Introduction
[00:01:10] Today we’re going to be talking about a medication called Atopica, also known as cyclosporine. In order to do that, I want to tell you a story about one of my favorite patients. His name is Nash. There’s something about a big goofy lab that can’t stop smiling and wagging its tail at me that just makes me so happy to be at work. Nash is truly the embodiment of that joyful spirit. I’ve been treating him for several years and during that time I was pregnant with my second child. My veterinary technicians, who are absolutely phenomenal women I could not live without, they had to run interference when Nash would come in because he would inevitably try and jump up on my lap when I would see him, despite my giant belly getting in his way. It wasn’t until I came back from maternity leave that I realized just how much I missed him climbing up for snuggles. On today’s episode of Your Vet Wants You to Know, we’ll be talking about Nash and a medication called Atopica that has completely changed his quality of life.
[00:02:10] When Nash first came to see me, his paws were incredibly swollen from allergies. They had developed these large bulges of tissue between the toes called interdigital furuncles, also known as interdigital cysts.
Interdigital furuncles (cysts) on the paws of two different dogs with severe allergies.
[00:02:33] Nash’s paws were so bad that he had multiple surgeries on his paws before he even came to see me, and despite the surgery, his paws were still not well controlled. Nash’s owner was heartbroken from everything that they had been through. We talked for a long time about investigating the underlying causes of his paw swelling, and we committed to working closely together to get him back on track. Nash does have both food and environmental allergies, so if you’d like to learn a little bit more about how we diagnose and manage those diseases longterm, I would encourage you to listen to episodes two and three for more discussion on food and environmental allergies, as well as next week’s episode on allergy testing and immunotherapy, where I dive into how to actually retrain the immune system so that we can minimize those allergic reactions to the things that Nash is over responding to in the environment.
[00:03:30] Because Nash has both a food allergy and an environmental allergy, he is happily on a prescription hydrolyzed diet to control his food allergy, and we are working on retraining his immune system with immunotherapy to reduce the recurrence of itch, swelling and infection. As you’ll hear me talk about next week, immunotherapy or desensitization with allergy shots or allergy drops, It’s a really long process that can take six to 12 months sometimes longer before it reaches its maximum effect. In the meantime, I don’t want these pets to be uncomfortable. So I use symptomatic medications to keep the allergies under control while the immunotherapy is kicking in. For many of the allergic dogs that I treat when I see them for an initial consultation, they’ve already tried medications like Apoquel and Cytopoint, which are the newer symptomatic medications I’ve discussed on previous episodes. Apoquel and Cytopoint work very well for itch, which is why they are commonly used in the symptomatic treatment of allergies, but they’re less effective in reducing swelling of things like paws and ears commonly seen in allergic dogs. When I need safe long-term control of inflammation, Atopica is my symptomatic treatment of choice, hands down. For Nash, while I was working on figuring out if he had a food allergy and starting him on immunotherapy to address his environmental allergy, I started using Atopica or cyclosporine along with a short course of steroids to really stop the inflammation of the paws right in its tracks.
Severely swollen ear canals from allergies. These ears need treatment with anti-inflammatory medications like Atopica or steroids.
Benefits
[00:05:10] In episode six, Dr. Curtis Plowgian and I discussed the benefits and risks of steroids. Even though steroids are really good at quickly stopping inflammation, they can be harmful long-term. I didn’t want to rely on months and months, maybe even years of steroids for Nash. Atopica is also an excellent therapy at reducing inflammation associated with allergies and it’s been considered a good steroid sparing therapy for several decades with over 75% of dogs showing benefit. What this means is Atopica can be used to decrease or even eliminate the need for steroids as symptomatic treatment of allergic skin disease in dogs and cats.
[00:05:50] So I tried to explain the mechanism of action of Atopica to my husband, who is a genius when it comes to making a perfect Neapolitan pizza or making me laugh, but who has absolutely no medical background. He said he had no idea what any of the words I just used meant. So I’m not going to go into those details for you. What is important for you to understand is that Atopica downregulates the production of allergy signals from the cells, because it takes a little while to alter those signals being pumped out by the cells, Atopica doesn’t work quite as quickly as steroids, which is why many dermatology veterinarians will combine the two medications when we first start Atopica, since steroids work really rapidly and we aim to provide relief as quickly as possible. Atopica takes at least two to three weeks to start seeing improvement in your pet and up to six weeks to reach ideal levels in the body, making it a much better choice for longer term symptomatic relief of itch and inflammation rather than for fast acting relief. Compared with steroids, atopica has far fewer long-term side effects. When I’m treating a pet with severe inflammation or swelling associated with allergies or a cat with allergies, I feel much more comfortable with using Atopica for months on end than I do using steroids. If allergy immunotherapy is not effective enough to control the allergies by itself, Atopica’s benefits do not diminish with long-term use. So that’s a good therapy that we can use long-term.
Allergies can make cats very itchy, causing them to overgroom the belly and sides, as seen in these two cats. The first cat developed plaques and infection on the belly also.
[00:07:24]After the initial period of daily administration of Atopica over that first four to six weeks, if the pet’s clinical signs of allergies like itch and inflammation are well controlled, we can start to decrease the frequency with which the pet receives this medication since it lasts longer in the body than other symptomatic therapies like Apoquel. If the pet is doing well, I try to reduce the dose slightly every four weeks. Many dogs can have their dose decreased to 50% or even 25% of the initial dose for long-term control. This is a huge benefit and helping to reduce the cost of the medication. Whereas Apoquel, which I discuss in episode four, does not last very long in the body and has to be given on a daily basis. It’s really satisfying to me when I can get the dosing down to every other day or even two days a week. This is also helpful with cats because it decreases the frequency that pet owners have to give the cat medication, which can be challenging in some cats. In addition to the capsules we use for dogs, Atopica also comes in a liquid for cats, making specific dosing based on their weight very easy to do. Most of my cat patients are on the liquid form, but every once in a while, I’ll have a pet owner tell me it’s easier to give them the capsule. Other methods for making it easier to give this to the cat are mixing it in a small amount of food, which works for about a third of cats or giving a syringe of fresh water in their mouth after the medication if they tend to like crazy, when you give their medicine. You can also try the method I used for getting my four year old to do something which recently has been threatening that Santa Claus won’t come, but that won’t work year round. If you’re having trouble with giving a medication to your pet, talk to your veterinarian about options that they recommend for helping to solve that problem for your specific pet.
Risks with Atopica
[00:09:13] Let’s talk about risk versus benefit because that’s how veterinarians make decisions when we’re treating pets. Clearly there is a huge benefit to this therapy in improving quality of life for severely inflamed, paws and ears. The most common risk with Atopica is in the first two weeks of starting the medication, when some pets will experience gastrointestinal upset with vomiting or diarrhea. If you have a dog taking Atopica capsules, put them in the freezer. It won’t affect the stability of the medication, but it may reduce the amount of tummy upset that your dog has. Some pets do better when Atopica is given on an empty stomach, some do better when it’s given with a meal, some do better when it’s given an hour after eating. You may just have to play around to see what sits well in your pet’s belly. If the pet tolerates this medication, or if there’s just minimal tummy upset, usually by two weeks, there’s no further risk of gastrointestinal upset.
[00:10:09] There are far fewer long-term side effects with Atopica compared to steroids. Long-term side effects that may occur include an overgrowth of the gum tissue in a really small percentage of dogs, so physical exams are important for checking dental health. Cats may be more susceptible to certain infectious diseases like FIV, FeLV and toxoplasmosis. The risk of these diseases when using Atopica can be reduced by screening for them prior to starting with a simple blood test, not allowing your cat outside to hunt, and not feeding a raw diet. Now, there will be a whole episode on the risks of raw diets in the future. But what I will say now is when we talk about the evidence-based risks and benefits to pet health decisions, there are numerous studies indicating the risks of raw diets, and I have yet to find a single peer reviewed, published research study demonstrating the benefits. So even if your cat isn’t receiving Atopica, raw diets are a risky idea without significantly scientific, proven benefit.
[00:11:14] Other types of infections like opportunistic, fungal infections have been reported, but are extremely rare at the doses that we use for the treatment of allergies and more often occur when we’re trying to significantly suppress the immune system from really severe autoimmune diseases.
[00:11:32] The main drawback when we use Atopica is the cost. This medication can be much more expensive, particularly for large breed dogs. This highlights a good reason to invest in pet insurance when you first get an animal so that you can make medical decisions for your pet rather than financial ones. I’ll have an upcoming episode of Your Vet Wants You to Know about how to make pet care more affordable and I’ll talk a little bit more about pet insurance during that episode. Once Nash’s paws were under control, we actually tried to switch him from Atopica to Apoquel to see if we could manage his paws and save some money. It really only took a few weeks for his paws to become inflamed again, highlighting how effective this particular medication was for him. I think this also highlights how important it is to work closely with your veterinarian if you have an allergic pet, because not all pets with allergies will respond to medication the same way, and it often takes trial and error to determine the right therapy at the right dose and the right frequency. Managing your expectations and communicating consistently with your veterinarian is going to go a long way towards helping control this chronic disease.
[00:12:40] As with any long-term medication, regular physical exams and blood work monitoring are important for minimizing the risk of this medication. Many family veterinarians are comfortable managing allergies, but if you are interested in consulting with a specialist, there is a link to the American College of Veterinary Dermatologists on the Your Vet Wants You to Know website.
[00:13:00] If you have a pet who has received Atopica for treatment of its allergies, I love seeing before and after pictures. I would encourage you to join our Facebook group, Your Vet Wants You to Know, so that you can share pictures of your allergic pets and connect with other pet owners who have been through the same things that you.
[00:13:32] You can follow us on Instagram and Facebook @yourvetwantsyoutoknow. If you found value from these episodes, I would encourage you to subscribe so that you don’t miss upcoming topics and leave us a quick review, letting other pet owners know what you think of the podcast.
Scratching the Itch
[00:13:46] I like to end each episode with a segment, I call “Scratching the Itch.” This segment is designed to highlight something that provides relief or just makes you feel good. Hence, “Scratching the Itch.” If you have something that you think scratches the itch, please contact me through the website or social media, where we have “Scratching the Itch” Saturdays. I’d love to hear your suggestions for something that I should feature in the future.
[00:14:07] This week’s “Scratching the Itch” is zoo animals opening Christmas presents. I can’t even say that without just having my whole face break out into a smile. I got an email from the Los Angeles Zoo recently. Our family has been members for several years. My daughter loves spending time there. So it’s been a little rough, not having our regular zoo trips this year. The LA zoo is dear to my heart because I did a rotation there during veterinary school. By the time this episode airs, I will have gone to visit their hospital to consult on a Fennec Fox that has skin issues. Whenever I go, I am thrilled with the amount of enrichment that they take the time to do for all of the animals in the zoo. It really is a Testament about how much the keepers and the veterinary staff care about the mental wellbeing of these animals, as well as their physical wellbeing.
[00:14:54] So when I opened up this email, it was just a really nice bright spot in my day. I got to watch all of these animals have such a good time exploring the presents that the keepers had gone out of their way to paint and to make look absolutely beautiful. They were filled with all sorts of yummy goodies for each particular animal. So it was really nice to watch and share the joy of them being curious and exploring and having a special reward at the end. I will post the link to the video in the show notes as well as on the website where you can find all of the “Scratching the Itch” segments, if you are in the need for a feel good moment. If you really enjoy watching zoo animals opening Christmas presents like I do, you can go down a very deep rabbit hole in YouTube with zoos all over the world providing Christmas presents to their animals and that made me feel really good. I hope it does the same for you too. That’s all for today’s episode. I look forward to your next visit with Your Vet Wants You to Know
References:
- Archer, T.M., Boothe, D.M., Langston, V.C., et al. Oral cyclosporine treatment in dogs: a review of the literature. J Vet Intern Med, 28 (2014), pp. 1-20
- Nuttall, T., Reece, D., Roberts, E. Life-long diseases need life-long treatment: long-term safety of ciclosporin in canine atopic dermatitis. Vet Rec, 174 (S2) (2014)
- Palmeiro, B.S. Cyclosporine in veterinary dermatology. Vet Clin North Am Small Anim Pract, 43 (2013), pp. 153-171
