TRENDS IN YOUR INBOX: Allergies—The Personalized Medicine Approach
Tackle Atopic Dermatitis with a Personal Touch
Making It Personal
Personalized medicine (also known as lifelong care, client-centric care, precision medicine, and many other terms) seeks to customize veterinary care based on a pet’s susceptibility to disease and his likely response to our intervention. Our current approach is to wait for pets to become clinically problematic and then start managing the clinical signs (in this case, pruritus). Personalized medicine would encourage us to intervene sooner and to consider how prevention, early detection, and risk-management strategies might positively influence outcomes.
Regardless of your drug(s) of choice, simply treating the clinical signs of CAD is just putting a bandage on the problem. Canine atopic dermatitis is a lifelong condition. It may very well start out seasonal based on initial causative allergens, but many cases eventually become year-round. And, yes, since it typically spans a lifetime, you not only need a treatment strategy to manage the itchiness, you need to set realistic expectations for the pet owner, so you can remain an advocate rather than an adversary as you manage the condition year after year and invoice after invoice.
Let’s consider how we might personalize our approach to common maladies, such as atopic dermatitis. We know that CAD is common and that there are striking breed predispositions, so our intervention can often start quite early. Those breed predispositions are influenced by gene pools, so a good place to start, if practice management software allows, is to identify the most common breeds (and crosses) in your practice for which a diagnosis of atopic dermatitis has been made. An alternate approach is to search records for patients on long-term antipruritic therapy and crudely discern breed predisposition to CAD from that information. Don’t be surprised if just a dozen or so breeds are responsible for the vast majority of allergies seen in your hospital. Once you have identified the breeds most at risk in your practice, it becomes a simpler task to personalize an approach to the problem.
Many animals are prone to allergies, but it is sufficient to start with the breeds and their crosses that you have identified to be most at risk in your practice. While CAD has strong genetic tendencies, it is not purely a genetic condition. There are other variables that can contribute to the clinical expression of the disorder. While most pets with CAD start to develop clinical issues between six months and three years of age, you can actually determine animals at potential risk for allergies from birth from the breeds and their crosses that you have already identified.
Once we have identified the potential risk, the management of that risk should be our top priority. Why wait until allergies start to develop over the ensuing months and years when you can have important conversations with pet owners starting with puppy and kitten visits?
8, 12, 16: Make Those Early Weeks Count!
A good time to start such conversations is when pets are eight weeks of age, long before any problems are evident. At this time, you can alert the owners of at-risk breeds to be vigilant for evidence of early clinical signs, such as licking and chewing at the feet, face rubbing, rashes in the armpit and groin areas, and even redness of the inner aspects of the pinnae. The intention is not to scare owners but to set realistic expectations for a risk you have identified and confirmed in your own practice population. If your conversation was productive, it might also prompt the owner to ask what it would mean for their pet if she did develop allergies and what it might mean for them in terms of care and costs. You might think that you don’t want to have those discussions during a puppy visit, but in time, you will likely realize that it was time well spent and develop resources (client handouts, website pages, trained staff, etc.) to facilitate client education.
Pet owners tend to know some aspects of pet care, and they can often predict the costs of such things as feeding, grooming, and boarding, but the costs of veterinary care are often much harder to predict. If we lead pet owners to believe that their only veterinary expenses are likely to be periodic office visits, vaccinations, parasite control, and a one-time neutering surgery, we are actually doing them a disservice. Over the course of a lifetime, a pet could develop a chronic condition (such as atopic dermatitis, osteoarthritis, diabetes mellitus, etc.), need a referral to a specialist, or end up at an emergency clinic. While the costs of routine preventive care are relatively easy to predict, and for pet owners to afford, it doesn’t take much else to happen before pet owners start to worry about the out-of-pocket expenses associated with veterinary care. Much of this can be avoided by taking the time to have such conversations and discuss realistic expectations during puppy and kitten visits.
Why have such burdensome discussions during visits when pet owners are still bonding with their new pets? It’s simple. If pet owners can appreciate that every pet comes with some healthcare risks and that some of those risks can be associated with considerable expenditures, they may decide to mitigate those risks with a tool like pet health insurance, especially policies that will cover chronic care and hereditary diseases. By having these discussions during puppy and kitten visits, when pets are typically completely healthy, you can help ensure that pets have few if any pre-existing problems that would be excluded from insurance coverage. This is particularly important for conditions such as atopic dermatitis, where pets may start showing early evidence of allergies within a few months.
If pet health insurance is in place by 8 weeks of age, early detection testing can commence by 12 weeks of age. This might include performing genetic screening panels, which can yield DNA results for dozens of different conditions on a single sample (blood or cheek swab). At this point in time, specific genetic markers for CAD are not commercially available in panels, but there are variant-based tests for many dermatologic (ivermectin sensitivity, ichthyosis, nasal hyperkeratosis, etc.) and nondermatologic (von Willebrand disease, glaucoma, degenerative myelopathy, etc.) conditions. At some point, there will likely be marker-based DNA tests for risk of CAD in different breeds, and that will make an even stronger case than just breed predisposition to alert owners about potential future risks for their pets. In the meantime, there are a lot of other conditions for which early detection is possible by genetic screening, so it is worth building such an approach into your standards of care, typically starting around 12 weeks of age.
By 16 weeks of age, we can start looking for phenotypic evidence of allergies (e.g., skin scrapings and cytologies) as rashes develop rather than just reaching for corticosteroids or antibiotics, and make sure pet owners know what to be looking for at home.
Putting It All Together
Once we have done our best to identify pets in our practice who are at increased risk for canine atopic dermatitis, invited pet owners to consider how they will afford such care if their pet is affected, and alerted owners of early clinical signs to watch for so they can be vigilant and notify us as soon as any problems become evident, we are actually in a very good position when it comes to disease management.
At the very earliest onset of clinical signs (or even before then, with particularly keen pet owners), we can coach them on the critical nature of preserving skin barrier function, which can not only affect allergen penetration but also susceptibility to recurrent bacterial and yeast infections. It’s a perfect time for pet owners to condition their pets to accept and actually enjoy baths and other topical therapies. Very early in the course of management is also the best time to consider nutritional supplements rich in omega-3 fatty acids. These supplements often have a modest impact and typically take many weeks for eicosapentaenoic acid to be incorporated into skin cells.
At this point in time, we are managing the situation with a relationship-based strategy. The pet owner understands their financial commitment to the process as well as the lifelong nature of the condition and the different medical and immunotherapeutic options for long-term management, and they are embarking on a plan to control the condition early before chronic changes complicate the process. Just think about how much easier that makes the job of the veterinary team!
Canine atopic dermatitis is common and can be frustrating, but it is also predictable and amenable to early intervention. See how personalized medicine can make allergy management a much more positive experience for you, your clients, and the entire hospital team. At the same time as you are delivering a better level of medicine and customer service, you are also benefitting from a better business model for your practice and the profession.
Lowell Ackerman, DVM, DACVD, MBA, MPA, CVA, consults, writes, and lectures on a variety of topics in both medicine and management (lowellackerman.com).