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Disease type and severity determines the approach. Most dogs with discoid lupus erythematosus, rabies vaccine-induced cutaneous vasculitis, pinnal margin vasculitis, and symmetric lupoid onychodystrophy will respond favorably to, and can be maintained on, immunomodulatory drugs. Other diseases such as pemphigus foliaceus, erythema multiforme, systemic lupus, and various other vasculitides will need immunosuppressive therapies. Immunomodulatory drugs may take time to effect an improvement (generally seen within 3-4 weeks of starting therapy) so if the clinical signs are severe, a tapering course of high dose glucocorticoids can be utilized initially to obtain rapid control, along with a chosen immunomodulatory drug. Once remission is achieved the immunomodulatory drug can be continued as maintenance. Note that both the glucocorticoids and the immunomodulatory drug should be given initially since the latter class of drug can take time to be effective: this will help prevent relapse of the disease once steroids are tapered. The primary benefit of immunomodulatory drugs is that they have less serious adverse side effects and decreased health impact. When immunosuppressive therapy is utilized, the most commonly used drug is a glucocorticoid. Initially, high doses are needed to achieve remission, and then tapered to the lowest possible dose that will maintain remission with minimal adverse systemic effects. In many autoimmune diseases, adjunctive therapies are necessary in order to permit the glucocorticoid dose to be lowered to a level which minimizes adverse side effects. In the more severe cases, it is not unusual to combine several different immunosuppressant drugs to achieve and maintain remission. As many of these medications can have adverse side effects on the liver and bone marrow, blood monitoring every 2-3 weeks for the first several months is recommended, with maintenance monitoring every 4-6 months. If significant changes in the blood parameters are noted, the offending drug should be discontinued and replaced with another medication. The most commonly utilized adjunctive medications include azathioprine, cyclosporine, mycophenolate mofetil, cyclophosphamide, and chlorambucil. In more severely affected dogs, supportive care for open wounds, fluid corrective therapy and monitoring of serum protein levels may be necessary. Use of human intravenous immunoglobulin (hIVIg) has shown promise in treating severe autoimmune dermatoses when other treatments are failing (6). Topical therapies can be useful with more localized lesions or for sporadic flare-ups. The most commonly used topicals include betamethasone or tacrolimus. Betamethasone has the benefit of rapidly controlling inflammation and disease symptoms but can induce dermal atrophy with chronic use; therefore, transition to tacrolimus is prudent if a topical is needed for long-term use.
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