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There are four phases to consider in the treatment of cutaneous autoimmune dermatoses: induction phase, transition phase, maintenance phase and determining cure (1). With the induction phase, the goal is to stop the inflammatory component as quickly as possible and suppress the immunologic response directed towards the skin. In this phase, higher doses of medications are normally necessary. If an acceptable response is not noted in a timely manner, another treatment regimen should be considered; i.e., alternative medications chosen or additional medications added to the current treatment regimen. In the transition phase, drugs are tapered to minimize side effects and adverse reactions. When drug combinations are utilized, those with the greatest side effects – such as glucocorticoids – are the first to be tapered. Medications are slowly reduced, often over several weeks or months, until an acceptable maintenance dose of medications is achieved, or until signs recur. If this happens, the medications are increased until remission is again achieved, then tapered down to the last dose that maintained the patient’s symptoms under acceptable control (the maintenance phase). A “cure” is considered for cases of immune-mediated dermatoses that have achieved remission and are successfully controlled with maintenance therapy but do not then recur after cessation. Cessation of maintenance therapy in a patient that has been well-controlled is a difficult decision to make, especially if the initial disease was severe. This decision should be one that is mutually agreed between the clinician and owner; it is essential that the client is well informed, with the realization that if the patient relapses, achieving remission a second time may be more difficult. When to discontinue maintenance therapy depends on the type of disease, whether or not a trigger was identified and removed, and the risk to the patient if therapy is discontinued. In many cases, maintenance therapy for 8-12 months is recommended before cessation. In animals where the risk of recurrence outweighs the benefit of discontinuing therapy, the drugs can be maintained life-long with appropriate lab work monitoring. Future vaccinations are often discouraged in cases of autoimmune dermatoses, even in those where vaccination is not a known trigger. Concern lies with the idea that vaccination may stimulate a broad, non-specific immune response, possibly initiating recrudescence of the autoimmune disease .The author prefers to discontinue rabies vaccination and monitor titer levels for distemper and parvovirus.
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