C10007220 / invoice 10000

HISTORY
- Leptospirosis vaccine first dose on 12/12, booster on 01/12 so UTD 
- Noted sneezing, with clear nasal discharge and  vulva licking
- Occasional head shaking 
- Anal gland issues, last checked on 01/12
- Previously on Apoquel for skin issues, discontinued but worked well 
- Using Telfast 60 mg daily for allergies
- Malaseb shampoo recommended for skin care- do not have , did not purchase 
- History of nasal discharge, investigated at SASH with rhinos copy showing inflammatory disease, no neoplastic or foreign bodies found
- Previous use of Prednisolone/ doxy  for nasal issues
- DM sent email about 1-2 months ago with an ongoing plan , owner received but has not actioned 

EXAM
Anal glands: Full, expressed during visit, very hard to express and contents V thick 
Skin: Pruritic, can see that feet and vulva has chronic changes associated with licking  secondary infections likely from licking and chewing
Ears: no inflammation , limited discharge , smear just wax 

DIAGNOSIS
- Allergic dermatitis- ongoing 
- Nasal inflammatory disease- see full work up done at SASH 

PLAN
- Restart Apoquel, 0.25 tablets 16 mg  BID for 2 weeks, then SID for maintenance ongoing  reassess every 6 months required 
- Use Malaseb shampoo for affected areas, not whole body, to manage secondary infections- feet and bottom , went thru instructions on how to use 
- Continue Telfast 60 mg daily for allergies
- Recheck anal glands in 12 weeks earlier if concerned 
- Monitor response to sneezing with use of apoquel, could consider another doxy trial 

Hi Liz and Steve, 
In follow up to my previous email, the compounding chemist we use can make fexofenadine liquid to a maximum strength of 80mg/mL. I think Ruby is on 120mg daily so that would be 1.5ml which is a really nice, small dose. 
The cost for a 100ml bottle would be $145, for a 150mL bottle would be $155. 
We can order this in for if you wish, all compounding orders need to be prepaid. 
Kind regards, 
Donna McGrath

Hi Steve & Liz,
Glad to hear the Telfast is helping somewhat but I completely understand how stressful the daily “pill battle” can be.
I have contacted our compounding pharmacy to obtain pricing for a flavoured, concentrated, xylitol-free liquid formulation of fexofenadine (the active ingredient in Telfast). Many over-the-counter liquid antihistamines not only contain xylitol, which is unsafe for dogs, but they are very dilute — Ruby would require a large volume (around 20 mL of kids Telfast) to achieve an effective dose.
I will let you know as soon as I receive the quote.
Telfast tablets can be crushed and mixed into a small amount of food. However, they are quite bitter, which often leads to refusal. If you wish to try again, mixing the crushed tablet into a very small amount of something highly palatable (e.g. a teaspoon of wet food, sardines in springwater, or plain cooked chicken) and ensuring she eats that portion fully before offering the rest of the meal can sometimes help — but given your experience so far, this may continue to be challenging.

Most liquid antihistamines available in Australia are formulated for children and either contain xylitol or are too low in strength to be practical for Ruby.
As we discussed on the phone, antihistamines alone are often not sufficient to control chronic itch. Ruby’s ongoing licking of her paws and vulva suggests she is still uncomfortable.
For better long-term control, I strongly recommend a multimodal approach:
1. Medicated washes (Malaseb)

    Use at least twice weekly on affected areas
    Helps control secondary yeast and bacterial infections that worsen itch

2. Restart Apoquel

    ¼ tablet (4 mg) once daily
    Safe for long-term use
    Reduces itch and inflammation
    Can be used alongside antihistamines

As Apoquel is a prescription medication, Ruby would need a check-up at least every 6 months for us to continue prescribing it.
Please let me know if you would like me to organise the Apoquel and Malaseb for you, and I’ll be in touch soon regarding the compounded liquid option.
Kind regards,
Donna

Hi Steve & Liz,
Glad to hear the Telfast is helping somewhat but I completely understand how stressful the daily “pill battle” can be.
I have contacted our compounding pharmacy to obtain pricing for a flavoured, concentrated, xylitol-free liquid formulation of fexofenadine (the active ingredient in Telfast). Many over-the-counter liquid antihistamines not only contain xylitol, which is unsafe for dogs, but they are very dilute — Ruby would require a large volume (around 20 mL of kids Telfast) to achieve an effective dose.

I will let you know as soon as I receive the quote.
Telfast tablets can be crushed and mixed into a small amount of food. However, they are quite bitter, which often leads to refusal. If you wish to try again, mixing the crushed tablet into a very small amount of something highly palatable (e.g. a teaspoon of wet food, sardines in springwater, or plain cooked chicken) and ensuring she eats that portion fully before offering the rest of the meal can sometimes help — but given your experience so far, this may continue to be challenging.

Most liquid antihistamines available in Australia are formulated for children and either contain xylitol or are too low in strength to be practical for Ruby.
As we discussed on the phone, antihistamines alone are often not sufficient to control chronic itch. Ruby’s ongoing licking of her paws and vulva suggests she is still uncomfortable.
For better long-term control, I strongly recommend a multimodal approach:
1. Medicated washes (Malaseb)
Use at least twice weekly on affected areas
Helps control secondary yeast and bacterial infections that worsen itch
2. Restart Apoquel
¼ tablet (4 mg) once daily
Safe for long-term use
Reduces itch and inflammation
Can be used alongside antihistamines
As Apoquel is a prescription medication, Ruby would need a check-up at least every 6 months for us to continue prescribing it.
________________________________________
Please let me know if you would like me to organise the Apoquel and Malaseb for you, and I’ll be in touch soon regarding the compounded liquid option.
Kind regards,

Donna