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Discussion Starter #1
Newbie here with questions!

Can someone out there give me a crash course in Perianal Fistulas in German Shepherd Dogs? My 10-year old boy was just diagnosed with them and I want to help him "recover" as painlessly as possible ...

He's been on 100MG Cyclosporine for about 40 days now.
 

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Why didn't the vet add in ketoconazole? ketoconazole helps lower the dosage needed for cyclosporine because keto helps increase absorption of the cyclosporine thereby helping with adverse symptoms associated with cyclo alone at higher doses. Also helps with cost as cyclo costs significantly more than keto and the combined therapy is most optimal in terms of price/efficacy (current research)

Lifestyle and diet modifications:
http://www.germanshepherds.com/forum/health-issues/250393-perinal-anal-fistula-enzymes-probiotics-how-keep-dry-2.html#post3292145

How bad are they? How are his stools?
 

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Not sure why she didn't prescribe Keto ... maybe because this isn't something she's been experienced with (fistulas)? I can call and ask her.

Any suggestions on dosage?

No issues with the Cyclosporine thus far. Stools are regular and solid. Licking has reduced drastically since treatment started.

The fistulas first came to my attention when I returned home from work one day to a "crime scene" of blood smeared all over the floor. Even with this, Koa was nonchalant and otherwise unaffected. He used to lick at himself quite a lot, but I was a bad owner and didn't realize this wasn't normal ...

I'm just wondering if there are OTHER things I can be doing to help the healing and reduce any discomfort (although, he doesn't display any discomfort). I've seen so many different things here regarding diet change, applying topical treatments such as Desitin and such ... but my vet hasn't mentioned anything like this yet.
 

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Many vets just don't know how to deal with this disease. Perhaps you should shop around for one a little more informed about this disease as it requires long term management because it tends to be a chronic condition if it is true PF.

Cut the hair around the base of the tail, around the peri-anal area - shave if you can. Area has to breathe so the hair doesn't catch debris and increase chances of infection as the area is full of open wounds.

Wipe after each bowel movement. Spray with vetericyn or apply a thin layer of desitin - work some into the ulcers themselves. This will help keep local infection under control.

Since his stools seem ok, maybe you are fine on his current food, but I would consider switching to fish based grain free food as food allergies have been associated with PF. Pay attention to his treats and extras also.

Give your vet the following literature:
Cyclosporine-ketoconazole interaction. Long-... [Transplantation. 1993] - PubMed - NCBI
Cyclosporin and ketoconazole interaction for trea... [Aust Vet J. 2002] - PubMed - NCBI
Effect of ketoconazole on cyclosporine dose... [Vet Surg. 1998 Jan-Feb] - PubMed - NCBI
Cyclosporine
JAMA Network | JAMA | Cyclosporine-Ketoconazole Combination Offers Promise in Reducing Antirejection Therapy Costs
http://d-scholarship.pitt.edu/4413/1/31735062110691.pdf full article

Keto for some reason (mechanism not really worked out) helps reduce the liver clearance of cyclo so therefore the cyclo stays around in the bloodstream longer thereby allowing the meds to do their job and reducing the dose/cost to you.
 

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Discussion Starter #5
Koa and I thank you so much for this!

I'll be off to get a few things on my way home today, as well as drop this literature off with the vet!
 

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My dog is on 100mg of cyclo with 300mg of Keto 2x a day. He does not tolerate the meds well and does have quite a few side effects so I try to drop the dose to every other day if I can, but his PF are aggressive and recurrent.

Dosing info:
Cyclosporin and ketoconazole interaction for trea... [Aust Vet J. 2002] - PubMed - NCBI
http://www.ivis.org/proceedings/navc/2006/SAE/508.pdf?LA=1
[Sixteen dogs with clinical evidence of perianal fistulas were given ketoconazole (10 mg/kg once daily) and cyclosporin (1 mg/kg twice daily initially) for 16 weeks]

So you can reduce dosage and titrate as the fistulas recede and heal. Make sure to keep the dog on the loading dose for at least a month AFTER you see the outside ulcers and fistulas heal. The surface wounds in PF are just the tip of the iceberg - the real problem is the tunneling tracts that go deep into the soft tissue of the gut. The fistulas that present to the surface are just the last stage so you must be very careful to keep the loading dose until the fistulas are completely in remission. Then you can slowly start doing every other day, 3x/week, and so on depending on how the dog responds.
 

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Oh and some vets advocate that you do blood tests just to see how much of the cyclo is really present in the blood as different dogs can metabolize the meds different so some people advocate regular tests to see if the necessary level of cyclo is present in the body at a given time (rather than being cleared by the liver in which case you need to moderate your dose to make sure the proper dosage continues to be present in the body to do its job)

You might also want to run some liver enzyme tests to make sure he is tolerating the medicine well as the meds will be hard on the body.

You can put on a cone on him to reduce licking - helps the surface lesions heal faster.

Salmon oil, coconut oil, probiotics can help also.
 

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I highly recommend you go to this site perianal-fistulas which also has a list of vets that are savvy when dealing with fistula's per area.

Also join the email list, it's full of very knowledgeable people who can give alot of additional advice/suggestions/support.

The blood test to determine whether the levels of cyclo is high or low is called a trough test.
 
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