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Keith A. Hnilica DVM, MSDiplomate ACVDThe University of Tennessee

www.UTSkinVet.org

www.itchnot.comThe Itch Game

NonSteroid Alternatives (NSAs)

Atopica is the NSAID for Allergies!

% of arthritic dogs treated with steroids:% of itchy dogs treated with steroids:

Reason for treatment:Reason for treatment:

% of arthritic dogs that you offer steroids:

% of itchy dogs that you offer steroids:

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Do you treat arthritis with steroids?

Most vets would not even offer steroids for arthritis.

Why not?Better medications are available: Rimadyl, Deramaxx, etcToo many side effects with steroids.

The answers should be the same for allergies:

Young age of onsetSteroids have too many adverse effects.There are better treatments available:

AtopicaAllergy testingAntihistamines, topicals, EFAsReferral

Allergies should be managed exactly like arthritis regarding steroid usage. If you do not offer steroids for arthritis patient; do not offer it for allergies…When would you consider steroids for arthritis:

that is exactly when you should consider steroids for allergies!!

NSAIDsReplaced steroids

Arthritis

Works betterFewer adverse effectsModerately expensive

Atopica First in categoryWill replace steroids

AllergiesLupusPemphigusIMHA/ITP

Works betterFewer adverse effectsSame price as NSAIDs

Once past induction and on EOD

Allergies should be managed exactly like arthritis regarding steroid usage. If you do not offer steroids for arthritis patient; do not offer it for allergies…When would you consider steroids for arthritis:

that is exactly when you should consider steroids for allergies!!

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3 Most Common Disorders

Musculoskeletal

Dental

Dermatitis

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Treating Allergy in 10 Steps1. Selective Breeding2. Start Early3. Treat the Secondary Infections4. Avoid Allergens5. Bathe6. Flea Control7. Diet Change8. Symptomatic Therapies9. Allergy Testing and Vaccines10. Cyclosporine

Ears, Pinnae, Ears, Pinnae, Elbows, & Elbows, & PP reflexesPP reflexes

Face& FeetFace& Feet

LumbarLumbar

Scabies Scabies TreatmentTreatment

German German Breed Breed < 1 year< 1 yearyear aroundyear around

ChangeChangeDietDiet

Flea ControlFlea Control

Anti histaminesAnti histamines

Essential Essential Fatty AcidsFatty Acids

TopicalsTopicals Treat Treat PyodermaPyoderma

Treat YeastTreat Yeast

Change DietChange DietAllergy Allergy VaccineVaccine Treat YeastTreat Yeast TreatTreat

PyodermaPyoderma

TreatTreatPyodermaPyoderma

AtopicaAtopica Treat YeastTreat Yeast Treat ScabiesTreat Scabies

ReferralReferral

Steroids

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Amino-Acid shifts in KDR and RDL1

Guanine

Flea Resistance

0

20

40

60

80

100

120

30 days Reduced to 7-14 daysReducedcompletely

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Flea Resistance Solutions

7 Great Uses of Capstar1) Diagnose FAD in cats: Capstar qod for 30 days gives

you a yes or no answer regardless of the adulticideuse.

2) Speed resolution of FAD in dogs: qod for 30 days greatly reduces the symptoms!

3) Prevent hitchhike fleas that infest homes and clinics

4) Treats owner “Fleanial”: give Capstar and let the pet and owner sit in the exam room, they can count the fleas falling off.

5) Kill fleas jumping into your surgical site – rectally does the trick

6) Prevent transmission of resistant fleas from Florida, Texas, Georgia, etc (any traveling pet should use protection).

7) Kills maggots.

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A Pattern Approach

2o InfectionsPyoderma AllergiesDemodex Atopy

Dermatophyte Food

Yeast Dermatitis Scabies

OtitisPododermatitis Endocrine

HypothyroidCushing’s

Ears, Ears, Pinnae, Pinnae, Elbows, & Elbows, & PP reflexesPP reflexes

Face& FeetFace& Feet

LumbarLumbar

Scabies Scabies TreatmentTreatment

German German Breed Breed < 1 year< 1 yearyear aroundyear around

ChangeChangeDietDiet

Flea ControlFlea Control

Antihistamines

EFAs

Topicals

Steroids

3 injections

90 days

lbs X 15 = MYD pred

1. Referral

2. Revolution

3. Food Trial

4. Atopica

5. Allergy Testing

6. Steroids

What are the INFECTIONS?

PyodermaYeastOtitis

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http://dbtbs.hgc.jp/test/prom/mecA.png

Methicillin resistance

mecA geneInducibleTransferable

OxacillinCephalexinClavamox

FQ Resistance

Marbo

Cipro

Enro

Orbo

+FQ Induced Promoter

Staphylococcus

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Otitis Treatment4 steps : 6 products

1. Control the primary disease3. Use high volume, frequent

application therapies2. Use high antibiotic concentration 4. Don’t just stop but taper therapy

1. Vet Solutions – swimmers2. Epiotic – otitis3. Otomax4. T8 Solution with 5. 1% Baytril6. Steroids

www.itchnot.com

Recurrent Otitis

T8 solution with Baytril

10mg/ml fill the canal bid

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A Systematic Review and Meta-Analysis of the Efficacy and safety of cyclosporine for the treatment of Atopic Dermatitis.

Steffan j. et al. Vet Derm Feb. 2006

Results of Allergen-Specific Immunotherapy in 117 dogs with Atopic Dermatitis. Schnabl B. et al. Vet Record Jan. 2006

Methods:799 dogs followed for 2 -24 weeks in a meta-

analysis of data from the 10 studies.

Results and Conclusions:

“Up to 85% of dogs could experience” excellent to good efficacy.

Response at 1 month is predictive; high responders go on to do very well. Maximum response occurs at 3 months.

Approximately 55% tapered to every other day and 30% tapered to twice each week dosing.

Severity, weight, and administration with food did not affect efficacy.

Cyclosporine was equivalent to prednisone therapy.

Methods:117 dogs in a multiple group retrospective

study.Dogs followed for at least 1 year

Results and Conclusions:

64.5% excellent to good efficacy.

Most dogs responded between 2-5 months after starting immunotherapy.

Skin testing was equivalent to serum allergy testing.

The number of allergens (1 vial or 2 vials) did not impact efficacy.

Molds were administered separately (in a separate, additional vial).

2006 Meta-analysis of Cyclosporine Studies2006 Immunotherapy Retrospective

It is NOT Expensive – Dammit!

175.8681.6840.8421.67and rebates

87.9340.84and Keto50% Atopica dose

213.36106.6853.3426.6740% markupQOD

152.4076.2038.1019.05Vet cost200mg100mg50mg25mgAtopica80lbs40lbs20lbs10lbsDog

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Cyclosporine Therapy

If the patient demonstrated GI symptoms

Give Reglan (metoclopramide)

Give food

Give Atopica

Atopica Candidates

AntihistaminesEFAs

Topicals

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The Treatment is like transportation for your teenager!

http://www.negotin.co.yu/vilig/slike/Jeca%20und%20Milena%20am%20Kawasaki%20Ninja%20ZX-10.JPG== www.bfranker.badz28.com/ zx6.htm

Cyclosporins/TacrolimusAllergic DermatitisDiscoid LupusPemphigusBullous pemphigoidSystemic LupusSebaceous AdenitisGranulomatous

dermatosesPsoriasisActinic dermatitisDermatomyositisAlopecia X

VasculitisUrticariaRheumatoid arthritisSweet’s syndromePanniculitisErythema multiformeHypereosinophilic

syndromeEosinophilic granulomasSclerodermaSenile pruritus

VKHVitiligoPoison IvyAIHAColitisOrgan Transplants

Perianal fistulasInterdigital pyogranulomaPersian Facial DermatitisFeline Stomatitis

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Dr. Itchy’s “Best in Class” Derm List www.itchnot.com

Royal Canin - IVDDuck/rabbit

Vitamin ASepticane

SebaHexDomitorAntisedan

Other

Vet Solutions alcohol swimmers ear flush

Epi Otic Adv

T8 SolutionEpi Otic Adv

OtomaxBaytrilLA Inj100mg/ml

Otics

ClemastineDiphenhydramineAmitriptylineDextromethorphanDex Na Phos inj

DermalSoothe conditioner

GenesisResiCortSynotic

3V HP EFAAtopicaTemaril-PMedrol

Antipruritic

IvermectinBenzoyl Plus

PreventicCollarsKnockout premise spray

Frontline plus

CapstarIntercepterSentinel

Revolution Cats

Antiparasitics

CephalexinClindamycinStridex al free wipesketoconazole (dogs)fluconazole (cats)

LymDyp

ChlorhexidermMax

Malaseb

LamisilSimplicefPrimor

AntibioticsAntifungals

Generics/otherVetiquinolVirbacDVMScheringMerialBayerNovartisPfizer

Acral DermatitisPrimary Disease

AllergyNeuropathy

HypothyroidismBlasto

Neoplasia

Behavior

SecondaryBacterialinfection

Amitriptyline Allergy, BehaviorPain

HydrocodonePainEndorphins

Antibiotics2nd infection

Use ALL 3 for 1 month then taper or DC 1 by 1

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Agenda:Wal-Mart and Macy’s

How to make money!

Typewriters and LaptopsProgress

Excorts and CamerysTrading up

Wal-martAnd

Macy’s

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Walmart - FordPriceFocus on costWalk-in ApptsVolumeFast pacedDiscount productsNo frillsLong hours

Macy’s - ToyotaQuality – valueFocus on customerConference roomTreatment ProtocolsConsolidated pharmacyWeb pageFun

Walmart - FordTMSMitabanGriseofulvinPanalogIodineAllergy

Depo MedrolPrednisone

Macy’s - ToyotaSimplicefIvermectinFluconazoleOtomaxChlorhexidineAllergy

Temaril-PImmunotherapy VaxAtopica

Referral

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Lessons from my MBA year: #1

Begin using “Practice Protocols”55 common GP disordersClinic doc negotiatedNot written in stone

Improves customer serviceConsistent education from front desk to kennelEveryone knows what to expectEveryone recognizes when exceptions have been made

Lessons from my MBA year: #2

Owners want convenienceGive them what they wantBUT from your clinicIf you do not provide it: someone will

www.VetInternetPharmacies.com

Streamline pharmacyBased on agreed upon Practice Protocols

“Best in Class” drugsUse Vet Centric for non-protocol drugs

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Lessons from my MBA year: #41. All staff members are motivated to solve specific client problems with

practice specific protocols formulated to implement the “Best in Class”treatment options.

2. The mission statement includes a commitment to the highest quality of practice (not the cheapest).

3. Staff rounds are conducted to educate everyone in the clinic on the most common diseases and the practice’s protocols treatment.

4. All staff provides consistent client education and treatment recommendations: the same message from the front to the back of the practice.

5. The doctors are removed from all treatment cost discussions: decisions are made based on medical appropriateness not negotiated based on cost.

6. Follow up counts.7. Technicians are used to their full potential: great knowledge, tremendous

ability, and enthusiasm produce an effective patient advocate that functions like a physician’s assistant.

8. The receptions are recognized as the store front window of the practice.9. Great emphasis is placed on disease prevention not just finding and fixing

problems.10. All employees play and hug the patients.

Practice Considerations

Some of the simplest issues can have dramatic impact. The following are a few estimations of your client’s experience.

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Sight: Initial impression: 1 2 3 4 5 wow Educational materials: 1 2 3 4 5 impressiv Clutter: 1 2 3 4 5 contained Cleanliness: 1 2 3 4 5 immacula Sounds: Noise level: 1 2 3 4 5 quite Phones: 1 2 3 4 5 absent Ability to eavesdrop: 1 2 3 4 5 limited Smell: Animal odor: 1 2 3 4 5 none Fragrance level: 1 2 3 4 5 pleasant Confidence Inspiring: Attire: 1 2 3 4 5 professio Lobby: 1 2 3 4 5 impressiv Exam rooms: 1 2 3 4 5 functiona

KA Hnilica DVM, MS, DACVD www.itchnot.com