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[00:01:04] Welcome everyone to today’s episode of Your Vet Wants You to Know. I’m very excited about today’s episode. I have a special guest here with me, Dr. Matt Levinson. Dr. Levinson is a board certified veterinary dermatologist who currently practices at a private specialty practice in Chicago.Before that he graduated from veterinary school at Oklahoma State University and did his veterinary dermatology residency at Animal Dermatology Clinic in Southern California. He and I were resident mates together and we struggled through studying for boards and I think he’s probably one of the reasons why I managed to get through one of the toughest times in my life. I’m very thankful for that. He and I also share a love of Italian food and cooking. He himself likes to cook. I like to enjoy my husband’s Italian cooking, so a little bit different there, but I’m very excited to have Dr. Levinson here today to talk about allergy immunotherapy, which is something that we use very commonly in the treatment of environmental allergies in dogs and cats. Welcome Dr. Levinson. 

[00:02:11] Dr. Levinson: Thank you. Thank you. Happy to be here. 

[00:02:14] Dr. Lancellotti: So we’ve spent a lot of time over the past few episodes talking about allergies themselves. We’ve talked about different types of allergies. We talked about all the different types of symptomatic treatment, like steroids and Apoquel and Atopica and Cytopoint, but now we’re getting into the meat of how do we treat the underlying environmental allergy. This is something that I think will be really important for people who want that long-term management of the disease, rather than just treating the symptoms of the disease.  Can you give our listeners a breakdown of what we’re going to be talking about with allergy immunotherapy today?

[00:02:51] Dr. Levinson: Yeah. So first, big thing is, we want to talk about what is allergy immunotherapy. So I’ll kind of go over, what that entails and then explain some of the reasons why  your veterinarian would recommend allergy immunotherapy. We’ll describe the process and what the pet owner can expect, explain the value of immunotherapy, even if the pet is well controlled on some of these other symptomatic medications, which I know you have other episodes about. We’ll describe some of the common pitfalls and some other tricks of overcoming those common pitfalls involved with allergy immunotherapy. 

A passion for allergy immunotherapy through Russell Sprout

[00:03:27] Dr. Lancellotti: That’s great. So it sounds like there’s going to be a lot of really good information coming for people who are interested in this therapy and for those people who may be struggling with it, we’ll have some pointers to how to really make this successful long term.  In the episode on environmental allergies, I introduced my dog, Russell Sprout, who is the beloved Your Vet Wants You to Know mascot. He is my allergy dog. He is allergic to lots and lots of different things in the environment and when I was a veterinary student, I actually shadowed at the Animal Dermatology Clinic in Pasadena and I worked with my mentors there to figure out exactly what he was allergic to and start him on allergy shots. Before that, he had just been on symptomatic medications. We had been using very short courses of steroids during his allergy season to get him comfortable and I didn’t want him on symptomatic medication throughout the course of his life. Since he started on those allergy shots, there has been a significant decrease in his overall itch level and the recurrence of his skin infections, which were really bad before. He had really horrible infections on his legs. He had actually chewed them raw and they were bleeding all over the place. Since we’ve been able to decrease the itch and the recurrence of infections it’s really allowed me to minimize the amount of other allergy medications that I need to use to keep him comfortable, like truly a life-changer for my itchy little street mutt. One of the reasons why I’m so passionate about advocating for this therapy with pet owners of allergic pets is because I’ve seen such a big difference in my own personal animal, as well as the many patients that I’ve treated over the course of my career. Today’s discussion is all about allergy immunotherapy and before we talk about the process and which patients would benefit from it, why don’t we start by telling everybody exactly what allergy specific immunotherapy or ASIT is. 

[00:05:34]Dr. Levinson: In allergic pets, the immune system views certain allergens as a perceived threat when otherwise it would be viewed as harmless to the body. What I find very cool about this whole process is we actually have the opportunity to reverse this abnormal immune system by constantly exposing the immune system to those specific allergens the pet is allergic to, over time, the immune system can develop a tolerance or become desensitized to those allergic triggers, thus reversing the original immune response. 

Russell Sprout immediately after getting picked up off the street. 

bleeding dog paws due to chewing from allergies

Allergic itch and inflammation would lead to secondary infections and trauma from intense chewing during Russell’s worst allergy seasons.

Who would benefit?

[00:06:07]Dr. Lancellotti: Desensitization, I think, is the key word there because in these animals with environmental allergies, their immune system is overly sensitized. It is hypersensitized to things that normal animals don’t react to. So by using immunotherapy, we’re retraining the immune system to not react to the things that it is overreacting to at that time and over the course of the animal’s lifetime, it becomes desensitized so that it can encounter all of those things in the environment that it once was allergic to, but not have that allergic response that was causing the itch and the infections to come back again and again. So it’s a really cool therapy that targets the immune system of each specific animal. So we’ll dive into that a little bit more, but for what types of pets do you recommend immunotherapy? Who do you think would you consider to be your ideal candidate for this treatment? 

[00:07:06] Dr. Levinson: You can essentially use immunotherapy on any animal or person, right? Because on the human side of things, we definitely do immunotherapy for humans, but anything from a small mouse to a giant horse can be on immunotherapy and reverse the course of these allergic triggers. So the ideal candidate would be of course one that you first rule out all the other causes of itchiness, right? So you want to rule out other things which have been talked about in other episodes, such as food allergic triggers , other types of infections that may cause itchiness and, parasitic infections, you name it. Then of course, it has to fit certain types of histories, is it seasonal versus non-seasonal? Did this start occurring from as early as six months to a year up to three years of age? Has there been travel involved?  But of course, any pet with environmental allergies would be an ideal candidate for immunotherapy, because once again, that’s the only way we can reverse the course of action of what’s occurring in the immune system. 

[00:08:12]Dr. Lancellotti: Excellent, I think you brought up a lot of really good points there. To kind of relate it to Russell Sprout, he was for sure an ideal candidate. He was a fairly young animal, maybe three years old at the time that we did his allergy testing, so he had already gone through a couple allergy seasons and we knew what season was causing the worst flares for him.  I had already gone through a diet trial and ruled out food allergies as a major contributor to his allergies and we had his infections under control, so even when there wasn’t any infection, he was still itching, which is that hallmark sign of allergies. I knew that as a young dog, he had many allergy seasons ahead of him and I didn’t want him to be on steroids and antibiotics for his whole life. So I think having a young animal with lots of allergy seasons ahead of them where you’ve done the work to rule out food allergies, flea allergies, infections, that is the ideal candidate. Like you said, any dog or any cat that has environmental allergies is a good candidate for immunotherapy. You did bring up something about travel, which I thought was interesting because different parts of the country and different parts of the world have different things that are environmental triggers. In Southern California, there are very common pollens that I test for on a regular basis, but I always try and ask my pet owner if they have any intention of moving to different parts of the country so that when I do my allergy testing, I know which things to test for. I know in your practice in the Midwest, you guys do a lot of testing for corn, right? 

[00:09:45]Dr. Levinson:  Obviously we have a lot of, farmland around the area, not particularly in the city, but yeah, in the surrounding areas we have a lot of corn and we have a lot of dogs and cats that are very reactive to not only the corn pollen, but also to the corn molds in the area. We have a lot of people who spend their winters down somewhere warmer, whether it’s Florida or Arizona. So I have to factor that in as well in terms of coming up with some of their possible allergic triggers when I’m formulating their therapy, 

[00:10:17] Dr. Lancellotti: Yeah, that’s a really great point. And I think all of this kind of leads back to a common theme I’ve tried to stress over and over again on this show is communication. Tell your veterinarian what it is that your animal is experiencing, what sort of environment they’re involved in, what your plans are as a family, because the more information you can give your veterinarian, the better able they will be to come up with a recipe that is going to work well and provide the most relief for your pet. 

The process of allergy testing

[00:10:45] Dr. Lancellotti: Before we can formulate these allergy shots or immunotherapy, we have to figure out what the pet is allergic to. So can you tell the listeners a little bit about the testing process, what’s involved and what should a pet owner expect from those tests? 

[00:11:01]Dr. Levinson:  There’s a couple of different ways we can go about allergy testing. One is intradermal allergy testing, which most dermatologists prefer. There’s also serum testing, which is taking a blood test. Intradermal allergy testing involves giving your pet a light sedative, as I like to joke, I say it’s giving them a nice, strong martini to help them relax. Once they are in that kind of Twilight stage, essentially what we’re doing is we’re shaving a small patch of hair on the side of their chest cause that’s a nice flat area.  Then we’re taking all the common allergens in the area, so that’s both indoor and outdoor, and remember these are regional. Then we’re injecting them just underneath the surface of the skin and looking for reactions. Those reactions can start occurring anywhere from 10 to 20 minutes later. While this is the preferred method for environmental allergy testing, not every candidate, fits the mold for having this test done. There are certain situations where you may want to offer serum or blood testing, and that could be, certain dogs may be a risk for sedation. They could be on certain medications, things like steroids and anti-histamines can interfere with it.  There’s other scenarios where we may want to opt for doing serum testing.  Serum testing involves taking a blood sample and looking at particular antibody levels in response to those allergens tested. Then we formulate the allergy specific immunotherapy based on those. 

[00:12:33] Dr. Lancellotti: Yeah, I think that’s a really nice explanation of what it is that the testing process involves  So we have these two methods to test and it’s not a  one size fits all kind of approach when we’re doing allergy testing. Some pets respond better to doing the blood test, so if we can’t get them off of steroids or anti-histamines.  Whenever I have a pet, that is what’s called a brachycephalic breed. These are going to be animals like English Bulldogs or French Bulldogs or Pekinese, any of the breeds that have a really tough time breathing when they’re sedated and they need to have their airway protected. So sedation is not a good idea for them and they would need general anesthesia in order to have the skin tests done. Those are going to be breeds where I start with a blood test and say, all right, if I get good results on my blood tests, then we’re just going to do the blood test because I don’t want to put my pets at risk when I am trying to do this testing process. That’s something that I think is important for pet owners to understand. There’s very minimal risk associated with doing the intradermal skin testing under sedation because it is such a light sedation. It’s just enough so that your pet is holding still. They’re not aware of those injections that we’re giving. As a Fear Free certified practitioner, it’s really important to me that I make this as pain-free and as stress-free as possible for the pets that I’m treating. So I don’t want them to know that I’m giving those 84 injections. I just want them to come in, be happy, get a very small poke so that they are sedated, and then when they wake up, they’re not aware of that testing process. I have some really good pictures on the website of the skin tests for people to get an idea of what that looks like. You and I both get really excited when we have a really good skin test where a positive reaction comes up and that positive reaction is a huge hive.

These intradermal skin tests show the reactions to what the dog is allergic, which appears as a red, raised, firm hive for the specific allergen. A rectangular patch of hair is shaved on the side of the body and a dot of black marker indicates each different antigen.

Formulating the injections

[00:14:28] Dr. Lancellotti: So once we have this information, once we’ve done the testing and we get the results and we go over the results with the pet owner, what is the next step? Are we just trying to avoid the things  in the environment that the pet is allergic to? 

[00:14:42] Dr. Levinson: Yeah. So obviously we don’t want them to live in a bubble, right? That’s not realistic.  I always say, when I talk to my pet owners, I want your dog to be a dog. I want your cat to be a cat. I don’t want the owner to be walking on eggshells, worrying about these things. So once again, I keep emphasizing, this is a reversible process. That’s what makes immunotherapy so cool. We can reverse these processes. Now I should mention it’s not a hundred percent guarantee, but we do have a  good high success rate. Various studies, will say anywhere from 60 to 70% success rate. The next step involved is once we have that information from those allergy tests, then we’ll pick out those specific antigens and, some dogs or cats may have, out of the 80 allergens, you’ve tested, they may have 40 or 50 positive triggers. So that’s where a little bit of an art is involved with it and that’s what us trained dermatologists are equipped to do is looking at those particular allergens and formulating and figuring out what’s the best combination that’s going to work for that particular pet.

[00:15:51]Dr. Lancellotti:  I think it’s something that’s really important to understand with allergy testing is you don’t have to desensitize to every single thing that the pet is allergic to. We talk about an itch threshold that an animal reaches once it’s allergies are compounded if we can desensitize to the things in the environment that the pet is most allergic to, then we can very likely be able to bring that itch level below the itch threshold for that pet. Working with someone who is really knowledgeable about the things in the environment, in your region, as well as in other parts of the country, if you do travel or if you’re planning to move, it’s helpful to determine what things should be added into the animal’s recipe that we use to desensitize them. Finding someone who is an expert in their field is really important to getting the most value from what you are putting in as far as the time and the money commitment that it takes in order to do this testing.

Because cats do not make as dramatic reactions on their skin as dogs, we use a fluorescein dye viewed under a special lamp to observe the reactions on their intradermal allergy test.

fluorescence on a cat skin test

The value of allergy testing

[00:16:54] Dr. Lancellotti: Immunotherapy seems like an investment of time and effort on the pet owner’s part.  Why would this be a valuable undertaking for pet owners even if their pets are well controlled with other symptomatic allergy medications?

[00:17:11] Dr. Levinson: Yeah. That’s a very good point. Once again, I keep repeating, the nice thing about immunotherapy is we can reverse this process of what’s going on with these environmental triggers. So we have the ability to reverse it, where the symptomatic therapies are they’re just putting a bandaid on things. They’re not treating the issue, they’re just covering up the symptoms. When I’m formulating the particular pet’s antigen specific immunotherapy, I always first have a very long conversation with the owner because it’s really important that the owner is on the same page. Compliance is a huge deal with this because it does take time and it takes a lot of patience involved.  I always tell the pet owner,  if I’m asking you to do things that just aren’t reasonable or you can’t do, that’s fine and we have to come up with a plan that’s going to work to achieve as much success as we can with this process. This is not an overnight fix. What we’re trying to do is desensitize this immune system over time. This can take anywhere from a couple months, sometimes to over a year before we have a response. So I really emphasize not for them not to give up too early on this, that this is going to take time. I always try to push doing immunotherapy the earlier the better, because it does take time and you’re going to have a much better success rate in a three-year-old dog with environmental allergies, probably verse a 12 year old dog who’s been having these chronic issues for the past several years or longer.  

[00:18:45] Dr. Lancellotti: Yeah, I think that’s really something to emphasize is that the sooner we can start doing the immunotherapy, even if the animal is well controlled on those symptomatic treatments, like steroids and Apoquel and Cytopoint and Atopica, the less reliant we will be on using those medications. With immunotherapy, there are no long-term risks associated with this. So while it does take a while, anywhere from six to 12, some say even 18 months to really reach maximum efficacy in decreasing the recurrence of itch and infection, it’s still going to be the safest long-term plan for these pets with a chronic lifelong disease. By minimizing the amount of symptomatic medication that we need, we’re minimizing the risk of long-term side effects from treatment of this chronic disease. I think it’s really valuable to try and do this as soon as you recognize that the animal has environmental allergies. Because this should not be a last resort therapy. It is much more successful when we can retrain the immune system that’s only been hyperactive for a couple of years, rather than trying to retrain an immune system that has been going hyperactive nonstop throughout the course of the animal’s life. The symptomatic treatment is not addressing the underlying immune dysfunction. It’s just treating the symptoms. The immunotherapy is the only thing that is reversing the underlying disease process. It is the only treatment we have for environmental allergies to minimize the use of antibiotics and get off of all these other anti-itch medications. I think that is the safest long-term therapy and oftentimes the most cost-effective therapy too, especially for large breed dogs. It’s something that if people are concerned about the cost of managing their pet over the course of its life, if they can save up for doing the testing, which is the most expensive part of this process, then they are decreasing the cost of treating this animal over the course of many allergy seasons. So I think it’s a very economical option for people as well if they can afford to do the testing. 

Subcutaneous immunotherapy (Allergy Shots)

[00:21:01]Dr. Levinson: Exactly. That’s why I always emphasize to pet owners, not only is this the safest approach to managing your pet’s allergies. Long-term it’s also the most cost-effective long-term. So yeah, I agree on all those points. Then, once we have that conversation, I talk to them about the different types of immunotherapy because there are a few different types that we can do. I try to see which ones are gonna fit with that pet and that owner. So, there are several different types, whether we do injections versus sublingual, which are oral drops, versus now there’s a newer therapy I’ve been doing, which is called intralymphatic immunotherapy, which involves injecting the immunotherapy into the lymph node. In terms of whether we do injections or drops, the idea still is, over time, we’re going to try to desensitize that pet to what they’re allergic to.  It’s just different routes and means to deliver these immunotherapies. The standard, classic way is subcutaneous immunotherapy, which involves, giving an injection just under the skin.  Over the course of, several weeks, you’re going to give the injections more often and then slowly you’re going to taper that out to every five days or weekly injections, 10 days.  Sometimes, for maintenance, it can vary whether it’s every two weeks or three weeks, depending on how that particular pet does. Once again, this is all tailored to how that particular pet responds. Some dogs or cats may do better on weekly injections versus others may do so well they only need it every two or three weeks. What’s different, with dogs and cats compared to humans is oftentimes we don’t get them off immunotherapy long-term where we can get them what we call clinically cured. That’s probably not something realistic. My goal and in terms of success is, long-term, if I can get that dog or cat on these subcutaneous injections alone, where they’re only getting the injection a couple of times a month, no longer on any symptomatic therapies, they’re not on steroids, Cytopoint, Apoquel, they’re not having secondary infections, they’re not itchy and they’re just cruising on those injections. I call that a real strong success. 

[00:23:17]Dr. Lancellotti: I think that’s really important is to manage expectations as well. The expectation is not that the immunotherapy is going to cure the pet and then they will be off all therapy for the rest of their life. The expectation is that if you can just use allergy shots and strict year round flea prevention and topical therapy, like medicated baths for dogs, not so much for cats, but for dogs. That is a huge success and that’s what we’re looking for is the shots, the flea prevention and the medicated baths should be the thing that are controlling the dog year round. If we only need a little bit of symptomatic medication, if there’s a mild flare that in my book is still a success too. I want my pets to be off year round symptomatic medication. That’s the goal.  The immunotherapy is something that will very likely be a lifelong treatment, but at manageable intervals. So once every two to three weeks, maybe once weekly, if your pet is one of those animals that does better with more frequent injections. Again, this goes back to communication, working with a veterinary dermatologist or with your family veterinarian to talk about what sort of patterns you’re seeing at home in regards to your animal’s itch so that you can figure out what is the best schedule for the injections to be able to achieve optimal success.

Sublingual Immunotherapy (Allergy Drops)

[00:24:39]Dr. Levinson:  So continuing with the different types of immunotherapy, some pet owners, prefer doing oral drops, which is sublingual immunotherapy, also known as SLIT. SLIT, I believe originally was used in children as a way to give them therapy because children, like most people, don’t like injections period, but especially kids. So an easier route to give was actually giving the drops under the tongue. We took on this concept in the veterinary world, where we came up with these oral drops and the idea behind that is it’s the same idea that we’re formulating these allergy specific immunotherapy into these oral drops. Sublingual immunotherapy is a good option for pet owners who are really adverse to giving injections, or if the dog or cat does not tolerate receiving injections. The idea behind that is you want to give these drops under the tongue because you want them to be absorbed, not swallowed. So it’s important that it’s absorbed into the mucus membrane as that route of administration. So sometimes that can prove to be a little difficult as well. The other, downside to this compared to doing subcutaneous immunotherapy is it has to be administered more often given the route. So it is something that will have to be administered daily sometimes even twice daily long-term  

[00:26:03] Dr. Lancellotti: So when I talk about slit to pet owners, one of the things that I often mentioned is while it may be easier to administer as far as not having to give an injection and it’s just being done in the mouth, there is a drawback because with the injections, we can space out how frequently they’re getting the injection.  With sublingual immunotherapy, there’s no decreasing the frequency. So it’s that once or twice a day dosing every day in perpetuity. I know for my family, that would not be realistic, but it’s easy for me to give Russell his injection once every two weeks because I remember every other weekend I have to do it. If I had to do it, once or twice a day, every day for year after year after year, it would become something that we wouldn’t be able to comply with. 

Intralymphatic Immunotherapy

[00:26:47] Dr. Lancellotti: Tell us a little bit about the intralymphatic immunotherapy that you’ve started doing in your clinic.

[00:26:53] Dr. Levinson: Over the last several months, I’ve started introducing a new form of immunotherapy called intralymphatic immunotherapy, which I think is a very exciting, newer way to desensitize these pets, both dogs and cats. What that involves is actually taking the allergens and injecting them directly into one of the lymph nodes to create a quicker and greater immune response. There’ve been numerous studies now on the human side of things that have shown that allergic patients can have success and fully be desensitized with intralymphatic immunotherapy in as soon as eight weeks compared to doing three years of traditional subcutaneous injections. Once again, dogs and cats aren’t humans. So we have to take that success rate with a grain of salt. On the limited studies that have been done in dogs, it has been shown to be as efficacious as subcutaneous immunotherapy and sublingual immunotherapy, if not more efficacious.  My protocol involves a series of five injections given on day zero, 14, day 30, 60, and 90. After that course of those five injections, then I actually recommend that we switch to subcutaneous immunotherapy just on a monthly basis, more as a booster, because there has been some studies showing that even though they’ve gotten that series of injections, that there is more likely for a dog or cat to have a relapse, meaning that we can’t once again fully desensitize them, like we can with people. So I do recommend doing monthly injections just to, as a booster, to keep things going and so far, it’s been really exciting with the results. Safety-wise, it’s proven just as safe as giving the sublingual immunotherapy or subcutaneous immunotherapy.

[00:28:46] Dr. Lancellotti: Yeah, this is a really exciting avenue of treatment that we’re starting to explore and I think one that provides us with a great option for those pet owners that aren’t able to do as much at home.  With the other types of immunotherapy, the subcutaneous, which are the injections under the skin and the sublingual, which are the drops under the tongue, those are things that the pet owners are doing at home. They’re not bringing the pet into the hospital or the clinic to have those done typically.  For those pet owners that may be having some struggles with giving the animal it’s therapy at home, I think the intralymphatic immunotherapy offers a really exciting opportunity to have that immunotherapy done under the supervision of a veterinarian on a pretty manageable frequency. I mean, if you think about Cytopoint, which is one of the most common symptomatic treatments for allergic dogs, that’s given as typically a monthly injection in the hospital. So I think it’s a really interesting avenue for increasing pet owner compliance and making things a little bit easier for these pet owners that may have to be doing a lot of other things like medicated baths or ear cleanings or giving antibiotics to treat all the other stuff that goes along with allergies. I’m excited to do this because the research that has come out has been very encouraging.

Rush/Accelerated Immunotherapy

[00:30:05] Dr. Lancellotti: What about for pet owners that are okay doing the injections at home, but maybe they travel a lot or maybe their schedule is really hectic and they’re not able to do that build up period in the beginning of the induction phase where we’re asking them to do it every two days, every five days, every 10 days before they get to that once every two to four weeks as the maintenance. Is there an option for those pet owners that may not want to do the intralymphatic or maybe intralymphatic isn’t available where they live? What other options do we have there? 

[00:30:38] Dr. Levinson: Yeah. So for the pet owners who do not want to do the introduction injections, which are given much more often, like you said, every other day, we do offer a different type of immunotherapy, which is called Rush immunotherapy. What that involves is essentially that dog or cat would hang out with us in the clinic for the day. We put an IV catheter in them just to be safe in case there’s any reactions, which I have not had any reactions because it’s still a very safe way to do this. What that involves is we give their intro vial over the course of one day. So they’re getting several injections throughout the day and then once they go home, we just start the maintenance dosing, whether that’s weekly or every two weeks or whatever that particular dermatologist wants to do in terms of their scheduling. So it’s a really nice option for those who don’t want to give injections as often, where you can have it all done all at once. Then you just go home and start the maintenance dose. Success rate is about on par or the same for doing it this route versus doing the more traditional route of the injections at home. The nice thing about immunotherapy is that there seems to be now almost options for every type of pet owner. The ones who are willing to do it the more traditional way and have time to do those injections, then we can certainly do subcutaneous immunotherapy. The ones who don’t like injections or adverse to it, then there’s sublingual immunotherapy, you’re doing drops. Now there’s the newer intralymphatic immunotherapy, which involves less injections and may be more efficacious than the other options. As we continue to advance in the field of veterinary dermatology, we should continue to have new, exciting ways to retrain the immune system, to desensitize them to these allergens.

Setting yourself and your pet up for success

[00:32:29] Dr. Lancellotti: I know there’s some pet owners out there that are a little bit hesitant about giving injections at home and I want to talk a little bit about some of the ways to make that injection experience more positive because not everyone is a medical professional and I like to tell pet owners about my husband, Stephen, who is a wonderful person, just absolutely amazing. He is so good with our dogs, but he is not a medical professional at all. No medical knowledge except for the little tidbits that he picks up when he hears me studying with my study groups or talking about cases with my colleagues. He is as much an average pet owner as anyone who’s listening today. When I was in vet school, I tested Russell for his allergies and we got him on desensitization and then I had to leave for a month to go rotate to a different veterinary hospital in a different part of the country. I was not home when my husband was doing those injections and he was forced to do them all by himself and, God bless his heart, he did not give me a hard time for it.  In order to set him up for success, because he needed some setup, Russell is not a happy-go-lucky golden retriever. I say this all the time. He is as feisty as he is ugly. Working with him was a challenge, even for me as a medical professional. So one of the things that I think is important for pet owners to understand is that with this lifelong therapy, it is so important to create a positive association with the routine of getting the injection, finding what your animal really loves and using that to your advantage. Do not be ashamed to bribe your pet to make this a positive experience, because the more positive you can make it for your pet, the more positive it will be for your family and the more successful you’re going to be in the long run because you’re not going to dread giving those allergy shots. Dr. Levinson, do you have some tips and techniques for pet owners as far as giving the injections at home? 

[00:34:38] Dr. Levinson: I can’t tell you how many pet owners, when I start going through this process and ask them if they would be comfortable giving injections at home, how they squirm and squeal and are so adverse to doing so until they actually do it. Every time I go, “I know it sounds scary and intimidating, but I promise you when you come back a month from now you’ll be a pro at it and you’ll tell me what a breeze it is and how much easier it is than administering oral medications half the time. “

[00:35:07]Dr. Lancellotti:  I agree with you, especially in cats too. I feel like giving injections in cats is way easier than giving them oral medications. 

[00:35:15]Dr. Levinson: Yes, definitely. One thing we do at my clinic and, I know you guys do at yours is we do live demonstrations. Before COVID, and hopefully in the near future, once we get past it, we do in person demonstrations where we actually have the pet owner come in with the pet and we go over the scheduling and how to administer the injections and we actually have them practice in front of us to get that comfort level going and administer the first injection right then and there, so that I think relieves a lot of the stress, not only for the pet, but for the pet owner too, just having someone there to walk them through and guide that. I also send home a lot of instructions on how to do it, as well as there’s several YouTube videos I recommend on how to administer injections.  Positive reinforcement is the best way to go about this, make it a positive experience for them. As long as they’re not food allergic, offer their favorite treats. Peanut butter seems to work always great for dogs. I usually recommend at least to start making it a two person job. So that way you have someone distracting the pet while the other one person’s administering it. Then over time, once they get that comfort level and you’re not giving them as often, then, if you can handle it as a one person job, then that’s fine. I can’t tell you how many people say, “Oh, it’s a breeze to give the injections. I don’t know why I was so scared to administer that at first.”  

[00:36:38] Dr. Lancellotti: I think people don’t give themselves enough credit for being able to do this and my husband for sure was the same way. Unfortunately he couldn’t do a two person job when I was gone for the beginning. So he rigged a spatula with some peanut butter on it, so that Russell would be distracted by that and then he would give the injection while Russell was licking the peanut butter. That seemed to work in his one person setting. Now every other weekend, when he has to get his maintenance injection, my four year old helps by giving Russell his treats while I give his injection. It’s been something that the whole family has been involved in. So I think the more people you can get to be helping in creating a positive experience, the better off you’re going to be for your family pet. One thing that I think is helpful is creating that routine. Even on days when the animal is not getting the injection in the beginning, creating a routine where you have them come to a certain set location where you’re going to give the injection, you have all of your supplies and your tools, whatever you’re going to use ready before you bring the animal there. Then you go through this step wise process of rewarding each incrementing step of the process. So there’s a great video that I have on the website of Russell getting his allergy shot and getting rewarded at each step of the process. Rewarding just being in that location. Rewarding when I touch on his shoulders where he’s going to get his injection with the hand that I’m going to use to hold up the skin. Rewarding when I touch the skin with the capped syringe, so the needle still has the cap on it, gentle touching. Then waiting until he’s focused on the treats and then giving the injection and getting rewarded as he’s getting the injection. As soon as we’re done giving the injection, then giving more treats at the end too, so that he ends on a positive note. The important thing is to make sure that you’re not rewarding any type of escape behavior or any sort of behavior where they are showing resistance. So that’s one thing that I think pet owners may have a little bit of a struggle with if the animal isn’t quite as accepting as they had first anticipated. You don’t want to give the reward as the animal’s trying to get away, you want to give the reward as the animal is staying there and being happy and and focusing on what you’re trying to do. So on those days in the beginning, when the animal’s not due for their injection, going through that whole process, rewarding being in that spot, touching the skin, tenting the skin, touching the skin with a capped syringe. That whole process should be rewarded so that when it does come time on the next day, or whenever they’re due for their next injection, the animal already associates the whole routine with something positive.

[00:39:29] Dr. Lancellotti: Then the other thing that my technicians and I like to mention to pet owners is you can use an ice pack as well. Ice is a really inexpensive numbing tool so that the animal doesn’t feel the injection that’s going into their skin. So having them sit in your lap, have an ice pack on their shoulder or wherever you’re going to give the injection for 30 to 60 seconds, just to numb it a little bit, giving them treats while you’re holding the ice pack on there. They’re less likely to feel that tiny little poke. I mean, it’s such a small needle that we’re using and such a small volume of liquid that’s going in. If you numb that area, it may help with any pain that’s associated with the injection. Typically once the animal is distracted with food, they don’t feel the needle going in. 

[00:40:16] Dr. Levinson: You could also let the syringe set out for a few minutes once you pull out the allergens because they are refrigerated and sometimes that cool feeling can create a little bit of an uncomfortable sensation.  Sometimes I’ll recommend just drawing it up and letting it sit out for 15 minutes before giving an injection, or you can warm it up between your hands real quick.

One Piece of the Puzzle and Managing Expectations

[00:40:36] Dr. Lancellotti: Dr. Levinson, I think we’ve gone over a ton of information for pet owners today in regards to what immunotherapy is, what the testing process involves, the different types of immunotherapy available as far as desensitizing the animal and ways that we can troubleshoot if they’re having some issues. Do you have any other advice or gems that you want to share with pet owners who are considering immunotherapy for their pet?

[00:41:03]Dr. Levinson: Just one thing I want to emphasize once again, is immunotherapy is just one piece of the puzzle too. So while ultimately the goal is we can desensitize the pet where they may not need symptomatic therapy, keep in mind, there are other things still wrong potentially with that dog or cat’s skin. They could have an abnormal microbiome, they could have an abnormal barrier function of the skin. While immunotherapy can help normalize it, it may not completely normalize it. I know you had mentioned continuing with topical therapy. There are still other things involved other than just giving the injection. This isn’t a cure. All we cannot cure allergies. We can only manage them. This is the best way long-term to manage it and reverse some of that process that’s happening.

[00:41:53] Dr. Lancellotti: Yeah, managing expectations is really important. This is a chronic lifelong disease, and every pet responds differently to different allergy therapies. There’s no one single therapy that is going to completely fix an animal. Immunotherapy is an important tool that we can use in the management of these pets so that we can reduce the recurrence of itch and infection over the course of their lifetime. Again, it does take a long time to kick in so six to 12 to 18 months in some pets. Understanding that other symptomatic medications like steroids or Cytopoint or Apoquel or Atopica may be needed during that time to keep the pet comfortable while the allergy shots or allergy drops are starting to take effect is a reasonable expectation to have. I would encourage pet owners to visit the website to see pictures of the skin tests that we’ve done so that they can get an understanding of what those reactions look like. There’s video on the website of Russell Sprout getting his injections and how to do the rewards in a stepwise approach so that the animal is accepting of it. Like I said, he is not a happy-go-lucky golden retriever. He’s a feisty dog. So for him to be this good with allergy shots, I truly believe that almost any dog and any cat will be a good candidate for getting the injections at home. Also on the website, links to find a veterinary dermatologist within the United States through the American College of Veterinary Dermatology, so that if you would like to consult with a specialist and consider skin testing and blood testing to get your animals started on immunotherapy, you can find one in your area. If you have a pet that has allergies, I would encourage you to join our Facebook group. Let us know about your experience with performing allergy shots, any things that worked for you as far as when you were troubleshooting, what worked best for your pet, because you may be able to help other pet owners who are struggling and really want this therapy to succeed. Come join our community, talk with us about what you’re going through and just share with other pet owners the experience. If you found value from today’s episode, please leave a review so that other pet owners will find value from these episodes as well.

"Scratching the Itch"

[00:44:10] Dr. Lancellotti: I like to end each episode with a short segment that I call “Scratching the Itch.” The segment highlights something, either a human interest story, a product or a website that either provides relief or just makes you feel good. Hence, scratching the itch. If you have suggestions for something that we should feature on “Scratching the Itch” in the future, you can contact me through the website or through the Facebook group to let me know. Dr. Levinson, do you have anything that scratches the itch for us today? 

[00:44:41] Dr. Levinson: Yeah, one good thing I guess, to come out of COVID, at least in the Chicago land area was Paws, which is a no kill shelter here, for the first time ever actually was able to adopt out all their dogs and cats, and they actually had no dogs or cats in the shelter for a period of time, which was great. I guess all those people spending time at home wanted to bring home some new family members, which I really enjoyed. 

[00:45:07] Dr. Lancellotti: Absolutely wonderful, such a silver lining to this horrible year has been so many people taking in new pets in their home and having a new family member to share this isolation with. I definitely have seen a lot of new pandemic puppies in our clinic over the past year. I think that’s wonderful that shelter who I’m sure has struggled for many years to try and get homes for these pets to have the shelter be completely empty is just astounding. That’s wonderful. Thank you very much, Dr. Levinson for taking the time to go through this really complex topic for pet owners and break it down so that they can get a good understanding of this long-term treatment of a very common disease. I hope that people will talk to their family veterinarian and seek out veterinary dermatologists to help them through this process and really communicate, as far as what’s happening with their pet at home, what’s happening after they start immunotherapy, because communication is such an important part of managing these long-term diseases. The best person to talk to and to get information from is your veterinarian. So thank you very much for joining us, Dr. Levinson. 

[00:46:19] Dr. Levinson: Thank you, it was fun.

[00:46:21] Dr. Lancellotti: I look forward to your next visit with Your Vet Wants You to Know.

veterinarian holding a sloth

Special thanks to guest Dr. Matt Levinson. 


  1. DeBoer, D.J. “The Future of Immunotherapy for Canine Atopic Dermatitis: A Review.” Veterinary Dermatology, vol. 28, no. 1, Feb. 2017, p. 25.
  2. Fischer, N. et al. “Intralymphatic Immunotherapy: An Effective and Safe Alternative Route for Canine Atopic Dermatitis.” SCHWEIZER ARCHIV FUR TIERHEILKUNDE, vol. 158, no. 9, Sept. 2016, pp. 646–652.
  3. Mueller, Ralf S. “Update on Allergen Immunotherapy.” VETERINARY CLINICS OF NORTH AMERICA-SMALL ANIMAL PRACTICE, vol. 49, no. 1, Jan. 2019, p. 1–+.
  4. Mueller, R. S., et al. “Conventional and Rush Immunotherapy in Canine Atopic Dermatitis.” Veterinary Dermatology, vol. 15, Aug. 2004, p. 4.
  5. Timm, K. et al. “Long-Term Effects of Intralymphatic Immunotherapy (ILIT) on Canine Atopic Dermatitis.” VETERINARY DERMATOLOGY, vol. 29, no. 2, Apr. 2018, p. 123–+.

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3 thoughts on “Immunotherapy”

  1. My dog, Sammy, has recently started shots for his allergies. And in his typical fashion he began having red patches and itching after the second shot… My Veterinarian gave the okay to start him back on Apoquel while taking the allergy shots.

    My question is, does Apoquel interfere with the bodies process during immunotherapy of building up resistance to the new allergens being introduced? Or it is okay to take while doing immunotherapy?

    Can I get reassurance? I just want to be really sure I am doing this correctly for my Sammy!

    • Jodi,
      Thank you for your comment. There are plenty of dogs who need symptomatic therapy (Apoquel, Cytopoint, steroids, Atopica) while starting immunotherapy to help keep them comfortable because immunotherapy can take up to 6-12 months to reach maximum efficacy. We do not have data at this time to indicate that Apoquel interferes with the effects of immunotherapy. When in doubt, we always recommend you follow up with your primary care veterinarian for questions specific to your pet. Thanks!


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