00:00

Hello, I'm Dr Jen, the vet. Dr Jason is on vacation, and this is chats with the Chatfields.

00:17

This episode is brought to you by full bucket veterinary strength supplements, the leader in digestive health for dogs, cats and horses. 

00:27

All right, welcome into the chat room. Everyone joining us today is a first timer on the show. It is my friend and colleague, Dr Brittany Lancellotti. Dr Lancellotti is a board certified veterinary dermatologist practicing veterinary skin and ear in very fabulous Los Angeles. But more importantly, she is the creator and host of a fabulous podcast called your vet. Wants you to know. So if you're not aware of her show yet, after we get done, I want you to head over to Spotify Apple, wherever you get your podcast on, and subscribe and give her a listen, because it's good stuff that your vet wants you to know. Okay, so welcome. Dr Lancellotti, into the chat room.

01:12

Thank you very much. Dr Jen, I am so excited to be here, wonderful, because we're going to talk today about something that I think very few people actually understand.

01:22

So we're going to talk about, obviously, dermatology, right?

01:27

Itchy pets, because I feel like they're sort of the bane of everyone's existence, especially certain times of the year.

01:35

But one of the like, coolest and most interesting new things in vet med is this new category of drugs, and now I shouldn't say new, right? Like, they've been around a little bit now, but, but they're called Jack inhibitors.

01:52

Like, what? Like? Just first of all, what do you think about Jak inhibitors?

01:59

Oh, that's a big question. So Jak inhibitors are in both veterinary medicine and human medicine, and the first Jak inhibitor in veterinary medicine is called apoquel, or ocasit nib, and that medication came out in 2013 so it's been around for a little over 10 years now. They actually just published a great article in Jasmine, kind of reviewing all of the data that's come out since the launch of that medication to kind of give us an overview of where it was when we started, and what we've learned in the last decade. And what's really exciting is there is a new Jak inhibitor called Zen relia, or a lunacitinib that has just been approved by the FDA. So in human medicine, there's a whole bunch of different Jak inhibitors that are used for a number of different health conditions. And now in veterinary medicine, we have at least two that we can put to use in our patients. Okay, so, and I feel like right now, every

03:00

pet parent with an itchy pet that's listening just heard a word that they're familiar with, right? Like they just heard epicoil, okay? Unless you've been living under a rock, you know, especially here in Florida, like we people talk about it all the time.

03:15

So when, when it, when it first came on the market, was really interesting, right? Because everyone said it actually what I legitimately had someone tell me when it first hit the market was, oh, it's not a drug.

03:31

I mean, like, of course it's a drug, right? And so I think there's a lot of things that go around about it, especially because, at least in general practice, and perhaps I'm about to out myself for not using it right. Like sometimes I'll use it for two weeks with a pet. Sometimes I'll just put them on it for ever. And so in what is the right thing to do with something like these Jak inhibitors? Is it? How are we supposed to use that?

04:04

Oh, gosh, that's a loaded question, and I could probably talk for an hour about how to use this in practice,

04:11

but it really depends on the patient, right? So we do have a number of different allergic triggers, and I think this is the thing to keep in mind when you're deciding when to use this drug and how to use these drugs, if you have an animal who has a flea allergy, got bit by some fleas because maybe the owner lapsed on some prevention, or they just got a really heavy flea burden, and they've got this major increase in itch. The nice thing about our Jak inhibitors is they work really quickly, and they're generally very effective for relieving itch, and so for that situation, that's a great time to use it for like, two weeks, right? Get that flare under control, get the pet back on their flea prevention, and then you're good to go. You don't necessarily need to use it ongoing, because the pets not going to have ongoing signs of allergies. Same thing with food allergies, which is another.

05:00

Trigger that we see very commonly in our companion animals. You can use that during the beginning of our elimination diet trial, which is so crucial in figuring out whether or not a pet does have a food allergy. And the these medications don't last very long in the body. So typically, what I tell owners is by the end of a really well performed eight week elimination diet trial. If your pet only has food allergies, we should be able to discontinue your anti itch medication and very quickly see whether or not that pets itch is going to come back. So if we're at like week seven of our diet trial, the dog's doing great. The owner stops the apoquel and they just cruise on the diet. I don't have to necessarily reach for apoquel again, unless, of course, they've got their father in law come over and slip the dog bacon, which is exactly what my father in law would do, right, and then use a couple days just to get that player under control, right? And there's bigger problems right with the bacon, because now the dog has a little gif set, right? Because if you're going to have it, you have it with pork, as we all know. Okay, so that's interesting. So I actually never, honest, honestly, have never considered using epic quell when I suspect a food allergy and a dog. So that's Pearl number one for me from today, which is why I love the podcast. So, so now we have a couple of instances that you've described where, where it's appropriate, right? That flea prevent, gap in flea prevention, and a dog that has flea allergy and they get some flea bites, we can use applicable to put the fire out. We can use it when we suspect a food allergy at the beginning, or through that that diet trial, etc. And so we're going to take a very quick break, folks, and we're going to be back because I really, I want to drill down like, what actually are Jak inhibitors? I mean, we're talking about it, and it sounds cool, but what are they doing? And why would someone have told me they weren't a drug? I don't know if we have answers to all those things, but we're going to answer some of those things on the other side of the break

07:02

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07:39

Okay, we're back in the chat room with board certified veterinary Dermatologist, Dr Lance a Lotti from veterinary skin and ear in LA, and we're talking about Jak inhibitors. Okay, so I know my dog is itchy, my vet doesn't want to use steroids, which is a whole other conversation, because I kind of want to ask you about the use of steroids in conjunction with these.

08:01

But first of all, for the uninitiated, can you share with us a little bit more about what? What is a Jak inhibitor? Like, kind of, how does it work? What's the mechanism here?

08:16

Sure, if we are going to do this, I want everybody to hop on my magic school bus so we can kind of take a dive inside the cells and figure out what's happening at a kind of a cellular level. So in we when we have a cell, we're talking about kind of the the cells that are in the skin and the areas where dogs get itchy, they have on the surface of the cell receptors. And those receptors can respond to a lot of different things, and many of the things they respond to are called cytokines. This is a way that a body sends signals through the bloodstream to other parts of the body. So when there is a lot of inflammation, there are a number of different cytokines that are released. And for those of you who are really into this, the cytokines that are going to be impacted or blocked by the medications that are in this class of Janus kinase inhibitors are il two, which stands for interleukin, interleukin 246, 13 and 31 really all pro inflammatory cytokines. They cause a lot of itch inflammation, and those lead to secondary infections. What these Janus kinase inhibitors do is they block those cytokines from binding to these Janus kinase receptors on the cell membrane. That stops those receptors from undergoing phosphorylation, which is a fancy word for a change that occurs when a cytokine binds and that phosphorylation typically causes some cellular changes inside the cell. So the nucleus of the cell is responsible for protein synthesis and or for genes that encode for protein synthesis and leading to all of these down.

10:00

Stream effects from these inflammatory and itch cytokines. So when we block those cytokines from binding onto the cells, it decreases the amount of other things that happen as a result of allergic inflammation. So it's a really helpful way of targeting those cytokines that are primarily involved in itch and inflammation and helping to decrease some of the adverse effects that we see with other drug classes, like steroids, which there are steroid receptors in every organ system in the body. And so we get lots and lots of side effects from that, whereas the side effects from our Janus kinase inhibitors are much, much less in comparison. Okay, so instead of the bazooka, or actually, it's not even really a bazooka, because it's not a big bang, but it's more broad, right? So instead of, I guess, like, there's the machine gun, yeah, of the steroid, this is a more sophisticated approach, and I do love that was like the best. I feel like we should have applause for that being the most succinct but very, very lovely explanation of the Janus kinase. That's where we get Jack from friends. In case you didn't know, we like acronyms, that's where they get jack from the Janus kinase receptor that we're trying to inhibit or block and and I also love the phosphor phosphorylation is fire, right? So we're inhibiting the fire. And you also provided me with an opportunity to mention influenza, because we can't go a single episode without mentioning influenza. So, uh, everyone who is a fan of the show knows that influence. One of the things that influenza can do is kick off that cytokine storm in the immune system of an immune naive system. And so cytokines, I'm sure that they serve a purpose, and I'm sure it's reasonable and necessary, but in the land of inflammation, we would like them to not be so good at it, right? And so that. So the jack inhibitor, I guess, is also

12:09

trying to tamp down that cytokine response for the for the inflammation, right for the itch,

12:16

yeah, absolutely. You think about these animals, this is an inappropriate inflammatory response, right? The body is overreacting to things that it should not overreact to. So we want the body to respond to infectious diseases that helps to clear that infection and make the keep the animal healthy. But if it's overreacting to things like dust mites or pollens like that's ridiculous, we need to slow down that inflammation, because it's unnecessary and it's going to lead to problems, rather than leading to keep keeping the body healthy. That's right. Don't you get ridiculous immune system, or will bring in the jack inhibitor, right?

12:55

Okay, so, so, like so many cartoons right now, dancing in my brain with the magic school bus and with with the inappropriate response, that's perfect. Okay, so so that that's that is really what they are and how they work. You did mention because I think a lot of times

13:13

pet owners who have dealt with a dog that has allergy issues, a lot of times they come into my exam room and they're saying, I don't want steroids, but my dog is on fire, right? But I don't want steroids, but my dog is on fire because I, because I've read that steroids are bad, and I myself appreciate a little, a little steroid,

13:35

um, especially if the dog is on fire. Uh, but is that okay? So if they're veterinarians talking to them and says, you know, we have, we got to do something here, and they want to use a little steroid with that Jack inhibitor, is that? Is that appropriate from the land of the veterinary dermatologist, or are they just creating a mess?

13:57

Well, this is a loaded question, and I think because you know, every single allergic patient that we see has a different presentation or a different phenotype. Some of these animals are a lot more itchy than others, and would benefit from just some anti itch medication. Some of them are a lot more inflamed, and that's when I am going to consider reaching for steroids. There was a study published a few years ago looking at the concurrent use, which means looking at two medications being given together of a short course, like four days of prednisone, which is a commonly used steroid, combined with apoquel, to see if that four days of steroids would help with something that we see pretty commonly when we're using apoquel, and that's the rebound effect that may occur after animals have been taking apoquel For twice a day for two weeks and then decrease to once a day, because that's what the FDA label says that we should be doing with that drug. No more.

15:00

Than twice a day for 14 days, and then going down to that once a day dosing. And because there were a number of practitioners that were seeing, animals, did great on that twice a day, but as soon as we took them down to once a day, they started to get itchy and inflamed again. These researchers decided to look to see if maybe they could help with that rebound effect by just given like a smidge of steroids right at the beginning to really get that inflammation under control, and they did find a statistically significant improvement in the occurrence of that rebound effect. So I think that is something that you can consider doing. But one thing that I want to mention is apoquel is a really great anti itch medication, and it does have some anti inflammatory properties. But if your dog is really swollen, or if you have a patient that has a lot of edema, maybe those paws are getting really swollen. Their ear canals are swelling up and closing shut. The level of anti inflammatory action of our Janus kinase inhibitors is not going to be anywhere near the level of anti inflammatory action of steroids and another class of medication that I feel is very underutilized in veterinary dermatology, maybe not by dermatologist, but in general practice, for sure, is and that is modified cyclosporine, and there's a number of different drugs in that class. So atopica, cyclovance, SPOR immune, those medications take a little bit longer to start working, but they have great anti inflammatory action and are much safer on a long term basis than steroids. So if you're trying to find that balance between alright, this this animal is really inflamed, but it's also having these side effects from steroids, what else can I do? I may not be reaching for a Janus kinase inhibitor in those dogs. Okay, so, so that's something I hadn't considered. So, because I'll just tell you, like, my standard approach is to put the fire out, sometimes even just with a short acting injection of a steroid that day. Because if I see, you know, this dog has just been going like, chewing their fur off for, you know, two or three days, or what have you I get them on the flea prevention.

17:02

I usually give them a little pop with the like a Dex SP, that's short acting, and maybe start them on apoquel. But maybe it be, I would be the better served to put them on a four day or three day taper of prednisone at the same time as apoquel? Or do you think that there's, and I know there may not be data to support this,

17:26

but do you think there's any a big difference there? If the veterinarian does it like a short acting injection, like that one, like once friends, I'm not saying give the dog a shot, like every, every week or every like, no, stop, stop, stop. I'm just meaning that day when I see him, I got to put the fire out today, right? This dog's just, they're going to come back with a crazy infection, if I don't, you know, put the fire out. So if I do that, and then also topically, treat whatever is ulcerated and angry, and then send them home with epicuel, am I? Am I okay?

18:04

Yeah. I mean, you have my blessing to do that. Thank you. Think that's a very reasonable approach, especially if,

18:12

especially if you've got an animal who is really inflamed. But what's, I think, what's interesting, you brought up a couple things there, and one is the concept of the infections. So in animals with allergies, their allergies very much put them at risk for relapsing skin infections with bacteria and yeast. And what's really concerning to me as a dermatologist, who I hope I have many years of practice ahead of me, is the number of increasing reports of multi drug resistant bacterial infections that we're seeing, and so we really need to be concerned about our use of systemic antibiotics. These are oral or injectable antibiotics, and if we can better control the inflammation that these animals have on their skin, we're able to use fewer antibiotics and slow the progression of those multi drug resistant infections. Another thing that you mentioned it was, you know, really needing to put that fire out and get that animal comfortable. What I think is interesting about the new Janus kinase inhibitor, the Zen relia, is there was a head to head study that was performed in Europe, looking at allergic dogs using either apical or Zen relia, and they had a similar response for those first 14 days, because the apical is given twice a day, Zen relia is only given once a day. And then after 14 days, when the apical is tapered to once a day, and the Zen relia was continued at its once a day dosing. There was a statistically significant difference in the number of animals whose itch score was below two on a scale of one to 10. And this is a validated scoring system that we use for measuring itch in animals. It's called the pruritus visual analog scale, and.

20:00

The owners mark on that scale where the animals itch level is. And then we grade it on from zero to 10 using a ruler. But once the the 14 day initial course was was finished, those animals had had a difference. There were more animals that were normal with the once a daylia than the once a day apoqua. So I'm interested to see in terms of incorporating this into practice, if I get better anti inflammatory action from this medication compared to the other Janus kinase inhibitor, because they are slightly different. So it's interesting to to kind of see how that interacts with our patients when they have differences with how their allergies present as well, yeah, but, and, but, and that's the difference was seen in a specific group of dogs. You just said, like, who had scores of one to two. Is that right? So is that dogs that had milder pruritus or itching? Is that the dogs that saw kind of the most benefit in that study, or

21:01

so all of these dogs started with moderate to severe itch just that they were at least a pruritus visual analog scale or pvas of six or more, and there was no statistically significant difference between the two groups at the start of the study and during those first 14 days, when You look at the graph of the the data points in terms of what their itch score was, there was no difference whatsoever. I mean, the lines are basically on top of each other for these two groups of dogs in terms of watching that itch score dramatically decrease. So both of these medications are very helpful in relieving itch in allergic dogs, it was just interesting to see when the apoquel dogs went down to once a day their itch level, kind of it didn't continue to decrease the way that the dogs in the Zen relia Group continue to have their itch score decrease. Now that's not to say that the dogs in the apoquel group were were miserable. I mean, these were dogs that were around a two and a half to three and a half, so still pretty mild compared to where they started. But the Zen relia dogs were at all the time points after that, underneath that level of two or less. Okay, so, so and that, and that's also kind of a sophistic or nuanced difference that I think your veterinarian should heed and be aware of. But for heaven's sakes, just start on one of them, right? Like, and every dog is a little bit different, right? Like, every dog is a little bit different. And so I feel like when we get a class of drugs,

22:41

and the more drugs we get in that same class, like, if we said NSAIDs, for example, it's like, like in humans. For some people, Tylenol is more effective than Advil, right? And vice versa. So I think you just got to pick one and find the one that works for your dog, right, to have them be the most comfortable that they can be. So a little bit too, because, because we would all still be using steroids, we wouldn't even have been looking for something different if decades ago, vet med didn't recognize kind of the risks and the massive unwanted side effects of chronic steroid administration, right? So, and also, please, everyone understands steroids are really good at what they do at and they're really okay. They're really okay to use when it's okay to use them, right? Like, you know we're not, we're not, we're not slamming that. I think some veterinarians are afraid of steroids. Sometimes they're good to use for what they're good for, but recognizing that you can't use them long term without side effects. So I guess that's my long way to lead up to what are, if any, what kind of what are the risks to using these Jak inhibitors? Because I know when I put a dog on one of these for extended periods, because some dogs just have to be on them all the time. They just do. They're allergic to the world, and this is what works for them. This is what their owners want. So this is what we do.

24:05

And I usually do blood work monitoring for those but you know, what are the risks? I have not seen any adverse impact, thank goodness for any pets that I've put on them, but I still do the monitoring, right? So what are those risks?

24:21

Yeah, so this is something I talk about with my clients on a daily basis. And, you know, I've put 1000s of dogs on on apoquel and steroids, and have a lot of experience with kind of not only having that discussion about balancing risk versus benefit, but also seeing what are some of the uncommon side effects, because the you know, the more patients you treat with a medication, the more chance you have of seeing those really rare side effects to occur. When we're talking about Janus kinase inhibitors, the side effects are very uncommon. So in the studies of both Epicure.

25:00

And Zen, really, the reported incidence of vomiting and diarrhea is similar to the placebo, so anywhere from 10 to 13% of animals, and again, this may be unrelated to the drug. It could have been just that the animal happened to get into something during that during that clinical trial, and so that vomiting and diarrhea has to be reported, even though it may not be as a result of that particular medication. In my clinical practice, I talked to owners about doing blood work monitoring as well. I think that's really something that's, that's, that's helpful in balancing that risk and benefit when we're using any medication on a long term basis, and the things that I'm looking for on my blood work when I'm using a Janus kinase inhibitor is primarily what's happening with the white blood cell counts. So we talked about those interleukins, those cytokines, those are also sometimes involved in the production of white blood cells, which are important in the immune system. And so when we're using those medications, especially if they're being given on a long term basis, we want to make sure those white blood cell counts are staying within the normal range. If you're using very high doses of apoquel or Zen reliant I have seen animals come to my practice from primary care veterinarians who are having to use higher than label dosing because the animal is really uncomfortable, then you increase the risk of those side effects. And so it's really important to do that blood work monitoring, again, when you're using really high doses, we can see some opportunistic infections because of the way that that medication does modulate the immune system. And so when I talk about opportunistic infections, these are infections that usually only happen in dogs whose immune systems are compromised, so primarily puppies whose immune systems haven't developed yet. Janus kinase inhibitors are not labeled for the use in puppies. But what happens is their immune the adult dogs who are on these medications, their immune systems can be modulated so that they're kind of immature or aren't able to keep in check these infections that we we wouldn't expect adult, healthy dogs to get, and that's going to be things like Demodex mites. Demodex mites are on the skin of all dogs, but they're in super, super low numbers, so they never really cause a problem unless the immune system is compromised. So puppies and older dogs with immune mediated disease or immune suppressive disease like Cushing syndrome, those are the animals where we expect to get naturally occurring Demodex but if you're on medications to suppress the immune system, you can see those Demodex mites develop. One of the nice things is we have flea intake preventatives that actually cover for Demodex mites as well. So that's important. Another important reason to keep your animal on flea intake prevention if they're allergic and then viral papillomas is something that I see pretty commonly, but most often, when the medications are being used at higher than labeled dosing is when I'll see those viral papillomas occur. But overall, a very short list of side effects, compared to the animals who are on steroids, where we see immediately increased thirst and urination, increased hunger, increased panting. And long term we see liver problems, kidney problems, diabetes, heart disease, muscle weakness, calcinosis, cutest on the skin. I mean, the list just goes on and on and on. So in terms of safety and balancing risk and benefit, if your dog doesn't have a ton of inflammation, and it's really mainly itch with a little bit of redness, I'm going to be reaching for those Janus kinase inhibitors. Yeah, I think, and I think that's important. So, so basically it does. It's very that's a very common sense

28:46

kind of way to look at those side effects, right? So the side effect is immunosuppression, right? That that could become pathologic if they're on those higher than labeled doses, or if your dog is a unicorn and accidentally has it on the label dose, which it does happen, but, but it's really rare. Friends, it's not your dog. Don't worry. But, but I also if you're one, if you're sitting at home wondering like, Well, my dogs on that is my dog at higher than labels, your veterinarian should, should have talked to you about that. It's unlikely that your veterinarian is going to put your dog on higher than a labeled dose of something like that, unless the label dose has failed to provide resolution, and they're probably going to or they should talk with you about that, because it does have an increased risk. So you shouldn't have to wonder. You should already know, right? They should have talked with you about that. So, yeah, so don't, don't be, don't be given the side eye, right? Like you should know if you're if your vets doing that with your pet. So, yeah, okay, so I and I guess, I guess that's the other thing that clients will often ask me, and I think this is true about these.

30:00

Jak inhibitors that are on the market, if you remove the Jak inhibitor, are those side effects, temporary, the dog doesn't stay chronically immunosuppressed. I wouldn't think,

30:13

yeah, that's another great thing about this particular class of of anti inflammatory, anti itch medications is they have a very short half life. So the half life is the time that it takes for half of the drug to be metabolized in the body, and eventually it's going to be out of the system completely. So the half life is about four to five hours. So if you think about that, at an exponential rate of being metabolized, it's usually going to be out of the system by the next day. And so the one thing that I think is really helpful about these drugs is they do start working very quickly, but they're also out of the body very quickly. We talked earlier about how that helps in terms of diagnosing a food allergy versus an environmental allergy, really allows me to see very quickly whether or not we can control the animal's allergies on food alone, and if their itch comes back really quickly, I've got a very clear diagnosis of an environmental allergy. What's also really helpful is that when I know that an animal has an environmental allergy, I can use these drugs to keep them comfortable while I'm starting allergy immunotherapy to desensitize them to what they're allergic to in the environment. And I love immunotherapy. I could talk about that all day long, but when I see that that immunotherapy is starting to work, and it does take about six to 12 months to really start to show signs of of efficacy, then I can have the owner kind of play around with their symptomatic medications. Do they does the dog need to get the apoquel on a daily basis? Can we go down to every other day and then can we discontinue and they can see very quickly whether or not the dog's primary disease, the underlying disease process, is controlled on the immunotherapy, or if it's not quite there, they can very quickly restart that medication after seeing very quickly that the itch is coming back and the pets gonna get relief without having too much of a flare because of some skipped doses. Yeah, which, which I think is great. Any drug that that I can just withdraw from the system and have kind of the system go back to normal from before the drug is wonderful. We don't have that risk of anticipated long term impact, so that that makes me much more confident prescribing it, and it should hopefully make the pet parents much more confident in using it for their dog. So so here's the next question, and

32:33

like, I didn't prepare Dr Lancellotti For this, friends, but so I'm just gonna ask, because frequently I'll uh, talk in the same conversation with a pet owner with a dog that's itchy from either a seasonal or environmental, potentially allergens or, you know, something where, don't cringe, my friend dermatologist, but they're not like, we're not investigating something significant, anything like this dog is itchy, and so we're to do The Flea stuff. We're gonna whatever. I'll either want to consider apoquel or cytopoint,

33:07

right? And so how, like, obviously, apoquel is oral and cytopoint is injectable.

33:14

Like you know, up to once every 28 days,

33:18

is cytopoint an injectable Jack inhibitor. Is cytopoint operating with a different mechanism? How do those two compare? Because I know pet parents are also seeing those two things at the same time.

33:30

Yeah, that's a great question, and I hear

33:33

pretty frequently, cytopoint being described as injectable apoquel. And this is not the case. They are completely different classes of therapeutics. And when you talked about apoquel Not being a drug, cytopoint actually is not a drug. It is what's called a biologic. So this is a canine monoclonal antibody that binds to interleukin 31 one of those itch cytokines that I mentioned earlier, and stops il 31 from binding to the receptors on the cell. So the apoquel and the

34:09

Janus kind inhibitors as a whole are going to block that receptor that's on the cell surface, whereas cytopoint is is actually binding up the the signals before they can even reach the receptor, because cytopoint only binds to il 31 it's

34:30

its safety margin. Is very, very good. Il 31 has only been implicated in terms of what it does in the body as a messenger of itch, and so there's no really major side effects or risks that we need to be worried about with this particular therapy. It's safe to use in dogs of any age with any other medical condition, receiving any other medication, because it's not going to have an interaction on any of.

35:00

Those things, it is not safe to giving cats because it is a canine monoclonal antibody, and if it's given in cats, cats can have a severe anaphylactic reaction because it is not a cat monoclonal antibody. So cytopoint, in terms of safety, I think, is an excellent tool. It's also very convenient for owners, because they don't have to give anything at home. It's just an injection that's given in the vets office, and then it gives the animal 28 days of itch relief. Now that is the only thing that cytopoint is doing. It is relieving itch. It does nothing for inflammation, because il 31 is not a pro inflammatory cytokine. So this is something that I think is really important for both veterinarians and pet owners to understand. If the animal is really red or swollen, cytopoint is not what I'm going to be reaching for, because I'm not going to get the benefit out of that therapy that I would with some of my other anti inflammatory therapies, because apoquel has a broader mechanism of action, we do see that there are effects on inflammation. So if an animal is red in addition to being itchy, or they're swollen in addition to being itchy, that's when I'm going to reach for one of the Janus kinase inhibitors instead of reaching for cytopoint. Okay? And I feel like you probably the, I feel like the answer probably is yes for this. Have you had dogs come to your practice where the general practitioner has them on epicuel and cytopoint,

36:35

yes, on a very regular basis, and is that okay? This is the case, and

36:42

the the official, the official word from Zoetis is they should not be used together

36:49

friends, she went for the official word.

36:53

Yeah,

36:54

okay, you know, it's something to think about, like, why is this animal needing multiple anti itch therapies in order to be comfortable. Are we doing

37:04

can we be doing a better job at getting at the underlying trigger to what's going on with them? Are these the right therapies for this animal, or do they need something that's more anti inflammatory? I think that's probably one of the reasons why I see this multimodal therapy being used, or multiple medications at a time, is because the animals more inflamed than just what apical and cytopoint can relieve. And so for those animals, many times I'm I'm using steroids, steroids, steroids,

37:35

topic or or cyclance, in order to really get the inflammation better controlled. And also, I do find quite a bit that the animals that need multiple anti itch or anti inflammatory therapies are ones that have an underlying food allergy that has not been addressed. And this is really important. There's no blood test that's accurate in the diagnosis of food allergies. You really need to work with your veterinarian to use a prescription food, primarily hydrolyzed protein, sometimes use novel proteins, but a prescription diet with nothing else, no treats, no table scraps, no hiding the medication and other types of food, no rawhide, no dental chews, no greenies, Nothing else, except for that prescription food for eight weeks to really investigate food allergies. And you'd be surprised, even with the animals that have both food allergies and environmental allergies, how much further we can pull back on the medications they need to stay comfortable once we get that food component under control. Yeah, I mean, it is the Princess and the Pea like, that's how I like to tell clients. And no matter how many mattresses you put on top of the pea, like, your dog is still itching because they're eating the allergy, they're still exposed to it, right? Like, it just doesn't matter how how many things you wrap it in, it still annoys their skin and their system. And so I and I, but I also feel like so many veterinarians

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are afraid of steroids,

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especially they, you know, they'll say, Well, I don't want to refer it to a dermatologist, and I've had it on some steroids, right? Because then the dermatologist looks down on me and whatever. But you know, I think that has to be balanced with is that dog going to scratch his skin off and create a bigger problem for himself before he gets to the dermatologist? Like, how miserable is this dog itching? And I don't think the answer is just putting an E collar on them so they can't chew effectively, right? They're like, I think because then, then it's still itching, it's still on fire. I just can't reach it now, right? Like, so I think we we do ourselves a disservice as practitioners when we make kind of these blanket statements, like, I will never use steroids. Like, steroids are really good for some stuff, right? Like, they're very good at what they do.

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So,

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you know, I think it's just a more sophisticated understanding and approach to their use probably is what, what we want to strive for in this situation. So I feel like I'm campaigning for steroids. Dr Lancellotti, I'm not. I'm just, I feel like, no, there's so many drugs in the universe that no creature should be uncomfortable unless they just want to be right like and so that's one of the, one of the the things that's in in the toolbox that we can use. And so I, I, I talked to so many practitioners who were just afraid of of them, but and also clients. So pet owners listening out there. Don't tie one hand behind your veterinarians back by recoiling at the option of steroids. Just make sure. Just talk with your veterinarian so that they know that you're a little bit concerned and that you don't want to use them long term. No one should unless it's the only thing available, and that you know, we want to seek that, that better control of that itch response, right?

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Yeah, absolutely. I think, you know, the toolbox is really the important word here. There are lots of different therapies that we have in our allergy toolbox, and it the more you can, as a veterinarian, educate yourself on what each tool is used for. You're going to be better able to select that and help to minimize the risk with each individual patient. And so you know, going to continuing education, getting yourself informed about that, it will make you more comfortable. I don't mind seeing steroids prescribed when I get a referral from a primary care veterinarian? I actually just earlier this week, I had a case come to me because the dog had recurrent ear infections, and I was going through and I'm like, I wonder if they gave some steroids to help to decrease the inflammation. And sure enough, they did, and it was an appropriate course with an appropriate dose. And at the same time, she started an elimination diet trial. And I was so proud of that veterinarian, I actually texted her after the appointment. I was like, great job with this work up. Really well done. But you know, you mentioned referral to a dermatologist, there was a really interesting survey that was done by the American College of Veterinary dermatology in 2019 looking at referral habits of primary care veterinarians and clients in terms of going to see a dermatologist for the animal skin and ear disease. And there's a lot of work to be done in this space. We do have far fewer dermatologists in the country than we do have general practice veterinarians, but those dermatology tends to be one of the specialties where referral is very, very low compared to the number of cases that are being seen at general practices. I want pet owners to know that there are specialists out there who have gone through extensive training to really dive into this disease and the medications and all the different solutions that we have out there and that we love helping these patients. If you're looking for a veterinary dermatologist in your area, I've got a link on my website where you can go and find one, but that's a great thing to talk about with your primary care vet. Do you think my pet needs to go see a dermatologist and and get a little bit of help? They don't necessarily have to stay at the dermatologist for all of their skin and ear conditions, but even going and getting some advice for just a consultation can help your veterinarian kind of guide a more long term treatment plan for your pet. Yeah, and I so, I think for me, because there's, there's two things that can be incredibly frustrating for everyone in the pet care triangle, and in my, in my opinion. And one of those is behavioral issues, and the other one is Derm, right? DERM issues because I can see it on my dog all the time. I can see their behavior change to accommodate this DERM issue that they're having, whether it's itchy or something more

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severe. I can see it all the time, and so I usually will tell pet parents, like, if I see that, we could be headed down a long track here. I'll just start at the beginning by saying, Listen, you're gonna have to be patient. It didn't happen overnight. We're not gonna fix it overnight. And, oh, by the way, you are more than welcome. How can I help you? If you would like to start this off with a dermatologist. I'm gonna put the fire out today, right? But I think if i i see a constellation of things that look like something that might require a specialist. So I try to, I try to head those off at the pass. And I think that the more important.

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Formed pet owners are at the outset of these kind of battle. They're not battles, but there are battles. I think that the more compliant and the better outcome we're going to get for both them and their pet.

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You know, as long as we're transparent at the beginning, like I'm going to try this thing, right, this is what I have. But this looks complicated. And you know, we let, let me, let me bring a friend in onto the care team here, who's boarded. So I think that's a wonderful thing to say. We're going to put a link in the show notes as well, folks to Dr Lancellotti podcast, as well as what she just indicated, which is how to find a dermatologist in your area?

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Yeah, I think that's a really important point. One thing I noticed with my clients that come to see me is the ones that are the most frustrated are the ones that found out about me through a friend or through Google and didn't have their primary care vet, and tell them that there were dermatologists available. So for those of you who are veterinarians, who are listening, having that conversation right up front, like Dr Chatfield said, I mean, it makes a big difference in terms of having that client trust your recommendations. And this is a lifelong disease. It's not going anywhere the If an animal is allergic, they will always be allergic, even with immunotherapy working to reverse environmental triggers in the even with immunotherapy working to help and reverse the disease and how much that pet reacts to environmental triggers, there will still need to be some type of management in place. So if you're getting frustrated, especially if you've got a young dog with many allergy seasons ahead of them, seek out a dermatologist. They really want to help you. Yeah, and that really is, you know, kind of why our show exists, right? Is to help spread information to animal lovers everywhere. It just so happens that today we're spreading the love for itchy dogs,

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which is, which is wonderful. I know, like, that's, that's what you get up in the morning for, right? But, but I especially appreciate that because we, I think a lot of people in the last three years are first time pet owners, and if you can't know what you don't know, right? And so there's a lot of things that wait for it, your veterinarian wants you to know. And so I think understanding itch in your dog and the sources of it, what you can do about it, and what they can help you do about it is is going well armed and well informed and so so. Thank you so much. Dr Lancellotti, is there anything else that you just really wish that everyone knew about DERM or itchy pets or anything like that?

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So I have two things. One, if you have an itchy pet, there are a ton of episodes on basically everything you need to know about allergies, ear infections, skin infections, all the drugs we talked about. Each one of those things has different episodes of your vet wants you to know. So that's a really great resource for you, and you can use those episodes to have a conversation and a dialog with your family veterinarian or your veterinary dermatologist, ask them what they think, because they know your pet, and they know the individual risks for certain therapies and the benefit that your pet might want to get, but definitely have that conversation. The other thing for veterinarians who are listening, if you want to get more familiar with these medications and really have a better understanding of how to utilize them in practice. My brilliant and wonderful colleague, Dr Megan painter, who works up at Angel West in Boston, she put together a website called Live, learnvet.com and she's got a course. She got a number of different courses, but one of them is medication masters, and it goes through all of these different therapies when you might want to reach for them, for your allergic patients, and what the risk and benefit is for each one of them. She's also got a course on immunotherapy. She's got a course on cat allergies. Really great resource if you love skin but feel like you need a little bit more help in understanding how to improve your practice. Wonderful. I think that's great information to have. We will put a link to that in the show notes for this as well.

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And you know, like having the conversation with your vet is where it starts, which is why we always say here in the chat room, if you don't trust your vet, get a new one. So if it's not a conversation you're comfortable starting, etc, or it doesn't, doesn't go well, you're not confident when you leave. Try again or try a new one. There's a lot like you should trust your veterinarian. Okay, folks, that's the that's the bottom line. And talk with them about it. All right, I think that's all that I have. I want to thank you so very much. Dr Lancellotti for sticking with us here in the chat room.

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Them and coming on the show. And I hope everyone checks out. Your vet wants you to know it's a really great show with good information as well. And as for me, I'm Dr Jen, the vet, and we'll catch you all on the next episode.

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This episode is brought to you by full bucket veterinary strength supplements, the leader in digestive health for dogs, cats and horses, your pack. Ce code for this episode is CC, 220090,

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you.