Vet619 Small Animal Medicine Critically Appraised Topic PDF

**ABOUT THE SUBMISSION:** -------------------------------------------------------------------------------------------------------------------------------- ---------------------- *Title of CA...

**ABOUT THE SUBMISSION:** -------------------------------------------------------------------------------------------------------------------------------- ---------------------- *Title of CAT (maximum of 25 words):* In dogs with IMPA, immunosuppressive therapy superior to NSAIDs or corticosteroids in controlling the patient's immune system? *Author (student name):* Alfred Lee Shen Hann *Student number:* 33307304 --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- **CRITICALLY APPRAISED TOPIC - Overview:** --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- *(8) Clinical bottom line:* Category of research question: IMPA\ \ The number and type of study designs reviewed: Three papers were critically reviewed, all of which were retrospective study.\ \ Strength of evidence: Poor\ \ Outcomes reported: Treatment modalities for IMPA includes immunosuppressive drugs (leflunomide, cyclosporine, cyclophosphamide, azathioprine) and corticosteroids (prednisolone) shows significant variabilities in terms of efficacy, duration of treatments, and recurrence of clinical signs of the disease.\ \ Conclusion: At present, there is poor evidence that immunosuppressive therapy is superior to NSAIDs or corticosteroids in controlling the clinical signs of the disease. However, there is evidence that complete clinical remission when using immunosuppressive therapy. While some needed a combination therapy of immunosuppressive drugs and corticosteroids to control the clinical signs. The variability and lack of complete therapy regime shows that there is not one set of therapy regime that should be followed, and it is curated based on patients' signalment, duration of disease, and the financial capability of pet owners. *(1) Question (in PICO format -- see instructions):* In dogs with IMPA, immunosuppressive therapy superior to NSAIDs or corticosteroids in controlling the patient's immune system? *(1) Clinical scenario:* An 11 year old female spayed Staffordshire Bull Terrier Cross presented to a teaching veterinary hospital for a revisit for its IMPA previously diagnosed in January 2024. Patient had an episode of relapse whilst being managed with prednisolone at a immunosuppressive dose and tapered down. An additional immunosuppressive drug (cyclosporine) was added along with prednisolone to control the clinical signs. The addition of cyclosporine helped in controlling the clinical signs. The veterinary student wonders if immunosuppressive drugs were far more superior than corticosteroids in managing cases like this. *(7) The evidence (descriptive paragraph for evidence found overall):* The search identified 3 retrospective studies that were related to the PICO question. The experimental designs provide a poor strength of evidence as the patient follow-up was lacking, patients never complete the therapy regime. The studies were well planned and all studies were carried out in a realistic clinical setting. The limitation in all the studies was the small sample size, and the lack of patient follow-up. --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- +-----------------------------------------------------------------------+ | \(4) **Summary of the evidence - Quality:** | +=======================================================================+ | +--------------------------------+--------------------------------+ | | | 1. | | | | +================================+================================+ | | | **Population:** | **Clinical records and | | | | | radiographic reports from 3 | | | | | university referral | | | | | hospitals** | | | +--------------------------------+--------------------------------+ | | | **Sample size:** | **39 dogs** | | | +--------------------------------+--------------------------------+ | | | **Intervention details:** | **All samples were treated | | | | | concurrently at diagnosis of | | | | | the disease:\ | | | | | - Treated with prednisolone | | | | | alone\ | | | | | - Treated with prednisolone | | | | | and levamisole\ | | | | | - Treated with prednisolone | | | | | and azathioprine\ | | | | | - Treated with prednisolone | | | | | and cyclosporine\ | | | | | - Treated with prednisolone | | | | | and other therapies** | | | +--------------------------------+--------------------------------+ | | | **Study design:** | **Retrospective study** | | | +--------------------------------+--------------------------------+ | | | **Outcome studied:** | **- Complete cure was achieved | | | | | in 56% of dogs with | | | | | chemotherapeutic | | | | | immunosuppression\ | | | | | - Continuous medication was | | | | | required in 18% of dogs\ | | | | | - Relapses were treated | | | | | successfully in 13% of dogs\ | | | | | - 15% died of the disease or | | | | | euthanised** | | | +--------------------------------+--------------------------------+ | | | **Main findings (relevant to | **- Most dogs responded to | | | | PICO questions):** | immunosuppression with | | | | | prednisolone (81%), 31% of | | | | | these dogs subsequently had | | | | | relapsed or required | | | | | continuous anti-inflammatory | | | | | treatment or were euthanized | | | | | because of the disease.\ | | | | | - No significant differences | | | | | in mortality rate when using | | | | | multiple immunosuppressive | | | | | drug treatments compared with | | | | | single immunosuppressive | | | | | drugs.** | | | +--------------------------------+--------------------------------+ | | | **Limitations:** | **- Wide variety of treatment | | | | | regimes and no single | | | | | treatment regime was | | | | | completely successful\ | | | | | - Small sample size reduces | | | | | the reliability of results.** | | | +--------------------------------+--------------------------------+ | | | | +--------------------------------+--------------------------------+ | | | 2. | | | | +================================+================================+ | | | **Population:** | **Medical records diagnosed | | | | | with IMPA that were treated | | | | | with leflunomide.** | | | +--------------------------------+--------------------------------+ | | | **Sample size:** | **14 dogs with cytologically | | | | | confirmed IMPA** | | | +--------------------------------+--------------------------------+ | | | **Intervention details:** | **All samples were treat with | | | | | leflunomide at the time of | | | | | diagnosis:\ | | | | | - Administration of | | | | | leflunomide, duration of | | | | | clinical signs before | | | | | treatment, dosages, concurrent | | | | | medications, treatment | | | | | duration, and response to | | | | | treatment.** | | | +--------------------------------+--------------------------------+ | | | **Study design:** | **Retrospective case series** | | | +--------------------------------+--------------------------------+ | | | **Outcome studied:** | **- Of the 14 dogs treated | | | | | with leflunomide, 8 had | | | | | complete resolution of | | | | | clinical signs initially, 5 | | | | | had partial response, 1 had | | | | | minimal response.** | | | +--------------------------------+--------------------------------+ | | | **Main findings (relevant to | **- 2 dogs were treated with | | | | PICO questions):** | tapering immunosuppressive | | | | | doses of prednisolone before | | | | | initiation of leflunomide | | | | | administration. Initially | | | | | responded well to prednisolone | | | | | however, clinical signs | | | | | returned as the drug was | | | | | tapered.\ | | | | | - 7 dogs were given NSAID | | | | | prior to leflunomide and were | | | | | insufficient in alleviating | | | | | clinical signs.\ | | | | | - 1 dog did not respond to | | | | | treatment with leflunomide and | | | | | elected to switch to | | | | | prednisolone, it responded | | | | | well and had remission of | | | | | clinical signs.\ | | | | | - 5 dogs had partial response | | | | | to leflunomide, however | | | | | quality of life was not | | | | | considered normal. 2 out of | | | | | the 5 dogs discontinued | | | | | leflunomide, 1 started | | | | | cyclosporine and firocoxib and | | | | | was clinically better. The | | | | | other started prednisolone and | | | | | was in clinical remission.\ | | | | | - 8 out of 14 dogs had | | | | | adequate response to | | | | | leflunomide. 3 of those had | | | | | complete clinical remission | | | | | but were lost to follow up or | | | | | the dose had not been altered. | | | | | 1 of them had complete | | | | | remission and no further | | | | | recurrence of clinical signs. | | | | | The remaining 5 had complete | | | | | remission but clinical signs | | | | | recurred after tapering the | | | | | dose or discontinued, they are | | | | | still receiving leflunomide at | | | | | the lowest effective dose.** | | | +--------------------------------+--------------------------------+ | | | **Limitations:** | **- Lack of a consistent | | | | | treatment regime\ | | | | | - Small sample size reduces | | | | | the reliability of results.** | | | +--------------------------------+--------------------------------+ | | | | +--------------------------------+--------------------------------+ | | | 3. | | | | +================================+================================+ | | | **Population:** | **Medical record database of a | | | | | veterinary teaching hospital** | | | +--------------------------------+--------------------------------+ | | | **Sample size:** | **13 dogs with erosive IMPA | | | | | and 66 dogs with non erosive | | | | | IMPA** | | | +--------------------------------+--------------------------------+ | | | **Intervention details:** | **IMPA-affected dog | | | | | information extracted from the | | | | | medical record:\ | | | | | - Treatments administered\ | | | | | - Duration of treatments\ | | | | | - Response to treatment** | | | +--------------------------------+--------------------------------+ | | | **Study design:** | **Retrospective case series** | | | +--------------------------------+--------------------------------+ | | | **Outcome studied:** | **- 13 dogs with erosive IMPA | | | | | were administered | | | | | immunosuppressive therapy. 9 | | | | | dogs treated with leflunomide, | | | | | 3 with prednisolone and 1 with | | | | | prednisolone and azathioprine\ | | | | | - Among the 13 dogs with | | | | | erosive IMPA, 10 developed | | | | | unilateral or bilateral CCLR | | | | | before, at the time of, or | | | | | after the diagnosis of erosive | | | | | IMPA** | | | +--------------------------------+--------------------------------+ | | | **Main findings (relevant to | **- All dogs responded to the | | | | PICO questions):** | immunosuppressive therapy. | | | | | Clinical improvement was | | | | | confirmed for 10 dogs during | | | | | recheck at the hospital.** | | | +--------------------------------+--------------------------------+ | | | **Limitations:** | **- The time from initiation | | | | | of immunosuppressive therapy | | | | | to owner-perceived clinical | | | | | response was not recorded for | | | | | any of the dogs.\ | | | | | - Small sample size reduces | | | | | the reliability of the | | | | | results.** | | | +--------------------------------+--------------------------------+ | +-----------------------------------------------------------------------+ \(5) **Summary of the evidence - Application:** ------------------------------------------------- \(6) **Summary of the evidence -- Clinical Message:** ------------------------------------------------------- +-----------------------------------------------------------------------+ | **Summary of the evidence - Quantity:** | +=======================================================================+ | *You should use CAB Abstracts and then at least one other database of | | your choosing.* | | | | ------------------------------------------- ----------------------- | | ------------------------------------------------------------ | | **Databases searched and dates covered:** **PubMed NCBI (2000-202 | | 4)** | | **Search terms:** **(dogs or dog or canin | | e or canines) AND (IMPA) AND (immunosuppressive therapy)** | | **Dates searches performed:** **14/9/2024** | | ------------------------------------------- ----------------------- | | ------------------------------------------------------------ | | | | ---------------- -------------------------------------------------- | | --------------------------------------------------------------------- | | ------------------------------------------------------------- | | **Exclusion:** **- Papers not written in English\ | | - Papers with no author name, abstract or DOI numb | | er\ | | - Papers that uses immunosuppressive therapy for n | | on-immune mediated diseases\ | | - Review articles or conference proceedings** | | | | **Inclusion:** **Papers that look at IMPA and use immunosuppressi | | ve therapy. The paper must compare and contrast the efficacy of the d | | rug plus recurrence of the clinical signs of the disease.** | | ---------------- -------------------------------------------------- | | --------------------------------------------------------------------- | | ------------------------------------------------------------- | | | | \(3) **Search Outcome:** | | | | | | | | | | ---------------------------------------------------- -------------- | | --------- ---------------------------------------------- ------------ | | ------------------------------------------- ------------------------- | | -------------- ------------------------------------------------------ | | ---- --------------------------- | | **Database** **Number of st | | udies** **Excluded - Not relevant to PICO question** **Excluded - | | No author name, abstract or DOI number** **Excluded - Not written | | in English** **Excluded - Review articles or conference proceedings | | ** **Total relevant papers** | | **PubMed** **12** | | **9** **0** | | **0** | | **0** | | **3** | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | **Total relevant papers when duplicates removed:** **3** | | | | | | | | | +-----------------------------------------------------------------------+ +-----------------------------------------------------------------------+ | **REFERENCES:** | +=======================================================================+ | 1. *Please format your references correctly.* | | | | 2. *References should appear in the text in parentheses with the | | first author's surname followed by a comma or et al., and then | | the year (Whiting et al., 2006).* | | | | 3. *Use the Harvard referencing style and include the DOI:* **Last | | name, First initial. (Year published). Article title. *Journal*, | | Volume (issue), Page(s). DOI** | | | | 4. *List the names of up to three authors; where there are more than | | three authors, list the first three only, followed by et al.* | | | | 5. *Each reference should be numbered and on a separate line and | | listed in alphabetical order.* | +-----------------------------------------------------------------------+ | 1. 2. 3. | +-----------------------------------------------------------------------+