1
|
LeVine DN, Goggs R, Kohn B, Mackin AJ, Kidd L, Garden OA, Brooks MB, Eldermire ERB, Abrams-Ogg A, Appleman EH, Archer TM, Bianco D, Blois SL, Brainard BM, Callan MB, Fellman CL, Haines JM, Hale AS, Huang AA, Lucy JM, O'Marra SK, Rozanski EA, Thomason JM, Walton JE, Wilson HE. ACVIM consensus statement on the treatment of immune thrombocytopenia in dogs and cats. J Vet Intern Med 2024. [PMID: 38779941 DOI: 10.1111/jvim.17079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2024] [Accepted: 04/04/2024] [Indexed: 05/25/2024] Open
Abstract
Management of immune thrombocytopenia (ITP) in dogs and cats is evolving, but there are no evidence-based guidelines to assist clinicians with treatment decisions. Likewise, the overall goals for treatment of ITP have not been established. Immunosuppressive doses of glucocorticoids are the first line treatment, but optimal treatment regimens beyond glucocorticoids remain uncertain. Additional options include secondary immunosuppressive drugs such as azathioprine, modified cyclosporine, and mycophenolate mofetil, usually selected based on clinician preference. Vincristine, human IV immunoglobulin (hIVIg), and transfusion of platelet or red blood cell-containing products are often used in more severe cases. Splenectomy and thrombopoietin receptor agonists are usually reserved for refractory cases, but when and in which patient these modalities should be employed is under debate. To develop evidence-based guidelines for individualized treatment of ITP patients, we asked 20 Population Intervention Comparison Outcome (PICO) format questions. These were addressed by 17 evidence evaluators using a literature pool of 288 articles identified by a structured search strategy. Evidence evaluators, using panel-designed templates and data extraction tools, summarized evidence and created guideline recommendations. These were integrated by treatment domain chairs and then refined by iterative Delphi survey review to reach consensus on the final guidelines. In addition, 19 non-PICO questions covering scenarios in which evidence was lacking or of low quality were answered by expert opinion using iterative Delphi surveys with panelist integration and refinement. Commentary was solicited from multiple relevant professional organizations before finalizing the consensus. The rigorous consensus process identified few comparative treatment studies, highlighting many areas of ITP treatment requiring additional studies. This statement is a companion manuscript to the ACVIM Consensus Statement on the Diagnosis of Immune Thrombocytopenia in Dogs and Cats.
Collapse
Affiliation(s)
- Dana N LeVine
- Department of Clinical Sciences, College of Veterinary Medicine, Auburn University, Auburn, Alabama, USA
| | - Robert Goggs
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, New York, USA
| | - Barbara Kohn
- Small Animal Clinic, School of Veterinary Medicine, Freie Universität Berlin, Berlin, Germany
| | - Andrew J Mackin
- Department of Clinical Sciences, College of Veterinary Medicine, Mississippi State University, Mississippi State, Mississippi, USA
| | - Linda Kidd
- Linda Kidd Veterinary Internal Medicine Consulting, Carlsbad, California, USA
| | - Oliver A Garden
- School of Veterinary Medicine, Louisiana State University, Baton Rouge, Louisiana, USA
| | - Marjory B Brooks
- Department of Population Medicine and Diagnostic Sciences, College of Veterinary Medicine, Cornell University, Ithaca, New York, USA
| | - Erin R B Eldermire
- Flower-Sprecher Veterinary Library, College of Veterinary Medicine, Cornell University, Ithaca, New York, USA
| | - Anthony Abrams-Ogg
- Department of Clinical Studies, Ontario Veterinary College, University of Guelph, Guelph, Ontario, Canada
| | - Elizabeth H Appleman
- Department of Internal Medicine, The Animal Medical Center, New York, New York, USA
| | - Todd M Archer
- Bluff City Veterinary Specialists, Memphis, Tennessee, USA
| | - Domenico Bianco
- College of Veterinary Medicine, Western University of Health Sciences, Pomona, California, USA
| | - Shauna L Blois
- Department of Clinical Studies, Ontario Veterinary College, University of Guelph, Guelph, Ontario, Canada
| | - Benjamin M Brainard
- Department of Small Animal Medicine and Surgery, College of Veterinary Medicine, University of Georgia, Athens, Georgia, USA
| | - Mary Beth Callan
- Department of Clinical Sciences and Advanced Medicine, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Claire L Fellman
- Department of Clinical Sciences, Cummings School of Veterinary Medicine, Tufts University, North Grafton, Massachusetts, USA
| | - Jillian M Haines
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, Washington State University, Pullman, Washington, USA
| | - Anne S Hale
- Zia Pet Hospital, Rio Rancho, New Mexico, USA
| | | | - John M Lucy
- Oradell Animal Hospital, Paramus, New Jersey, USA
| | - Shana K O'Marra
- Northwest Veterinary Critical Care Services, Vancouver, Washington, USA
| | - Elizabeth A Rozanski
- Department of Clinical Sciences, Cummings School of Veterinary Medicine, Tufts University, North Grafton, Massachusetts, USA
| | - John M Thomason
- Department of Clinical Sciences, College of Veterinary Medicine, Mississippi State University, Mississippi State, Mississippi, USA
| | - Jenny E Walton
- Veterinary Apheresis Service UK, Washington, Tyne and Wear, United Kingdom
| | - Helen E Wilson
- Langford Vets, University of Bristol, Langford, Somerset, United Kingdom
| |
Collapse
|
2
|
Spear DJ, Crouse ZJ, Kearns SA. Retrospective evaluation of leflunomide as an adjunctive therapy in dogs with non-associative immune-mediated thrombocytopenia: 20 cases (2008-2021). J Small Anim Pract 2024; 65:261-269. [PMID: 38433454 DOI: 10.1111/jsap.13715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 01/22/2024] [Accepted: 02/07/2024] [Indexed: 03/05/2024]
Abstract
OBJECTIVE To describe leflunomide as an adjunctive therapy in the treatment of non-associative immune-mediated thrombocytopenia. MATERIALS AND METHODS A retrospective study of dogs with a diagnosis of non-associative immune-mediated thrombocytopenia treated with leflunomide March 2008 to September 2021 was conducted. Data collected included signalment, clinical signs, physical examination findings and diagnostic testing performed. Medications administered, duration of hospital stay, time to platelet concentration >150×109/L and adverse events during leflunomide therapy were recorded. Relapses within a year of diagnosis were reported. RESULTS A total of 20 client-owned dogs met inclusion criteria. Nineteen of 20 dogs (95%) achieved a platelet concentration >150×109/L with leflunomide and prednisone combination therapy and four dogs (21.1%) relapsed during treatment or shortly after treatment. Adverse effects included diarrhoea (n=5), mild lymphopenia (n=9) and mild intermittent anaemia (n=1). A single dog developed hepatotoxicity presumed to be secondary to leflunomide therapy that resolved after drug discontinuation. One dog was treated for aspiration pneumonia during treatment. Two dogs were euthanased while receiving leflunomide. CLINICAL SIGNIFICANCE Length of hospitalisation, time to platelet recovery, treatment response and relapse rate were comparable with alternative treatment protocols. Most adverse effects did not require leflunomide dose adjustment; however, two dogs died while undergoing leflunomide treatment and there is compelling evidence that one of these dogs experienced fatal infection secondary to immune-suppression. Hepatotoxicity remains a known complication of leflunomide treatment and serial biochemistry testing is recommended.
Collapse
Affiliation(s)
- D J Spear
- Department of Internal Medicine, Massachusetts Veterinary Referral Hospital, Woburn, MA, 01801, USA
- Department of Internal Medicine, Angell Animal Medical Center, Boston, MA, 02130, USA
| | - Z J Crouse
- Department of Internal Medicine, Angell Animal Medical Center, Boston, MA, 02130, USA
| | - S A Kearns
- Department of Internal Medicine, Angell Animal Medical Center, Boston, MA, 02130, USA
| |
Collapse
|
3
|
Mane RR, Kale PP. The roles of HDAC with IMPDH and mTOR with JAK as future targets in the treatment of rheumatoid arthritis with combination therapy. JOURNAL OF COMPLEMENTARY & INTEGRATIVE MEDICINE 2023; 20:689-706. [PMID: 36409592 DOI: 10.1515/jcim-2022-0114] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Accepted: 07/19/2022] [Indexed: 06/16/2023]
Abstract
Various studies have shown that cytokines are important regulators in rheumatoid arthritis (RA). In synovial inflammation alteration of the enzyme HDAC, IMPDH enzyme, mTOR pathway, and JAK pathway increase cytokine level. These increased cytokine levels are responsible for the inflammation in RA. Inflammation is a physiological and normal reaction of the immune system against dangerous stimuli such as injury and infection. The cytokine-based approach improves the treatment of RA. To reach this goal, various researchers and scientists are working more aggressively by using a combination approach. The present review of combination therapy provides essential evidence about the possible synergistic effect of combinatorial agents. We have focused on the effects of HDAC inhibitor with IMPDH inhibitor and mTOR inhibitor with JAK inhibitor in combination for the treatment of RA. Combining various targeted strategies can be helpful for the treatment of RA.
Collapse
Affiliation(s)
- Reshma Rajendra Mane
- Department of Pharmacology, SVKM's Dr. Bhanuben Nanavati College of Pharmacy, Mumbai, India
| | - Pravin Popatrao Kale
- Department of Pharmacology, SVKM's Dr. Bhanuben Nanavati College of Pharmacy, Mumbai, India
| |
Collapse
|
4
|
Glucocorticoids, Cyclosporine, Azathioprine, Chlorambucil, and Mycophenolate in Dogs and Cats. Vet Clin North Am Small Anim Pract 2022; 52:797-817. [DOI: 10.1016/j.cvsm.2022.01.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
|
5
|
Kristiansen PS, Nielsen LN. Immunomodulatory and immunosuppressive drug protocols in the treatment of canine primary immune thrombocytopenia, a scoping review. Acta Vet Scand 2021; 63:54. [PMID: 34961516 PMCID: PMC8721564 DOI: 10.1186/s13028-021-00620-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 11/18/2021] [Indexed: 11/29/2022] Open
Abstract
Primary immune thrombocytopenia (ITP) is a cause of severe thrombocytopenia in dogs. Immunosuppressive corticosteroid drugs are frequently used in the management of ITP, but treatment failure may occur. Immunomodulatory and non-corticosteroid immunosuppressive drugs might improve outcomes from therapy either alone or in combination with corticosteroids. The objectives of this scoping review were (1) to evaluate the current evidence relating to immunomodulatory and immunosuppressive drug protocols in the treatment of canine ITP, and (2) to answer the clinical question, whether or not therapy with immunomodulatory or non-corticosteroid immunosuppressive drugs alone or in combination with corticosteroids could improve outcome, compared to therapy with corticosteroids alone. A literature search was performed in the electronic databases of Agricola, CAB Abstracts, Embase, Medline and Web of Science for publications in November 2019 and again February 1, 2021. Selection criteria were relatively strict and included peer-reviewed research papers reporting outcome measures from immunomodulatory and immunosuppressive drug protocols in the treatment of canine ITP with a pre-therapeutic mean or median platelet count < 50,000/µL as a strict criterion for inclusion. Studies were evaluated if they had an appropriate diagnostic work up to exclude underlying conditions. Outcome measures and adverse events were compared between drug protocols both within studies and between studies. The search identified 456 studies, with six studies being eligible for inclusion. The studies were mostly case series while two were randomized controlled trials. Level of evidence varied with an overall uncertain subject enrollment, small groups, inadequate description and variable use of drug protocols or outcome measures. For outcomes such as platelet recovery time and duration of hospitalization, an improvement was observed using adjunctive therapy (human intravenous immunoglobulin) compared to therapy with corticosteroids alone. For outcomes of complete platelet recovery time, survival (6-month), mortality and relapse, no improvement was observed using adjunctive drugs compared to corticosteroids alone. Specifically, therapy with mycophenolate mofetil alone and adjunctive azathioprine were associated with more severe adverse events compared to other drug protocols. Evidence relating to immunomodulatory and immunosuppressive drug protocols in the treatment of canine ITP was of variable quality. Future larger case-controlled trials are required for determination of optimal treatment protocols in canine ITP.
Collapse
|
6
|
Fukushima K, Lappin M, Legare M, Veir J. A retrospective study of adverse effects of mycophenolate mofetil administration to dogs with immune-mediated disease. J Vet Intern Med 2021; 35:2215-2221. [PMID: 34231261 PMCID: PMC8478029 DOI: 10.1111/jvim.16209] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 06/11/2021] [Accepted: 06/18/2021] [Indexed: 01/20/2023] Open
Abstract
Background Information regarding adverse events (AEs) of mycophenolate mofetil (MMF) is limited. Objectives To evaluate the types and frequency of potential AEs of MMF in dogs with immune‐mediated disease. Animals One hundred thirty‐one dogs treated with MMF for management of suspected immune‐mediated disease. Methods Retrospective study. Medical records were reviewed to find and group suspect AEs in gastrointestinal (GI), hematologic, and other categories. Age, dosage, body weight, and sex were analyzed between dogs with and without AEs by using the Mann‐Whitney U‐test and chi‐squared test. Results The median starting dosage of MMF was 17.5 mg/kg/day (interquartile range [IQR] = 15.1‐20.6 mg/kg/day) and the median treatment duration was 56 days (IQR = 14‐236 days). Mycophenolate mofetil was prescribed for immune‐mediated hemolytic anemia (n = 31), immune‐mediated thrombocytopenia (n = 31), pemphigus foliaceus (n = 15), immune‐mediated polyarthritis (n = 12), and others (n = 42). Overall, potential AEs of MMF were observed in 34 of 131 dogs (GI 24.4% [31/127], neutropenia 4% [3/76], anemia 4% [1/25], thrombocytopenia 4.0% [1/25], and dermatologic 1.5% [2/131]). There were no significant differences among dogs with (n = 37) or without potential AEs (n = 94) in regards to sex, age, body weight, or dosage of MMF (P = .06, .13, .24, and .26, respectively). Conclusions and Clinical Importance In the dogs administered MMF, GI AEs were most common. Since potential hematologic and dermatologic AEs developed in a few dogs, clinicians should be aware of these when prescribing MMF to dogs with immune‐mediated disease.
Collapse
Affiliation(s)
- Kenjiro Fukushima
- Department of Clinical Sciences, Colorado State University, Fort Collins, Colorado, USA
| | - Michael Lappin
- Department of Clinical Sciences, Colorado State University, Fort Collins, Colorado, USA
| | - Marie Legare
- Department of Environmental and Radiological Health Science, Colorado State University, Fort Collins, Colorado, USA
| | - Julia Veir
- Department of Clinical Sciences, Colorado State University, Fort Collins, Colorado, USA
| |
Collapse
|
7
|
Polydoros T, Ioannidi OM, Korsavvidis I, Stefanidis S, Antoniadis T, Mylonakis ME. Romiplostim as Adjunctive Treatment of Refractory Amegakaryocytic Immune Thrombocytopenia in a Dog. Top Companion Anim Med 2020; 42:100488. [PMID: 33115689 DOI: 10.1016/j.tcam.2020.100488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 09/15/2020] [Accepted: 09/28/2020] [Indexed: 11/19/2022]
Abstract
A 9-year-old, intact male, mixed-breed dog was admitted with a 3-day history of severe thrombocytopenia and bleeding diathesis. Physical examination revealed mucosal and cutaneous petechiae and ecchymoses, melena, and gross hematuria. Clinicopathologic evaluation indicated severe thrombocytopenia, anemia, and panhypoproteinemia. Serology for common endemic vector-borne pathogens was negative and thoracic and abdominal imaging was unremarkable. Bone marrow aspiration cytology revealed aplasia of the megakaryocytic lineage, in the context of a mildly hypoplastic myeloid and a normal erythroid series. A diagnosis of presumptive primary amegakaryocytic immune thrombocytopenia (ITP) was established. Treatment with vincristine, prednisolone, and mycophenolate mofetil along with several whole blood transfusions failed to achieve clinical and clinicopathologic remission. As an adjunct treatment, romiplostim was administered at a cumulative dose of 15 μg/kg, subcutaneously, in 2 sessions, 1 week apart, and complete clinical and hematological remission was noted 8 days postinitiation of romiplostim. Thirty-eight months later, the dog remains clinically healthy with no evidence of hematological relapse. Romiplostim could be a promising adjunctive treatment option in dogs with refractory ITP.
Collapse
Affiliation(s)
- Thomas Polydoros
- Companion Animal Clinic, School of Veterinary Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Olympia M Ioannidi
- Companion Animal Clinic, School of Veterinary Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | | | | | - Theocharis Antoniadis
- Diagnostic Laboratory, School of Veterinary Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Mathios E Mylonakis
- Companion Animal Clinic, School of Veterinary Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece.
| |
Collapse
|
8
|
Goggs R, Brainard BM, LeVine DN, Calabro J, Harrell K, Mills T, Stone R, Davidson B, Iacovetta C, Harris L, Gicking J, Aslanian M, Ziegler A, Fulcher B, Lightfoot T, Miller M, Loftus J, Walton R, Blong A, Kishbaugh J, Hale AS. Lyophilized platelets versus cryopreserved platelets for management of bleeding in thrombocytopenic dogs: A multicenter randomized clinical trial. J Vet Intern Med 2020; 34:2384-2397. [PMID: 33016527 PMCID: PMC7694820 DOI: 10.1111/jvim.15922] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 09/17/2020] [Accepted: 09/22/2020] [Indexed: 12/15/2022] Open
Abstract
Background Thrombocytopenia in dogs is common in critical care medicine, but availability of fresh platelet concentrates in veterinary medicine can be limiting. Lyophilized platelets have long shelf‐lives and can be easily transported, stored, and administered in various settings. Objective To evaluate the efficacy and safety of a novel trehalose‐stabilized canine lyophilized platelet product in thrombocytopenic dogs with clinically‐evident bleeding. Animals Eighty‐eight dogs with platelet counts <50 × 103/μL and a standardized bleeding assessment tool (DOGiBAT) score ≥2. Methods Multicenter, randomized, non‐blinded, non‐inferiority clinical trial comparing dimethyl sulfoxide (DMSO)‐stabilized cryopreserved platelet concentrates (CPP) with trehalose‐stabilized lyophilized platelets (LP) for control of bleeding in thrombocytopenic dogs. Dogs were randomized to receive 3 × 109 platelets/kg of LP or CPP. Primary outcome measures were change in DOGiBAT score, platelet count, need for additional red cell transfusion and all‐cause mortality. Results Fifty dogs received LP and 38 received CPP. Baseline demographics and clinical characteristics of both groups were comparable. At 1‐hour post‐transfusion, LP were superior for change in DOGiBAT score, and non‐inferior at 24‐hours post‐transfusion. The LP were non‐inferior to CPP for change in platelet count, need for additional red blood cell units, and survival to discharge. The LP were superior for change in hematocrit at 1‐hour post‐transfusion, and non‐inferior at 24‐hours. No adverse effects were noted in either group. Conclusions and Clinical Importance A novel trehalose‐stabilized canine LP product appears to be logistically superior and is clinically non‐inferior to DMSO‐stabilized canine CPP for management of bleeding in thrombocytopenic dogs.
Collapse
Affiliation(s)
- Robert Goggs
- Department of Clinical Sciences, Cornell University College of Veterinary Medicine, Ithaca, New York, USA
| | - Benjamin M Brainard
- Department of Small Animal Medicine and Surgery, College of Veterinary Medicine, University of Georgia, Athens, Georgia, USA
| | - Dana N LeVine
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, Iowa State University, Ames, Iowa, USA
| | | | - Karyn Harrell
- College of Veterinary Medicine, North Carolina State University, Raleigh, North Carolina, USA
| | - Tracy Mills
- VCA Clinical Research, VCA Animal Hospitals, Los Angeles, California, USA
| | | | | | | | | | | | | | | | | | | | - Meredith Miller
- Department of Clinical Sciences, Cornell University College of Veterinary Medicine, Ithaca, New York, USA
| | - John Loftus
- Department of Clinical Sciences, Cornell University College of Veterinary Medicine, Ithaca, New York, USA
| | - Rebecca Walton
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, Iowa State University, Ames, Iowa, USA
| | - April Blong
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, Iowa State University, Ames, Iowa, USA
| | | | | |
Collapse
|
9
|
Goggs R. Therapeutic Strategies for Treatment of Immune-Mediated Hemolytic Anemia. Vet Clin North Am Small Anim Pract 2020; 50:1327-1349. [PMID: 32814628 DOI: 10.1016/j.cvsm.2020.07.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Immune-mediated hemolytic anemia is a common hematologic disorder in dogs. Disease management involves immunosuppression using glucocorticoids, potentially in combination with other medications such as azathioprine, cyclosporine, or mycophenolate mofetil. Therapeutic drug monitoring may enhance the utility and maximize the safety of cyclosporine and mycophenolate mofetil. The disease is proinflammatory and prothrombotic. Antithrombotic drug administration is therefore essential, and anticoagulant therapy should be initiated at the time of diagnosis. Additional therapies include red blood cell transfusion to support blood oxygen content. Future therapies may include therapeutic plasma exchange, anti-CD20 monoclonal antibodies, and complement inhibitors.
Collapse
Affiliation(s)
- Robert Goggs
- Emergency and Critical Care, Department of Clinical Sciences, Cornell University College of Veterinary Medicine, 930 Campus Road, Ithaca, NY 14853, USA.
| |
Collapse
|
10
|
Song JH, Yu DH, Lee HC, Hwang TS, Kim YJ, An SJ, Jung DI. Evaluation of treatment with a combination of mycophenolate mofetil and prednisolone in dogs with meningoencephalomyelitis of unknown etiology: a retrospective study of 86 cases (2009-2017). BMC Vet Res 2020; 16:192. [PMID: 32532259 PMCID: PMC7291637 DOI: 10.1186/s12917-020-02414-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Accepted: 06/04/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Combination therapy with glucocorticoids and adjunctive immunomodulating drugs has been generally accepted as a standard treatment regimen for meningoencephalomyelitis of unknown etiology (MUE). We hypothesized that treatment with MMF as an adjunctive agent along with glucocorticoids would be effective and well-tolerated protocol in dogs with MUE. Eighty-six dogs with MUE between May 2009 and June 2017 were included (59 females and 27 males; mean age of 5.93 years; mean body weight of 3.83 kg). The medical records of dogs with MUE treated with prednisolone and MMF were retrospectively evaluated to determine the therapeutic response, survival time, and treatment-related adverse effects. RESULTS A partial or complete response (CR) was recorded for 75 dogs. The overall median survival time from the initiation of treatment was 558 days. Dogs that showed CR with no relapse over the treatment period (from diagnosis to death) had significantly longer median survival times. A significantly higher mortality hazard ratio of 4.546 was recorded in dogs that failed to achieve CR. The interval between the onset of clinical signs and the clinical presentation was not significantly associated with CR, relapse rate, and survival time. Adverse effects included gastrointestinal upsets in 26 dogs (30.23%), sporadic infections in 17 dogs (19.77%), and pancreatitis in seven dogs (8.14%). CONCLUSIONS The results suggest that adjunctive MMF treatment for MUE is safe and comparable to other immunosuppressive protocols. The treatment should focus on the achievement of CR and preventing relapse for successful management.
Collapse
Affiliation(s)
- Joong-Hyun Song
- Institute of Animal Medicine, College of Veterinary Medicine, Gyeongsang National University, Jinju, 52828, South Korea
| | - Do-Hyeon Yu
- Institute of Animal Medicine, College of Veterinary Medicine, Gyeongsang National University, Jinju, 52828, South Korea
| | - Hee-Chun Lee
- Institute of Animal Medicine, College of Veterinary Medicine, Gyeongsang National University, Jinju, 52828, South Korea
| | - Tae-Sung Hwang
- Institute of Animal Medicine, College of Veterinary Medicine, Gyeongsang National University, Jinju, 52828, South Korea
| | - Young Joo Kim
- College of Veterinary Medicine, Western University of Health Sciences, Pomona, California, 91766-1854, USA
| | - Su-Jin An
- Institute of Animal Medicine, College of Veterinary Medicine, Gyeongsang National University, Jinju, 52828, South Korea
| | - Dong-In Jung
- Institute of Animal Medicine, College of Veterinary Medicine, Gyeongsang National University, Jinju, 52828, South Korea.
| |
Collapse
|
11
|
Kopke MA, Galloway PEJ. Suspected hepatopathy and pancreatitis associated with mycophenolate mofetil use in a cat with immune-mediated haemolytic anaemia. JFMS Open Rep 2020; 6:2055116920905038. [PMID: 32095260 PMCID: PMC7013118 DOI: 10.1177/2055116920905038] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Case summary A 5-year-old spayed female domestic shorthair cat was referred for severe
anaemia. Findings on initial work-up were consistent with a diagnosis of
idiopathic immune-mediated haemolytic anaemia. A combination of prednisolone
and mycophenolate mofetil (MMF) was instituted. On revisit approximately 2
months later, red blood cell parameters were normal, but the plasma was
described as icteric, prompting further investigation. Concurrent
hepatopathy and pancreatitis were diagnosed, suspected as being adverse
reactions to MMF, as has been reported with use of the drug in humans.
Resolution of serum biochemistry abnormalities took approximately 2 months,
following discontinuing MMF. At the time of writing, the cat remained
clinically well 1 year after initial presentation. Relevance and novel information With increasing use of MMF as an immunosuppressive agent in cats, clinicians
should be aware of both common and potentially rare adverse effects, such as
those described herein. In addition, suitable monitoring tools need to be in
place to facilitate early detection and appropriate management.
Collapse
Affiliation(s)
- Matthew A Kopke
- School of Veterinary Science, Massey University, Palmerston North, New Zealand
| | | |
Collapse
|
12
|
Whitley N. Dealing with immune‐mediated haematological diseases in dogs and cats 2. Thrombocytopenia and Evan's syndrome. IN PRACTICE 2020. [DOI: 10.1136/inp.l6458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
|
13
|
Swann JW, Garden OA, Fellman CL, Glanemann B, Goggs R, LeVine DN, Mackin AJ, Whitley NT. ACVIM consensus statement on the treatment of immune-mediated hemolytic anemia in dogs. J Vet Intern Med 2019; 33:1141-1172. [PMID: 30847984 PMCID: PMC6524099 DOI: 10.1111/jvim.15463] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 02/06/2019] [Indexed: 01/07/2023] Open
Abstract
Immune‐mediated hemolytic anemia (IMHA) causes severe anemia in dogs and is associated with considerable morbidity and mortality. Treatment with various immunosuppressive and antithrombotic drugs has been described anecdotally and in previous studies, but little consensus exists among veterinarians as to the optimal regimen to employ and maintain after diagnosis of the disease. To address this inconsistency and provide evidence‐based guidelines for treatment of IMHA in dogs, we identified and extracted data from studies published in the veterinary literature. We developed a novel tool for evaluation of evidence quality, using it to assess study design, diagnostic criteria, explanation of treatment regimens, and validity of statistical methods. In combination with our clinical experience and comparable guidelines for humans afflicted with autoimmune hemolytic anemia, we used the conclusions of this process to make a set of clinical recommendations regarding treatment of IMHA in dogs, which we refined subsequently by conducting several iterations of Delphi review. Additionally, we considered emerging treatments for IMHA in dogs and highlighted areas deserving of future research. Comments were solicited from several professional bodies to maximize clinical applicability before the recommendations were submitted for publication. The resulting document is intended to provide clinical guidelines for management of IMHA in dogs. These guidelines should be implemented pragmatically, with consideration of animal, owner, and veterinary factors that may vary among cases.
Collapse
Affiliation(s)
- James W Swann
- Kennedy Institute of Rheumatology, University of Oxford, Oxford, United Kingdom
| | - Oliver A Garden
- School of Veterinary Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Claire L Fellman
- Cummings School of Veterinary Medicine, Tufts University, North Grafton, Massachusetts
| | - Barbara Glanemann
- Royal Veterinary College, University of London, London, United Kingdom
| | - Robert Goggs
- College of Veterinary Medicine, Cornell University, Ithaca, New York
| | - Dana N LeVine
- College of Veterinary Medicine, Iowa State University, Ames, Iowa
| | - Andrew J Mackin
- College of Veterinary Medicine, Mississippi State University, Mississippi State, Mississippi
| | - Nathaniel T Whitley
- Davies Veterinary Specialists, Manor Farm Business Park, Huntingdon, United Kingdom
| |
Collapse
|
14
|
Jaffey J, DeClue A, Cannon A, Tocci L, Hyland J. Presumptive Glucocorticoid-Induced Refractory Hypocalcemia in a Dog with Idiopathic Immune-Mediated Hypoparathyroidism, Thrombocytopenia, and Hemolytic Anemia. J Am Anim Hosp Assoc 2018; 55:e55104. [PMID: 30427709 DOI: 10.5326/jaaha-ms-6705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Clinically relevant hypocalcemia is a well-documented complication of glucocorticoid administration in people with hypoparathyroidism. The current report describes the phenomenon in a dog. A 7 yr old neutered male Pomeranian was diagnosed with immune-mediated thrombocytopenia, immune-mediated hemolytic anemia, and primary hypoparathyroidism. This dog required long-term parenteral calcium gluconate to prevent clinical hypocalcemia despite appropriate doses of oral calcitriol and calcium carbonate. This is the first description of clinically significant presumptive glucocorticoid induced hypocalcemia in a dog with primary hypoparathyroidism.
Collapse
Affiliation(s)
- Jared Jaffey
- From the Department of Veterinary Medicine & Surgery, College of Veterinary Medicine, University of Missouri, Columbia, Missouri (J.J., A.D.); Lauderdale Veterinary Specialists, Fort Lauderdale, Florida (A.C., L.T.); and Bronson Animal Disease Diagnostic Laboratory, Kissimmee, Florida (J.H.)
| | - Amy DeClue
- From the Department of Veterinary Medicine & Surgery, College of Veterinary Medicine, University of Missouri, Columbia, Missouri (J.J., A.D.); Lauderdale Veterinary Specialists, Fort Lauderdale, Florida (A.C., L.T.); and Bronson Animal Disease Diagnostic Laboratory, Kissimmee, Florida (J.H.)
| | - Allison Cannon
- From the Department of Veterinary Medicine & Surgery, College of Veterinary Medicine, University of Missouri, Columbia, Missouri (J.J., A.D.); Lauderdale Veterinary Specialists, Fort Lauderdale, Florida (A.C., L.T.); and Bronson Animal Disease Diagnostic Laboratory, Kissimmee, Florida (J.H.)
| | - Lynel Tocci
- From the Department of Veterinary Medicine & Surgery, College of Veterinary Medicine, University of Missouri, Columbia, Missouri (J.J., A.D.); Lauderdale Veterinary Specialists, Fort Lauderdale, Florida (A.C., L.T.); and Bronson Animal Disease Diagnostic Laboratory, Kissimmee, Florida (J.H.)
| | - Joanna Hyland
- From the Department of Veterinary Medicine & Surgery, College of Veterinary Medicine, University of Missouri, Columbia, Missouri (J.J., A.D.); Lauderdale Veterinary Specialists, Fort Lauderdale, Florida (A.C., L.T.); and Bronson Animal Disease Diagnostic Laboratory, Kissimmee, Florida (J.H.)
| |
Collapse
|
15
|
Klotsman M, Sathyan G, Anderson WH, Garden OA, Shivanand P. Mycophenolic acid in patients with immune-mediated inflammatory diseases: From humans to dogs. J Vet Pharmacol Ther 2018; 42:127-138. [PMID: 30375004 DOI: 10.1111/jvp.12731] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Revised: 10/02/2018] [Accepted: 10/03/2018] [Indexed: 12/26/2022]
Abstract
Mycophenolic acid (MPA), a noncompetitive, selective and reversible inhibitor of inosine 5'-monophosphate dehydrogenase (IMPDH), is an immunosuppressive agent that has a long history in medicine. Mechanistically, the inhibition of IMPDH leads to the selective and eventual arrest of T- and B-lymphocyte proliferation. Mycophenolate mofetil (MMF), the first MPA-based product to receive marketing approval over two decades ago, was originally indicated for the prophylaxis of organ rejection in human transplant patients. Given its broad immunosuppressive properties and ability to selectively inhibit lymphocyte division and effector functions, the clinical utility of MPA was subsequently explored in a host of autoimmune diseases. Human clinical studies have shown MPA to be safe and effective and support its off-label administration for immune-mediated diseases such as lupus, myasthenia gravis and atopic dermatitis. MMF became generically available in the United States in 2008, and its clinical utility is increasingly being explored as a treatment option for dogs with immune-mediated diseases. This review summarizes the available literature for MPA pharmacokinetics and pharmacodynamics, and the current status of MPA as a treatment for client-owned dogs diagnosed with immune-mediated diseases.
Collapse
Affiliation(s)
| | | | - Wayne H Anderson
- Okava Pharmaceuticals, San Francisco, California.,Pulmonary and Critical Care Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Oliver A Garden
- Clinical Sciences & Advanced Medicine, University of Pennsylvania School of Veterinary Medicine, Philadelphia, Pennsylvania
| | | |
Collapse
|
16
|
Morassi A, Rivera-Vélez SM, Slovak JE, Court MH, Villarino NF. Ex vivo binding of the immunosuppressant mycophenolic acid to dog and cat plasma proteins and the effect of co-incubated dexamethasone and prednisolone. J Vet Pharmacol Ther 2018; 41:513-521. [PMID: 29687456 DOI: 10.1111/jvp.12507] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Accepted: 03/26/2018] [Indexed: 11/30/2022]
Abstract
Mycophenolic acid (MPA) has been shown to be promising for the treatment of autoimmune diseases in dogs and cats. In humans, MPA is highly bound to plasma proteins (~97%). It has been recommended to monitor free drug plasma concentrations because the free MPA correlates with its immunosuppressive effect. However, it is unknown if MPA is highly bound to plasma proteins in dogs and cats. The objectives of this study were to determine the extent of plasma protein binding of MPA and evaluate the effect of prednisolone and dexamethasone on the extent of protein binding of MPA in dogs and cats. The extent of plasma protein binding of MPA was determined in plasma collected from clinically healthy adult cats (n = 13) and dogs (n = 14) by combining high-throughput dialysis and ultra-high-liquid chromatography. This study reveals that MPA is highly bound to plasma proteins (>90%) in dogs and cats, mean extent of binding of MPA at 15 μg/ml to plasma proteins being 96% (range, 95%-97%) and 92% (range, 90%-93%) for dogs and cats, respectively. In dog plasma, MPA is primarily bound to albumin. In vitro, prednisolone increased the unbound MPA in dogs (p < .01) but not in cats (p = .07) while dexamethasone had no effect on MPA plasma binding in either species (p > .05). Results of this study provide valuable information for designing future pharmacokinetic and pharmacodynamic studies and also therapeutic monitoring programs for dogs and cats.
Collapse
Affiliation(s)
- A Morassi
- Department of Veterinary Clinical Sciences, Program in Individualized Medicine, Washington State University, Pullman, Washington
| | - S M Rivera-Vélez
- Department of Veterinary Clinical Sciences, Program in Individualized Medicine, Washington State University, Pullman, Washington
| | - J E Slovak
- Department of Veterinary Clinical Sciences, Program in Individualized Medicine, Washington State University, Pullman, Washington
| | - M H Court
- Department of Veterinary Clinical Sciences, Program in Individualized Medicine, Washington State University, Pullman, Washington
| | - N F Villarino
- Department of Veterinary Clinical Sciences, Program in Individualized Medicine, Washington State University, Pullman, Washington
| |
Collapse
|
17
|
Young WM, Oh A, Williams JG, Foster ML, Miller WW, Lunn KF, Mowat FM. Clinical therapeutic efficacy of mycophenolate mofetil in the treatment of SARDS in dogs-a prospective open-label pilot study. Vet Ophthalmol 2018; 21:565-576. [DOI: 10.1111/vop.12545] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Whitney M. Young
- Department of Clinical Sciences; North Carolina State University College of Veterinary Medicine; Raleigh NC USA
| | - Annie Oh
- Department of Clinical Sciences; North Carolina State University College of Veterinary Medicine; Raleigh NC USA
| | - Jonathan G. Williams
- Department of Clinical Sciences; North Carolina State University College of Veterinary Medicine; Raleigh NC USA
| | - Melanie L. Foster
- Department of Clinical Sciences; North Carolina State University College of Veterinary Medicine; Raleigh NC USA
| | | | - Katharine F. Lunn
- Department of Clinical Sciences; North Carolina State University College of Veterinary Medicine; Raleigh NC USA
| | - Freya M. Mowat
- Department of Clinical Sciences; North Carolina State University College of Veterinary Medicine; Raleigh NC USA
| |
Collapse
|
18
|
Cummings FO, Rizzo SA. Treatment of presumptive primary immune-mediated thrombocytopenia with mycophenolate mofetil versus cyclosporine in dogs. J Small Anim Pract 2017; 58:96-102. [DOI: 10.1111/jsap.12621] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Revised: 07/10/2016] [Accepted: 07/11/2016] [Indexed: 11/28/2022]
Affiliation(s)
- F. O. Cummings
- Practice Limited to Internal Medicine; Louisville Kentucky 40223 USA
| | - S. A. Rizzo
- Practice Limited to Internal Medicine; Louisville Kentucky 40223 USA
| |
Collapse
|
19
|
Kohn B, Bal G, Chirek A, Rehbein S, Salama A. Treatment of 5 dogs with immune-mediated thrombocytopenia using Romiplostim. BMC Vet Res 2016; 12:96. [PMID: 27283401 PMCID: PMC4901510 DOI: 10.1186/s12917-016-0718-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Accepted: 06/01/2016] [Indexed: 12/29/2022] Open
Abstract
Background Immune thrombocytopenia (ITP) in dogs is analogous to that in humans. Romiplostim, a novel thrombopoietin receptor (TPO-R) agonist, is currently used for the treatment of refractory ITP in humans, but not in dogs. Here, we describe the response to romiplostim in five dogs with refractory ITP. Five dogs with severe and refractory ITP (three primary and two secondary) received romiplostim subcutaneously. Four dogs were administered 3–5 μg/kg and one dog received 10–13 μg/kg body weight once weekly. Results Romiplostim was well-tolerated and administration was associated with an increase in platelet counts in all five dogs. Four of the five dogs entered remission and relapses were not observed over a follow-up period of 3–10 months. Conclusions Romiplostim is effective in the treatment of ITP in dogs at least as well as in humans. This finding may help to develop and use new therapeutics for ITP in dogs and humans.
Collapse
Affiliation(s)
- Barbara Kohn
- FB Veterinärmedizin, Klinik für Kleine Haustiere, Freie Universität Berlin, Oertzenweg 19 b, 14163, Berlin, Germany
| | - Gürkan Bal
- Institut für Transfusionsmedizin, Charité - Universitätsklinikum, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Aleksandra Chirek
- FB Veterinärmedizin, Klinik für Kleine Haustiere, Freie Universität Berlin, Oertzenweg 19 b, 14163, Berlin, Germany
| | - Sina Rehbein
- FB Veterinärmedizin, Klinik für Kleine Haustiere, Freie Universität Berlin, Oertzenweg 19 b, 14163, Berlin, Germany
| | - Abdulgabar Salama
- Institut für Transfusionsmedizin, Charité - Universitätsklinikum, Augustenburger Platz 1, 13353, Berlin, Germany.
| |
Collapse
|
20
|
In Vitro Influence of Mycophenolic Acid on Selected Parameters of Stimulated Peripheral Canine Lymphocytes. PLoS One 2016; 11:e0154429. [PMID: 27138877 PMCID: PMC4854421 DOI: 10.1371/journal.pone.0154429] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Accepted: 04/13/2016] [Indexed: 01/22/2023] Open
Abstract
Mycophenolic acid (MPA) is an active metabolite of mycophenolate mofetil, a new immunosuppressive drug effective in the treatment of canine autoimmune diseases. The impact of MPA on immunity is ambiguous and its influence on the canine immune system is unknown. The aim of the study was to determine markers of changes in stimulated peripheral canine lymphocytes after treatment with MPA in vitro. Twenty nine healthy dogs were studied. Phenotypic and functional analysis of lymphocytes was performed on peripheral blood mononuclear cells cultured with mitogens and different MPA concentrations– 1 μM (10−3 mol/m3), 10 μM or 100 μM. Apoptotic cells were detected by Annexin V and 7-aminoactinomycin D (7-AAD). The expression of antigens (CD3, CD4, CD8, CD21, CD25, forkhead box P3 [FoxP3] and proliferating cell nuclear antigen [PCNA]) was assessed with monoclonal antibodies. The proliferation indices were analyzed in carboxyfluorescein diacetate succinimidyl ester (CFSE)-labeled cells. All analyses were performed using flow cytometry. The influence of MPA on apoptosis was dependent on the mechanism of cell activation and MPA concentration. MPA caused a decrease in the expression of lymphocyte surface antigens, CD3, CD8 and CD25. Its impact on the expression of CD4 and CD21 was negligible. Its negative influence on the expression of FoxP3 was dependent on cell stimulation. MPA inhibited lymphocyte proliferation. In conclusion, MPA inhibited the activity of stimulated canine lymphocytes by blocking lymphocyte activation and proliferation. The influence of MPA on the development of immune tolerance–expansion of Treg cells and lymphocyte apoptosis–was ambiguous and was dependent on the mechanism of cellular activation. The concentration that MPA reaches in the blood may lead to inhibition of the functions of the canine immune system. The applied panel of markers can be used for evaluation of the effects of immunosuppressive compounds in the dog.
Collapse
|