Remission of the clinical signs of atopic dermatitis in dogs after cessation of treatment with cyclosporin A or methyiprednisolone

Clinical Guidelines for the Use of Antipruritic Drugs in the Control of the Most Frequent Pruritic Skin Diseases in Dogs

Pruritus is a common clinical sign in many skin disorders and is currently the main complaint in canine dermatology. Pruritic skin diseases can affect the quality of life of dogs and their owners. Several families of antipruritic drugs are available to help control pruritus in dogs. The aim of this review is to help practitioners select the most appropriate symptomatic treatment in the most frequent situations of dermatological pruritus in dogs. The molecules reviewed here are systemic and topical glucocorticoids, antihistamines, ciclosporin, oclacitinib and lokivetmab. A level of evidence (1, 2 or 3) has been established according to a detailed algorithm for each individual study in the literature published between 1990 and March 2021. The guidelines result from evidence grading using the strength of recommendation taxonomy (SoRT) and clinical recommendations using a thorough methodology.

A proposed medication score for long-term trials of treatment of canine atopic dermatitis sensu lato

BACKGROUND

The use of concurrent medications is necessary in trials of treatment of canine atopic dermatitis. Our aim was to use the best available evidence to construct and then to validate a medication score (MS) formula that will estimate the impact of concurrent medications on trial outcomes.

METHODS

Trials of 15 interventions were scrutinized to find those that were consistent in terms of specific medication, administration route and dosage regimen. A MS was constructed in five steps, starting from assigning a score of 1 for each day on oral prednisone, prednisolone or methylprednisolone at 0.5-1.0 mg/kg. The MS score was validated using the clinical records of 35 dogs with atopic dermatitis that had been treated for a period of 12 ± 2 weeks with six of these medications and compared with a previously published non-validated MS.

RESULTS

A MS could be assigned to eight treatments, six of which had been administered to the 35 dogs. A positive correlation was seen with the previously published MS and a negative correlation with changes in lesional and pruritus scores.

CONCLUSION

This MS may be a useful tool in new studies evaluating the efficacy of treatments in canine atopic dermatitis.

Proactive maintenance therapy of canine atopic dermatitis with the anti-IL-31 lokivetmab. Can a monoclonal antibody blocking a single cytokine prevent allergy flares?

BACKGROUND

Once the signs of canine atopic dermatitis (AD) are controlled, the proactive application of topical glucocorticoids can delay disease flares.

OBJECTIVES

We wished to determine if the proactive administration of the anti-IL-31 lokivetmab would prevent or delay flares of canine AD.

ANIMALS

We tested this strategy in four Maltese-beagle atopic dogs before enrolling 21 dogs with spontaneous AD.

METHODS AND MATERIALS

In our acute AD model, house dust mite (HDM)-sensitized dogs were injected once with lokivetmab. After seven days, an HDM suspension was applied epicutaneously, and both skin lesions and pruritus manifestations were quantified for 24 h. In a second study, 21 dogs with spontaneous AD controlled with anti-allergic drugs were treated with lokivetmab per manufacturer's recommendations; all anti-allergic drugs were discontinued within four weeks after the first injection. All dogs were followed prospectively for at least one year and the time-to-flare (TTF) of AD after the last day of anti-allergic treatment was determined.

RESULTS

In the experimental study, one injection of lokivetmab prevented nearly all expected allergen-induced pruritus manifestations but not skin lesion development. In dogs with spontaneous AD, the median TTF after lokivetmab proactive therapy was 63 days. One-fourth of dogs did not exhibit a flare for at least one year while receiving lokivetmab monotherapy.

CONCLUSIONS

Although lokivetmab seems more effective to prevent pruritus than skin lesions in dogs with experimental AD' it also can delay disease flares in some dogs with the spontaneous disease. Studies are needed to identify those patients most likely to respond to such a proactive regimen.

LD-aminopterin in the canine homologue of human atopic dermatitis: a randomized, controlled trial reveals dosing factors affecting optimal therapy

Background

Options are limited for patients with atopic dermatitis (AD) who do not respond to topical treatments. Antifolate therapy with systemic methotrexate improves the disease, but is associated with adverse effects. The investigational antifolate LD-aminopterin may offer improved safety. It is not known how antifolate dose and dosing frequency affect efficacy in AD, but a primary mechanism is thought to involve the antifolate-mediated accumulation of 5-aminoimidazole-4-carboxamide ribonucleotide (AICAR). However, recent in vitro studies indicate that AICAR increases then decreases as a function of antifolate concentration. To address this issue and understand how dosing affects antifolate efficacy in AD, we examined the efficacy and safety of different oral doses and schedules of LD-aminopterin in the canine model of AD.

Methods and Findings

This was a multi-center, double-blind trial involving 75 subjects with canine AD randomized to receive up to 12 weeks of placebo, once-weekly (0.007, 0.014, 0.021 mg/kg) or twice-weekly (0.007 mg/kg) LD-aminopterin. The primary efficacy outcome was the Global Score (GS), a composite of validated measures of disease severity and itch. GS improved in all once-weekly cohorts, with 0.014 mg/kg being optimal and significant (43%, P<0.01). The majority of improvement was seen by 8 weeks. In contrast, GS in the twice-weekly cohort was similar to placebo and worse than all once-weekly cohorts. Adverse events were similar across all treated cohorts and placebo.

Conclusions

Once-weekly LD-aminopterin was safe and efficacious in canine AD. Twice-weekly dosing negated efficacy despite having the same daily and weekly dose as effective once-weekly regimens. Optimal dosing in this homologue of human AD correlated with the concentration-selective accumulation of AICAR in vitro, consistent with AICAR mediating LD-aminopterin efficacy in AD.

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.

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.

Masitinib decreases signs of canine atopic dermatitis: a multicentre, randomized, double-blind, placebo-controlled phase 3 trial

This study investigated the efficacy and safety of masitinib, a selective tyrosine kinase inhibitor capable of downregulating mast cell functions, for treatment of canine atopic dermatitis (CAD). Dogs with confirmed CAD received masitinib at 12.5 mg/kg/day (n = 202) or control (n = 104) for 12 weeks. A reduction in CAD Extent and Severity Index (CADESI-02) score of ≥ 50% at week 12 was observed in 61% of masitinib-treated dogs versus 35% of control dogs (P < 0.001), according to the modified intent-to-treat population. For dogs resistant to ciclosporin and/or corticosteroids (60% of the study population), CADESI-02 response rates were 60 versus 31%, respectively (P = 0.004). The mean reduction in pruritus score of severely pruritic dogs was 46 versus 29%, respectively (P = 0.045). Furthermore, 65% of owners with severely pruritic dogs assessed masitinib efficacy as good/excellent versus 35% control (P = 0.05). Overall, 63% of investigators assessed masitinib efficacy as good/excellent versus 35% control (P < 0.001). Premature discontinuations from the modified intent-to-treat population (28.2% masitinib versus 26.0% control) were mainly due to adverse events (13.4 versus 4.8%, respectively) or lack of efficacy (12.4 versus 18.3%, respectively). In total, 13.2% dogs presented with severe adverse events (16.0% masitinib versus 7.7% control). Masitinib showed a risk of reversible protein loss, although regular surveillance of blood albumin and proteinuria allowed for discontinuation of treatment while the dog was still clinically asymptomatic. Masitinib proved to be an effective and mostly well-tolerated treatment of CAD, including severe and refractory cases, with medically manageable adverse effects.

Zinc-carnosine and vitamin E supplementation does not ameliorate gastrointestinal side effects associated with ciclosporin therapy of canine atopic dermatitis

Chelated zinc-carnosine and vitamin E [GastriCalm(®) (GCM); Teva Animal Health] is marketed as an anti-emetic supplement for dogs to assist the repair of damaged stomach and intestinal mucosa. The purpose of this prospective, double-blinded, placebo-controlled trial was to determine whether GCM reduced the frequency of vomiting, diarrhoea and appetite changes during initiation of ciclosporin (Atopica(®); Novartis Animal Health) therapy for the treatment of canine atopic dermatitis. Sixty privately owned dogs diagnosed with atopic dermatitis were randomly assigned to GCM (n=30) or placebo (n=30) groups. All dogs received ∼ 5 mg/kg ciclosporin (range, 3.5-5.8 mg/kg) once daily. Dogs <13.6 kg received half a tablet of GCM or placebo; dogs ≥ 13.6 kg received one tablet once daily. GastriCalm(®) or placebo was administered 30 min prior to eating, and the ciclosporin was administered 2 h after feeding. Owners recorded episodes of vomiting, diarrhoea and appetite changes. Dogs were examined on days 0 and 14. Forty-one of 60 dogs (68.3%) had at least one episode of vomiting, diarrhoea or appetite change, leaving nine placebo dogs (30%) and ten GCM dogs (33.3%) free of adverse events (AE). Twenty-seven of 60 dogs (45%) vomited, and 15 of 60 (25%) had diarrhoea. There was no significant difference in episodes of individual AEs, but the placebo group had a significantly lower total AE score (summation of episodes of appetite change, vomiting and diarrhoea; P=0.022). Small dogs (<6.82 kg) had significantly fewer total AEs in both treatment groups and tolerated ciclosporin better than larger dogs (P<0.05).

Investigation on the effects of ciclosporin (Atopica) on intradermal test reactivity and allergen-specific immunoglobulin (IgE) serology in atopic dogs

The ability to use ciclosporin (Atopica®: Novartis Animal Health, Greensboro, NC, USA) prior to intradermal testing (IDT) would help avoid exacerbation of clinical disease that can be associated with drug withdrawal. This study evaluated the effects of 30 days of administration of ciclosporin at a dose of 5 mg/kg once daily on IDT reactivity (immediate phase reactions) in a group of dogs with atopic dermatitis (AD) with initial positive IDT reactions. 16 dogs diagnosed with AD were included in the study. Eight dogs (group A) were treated with ciclosporin orally at 5 mg/kg once daily for 30 days. Eight dogs (group P) were treated with a placebo orally once daily for 30 days. IDT was performed at day 0 and day 30 on all dogs enrolled using a standardized panel of 45 aqueous allergens (Greer Laboratories, Lenoir, NC, USA) appropriate to our geographical region. IDT reactivity was assessed by both subjective and objective methods at 15 min post-intradermal injection. Serum for allergen-specific immunoglobulin (IgE) serology was obtained at day 0 and day 30. The study was designed as a double-blinded, placebo-controlled, cross-over study. Data were analysed using a split-plot analysis of variance with the grouping factor of treatment and the repeat factor of time (SAS System for Windows). At week 4, ciclosporin did not have a statistically significant effect on IDT reactivity or serology results. It therefore appears that, no withdrawal is recommended to evaluate immediate phase reactions.

Frequency of appropriate and inappropriate presentation and analysis methods of ordered categorical data in the veterinary dermatology literature from January 2003 to June 2006

Clinical outcomes that are difficult to measure directly are often graded with ordinal scales in the veterinary dermatology literature to approximate objective evaluation. Ordered categorical scales require statistical presentation and analysis methods consistent with the structure of the data. The objective of this study was to determine the frequency of inappropriate presentation and analysis methods of ordered categorical data in the recent veterinary dermatology literature. A total of 62 articles published between 1 January 2003 and 30 June 2006 in 16 journals reported categorical scales and were included in the study. The presentation and analysis methods of ordered categorical data were classified as appropriate or inappropriate based on published recommendations. Forty articles (64.5%) utilized a median of four ordinal scales (range 1-13). Inappropriate presentation methods of ordered categorical data were identified in 23 of 40 articles (57.5%). These included reporting inappropriate summary statistics (n = 17) and summation of ad hoc numerical rating scales (n = 15). Inappropriate analytical methods were used in nine of 40 articles (22.5%). These included inappropriate use of t-tests (n = 3) and analysis of variance (anova, n = 6). The frequency of inappropriate presentation and analysis methods of ordered categorical data in the veterinary dermatology literature is similar to that reported for several fields in the human medical literature. In order to reduce the likelihood of making unwarranted implications or conclusions regarding ordinal data, authors should follow established guidelines for methods of presentation and analysis of ordered categorical scales.

Clinical trial evaluating the efficacy and safety of cyclosporine in dogs with atopic dermatitis

OBJECTIVE

To determine efficacy and safety of cyclosporine in the treatment of atopic dermatitis among dogs in North America.

DESIGN

Randomized controlled (phase 1) and open-label (phase 2) trials.

ANIMALS

268 dogs with atopic dermatitis.

PROCEDURE

In phase 1, dogs were randomly assigned to be treated with cyclosporine (5 mg/kg [2.3 mg/Ib], PO, q 24 h) or a placebo. In phase 2, all dogs were treated with cyclosporine for 16 weeks. Frequency of cyclosporine administration was decreased if dogs improved clinically.

RESULTS

At the end of phase 1, canine atopic dermatitis extent and severity index (CADESI) scores for dogs treated with cyclosporine were significantly lower than scores for control dogs. Percentage of dogs with severe pruritus decreased from 67% to 16% for the cyclosporine group but from 66% to only 61% for the control group. During phase 2, cyclosporine dosage was decreased to every-other-day administration in 39% of the dogs after 4 weeks. After 12 weeks, 22% of the dogs were treated twice weekly and 36% were treated every other day. After 16 weeks, CADESI score had decreased > 50% in 68% of the dogs and 47% of dogs had no or mild pruritus. The most frequent adverse reactions were gastrointestinal tract signs.

CONCLUSIONS AND CLINICAL RELEVANCE

Results suggest that cyclosporine is efficacious for the treatment of atopic dermatitis in dogs and that frequency of cyclosporine administration can be reduced following an initial induction period. The drug was well tolerated.

Calcineurin Inhibitors: A Novel Approach to Canine Atopic Dermatitis

The introduction of calcineurin inhibitors represents a major addition to the armamentarium of drugs available to veterinary clinicians for the management of allergic skin diseases. Both cyclosporine and tacrolimus have been proven to be well tolerated and effective for the treatment of atopic dermatitis in dogs. Although broad spectrum in their mechanism of action, they lack the major adverse effects of glucocorticoids and provide an appealing alternative to traditional therapies. The purposes of this article are to review clinically relevant information regarding these agents and to provide tips for maximizing the benefit obtained from these therapies.