That ******* cascade again.

Re: That ******* cascade again.

Rob Loxley — Fri, 03 Feb 2012 19:23:53 GMT

If it's neurogenic KCS does that change the treatment? I've understood they respond less well to ciclosporin; tacrolimus?

Re: That ******* cascade again.

Hannah Wynne Richards — Wed, 01 Feb 2012 12:41:00 GMT

What really annoys me are the following:

a) I'mnot allowed touse my clinicaljudgement on the most effective treatment-I'm forced to use the licensed one

b) as Mark says it's so complicated I try to always obey the law-so get really annoyed when it's so complicated it's possible to break unintentionally

Wynne

Re: That ******* cascade again.

Mark Holmes — Wed, 01 Feb 2012 12:08:24 GMT

More casade stuff. Does it not make a complete mockery of all the licensing and casade regs when you use two or more drugs together. I currently have one dog on a bucket of different drugs. All licensed but not together. Do I need to get a off license form signed? Re Malcolms quiery regarding forms, Idon't currently get them signed for example if I use a drug s/c rather than IM, maybe I should who knows?

Its a complete mess

Re: That ******* cascade again.

Rob Loxley — Mon, 30 Jan 2012 13:43:09 GMT

[quote user="Martin Atkinson"]AFAIA there is still no equivalent for humans to Optimmune so they probably still make up the stuff - perhaps they more know more than we do.[/quote]

Moorfields sell Optimmune for human use! They will also make up different strength cyclosporin, though the protopic sounds like maybe a better way to go.

Re: That ******* cascade again.

Martin Atkinson — Mon, 30 Jan 2012 12:27:45 GMT

I don't think there is any justification in using anything else before Optimmune as it is efficacious in almost every case. In cases where it is unavailable or there is a poor response it worth remembering that before Optimmune came out we used to order cyclosporin in oil from Moorfields Eye Hospital. Saves phaffing making it yourself. AFAIA there is still no equivalent for humans to Optimmune so they probably still make up the stuff - perhaps they more know more than we do.

Re: That ******* cascade again.

Robert Lowe — Mon, 30 Jan 2012 09:00:46 GMT

We start off on Protopic 0.03% bid applied with a damp cotton bud. Basically using about 1-2mm bead onto the bud and then rolled onto lower eyelid margin.

Another way of applying (courtesy of Christine Heinrich) is to get the client to go and buy a tube of Anusol as apparently the applicator tip fits the protopic and delivers it in a thin bead. The clients tend to send their other halfs for this!

If no response in 1 month then we increase to 0.1%. This is a rare day as the vast majority respond well in my hands.

I warn the owners of the theoretical risk and advise they wear gloves while applying.

HTH

Rob

Re: That ******* cascade again.

james herriot lied — Sun, 29 Jan 2012 21:26:55 GMT

Thanks, Robert. Always good to hear from a diplomate on these things. What are your directions for use?

Re: That ******* cascade again.

Robert Lowe — Sun, 29 Jan 2012 20:08:03 GMT

Reference tacrolimus

It is something we use for non-responsive KCS i.e. when Optimmune is not working. You can get it as a compounded eye drop or use the skin cream (Protopic) as we do. The two concentrations are 0.03 and 0.1% and we find the majority respond to the 0.03% ointment. We have all but given up with increased strength cyclosporin drops.

There has been some discussion about tacrolimus causing skin tumours when used on human skin but the current recommendation is that it is safe to use in human dermatology as the risk is theoretical.

I advise the owners to avoid skin contact due to this theoretical risk.

Re: That ******* cascade again.

Rob Davis — Sat, 28 Jan 2012 16:00:26 GMT

I'm just recalling a posting from Malcolm Ness some time ago:

"Some months ago, a locum threw their toys out of the pram when my wife (a dermatologist) stopped the order of ??Tacrolimus - a substance so noxious that FDA have massively restricted its distribution", and "The patient and owner, a young mother with 2 year old twins and possibly pregnant again (read the Tacro. warnings!!)"

I have no idea myself whether owner exposure from applying topical application is a significant risk, but I would want to know more before prescribing it.

Re: That ******* cascade again.

HMC — Sat, 28 Jan 2012 14:36:40 GMT

Tacrolimus is/was the favoured treatment for the ophthalmologist at Glasgow Uni, George Peplinski.

I don't know in answer to your question. Do you mean do I tell them to wear gloves when applying? Or just tell them to wash their hands in case of accidental contact?

How much tacrolimus would have to come into skin contact to be a problem and is that likely to happen?

Re: That ******* cascade again.

Stephen Courtney — Sat, 28 Jan 2012 14:36:11 GMT

It's pretty simple, the licensed treatment gets tried first. If you don't get an improvement with optimuune in a reasonable time - 4 weeks is about adequate then you have to use something stronger, either neoral in oil or protopic - the stronger of the two strengths available.

I've got a couple of cats that vomit or get itchy faces on felimazole and vidalta. they seem to tolerate neomercazole though, and because i can prove i have tried the licensed options, and reported the adverse reactions, I can use neomerc with a clear conscience.

NB if using protopic, it is best applied by putting a little smidge on a cotton bud and rolling it onto the conjunctiva witht hat. a tube lasts ages and ages, and no you don't have to throw it away after 28 days - have this advice from a diplomate eye guy. the tubes are expensive but last ages, and he prefers protopic to the neoral in oil.

Re: That ******* cascade again.

Rob Davis — Sat, 28 Jan 2012 14:26:09 GMT

[quote user="Hannah Bose"]but then try tacrolimus[/quote]

Do you have any concerns about potential adverse effects for owners when prescribing tacrolimus?

Re: That ******* cascade again.

HMC — Sat, 28 Jan 2012 13:59:26 GMT

I would always start with optimmune and I would only change from that if the shirmer tear test showed a worsening of the KCS. (It was explained to me that the disease is progressive so if you see the STT results remaining static it may be that the optimmune is working, but just in the face of a worsening disease).

Personally I would not then faff around with higher concentrations of the same drug, generics and such like but then try tacrolimus (human licence skin preparation, so probably doubly off-licence!). I would argue that that follows the cascade as I would have tried the optimmune.

Re: That ******* cascade again.

Malcolm Ness — Wed, 25 Jan 2012 10:52:16 GMT

We try to be diligent about using Unlicensed Product Forms (UPF). What do others do? Notwithstanding the rights or wrongs of using home made cyclosporin as discussed in this thread, I think it fairly obvious that if you did choose to use home-made, then you should obtain a UPF.

However, what about the case where you are using, say, Synulox for a condition (or at a dose, frequency etc) that is not listed in the data sheet - strictly off-licence but I wouldn't bother with a UPF - would anybody else?

PS - Half way through a rather boring "paper-work catch-up week" hence the recent multiple postings!!

Re: That ******* cascade again.

Michael Woodhouse — Tue, 24 Jan 2012 22:18:08 GMT

[quote user="Mark Holmes"]I think you just need justification but cannot see what justification there would be for not using optimune first. [/quote]

Re: That ******* cascade again.

Clive Ansell — Tue, 24 Jan 2012 12:57:16 GMT

No, topical mixed with corn oil.

Re: That ******* cascade again.

Kate Richardson — Tue, 24 Jan 2012 12:42:42 GMT

Sorry, misunderstood. Are you talking about using oral cyclosporin for KCS as opposed to topical ointment? If so, I cannot see any justification in that at all. Second choice of treatment if Optimmune not working would be cyclo in oil as desribed above, still applied topically. I have never heard of treating KCS with oral meds

Re: That ******* cascade again.

Mark Holmes — Tue, 24 Jan 2012 12:26:51 GMT

I think you just need justification but cannot see what justification there would be for not using optimune first. How do you justify needing a different concentration unless the licenced concentration has failed?

Re: That ******* cascade again.

Kate Richardson — Tue, 24 Jan 2012 12:23:37 GMT

I think you need to give Optimmune at least 4 weeks bid in affected eyes before considering changing, and if not working, then we make up cyclosporin eye drops in corn oil at a higher concentration and increase the concentration of the cyclosporin if necessary as time goes on.