathogenesis of perianal fistulas, and whether manipulation of microbial populations may ameliorate disease, are needed.

Possible drug-drug interaction in dogs and cats resulted from alteration in drug metabolism: A mini review

Pharmacokinetic drug-drug interactions (in particular at metabolism) may result in fatal adverse effects in some cases. This basic information, therefore, is needed for drug therapy even in veterinary medicine, as multidrug therapy is not rare in canines and felines. The aim of this review was focused on possible drug-drug interactions in dogs and cats. The interaction includes enzyme induction by phenobarbital, enzyme inhibition by ketoconazole and fluoroquinolones, and down-regulation of enzymes by dexamethasone. A final conclusion based upon the available literatures and author's experience is given at the end of the review.

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.

Relationship of body weight to maintenance cyclosporine a dose in canine atopic dermatitis

Cyclosporine A (CsA) is a commonly prescribed and effective therapy for canine atopic dermatitis. The purpose of this study was to investigate the potential relationship between patient body weight and CsA dosing. Seventy-seven cases of canine atopic dermatitis managed between 2000 and 2011 were evaluated retrospectively. Duration of CsA therapy was at least 16 wk. Groups analyzed included the study population as a whole, those treated with only CsA, and those treated with both CsA and metoclopramide. The division between small and large dogs was set at 15 kg. Descriptive analysis, two-way analysis of variance, Pearson correlations, and a Student t test were used to analyze data. There were no significant differences between CsA dose and body weight regardless of method of analysis. Concurrent corticosteroid use, other medication use, and pruritus score were also analyzed over the study period. There was a significant decrease in CsA dose, corticosteroid dose, medication score, and pruritus score between the time points for all patients, but no significant relationship between those changes and body weight. These study findings suggest that differential CsA dosing is not warranted based on body weight.

Oral cyclosporine treatment in dogs: a review of the literature

Cyclosporine is an immunomodulatory drug used to treat an increasing spectrum of diseases in dogs. Cyclosporine is a calcineurin inhibitor, ultimately exerting its inhibitory effects on T-lymphocytes by decreasing production of cytokines, such as interleukin-2. Although, in the United States, oral cyclosporine is approved in dogs only for treatment of atopic dermatitis, there are many other indications for its use. Cyclosporine is available in 2 oral formulations: the original oil-based formulation and the more commonly used ultramicronized emulsion that facilitates oral absorption. Ultramicronized cyclosporine is available as an approved animal product, and human proprietary and generic preparations are also available. Bioavailability of the different formulations in dogs is likely to vary among the preparations. Cyclosporine is associated with a large number of drug interactions that can also influence blood cyclosporine concentrations. Therapeutic drug monitoring (TDM) can be used to assist in attaining consistent plasma cyclosporine concentrations despite the effects of varying bioavailability and drug interactions. TDM can facilitate therapeutic success by guiding dose adjustments on an individualized basis, and is recommended in cases that do not respond to initial oral dosing, or during treatment of severe, life-threatening diseases for which a trial-and-error approach to dose adjustment is too risky. Pharmacodynamic assays that evaluate individual patient immune responses to cyclosporine can be used to augment information provided by TDM.

Cutaneous nocardiosis in two dogs receiving ciclosporin therapy for the management of canine atopic dermatitis

BACKGROUND

Ciclosporin is a calcineurin inhibitor that is currently registered for the treatment of canine atopic dermatitis. The most common adverse effects include mild, transient gastrointestinal disturbances. Single case reports of opportunistic infections due to Nocardia spp., Neospora spp. and papillomaviruses have also been reported.

HYPOTHESIS/OBJECTIVES

Clinicians should be aware of the potential risk of systemic immunosuppression and subsequent infection with Nocardia spp. in dogs receiving ciclosporin.

ANIMALS

Cutaneous nocardiosis in two dogs receiving ciclosporin therapy for management of canine atopic dermatitis.

METHODS

Histopathology, PCR for Nocardia spp. and computed tomography.

RESULTS

One dog developed disseminated nocardiosis due to Nocardia brasiliensis and a second dog developed localized cutaneous nocardiosis due to a novel Nocardia species subsequent to ciclosporin administration at the recommended dose rate for the management of canine atopic dermatitis. The second case was receiving a combination of ciclosporin and ketoconazole, and serum trough ciclosporin levels were elevated.

CONCLUSIONS AND CLINICAL IMPORTANCE

Clinicians should be aware of the potential risk of systemic immunosuppression and subsequent infection with Nocardia spp. in dogs receiving ciclosporin. Measurement of serum ciclosporin levels may be useful in identifying those individuals which are at risk of opportunistic infections.

Cyclosporine in veterinary dermatology

Cyclosporine is an immunomodulatory medication that is efficacious and approved for atopic dermatitis in dogs and allergic dermatitis in cats; it has also been used to successfully manage a variety of immune-mediated dermatoses in dogs and cats. This article reviews the use of cyclosporine in veterinary dermatology including its mechanism of action, pharmacokinetics, drug interactions, side effects, and relevant clinical updates. Dermatologic indications including atopic/allergic dermatitis, perianal fistulas, sebaceous adenitis, and other immune-mediated skin diseases are discussed.

The use of ciclosporin A in veterinary dermatology

Ciclosporin A (CsA) has potent immunosuppressive and immunomodulatory activity that has been exploited in human medicine to prevent the rejection of transplanted organs and to manage atopic dermatitis and psoriasis. Over the past decade, CsA has been employed more frequently in veterinary dermatology and its value in the management of several canine and feline dermatoses is now well established. CsA inhibits calcineurin phosphatase, suppressing T cell activation and the synthesis of T cell cytokines consequently impairing the activity of B cells, antigen-presenting cells, mast cells, basophils and eosinophils. The pharmacokinetics of CsA are similar in humans, dogs and cats and the drug has a wide safety margin in dogs, cats and rabbits. Adverse effects, principally transient vomiting and soft faeces/diarrhoea, may be seen shortly after instituting treatment but often resolve despite continuing treatment. Gingival hyperplasia and cutaneous effects such as hirsutism may occur after prolonged treatment.

Effects of powdered whole grapefruit and metoclopramide on the pharmacokinetics of cyclosporine in dogs

OBJECTIVE

To determine whether oral administration of metoclopramide or a commercially available powdered whole grapefruit (PWG) nutraceutical in combination with cyclosporine enhances systemic availability of cyclosporine in dogs.

SAMPLE

8 healthy mixed-breed dogs in part 1 and 6 of these 8 dogs in part 2.

PROCEDURES

Cyclosporine pharmacokinetics were determined over the course of 24 hours after oral administration of cyclosporine (5 mg/kg) alone, cyclosporine with metoclopramide (0.3 to 0.5 mg/kg), cyclosporine with 2 g of PWG, or cyclosporine combined with both metoclopramide and 2 g of PWG by use of a Latin square crossover study with a 14-day washout period between treatments. Sixty days later, 6 of the 8 dogs were given 10 g of PWG followed by cyclosporine, and pharmacokinetic parameters were compared with those previously obtained after administration of cyclosporine alone.

RESULTS

Although metoclopramide or coadministration of metoclopramide and 2 g of PWG had no effect on the pharmacokinetic parameters of cyclosporine, compared with results for cyclosporine alone, the higher (10-g) dose of PWG resulted in 29% faster mean time to maximal plasma cyclosporine concentration, 54% larger area under the curve, and 38% lower apparent oral clearance.

CONCLUSIONS AND CLINICAL RELEVANCE

Adjustment of the cyclosporine dose may not be needed when metoclopramide is coadministered orally to prevent common adverse effects of cyclosporine. Powdered whole grapefruit has the potential to reduce the required orally administered dose of cyclosporine but only when PWG is used in an amount (at least 10 g) that is currently not cost-effective.

Presumptive Nocardia spp. infection in a dog treated with cyclosporin and ketoconazole

CASE HISTORY

A dog that had received 8 months of cyclosporin and ketoconazole therapy for treatment of atopic dermatitis subsequently developed severe neurological disease, that failed to respond to treatment with trimethoprim-sulphadiazine and clindamycin. HISTOPATHOLOGICAL FINDINGS: Histopathological examination of the pulmonary parenchyma and spinal cord revealed loose aggregates of Gram-positive, partially acid-fast, fine, beaded, filamentous bacteria, most consistent with Nocardia spp.

DIAGNOSIS

A presumptive diagnosis was made of disseminated nocardiosis of the spinal cord and lungs.

CLINICAL RELEVANCE

Nocardia spp. is an opportunistic actinomycete that may cause disseminated disease, particularly in immunocompromised animals. Cyclosporin is used in veterinary medicine to control immune-mediated and allergic disorders, with few reported adverse side effects. This case gives further evidence that involvement of the spinal cord in nocardiosis of the central nervous system (CNS) carries a poor prognosis, and opportunistic infection by Nocardia spp. may be a potential complication of immunosuppressive cyclosporin therapy in the dog.

Grapefruit juice, lyophilized grapefruit juice, and powdered whole grapefruit inhibit cytochrome P450-mediated triazolam hydroxylation by beagle dog liver microsomes

Coadministration of grapefruit juice (GFJ) has been proposed to enhance the systemic availability and decrease the required dose of drugs such as cyclosporine that are extensively metabolized in the intestine and liver. Although GFJ inhibits human cytochrome P450 (CYP) 3A, effects on dog CYP have not yet been reported. Consequently, we determined whether GFJ inhibits triazolam hydroxylation by Beagle dog liver microsomes (DLM) using human liver microsomes (HLM) as positive control. Results were compared with the effects of lyophilized GFJ and commercially-available powdered grapefruit capsules, which may be more convenient dosage forms. GFJ inhibited alpha-hydroxytriazolam formation in both DLM and HLM with similar IC(50) (inhibitor concentration producing a 50% decrease in reaction velocity) values of 0.56% and 0.52% (v/v), respectively. Lyophilized GFJ and powdered grapefruit also inhibited DLM alpha-hydroxytriazolam formation with IC(50) values of 0.76 and 1.2 mg/mL, respectively. Consistent with mechanism-based enzyme inhibition, preincubation of DLM with any of the grapefruit products for 20 min resulted in significant enhancement of inhibition of triazolam alpha-hydroxylation by 8-20%. The results indicate that 16 g of lyophilized GFJ or 23 g of powdered grapefruit would be equivalent to dosing 100 mL of GFJ. In vivo pharmacokinetic interaction studies are needed to confirm these in vitro findings.

Long-Term Evaluation of Canine Perianal Fistula Disease Treated With Exclusive Fish and Potato Diet and Surgical Excision

The records of 33 dogs that had perianal fistula disease treated with en bloc surgical excision and bilateral anal saculectomy, and that were perioperatively administered an exclusive white fish and potato diet, were reviewed to determine outcome. By 1 year after surgery, 87.9% of the dogs had complete or near-complete resolution of visible fistula disease, while only 20.7% continued to have mild intermittent clinical signs. Fecal incontinence was not reported in any dog. Overall, complications were considerably less in both severity and frequency when compared with previous reports.

Brain abscess in a dog immunosuppressed using cyclosporin

This report describes a dog that developed brain abscesses following prolonged immunosuppression with cyclosporin. Bacteria within the abscess were most likely Nocardia, an organism well recognised in immunosuppressed humans, and probably reached the brain through haematogenous spread from a more long-standing abscess in the mediastinum. Bacterial brain abscesses developing in this manner are very rare in dogs and this case highlights the wider range of possible diagnoses that need to be considered in immunosuppressed patients and the care with which potent drugs such as cyclosporin should be used.

Preoperative Immunosuppressive Therapy and Surgery as a Treatment for Anal Furunculosis

OBJECTIVES

To evaluate the efficacy of combining preoperative immunosuppressive therapy with surgical excision for treatment of anal furunculosis (AF) in dogs.

STUDY DESIGN

Retrospective study.

ANIMALS

Dogs (n=25) with stages 1-4 AF.

METHODS

Preoperative immunosuppressive therapy was either cyclosporine A (CyA) alone or in combination with ketoconazole (Group 1; n=18), or azathioprine combined with prednisolone (Group 2; n=7). Surgical excision of residual draining tracts, cryptectomy, and anal sacculectomy were performed. Only dogs with postoperative clinical follow-up exceeding 9 months were retained for the study.

RESULTS

Both immunosuppressive protocols were effective in reducing progression of AF. Subsequent draining tracts excision, cryptectomy, and anal sacculectomy were bilateral (12 dogs) or unilateral (13 dogs of which 4 had bilateral anal sacculectomy). Postoperative recovery was uneventful, except for 2 dogs that had wound breakdown. Recurrence was not observed in any of the dogs that had bilateral surgical excision and or in 9 dogs that had unilateral excision.

CONCLUSION

Preoperative immunosuppressive therapy, combined with bilateral surgical resection of affected tissue consistently, resulted in resolution of AF. Four dogs that had recurrence had unilateral excision despite initial bilateral involvement, suggesting that all diseased tissue should be excised.

CLINICAL RELEVANCE

These preliminary results suggest that immunosuppressive therapy before surgical excision for AF yields minimizes recurrence in dogs.

Cyclosporine treatment of anal furunculosis in 26 dogs

OBJECTIVES

To evaluate the effect of cyclosporine on anal furunculosis lesions in 26 dogs.

METHODS

Lesions were graded as mild in 11 dogs, moderate in eight and severe in seven. Each dog was treated with approximately 4 mg/kg cyclosporine orally every 12 hours until the lesions resolved or showed no further improvement. Residual lesions were resected surgically.

RESULTS

Eighteen dogs (69 per cent) experienced complete resolution, seven (27 per cent) improved but had residual lesions and one (4 per cent) showed no improvement. The mean duration of treatment until resolution or no further improvement was 8.8 weeks (range four to 24 weeks). Nine dogs (35 per cent) experienced recurrence. Six were from the group that had shown complete resolution and three were from the group that had surgery. Fifteen dogs (58 per cent) developed side effects to cyclosporine, although none required treatment to be discontinued. Mean duration of follow-up was 6.8 months (range one to 20 months).

CLINICAL SIGNIFICANCE

Cyclosporine was effective at resolving or reducing anal furunculosis lesions in 25 of 26 dogs (96 per cent). However, residual or recurrent lesions remain a potential problem, and surgical resection or long-term cyclosporine treatment may be necessary in some dogs.

The role of surgery in the management of canine anal furunculosis. A review of the literature and a retrospective evaluation of treatment by surgical resection in 51 dogs

AIMS

To retrospectively evaluate the outcome of surgical management of anal furunculosis (AF) in 51 dogs. To compare the outcome of surgery with those of current medical protocols by way of a review of the literature.

METHODS

Dogs referred for treatment of AF (n=51) were treated by en bloc surgical resection of diseased tissue and primary wound closure. This technique was combined with bilateral anal sacculectomy in all cases in which the anal sacs had not been previously removed. Immunomodulatory therapies were not used, with the exception of post-operative metronidazole antibiosis for 7-10 days. Follow-up was performed by the author using a telephone questionnaire.

RESULTS

Forty-eight dogs were eligible for post-operative follow-up 1.5 to 36 (mean 17.4, median 18) months after surgery. Lesion recurrence, faecal incontinence and stricture formation occurred in 2%, 4% and 13% of dogs, respectively. The percentage of dogs considered by their owners to have an acceptable level of faecal continence and an improved quality of life was 94%.

CONCLUSIONS AND CLINICAL RELEVANCE

The aetiopathogenesis of canine AF remains unclear. Whilst recent advances in medical management by the use of various immunomodulatory medications (such as cyclosporine) hold promise, this approach has yet to be refined with respect to affordability, long-term efficacy and morbidity. With meticulous surgical dissection and reconstruction techniques (anoplasty), excellent success rates can be achieved following a single surgical procedure with minimal complications. Surgery remains a viable treatment option, alone or in combination with immunomodulatory medications, until a more thorough understanding of this debilitating disease is achieved.

A systematic review and meta-analysis of the efficacy and safety of cyclosporin for the treatment of atopic dermatitis in dogs

The efficacy of cyclosporin A (CsA) for the treatment of canine atopic dermatitis was evaluated based on the systematic review of prospective clinical trials published between 2001 and 2005. Ten studies with adequate design characteristics were included. These studies enrolled 799 dogs, 672 (84%) treated with CsA, 160 (20%) with placebo, 74 (9%) with oral glucocorticoids and 23 (3%) with antihistamines. Treatment duration varied from 2 weeks to 6 months. For safety analysis, data were available from 660 dogs. Lesion scores were improved from baseline in the range of 30-52%, 53-84% and 52-69% after 4, 6 and 16 weeks, respectively. The percentage of dogs with only mild pruritus rose from 0-13% at inclusion to 32-59% and 46-90% after 4 and 12 weeks, respectively. In most studies, the frequency of CsA administration could be reduced to every other day in 40% to 50% of patients after 4 weeks and to twice weekly in 20-26% of the dogs after 12-16 weeks. Meta-analysis confirmed highly significant effects of CsA compared to placebo, but none between oral CsA and glucocorticoids. The initial disease severity, age or body weight of subjects did not influence treatment success. Improvement by more than 50% over baseline of lesion scores was predictive of a better response during treatment maintenance. Vomiting and soft stools/diarrhoea were the most frequent adverse events seen at least once during the studies. These occurred in 25% and 15% of subjects, respectively. The frequency of each other type of adverse events was lower than 2.1%. In summary, the administration of CsA for the treatment of canine AD was found to be as effective as that of glucocorticoids, and adverse effects were minimal.

DEMONSTRATION OF DOCOSAHEXAENOIC ACID AS A BIOAVAILABILITY ENHANCER FOR CYP3A SUBSTRATES: IN VITRO AND IN VIVO EVIDENCE USING CYCLOSPORIN IN RATS

To investigate the pharmacokinetic interaction between cyclosporin A (CsA) and docosahexaenoic acid (DHA) in vivo, 5 mg/kg CsA was orally or intravenously coadministered with DHA (50-200 microg/kg) to rats. The effect of DHA on CYP3A activity was determined using rat liver microsomes in vitro. Moreover, the effect of DHA on P-glycoprotein (P-gp) function was examined using cultured Caco-2 cells in vitro. After oral coadministration of CsA with 100 microg/kg and 200 microg/kg DHA, bioavailability (BA) was significantly increased, compared with control rats. In contrast, no pharmacokinetic interaction was observed when CsA was intravenously administered in rats dosed orally with DHA, suggesting that DHA did not affect hepatic metabolism. The formation of 6beta-hydroxytestosterone from testosterone in rat liver microsomes was competitively inhibited by DHA. The Km, Vmax, and Ki values were 25.5 microM, 2.45 nmol/min/mg protein, and 5.52 microM, respectively. Moreover, basal-to-apical transport of [3H]CsA in the Caco-2 cell monolayer was not affected by DHA but was decreased by valspodar (PSC 833), a P-gp inhibitor. Our finding is the first to indicate that DHA inhibits intestinal CYP3A both in vitro and in vivo, but not P-gp. It was thus demonstrated that DHA could be used as a BA enhancer for the drugs that are extensively metabolized by CYP3A in the gut.

Recurrent flank alopecia in a Tibetan Terrier

Recurrent flank alopecia is described in a 2-year-old, male, neutered Tibetan Terrier with concurrent atopic dermatitis. The diagnosis of recurrent flank alopecia was made after 3 consecutive years of localised, winter-onset alopecia. The diagnosis was based on history, compatible clinical signs and supportive histopathology. The diagnosis was complicated by the presence of concurrent pruritic dermatitis. To our knowledge this is the first report of recurrent flank alopecia in this breed.

Use of cyclosporine to treat granulomatous meningoencephalitis in three dogs

Use of cyclosporine to treat granulomatous meningoencephalitis in three dogs Three dogs with a presumptive diagnosis of granulomatous meningoencephalitis were treated with orally administered cyclosporine. In 2 dogs, cyclosporine administration replaced initial corticosteroid administration, and in 1 dog, cyclosporine was the only treatment used. One dog had the focal form of the disease in the brainstem, 1 dog had the focal form in the forebrain associated with a concurrent ocular form, and 1 dog had the disseminated form of disease. At 12-month follow-up, the 2 dogs with the focal form of the disease had no clinical signs. The dog with the disseminated form improved only partially, and euthanasia was performed 3 weeks after initial evaluation. Cyclosporine was considered effective at an initial dosage of 6 mg/kg (2.7 mg/lb) every 12 hours. Adverse effects associated with cyclosporine administration included transient lymphopenia, excessive shedding, and focal symmetric hair discoloration.

Canine atopic dermatitis: new targets, new therapies

Atopic dermatitis is a common allergic skin disease of complex etiopathogenesis in both humans and dogs. Immediate-type hypersensitivity to environmental allergens that arises as a result of environmental and genetic factors is a major part of the pathogenesis in most but not all patients. Alterations in epidermal barrier function, priming of cutaneous antigen-presenting cells with IgE, intrinsic keratinocyte defects, and even development of autoimmunity are also factors that contribute to the primary disease. Secondary factors, especially infections with Staphylococcus and yeast organisms, strongly influence the course of this skin disease. The relatively recent understanding of the complexities of atopic dermatitis has resulted in changes in diagnostic and therapeutic strategies for the disease. We now know that the best therapeutic approach is to use combinations of multiple modalities individualized for each patient over the course of his or her lifetime.

Efficacy of combined cyclosporine A and ketoconazole treatment of anal furunculosis

Cyclosporine A and ketoconazole were used as a combined therapy to treat 19 dogs with anal furunculosis. Complete resolution of all lesions was achieved in three to 10 weeks, but recurrences occurred in seven of the 19 dogs (36.8 per cent), with remission periods extending from one to six months for these dogs. Adverse effects of treatment included excessive hair loss, intermittent lethargy, vomiting and decreased appetite in some dogs, but none of the signs were considered serious. The results of treatment are comparable with, if not better than, the surgical alternatives. There is an approximate 70 per cent cost saving over the use of cyclosporine alone.

Multicentric lymphoma in a dog after cyclosporine therapy

An 11-year-old, neutered male German shepherd dog was presented with perianal ulceration and fistulas. A clinical diagnosis of anal furunculosis was made, and the dog was treated with cyclosporine and ketoconazole. The perianal lesions resolved. However, after four weeks of therapy the dog developed multicentric lymphoma. Complete remission was achieved with combination chemotherapy (Wisconsin-Madison protocol). Cyclosporine administration is associated with an increased risk of development of lymphoma in humans and a similar increased risk might be expected in dogs. Although a causative relationship between cyclosporine administration and the development of lymphoma cannot be proven in this case, it is possible that cyclosporine therapy may have contributed to lymphomagenesis. As the use of cyclosporine in small animals is increasing, further work is required to substantiate and quantify the proposed increased risk.

Cyclosporin A: a new drug in the field of canine dermatology

In the last few years, there has been growing interest in the use of cyclosporin to treat canine skin diseases. Cyclosporin exhibits potent immunomodulating properties that reflect its ability to block the transcription of cytokines genes in activated T lymphocytes. Cyclosporin also inhibits a number of immune allergic reactions that occur after activation of mast cells, Langerhans cells, eosinophils and keratinocytes. In randomized controlled trials, cyclosporin has proven to be as effective as glucocorticoids for treatment of canine atopic dermatitis at the inducing dosage of 5 mg kg(-1). The drug has also proven beneficial for the treatment of perianal fistulas in dogs. Other potential applications are suggested from small pilot open trials using dogs affected with various immune-mediated dermatological diseases. The pharmacokinetic properties of cyclosporin are very similar in dogs and man, but its safety margin is much wider in dogs. Therefore, routine cyclosporin blood level monitoring does not appear necessary. Although in man renal impairment and hypertension are often seen, even at low doses, these effects are not observed in dogs. Adverse reactions consist mainly of transient emesis and diarrhoea occurring during the first days of treatment. Other adverse reactions, such as gingival hyperplasia, verruciform lesions and hypertrichosis, appear to be dose-dependent, and occur rarely at therapeutic doses. An increased susceptibility to infections has not been reported in dogs receiving this drug.

Review of the pharmacokinetics, interactions and adverse reactions of cyclosporine in people, dogs and cats

Cyclosporine is being increasingly used in veterinary medicine. Oral formulations of the drug have found many therapeutic uses, but topical formulations have met with only limited success, probably owing to their poor penetration through the stratum corneum. The concurrent use of ketoconazole to inhibit cyclosporine metabolism has been shown to reduce the required dose and hence the cost of cyclosporine therapy. In human medicine, adverse reactions to the drug, especially nephrotoxicity, are common but in dogs given the commonly used oral dose of 5 mg/kg per day there have been few adverse reactions. However, no toxicity studies lasting longer than 12 months have been carried out in this species. This paper reviews the pharmacokinetics, drug and procedural interactions, contraindications and the adverse reactions to cyclosporine, with particular reference to its use in the treatment of dermatological conditions in dogs, cats and people.

Cyclosporin: applications in small animal dermatology

Cyclosporin has been increasingly used for the treatment of skin diseases in small animals. Reported uses include the treatment of atopy, cutaneous lupus erythematosus, feline acquired alopecia resembling pseudopelade of humans, pemphigus erythematosus, pemphigus foliaceus, perianal fistulae and sebaceous adenitis. In addition, cyclosporin has been used anecdotally for several other skin diseases. Few side effects have been noted at doses therapeutic for dermatologic diseases. Current suggestions for monitoring, and the value of trough cyclosporin serum concentrations for prediction of toxicity and efficacy are discussed.