In Episode 6 we were delighted to be joined by one of the giants of global veterinary dermatology - Ralf Mueller (Dr. med. vet., MANZCVSc (Canine Medicine), Dip. ACVD, FANZCVSDc (Dermatology), Dip. ECVD). Ralf has published over 250 studies, articles, book chapters and books and given more than twelve hundred seminars, lectures and talks all over the world - plus at least one podcast now!
Introduction
(00:00) John introduces the podcast with co-hosts Sue and Paul; Sue introduces us to Ralf Mueller and his work in dermatology.
Chapter 1 - Why Immunotherapy?
(02:37) Sue welcomes Ralf and asks him to introduce himself. Ralf shares details of his wealth of experience in dermatology and allergy.
(03:23) Sue asks about Ralf's approach to allergies and Ralf shares that firstly he makes sure he is happy that the patient is allergic and without other skin issues. Following this he would ensure thorough ectoparasite control to prevent flea allergy confusing the matter, before ruling out food allergy with an elimination diet in order to ascertain an environmental; then he would discuss this management long term with the owners.
(04:53) Sue asks if this approach would change depending on the patient or if this is set in stone and Ralf says he would build it around the patient and the owners and what will work for that case - with Allergen Specific Immunotherapy (ASIT) being his number one preference for environmental allergies as well as liking monoclonal antibody therapy; but he also uses a variety of other medications depending on the lifestyle, symptom and needs of that patient and owners.
(05:50) Sue asks for Ralf to clarify what ASIT is; Ralf clarifies it as 'taking an allergen a patent is allergic to and injecting them with it to expose them to it until the immune system tolerates it'.
(06:45) John asks Ralf to walk through the advantages and disadvantages. He says the first big advantage is relatively low side effects - anaphylactic reaction being one, however he has only seen 5 cases of this in 30 years in dogs and 2 or 3 in cats, so it's very rare. He mentions there is occasionally increased pruritus initially from the therapy, but this can be managed by tweaking the therapy regime. The other big advantage is how specific the therapy is, with other medications being like a band aid and immunotherapy approaching the problem directly by normalising the immune system. The third big advantage is that (medium to long term) it is one of the cheaper therapies. He counters that the disadvantages are that is doesn’t always work for every patient - working well in one third of patients, working not so much in another third and not at all in the final third. It can also take time for the patient to improve and Ralf asks his owners to stick with the therapy for a year before deciding it hasn’t worked. But it is the best long term treatment option available for those patients it does work for.
Chapter 2 - How Immunotherapy?
(11:13) Sue then asks how you select the right allergens to put in the vaccine. Ralf shares his approach - which is firstly to use allergens specific to that dog which has been shown to be more effective than using random allergens. Then he also discusses the number of allergens which can be added to a vial. He listens to the history of the patient - whether it is seasonal and how much they go outside and where - before looking at an allergy test and the positive results on it, in order to to ascertain which allergens are most relevant. Ralf then lists some examples with specific patient lifestyles to demonstrate this process and build a vaccine with the 4 to 10 most relevant allergens, taking into account the prevalence of those allergens in the area the patient lives.
(15:52) Sue then asks if an unsuccessful experience from a vet with immunotherapy may be down to them having simply added all the allergens in a positive test to a vaccine. Ralf feels like this could be a contributing factor, but does say there isn’t much evidence yet on whether putting too many in reduces the effect, this is just his, more specific approach.
(17:00) John asks how Ralf goes about adapting the therapy, and if he uses other treatments alongside immunotherapy. Ralf says it again depends on the patient, and that when he says adapting the therapy he is referring to a flexible approach to the administration of the immunotherapy itself - so giving a smaller dose if they are reacting more, or increasing the frequency if the patient begins to regress before the next month's dose (two-thirds of his patients are not on a standard protocol). He then speaks into concurrent therapy, using a product alongside the immunotherapy, and this is something he will nearly always do to manage the itch to a comfortable level in order to allow the therapy to take the time needed to work.
(20:34) John then asks if this is only aimed at dogs, but Ralf shares his experiences of using it in cats, horses, sea lions, leopards and more, so it is definitely suitable for other species!
Chapter 3 - Rush Immunotherapy?
(21:36) Sue then asks about rush therapy - using a different process for tapering up the dose in order to help the response build more quickly. Ralf shares that he offers rush therapy as routine and 90% of his clients take this up. He mentions a study being released soon which compares rush therapy and normal therapy with no difference in success - so rush remains the standard for him due to its speed. Ralf then expands on rush to describe it as keeping the patients in hospital, with a premedication of antihistamine for safety, before using the same protocol in terms of dosage which comes with the therapy but dosing every half an hour or an hour rather than once a week or every other week. Temperature and heart rate etc. are monitored during the therapy, with very few reactions.
Ralf shares details of another study he completed which showed the biggest improvement in a rush case was 6 months (versus 9 months for the normal protocol), and he believes it to be even faster in his experience with other cases.
(25:54) John then asks if these adaptive methods of using immunotherapy are possible within normal first opinion practice. Ralf thinks this could be to a practitioner with an interest in dermatology and allergy then this could be possible with application and support - and also from utilising referral if they feel less comfortable.
(27:37) John then asks if Veterinary Nurses can help facilitate this and Ralf agrees, suggesting that actually they could be more crucial than the vet in order to maintain communication with the owners and a complete understanding of the nature of allergy; Ralf says he uses his nurses heavily in this process.
(28:46) Sue shares that she always starts urgent cases by apologising to owners that they likely won't be fixed quickly, but does feel that with immunotherapy they can dangle the carrot of a (close to) cure/remission long term and Ralf agrees, again sharing his feeling for the rule of thirds, with a third completely improving, a third partially improving and a third not improving, and his desire to wait at least a year before beginning to make a judgment on this.
Outro
(32:10) Having said farewell to Ralf, Sue, John and Paul reflect on a fascinating conversation before then going on to wrap end the podcast (as ever) with an interesting thought...
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