adult onset demodicosis

Re: adult onset demodicosis

Julian Earl — Fri, 10 Oct 2014 20:30:33 GMT

I agree completely with looking for some other disease, because you will find it: either hotrmonal as suggested or perhaps an internal tumour. I was advised this at some good CPD and it seems to hold up. I think blood tests have to be first, but the specialist doing the CPD suggested x raya and scans for masses, but this probably depends upon what if any systemic signs are shown. HTH.Keep looking but Iinvariably would use ALUDEX as first line treatment When it was first around, we used to successfully treat with injectable IVOMEC[ standard warning applies... off-data-sheet of course etc., etc,THYROIDS AND CUSHINGS probably t hebest place to start?

Re: adult onset demodicosis

Noirin Ni Shimidh — Fri, 10 Oct 2014 19:37:31 GMT

For what it's worth, adult onset demodecosis in Shih Tzu's (especially on the paws) seems to be relatively common in my experience. I've had four cases & only identified an underlying cause in one, (and followed the others for several years). I don't know if there's a breed predisposition but I have spoken to a few others who've had the same experience. Depending on available finances it might be worth treating while warning the owners that something might show up later. I like daily oral ivermectin for these....

Re: adult onset demodicosis

Rob Loxley — Fri, 10 Oct 2014 17:52:06 GMT

[quote user="Robin Grimmer"]I don't know how Advocate got a licence for Demodex[/quote]

they tested it in juvenile onset cases that got better in spite of monthly advocate rather than because of?

Re: adult onset demodicosis

Rob Loxley — Fri, 10 Oct 2014 17:50:12 GMT

[quote user="Martin Atkinson"]The licenced drugs are often ineffective (Advocate) or unpleasant/toxic to use (Aludex) or in the case of Aludex not always available. Milbemycin has been shown to be both safe and effective abeint not cheap[/quote]

Is that justification enough? I'm not playing devil's advocate - if given free choice milbemycin would probably be my top choice as it seems to be well tolerated, simple and works well - and I wondered what a dermatologist uses to justify it - if using first line?

Re: adult onset demodicosis

Robin Grimmer — Fri, 10 Oct 2014 17:49:17 GMT

[quote user="Martin Atkinson"]

[quote user="robloxley"] Let me put it better maybe, what is your justification for going down the Cascade when Licensed drugs for demodecosis exist[/quote] I'll answer for him again. The licenced drugs are often ineffective (Advocate) or unpleasant/toxic to use (Aludex) or in the case of Aludex not always available. Milbemycin has been shown to be both safe and effective abeint not cheap

[/quote]

Agree. I don't know how Advocate got a licence for Demodex, I've never seen it work! And Aludex is very unpleasant stuff to use.

Re: adult onset demodicosis

Anthony Dennison — Fri, 10 Oct 2014 17:04:46 GMT

What about oral ivermectin?

Re: adult onset demodicosis

Martin Atkinson — Fri, 10 Oct 2014 14:28:04 GMT

Re: adult onset demodicosis

Rob Loxley — Fri, 10 Oct 2014 14:00:16 GMT

[quote user="Martin Atkinson"]

[quote user="robloxley"]What justification for going off-label would you give?[/quote]I guess its off label because you are giving it more freqently i.e. daily than is in the data sheets.

You can get milbemycin without the praziquantel which is cheaper but it would need to be imported from Europe on a special import licence as well as the off-label consent. Novartis should be able to help.

[/quote]

Yes, but again requires justification for a SIC when licensed drugs are sidestepped. Let me put it better maybe, what is your justification for going down the Cascade when Licensed drugs for demodecosis exist, Anthony?

Re: adult onset demodicosis

Martin Atkinson — Fri, 10 Oct 2014 11:23:43 GMT

[quote user="robloxley"]What justification for going off-label would you give?[/quote]I guess its off label because you are giving it more freqently i.e. daily than is in the data sheets.

Re: adult onset demodicosis

Rob Loxley — Thu, 09 Oct 2014 14:49:19 GMT

[quote user="anthony chadwick"]Demodex off-label worth treating with milbemycin[/quote]

What justification for going off-label would you give?

Re: adult onset demodicosis

Martin Atkinson — Thu, 09 Oct 2014 10:24:46 GMT

[quote user="HollyK"]Hi Martin, thank you for the reply, that's really helpful. Would you be testing for any other underlying conditions at this stage? Thyroid? Anything else? Could liver disease be a possible underlying cause? Holly

[/quote]I only mentioned liver disease because a dog I had with generalised demodecosis which turned out to have a liver tumour. Plus you have a raised ALP, albeit one which is probably on its own not indicating liver disease - more the levels you'd get with HAC. I think its worth testing for everything thats easy to do from a standard sample so liver function with GGT and bile acids and TT4 while you're at it, if nothing else you're eliminating things. If the TT4 is normal then its not hypothyroid but if its low it may just be due to chronic disease and you'll have to perform further testing if you're suspicious. Exogenous ACTH needs a frozen sample which a bit of a faff but the lab should be able to organise that for you.

Re: adult onset demodicosis

HollyK — Thu, 09 Oct 2014 10:23:33 GMT

Thanks for the replies.

Anthony - I've not used milbemycin for demodex before, would you routinely choose it over aludex? What dose would you use?

Emma - our lab say less than 13 rules out cushings. This dog's result was 16 so before the demodex was diagnosed i felt that we had more or less ruled it out but now I'm not so sure! The original ACTH stim was done because cushingoid dogs have a high incidence of calcium oxalate stones and he had a high alkp on routine bloods so I wanted to rule out cushings prior to surgery to remove the bladder stones. Thanks for the cushings link, really helpful :)

Re: adult onset demodicosis

emma_j — Thu, 09 Oct 2014 09:52:01 GMT

I tend to go with this algorithm http://thehormonelab.com/core/..uploads/csls/CSLS-Canine-Hyperadrenocorticism-Flowchart.png when considering Cushings (not perfect, but it's something!) - so for that reason, the lack of compatible clinical signs initially and usg would have me doubting HAC, why were the original ACTH stims run in 2013, why was it a differential then? Although as they always say, Cushings becomes more obvious over time.

What is your lab's ref range for cort:crea ratio? Ours would pretty much rule out HAC if <34 so results of 15 or 16 would have me in the not-Cushingoid camp.

My move at this point would be LDDS (depending on the ref range for the cort:crea) and T4/TSH, and probably an abdominal ultrasound. I think there are some nice webinars on the Dechra website about Cushings and atypical cases, I remember watching them when I had a weird one.

Re: adult onset demodicosis

anthony chadwick — Wed, 08 Oct 2014 21:28:12 GMT

Dear Holly

Interesting case. I think Cushings has got to be a possibility but would do a Ldds test. Not all Cushing cases have PU/PD so normal sg not necessarily rule out but a negative urine cortisol creatinine ratio should. Sometimes a borderline result might be positive in 6 months. Thyroid always difficult to evaluate on own. I would do a TSH conc and free T4 by equilibrium dialysis.

Demodex off-label worth treating with milbemycin and then re-do bloods when demodex under control.

Hope my few thoughts help

Anthony

Re: adult onset demodicosis

HollyK — Wed, 08 Oct 2014 21:15:27 GMT

Hi Martin, thank you for the reply, that's really helpful. Would you be testing for any other underlying conditions at this stage? Thyroid? Anything else? Could liver disease be a possible underlying cause? Holly

Re: adult onset demodicosis

Martin Atkinson — Tue, 07 Oct 2014 17:34:23 GMT

You're right that adult onset demodecosis is almost invariably secondary to some other underlying immunosuppressant disease. I've never like to depend on the ACTH stim. test in equivocal cases, even when we could get Synacthen, and think LDDS test is more reliable plus an endogenous ACTH may be useful at the same time.

I would also be doing some more specific testing for liver disease.Not sure about the hyper-sexuality and adrenal tumour thing - maybe ultrasound the adrenals or test for testosterone?