Apoquel not controlling otitis

RE: Apoquel not controlling otitis

Sarah Keir — Mon, 11 Sep 2017 19:36:53 GMT

[quote user="Pollyanna"]

clearly atopic on serology but if still having trouble controlling would double check.

[/quote]

Serology does not diagnose atopy - only guides choice of constituents for immunotherapy. Don't worry, it is a common trap propagated by those that sell these tests!

RE: Apoquel not controlling otitis

Anthony Todd — Mon, 11 Sep 2017 11:11:03 GMT

[quote user="Pollyanna"]Symptoms are consistent enough that we would be looking at long term low dose therapy rather than pulse/as needed.[/quote]

Why?

Long term low dose gives you the problems with the adrenal axis. [I know what I mean, I think]

You never know whether the low dose is unnecessary due to lack of challenge, ie it may be seasonal or other factors. [certain grassy walks, seasonal, granny's cat etc]

IMHO it doesn't give as effective control.

There's no chance of finding out what the allergen[s] is/are!

The owner gets to know when the itching is about to start so will use a preemptive dose.

You can adjust the preemptive dose to the minimum.

RE: Apoquel not controlling otitis

Pollyanna — Sun, 10 Sep 2017 19:05:30 GMT

Many thanks for all your suggestions.

- Paw chewing was always present alongside, although never the major symptom so topical only management is out.

- Allergic to mites, moulds, grasses, weeds and trees on serological panels (never expanded as not going down immunotherapy route) so allergy avoidance difficult. Dust mites, storage mites, ectoparasites all controlled.

- Food was changed onto Wafcol Salmon and Potato originally when initially improved, no change made there to explain the deterioration.

- Already on Yumega EFA supplement.

- Am happy with compliance.

- Having discussed it with the owner we are trialling Atopica (2 months) with pred as a third option if control not good enough. Symptoms are consistent enough that we would be looking at long term low dose therapy rather than pulse/as needed.

- Hadn't considered hypothyroidism or hyperadrenocorticism as clearly atopic on serology but if still having trouble controlling would double check.

Many thanks again for your help, if only to reassure myself that I hadn't missed anything glaringly obvious!

RE: Apoquel not controlling otitis

spenturn — Thu, 31 Aug 2017 11:51:24 GMT

Zoetis will shortly be launching Cytopoint in the UK which has been well received in the USA (https://www.zoetisus.com/products/dogs/cytopoint/)

Until it launches, you're stuck with Pred and/or Atopica.
You can read about them all here: http://vetmed.illinois.edu/steroids-vs-atopica-vs-apoquel-vs-cytopoint/

RE: Apoquel not controlling otitis

Emily Rainbow — Sat, 19 Aug 2017 00:01:20 GMT

[quote user="villagevet"]

my preferred options for recurrent pruritis/ otitis - not infection! hydrolysed food (RC anallergenic preferably); rule out hypothyridism (can present as otitis only); topical steriods (cortavance/recicort); EFAs; malacetic otic if prone to malassezia

[/quote]

also add hyperadrenocorticsm to the list!

RE: Apoquel not controlling otitis

Lindsey Edwards — Wed, 16 Aug 2017 18:12:41 GMT

RE: Apoquel not controlling otitis

Rob Davis — Wed, 16 Aug 2017 08:38:25 GMT

[quote user="Anthony Todd"]Expand please, I'll need convincing...[/quote]

Try this.

RE: Apoquel not controlling otitis

Anthony Todd — Tue, 15 Aug 2017 21:32:08 GMT

[quote user="Beats"]I am addicted to ear cytology and couldn't cope myself without it here.[/quote]

Expand please, I'll need convincing...

1,3,4,5 yep, agree to all of these....

RE: Apoquel not controlling otitis

Beats — Tue, 15 Aug 2017 19:09:04 GMT

[quote user="Pollyanna"]

Thoughts, comments, suggestions?

[/quote]

Some thoughts (please don't pay too much attention to them though as I'm not derm-geek!)

Rarely, contact sensitivities to, e.g. neomycin/framycetin occur that can be actually perpetuating otitis in presence of regular "management".
I am addicted to ear cytology and couldn't cope myself without it here.
Apoquel can be immunosuppressive and that can be an issue with chronic otitis and recurrent otic infections, perhaps more importantly, it is not hugely anti-inflammatory which is often desired / needed in otitis.
I'm assuming there's no ear mites, if unsure then a Bravecto or equivalent should zap any parasites and prevent fleas in an itchy dog (always a good idea)
When the rest of skin is NAD, with bilateral recurrent otitis without ongoing infections or otitis media or ear mites, then the solution is usually very simple... some steroids in the ear. This can be Maxidex, Cortavance, Recicort, Colvasone etc. etc. Once resolved (say after a week or two), then I'd personally recommend twice weekly to prevent further flare-ups and taper very gradually if wanted. Can either be neat or mixed with cleaner if regular cleaning required.

RE: Apoquel not controlling otitis

Anthony Dennison — Tue, 15 Aug 2017 17:55:23 GMT

[quote user="Martin Atkinson"]I have one patient with atopy which didn't respond well to Apoquell and is back on pred which does, so its not a panacea. [/quote]

Me too, has to have some preds to go along with it.

RE: Apoquel not controlling otitis

Anthony Todd — Tue, 15 Aug 2017 17:48:44 GMT

Turbo posting again in the hope that more will realise that this is a comparatively easy condition to control while the often futile search for the allergen continues in parallel.

Just give an adequate dose of pred at intervals only when the itchy or head shaking starts.

Definitely no need to give a course or taper the dose.

Sometimes you're lucky enough to deduce that it's only after a certain food or drink or when the dog is exposed to a certain grass pollen, for example.

Often it seems to be seasonal which gives you a clue or after the dog visits a cat etc.

Topical human steroids are available in very strong preps so Rx them and see which seems to suit

best.

IMHO, having never treated for it in my career, malazzesia disappears when there is no sebum to support it. It's just there for the food, and goodies, like my grandchildren.

Once the sebum dries up numbers fall to "commensal".

Just because you find a organism doesn't mean it's a pathogen!!

[don't just give one star, refute my post, with science, for once]

RE: Apoquel not controlling otitis

Martin Atkinson — Tue, 15 Aug 2017 16:09:58 GMT

I have one patient with atopy which didn't respond well to Apoquell and is back on pred which does, so its not a panacea.

Try an exclusion diet - you said diet was well managed does that mean this?

Try additional therapies like EFA supplements and regular washing with Malaseb/Adaxio or similar to minimise bacterial/malassezia load on the coat.

Consider steroid only ear drops e.g.Predsol, if you're sure there's not a lingering infection.

Despite what appears to be the case, re-visit client compliance - trick them into revealing how many tablets they have left from what they should have given.

[quote user="Will McMullan"]

AFAIK Apoquel masks itching rather than acting as an anti-inflammatory on the skin.

[/quote]Without looking up the science I'm pretty sure it does act locally on the inflammatory mechanisms.

RE: Apoquel not controlling otitis

Will McMullan — Tue, 15 Aug 2017 15:50:50 GMT

AFAIK Apoquel masks itching rather than acting as an anti-inflammatory on the skin. I think severely atopic animals probably will do better with steroids or ciclosporin than apoquel alone. Is this dog on a prescription hypoallergenic diet?

RE: Apoquel not controlling otitis

Rob Davis — Tue, 15 Aug 2017 15:48:22 GMT

Cortavance (for ears and feet)?