Atopic dermatitis often begins as a seasonal problem.  For many dogs, a relatively short course of prednisone or Temaril-P will get them through their allergy season for a year or two. But most of these patients will display signs over longer periods each year until it is a year-around problem.

When we find ourselves prescribing glucocorticoids for more than three months per year, it's time to have a talk with the owner about alternatives. The treatment options that have proven the most successful alternatives to glucocorticoids are cyclosporine (Atopica®) and subcutaneous immunotherapy (SIT). But which one should you recommend?

There are, of course, a number of factors for you and the pet owner to consider:

• efficacy, and the onset of activity
• expense, and the owner's acceptance of it
• ease of administration
• potential side effects
• owner experience and bias

One of the benefits of Atopica as compared to SIT is that you have a good idea of the efficacy within 4 weeks, in most cases. While some patients respond quickly to SIT, most require 3-6 months of therapy. It can take up to a full year to make an honest assessment of SIT efficacy due to seasonal variations confounding the observed response.

Atopica is beyond the budget of some pet owners, particularly for large-breed dogs. For both Atopica and SIT, the cost often decreases over time as dosing intervals are increased. Many patients can discontinue SIT after 3-4 years, with their signs remaining under control. While both treatments are more costly than prednisone, they may be comparable to Temaril-P. Over the long term, many owners find that improving their pet's quality of life and avoiding side effects of steroids justify the expense.

Some pet owners prefer giving a weekly injection (SIT) to giving a daily capsule (Atopica). Others faint at the sight of needles and have no interest in administering SIT themselves, but are willing to make the trip to see you weekly. The latest option is the daily administration of sublingual immunotherapy (we call our version RESPIT oromucosal spray).

Although Atopica has proven a safe treatment for the long-term management of atopic dermatitis, it is associated with vomiting and gastrointestinal upset in a significant percentage of patients. We find that starting dogs on Cerenia the day before Atopica prevents nausea and vomiting in most dogs. SIT is infrequently associated with side effects, but occasional dogs become more pruritic after injections or display other signs of allergy exacerbation. Imnunotherapy by the oromucosal route is associated with even fewer side effects, one of its main advantages.

Owner experiences and biases also influence which route they are willing to go. Medical professionals are often leery of Atopica, while pet owners that have not responded to SIT themselves are reluctant to try it on their pet.

At the end of the day, all we can do is recommend what we think is best for the pet, then talk through each of these factors with the pet owner. Immunotherapy is the only treatment that can change the course of atopic dermatitis, but pets usually need some shorter-term relief as well. For this reason, I often recommend both SIT and Atopica as the ideal approach, with the aim of reducing or stopping the Atopica after the immunotherapy has taken effect.

• Florida VMA Annual Conference (Tampa, FL, May 4-5) 
• GA-AL VMA Conference (Destin,FL, May 30 - June 2)
• PacVet Conference (San Francisco, CA, June 29-30) 
• AVMA Convention (San Diego, CA, August 4-6)  
• CVC (Kansas City, MO, August 25-27) 
• Southwest Veterinary Symposium (Dallas, TX, Sept. 21-23)