2016 Merck Advanced Medicine Symposium - Audience Q&A from NAVC

2016 Merck Advanced Medicine Symposium - Audience Q&A from NAVC

The following are the speaker responses to questions from the audience during the Symposium sponsored by Merck Animal Health held Monday, January 18, 2016 at NAVC in Orlando, FL.

The opinions expressed in these answers are those of the speakers and do not necessarily reflect the official label recommendations and point of view of the company or companies that manufacture and/or market any of the pharmaceutical agents, products, or services mentioned.

Dry Eye in Dogs: Let’s Give Them Something to Cry About

Shelby Reinstein, DVM, MS, DACVO

  1. Are there any alternatives in human eye drops such as Restasis® or others that could be used in dogs?
    Dr. Reinstein: Restasis is 0.05% cyclosporine and is generally way too low powered for dog with keratoconjunctivitis sicca (KCS). 
  2. With marked unilateral KCS and absence of nasal/dermatologic lesions, do you still consider this neurogenic KCS as a primary differential?
    Dr. Reinstein: Yes, depending upon where the nerve interruption is, you may only have ocular signs (if distal to the branching off of the caudal nasal nerve).
  3. Do you recommend the product Remend® for corneal ulcers?
    Dr. Reinstein: Products with hyaluronic acid such as Remend are used in my hands to improve corneal clarity (reduce scar formation) AFTER ulceration is healed. If quantitative/qualitative/distributional tear issues are present, a lubricating gel will generally be beneficial with ulcer IN CONJUNCTION with topical antibiotics, etc.
  4. How are you treating early cases of KCS?
    Dr. Reinstein: With a tear stimulant and lubrication +/- Neo/Poly/Dex Ophthalmic (neomycin, polymyxin B sulfates, and dexamethasone).
  5. Should we avoid zonisamide in breeds predisposed to KCS?
    Dr. Reinstein: The drug reaction is not terribly common, and if the patient requires zonisamide to control their seizures then I would still use it. If they develop KCS, then the drug will need to be stopped.
  6. Why not tacrolimus initially?
    Dr. Reinstein: Just personal preference. If there is any corneal pigment present, I will use tacrolimus first.
  7. Is it OK to use the dog’s own serum for therapy?
    Dr. Reinstein: Yes.
  8. In chronic KCS, how often should Neo/Poly/Dex be used?
    Dr. Reinstein: It depends greatly upon the Schirmer tear test (STT), degree of vascularization and inflammation etc.  I don’t often use it more than TID, and will taper it down to the lowest effective dose.
  9. In an ulcerated KCS eye, do you wait until the ulcer heals prior to starting immunomodulators (tacrolimus or cyclosporine)?
    Dr. Reinstein: This really is case dependent. If the ulcer is infected, then NO. If superficial and the dog is really dry, then you’ll have to get the tears up to get the cornea happier to heal!  If they are an established KCS patient on tear stimulants and develop an ulcer, I may decrease the frequency and up the lube, or stop it temporarily – depends upon the ulcer, honestly!
  10. Does serum need to be from same species with serum therapy? Can I use horse serum on a dog?
    Dr. Reinstein: You may use serum from different species. 
  11. Recommendation for dogs that react to corn or castor oil in cyclosporine drops? 
    Dr. Reinstein: You can try other types of oils (coconut, peanut) or you can have it compounded into aqueous solution.
  12. For neurogenic KCS do you use tear substitutes in addition to pilocarpine?
    Dr. Reinstein: Yes, usually. It helps with surface inflammation.
  13. How do I treat meibomian gland dysfunction?
    Dr. Reinstein: This is a very long answer and beyond the scope of the talk. You can refer to treatment of “meibomianitis” in various textbooks. If a qualitative tear deficiency develops secondary to chronic meibomianitis, then I’d treat just like a traditional KCS.
  14. If you suspect lacrimal gland aplasia in a puppy, how do you treat? What if there is no response to tear stimulants (multiple kinds used ‒ cyclosporine and tacrolimus)? Would you still continue use of stimulants?
    Dr. Reinstein: Please refer to the original publication describing this condition: Herrera HD, Weichsler N, Gómez JR, de Jalón JA. Severe, unilateral, unresponsive keratoconjunctivitis sicca in 16 juvenile Yorkshire terriers.Vet Ophthalmol. 2007;10(5):285-8.
  15. What is the chance that a dog with an unrepaired cherry eye will end up with KCS?
    Dr. Reinstein: Higher than if the gland was replaced in a timely fashion. There is no way to predict anything more specific.
  16. Do you continue stimulants if dog is not producing tears after 2 months?
    Dr. Reinstein: I would not continue to use the same protocol – I’d either increase the strength, frequency, or try combination therapy.
  17. What dose of pilocarpine do you use in dogs under 20 pounds?
    Dr. Reinstein: The starting dose is 1 drop / 20 pounds of the 1% solution. I have a 0.5% solution compounded for dogs under 20 pounds.
  18. Would you use pilocarpine in a dog without pigmentary keratitis?
    Dr. Reinstein: I do not use pilocarpine for pigmentary keratitis – it is used for neurogenic KCS. I use tacrolimus to help reduce corneal pigmentation.
  19. Should autologous serum be refrigerated while being used?
    Dr. Reinstein: Yes, it is good for 7 days after it’s made.
  20. In a case of chronic KCS, where a stimulant alone is not enough, would it be acceptable to use Neo/Poly/Dex chronically along with the stimulant?
    Dr. Reinstein: Yes, and this is often the case for Bulldogs. I find the lowest effective dose (once daily, etc).
  21. Please repeat the numbers for indicating moderate and severe KCS.
    Dr. Reinstein: Moderate is usually <10, severe is < 5 mm/min.
  22. Can corneal pigmentation be reversed or stopped?
    Dr. Reinstein: Yes to both. Tacrolimus is the best drug for this. The response is highly variable and case dependent.
  23. Do you use Neo/Poly/Dex with an ulcer?
    Dr. Reinstein: NO. Topical steroids are contraindicated in the presence of an ulcer.
  24. Is there a difference topically in prednisone, dexamethasone, and hydrocortisone?
    Dr. Reinstein: Yes, decreasing potency in that order.   

Parvovirus Pediatric Critical Care: What’s New


  1. You said to dilute the 50% dextrose and push over 2 to 3 minutes. What dilution do you use? If it makes the fluids hypertonic, do you need a jugular line?
    Dr. Lee: Ideally it should be diluted 1:2 or 1:3 with saline and given intravenously (IV). When appropriately diluted, it should NOT need to be given through a jugular line.
  2. What about using plasma as a colloid with albumin less than 1?
    Dr. Lee: I personally do not – that’s what colloids are for! I use Hetastarch or Vetstarch in these situations instead. As mentioned, you have to give a huge amount (45 mL/kg of plasma) to increase your albumin by 1 g/dL, so I feel that synthetic colloids are a safer, more cost-effective option.
  3. Do you replace losses as boluses? Have you ever used Pedialyte to replace losses?
    Dr. Lee: I’m assuming you only mean intravenous – absolutely not do not use Pedialyte IV. I replace losses as IV boluses, not oral boluses. If a patient is clinically dehydrated, you can hydrate them with oral water; however, I make sure my patient is stable, not vomiting, not nauseated, has antiemetics on board, and has normal physiological parameters before feeding the gut (eg, blood pressure, TPR).
  4. For owners that are unable to afford aggressive treatment for parvo, do you always recommend euthanasia or are there any “at home” treatments that give the patient a fair chance for survival?
    Dr. Lee: This was extensively discussed during the lecture based on the newest study by Sullivan and Twedt out of Colorado State (CSU). In this study, they compared standard in-hospital treatment versus a modified outpatient treatment (using volume resuscitation followed by subcutaneous fluid therapy and supportive care). Both protocols can be successful, with a survival only slightly lower in outpatients (80% vs 90%). A modified outpatient protocol may be a good alternative for less severely affected cases or those with financial limitations.
  5. I had a patient adopted from a shelter with known parvo outbreaks. The dog presented with parvo signs 3 weeks after adoption. Did the dog contract parvo at the shelter?
    Dr. Lee: Unlikely, as the incubation period is typically 7 days. It sounds like the dog wasn’t adequately vaccinated or protected.
  6. What dose of colloids do you use for parvo pups and do you decrease the crystalloids when giving colloids?
    Dr. Lee: It depends on what type of synthetic colloid you are using. If Hetastarch, I use 1 mL/kg/hour; if Vetstarch, I double that dose. I personally do not decrease the crystalloids when giving colloids but rather monitor for clinical response and monitor for signs of overload (rare in puppies).
  7. What is the AZO part of the Big 4? Same as creatinine? Is there one test or device that give you the Big 4?
    Dr. Lee: AZO is BUN, which is different from creatinine. These are AZOsticks that you can purchase.
  8. Aren’t most breeders supposed to get a health certificate before shipping to show the patient is vaccinated and in good health?
    Dr. Lee: This depends on the quality of the breeder. When in doubt, always confirm and document ALL the vaccine dates given when a new puppy comes into your clinic. This should be recorded in the medical record and the patient’s vaccine schedule adjusted appropriately.
  9. There are studies that show parvo patients tend to do better when they are offered and fed food, even if it’s via a nasogastric tube. How do you feel about this?
    Dr. Lee: There is one prospective study that I am aware of on this (Mohr AJ et al. Effect of early enteral nutrition on intestinal permeability, intestinal protein loss, and outcome in dogs with severe parvoviral enteritis. J Vet Intern Med. 2003;17(6):791-8). In that study, early enteral nutrition didn’t change the outcome in those parvovirus dogs, but the dogs that were fed sooner did have more weight gain. I clinically will only use a NG tube if my patient is stable, warm, not vomiting, not nauseated, has antiemetics on board, and has normal physiological parameters (eg, blood pressure, TPR). Once that is accomplished, it’s fine to use at your medical discretion.
  10. Do you use ProcalAmine® as part of the crystalloid IV fluids protocol? If so, when would you consider using it?
    Dr. Lee: No, I do not, but you can. ProcalAmine is amino acid and part of peripheral parenteral nutrition (PPN). When in doubt, feed the GUT.
  11. I work at a shelter and we vaccinate ASAP. What are the percentages of false positives? Also, we will treat. What are your thoughts on Tamiflu® on positive but non-symptomatic littermates?
    Dr. Lee: I don’t know the percentage of false positives, but depending on what type of MLV you are using, it can potentially cause false-positive results. You should treat these cases in a shelter, as they can do well, provided you are using appropriate isolation, barrier protection, disinfection, etc. I do NOT recommend the use of Tamiflu as there is no evidence for it.
  12. There have been numerous studies evaluating different “antidotes” for parvovirus. Equine endotoxin antiserum, recombinant human granulocyte-stimulating factor (rhG-CSF), or antivirals (eg, Tamiflu) have not been shown to be effective in improving survival or outcome. In small studies, the use of feline interferon has been weakly associated with improved survival; however, this is not readily available in veterinary hospitals.Will PCR differentiate from vaccine strains?
    Dr. Lee: Yes, I believe so, but I would check with the company you are submitting samples to confirm.
  13. What’s your opinion on the CSU “outpatient” protocol for those cases in which the owners can’t afford daily hospitalized care?
    Dr. Lee: As mentioned in my talk, I’m a huge fan of saving these critically ill pediatric patients while working within the pet owner’s financial limitations! Save lives! J
  14. You stated that you do not use serum in parvo cases, but I want to clarify – will you use it when PT/PTT are elevated? Also, I was surprised by the statement in general. I will often use plasma in patients that are critical with total solids of 2. Why do you say it is not beneficial in those cases?
    Dr. Lee: One shouldn't use serum – it should be plasma. Serum wouldn’t work as all the clotting factors are “clotted” out. Fresh or fresh frozen plasma from recovered dogs has been previously suggested in the past to provide anti-parvoviral antibodies, but recent studies have not found a beneficial effect and have found that even recently recovered animals have minimal anti-CPV antibody concentrations. Moreover, such treatment may prime the dog for future transfusion reaction at a later point in its life. In my opinion, transfusions are not benign, and have pro-inflammatory cytokines that can result in acute lung injury, circulatory overload, etc.  Again, as the literature has not shown FFP to be beneficial for parvovirus, I’m not a fan. I’ve saved hundreds of parvovirus patients without it and just reach for a synthetic colloid instead. I would use it only if my patient was coagulopathic with a PT/PTT > 25% of the upper range.
  15. If a blood transfusion is needed, do you recommend using a previous parvo dog?
    Dr. Lee: No, a recent study published showed that there is NO benefit from passing on “protective antibodies” from previously affected dogs. In this study, fresh or fresh frozen plasma from recovered dogs was NOT found to be beneficial; also, even recently recovered animals have minimal anti-CPV antibody concentrations. Moreover, such treatment may prime the dog for future transfusion reaction at a later point in its life. In my opinion, transfusions are not benign, and have pro-inflammatory cytokines that can result in acute lung injury, circulatory overload, etc.
  16. Have you seen parvo affect the lungs or CNS?
    Dr. Lee: No, I haven’t seen a parvovirus case with CNS signs. For “lungs,” yes; rarely, parvovirus can cause myocardial injury and result in secondary congestive heart failure and pulmonary edema. This is very rare and is usually only observed in very young neonates (vs pediatric patients).
  17. What about a ceftiofur and enrofloxacin antibiotic combo, both given once daily?
    Dr. Lee: You can use whatever antibiotic therapy you think is warranted. If it’s a really sick, septic dog, then yes, broad spectrum is important. If it’s stable but dehydrated, I often will just reach for a gram-positive antibiotic. I ALWAYS warn owners about the rare risks of side effects of these antibiotics (eg, enrofloxacin, OCD lesions/cartilage defects, etc). When in doubt, use your antibiotics appropriately.
  18. Do you use anything for pain management in your parvo cases?
    Dr. Lee: I personally am not a huge fan of analgesics in these parvovirus patients. When you’re really dehydrated from being hung over, you don’t need an opioid – you need hydration. Patients feel much better once stabilized and hydrated, and have anti-nausea agents on board! I will occasionally use buprenorphine if they have abdominal pain, but don't like pure mu due to risks of ileus, aspiration, worsening nausea, etc.
  19. Is cefovecin (Convenia®) acceptable for antibiotic treatment with parvo or is absorption an issue with dehydration?
    Dr. Lee: I personally don’t use this in hospitalized patients, as I want to use parenteral (IV) antibiotics that have slightly more broad-spectrum effect in my sick parvo puppies! However, this can definitely be used on an outpatient basis in a stable patient, and was the antibiotic used in the Sullivan/Twedt CSU study.
  20. Do you worry about clostridial overgrowth? I give all parvo puppies kefir.
    Dr. Lee: Parvovirus puppies can definitely have altered GI bacterial flora. I’ll often use metronidazole, but not sure it’s always indicated. If you’re having success with probiotics or other safe options, I think that’s appropriate!
  21. What are your thoughts on colloids causing acute kidney injury (AKI) or renal tubular collapse?
    Dr. Lee: Great question (I answered this live at the lecture). It has been shown in human medicine that the use of colloids is associated with AKI; however, these are critically ill patients (who are predisposed to AKI anyway!). A recent retrospective study evaluated this (Hayes G et al. Retrospective cohort study on the incidence of acute kidney injury and death following hydroxyethyl starch (HES 10% 250/0.5/5:1) administration in dogs (2007–2010), JVECC. 2016;26(1):35-40.) in critically ill dogs, and so yes, there is some concern about colloids contributing to AKI. That said, I have never clinically seen this, and feel that it is still a safer option than using plasma transfusions. It would be great to see further prospective veterinary studies evaluating this.
  22. At what point would you transfuse a parvo patient with anemia?
    Dr. Lee: Please see question #15 for further information on this. In general, puppies have a lower normal PCV (25‒35%), and so I tolerate anemia more in puppies than I do in geriatric patients. Growing puppies often have an ability to regenerate RBC very quickly (provided they don’t have bone marrow suppression), and often will respond well to IV crystalloids. However, if there is profound anemia (eg, secondary to GI loss, etc), and if patients are showing signs of hemorrhagic shock that fail to response to crystalloids and colloids, one may need to transfuse. That said, clinically, this is pretty rare based on my experience.
  23. What was the dosing for Convenia in the study from CSU just overviewed for outpatients?
    Dr. Lee: 8 mg/kg SQ.
  24. Do you recommend NaCl over LRS?
    Dr. Lee: I generally prefer a buffered crystalloid; as 0.9% NaCl has no buffer and is considered an acidifying solution, I rarely reach for it. That said, it is clinician preference.
  25. Do you use metronidazole for antibiotic therapy? Do you dispense antibiotics to go home once the WBC count is normal and clinical signs have resolved?
    Dr. Lee: Parvovirus puppies can definitely have altered GI bacterial flora and can potentially have Clostridium overgrowth. While in the hospital, I will sometimes use metronidazole, but I’m not sure it’s always indicated or beneficial. I don’t have any hard and fast rules on sending patients home with metronidazole, so I base it on each patient.
  26. Do you routinely add KCl to maintenance crystalloid?
    Dr. Lee: Typically yes, as most IV balanced fluids are potassium deplete (eg, 4 mEq/L); I like to use 20 mEq/L.
  27. Any concern for intussusception with metoclopramide as part of treatment?
    Dr. Lee: I haven’t clinically seen this; however, these patients can sometimes be hypermotile from their intestinal disease, which can potentially increase their risk of intussusception. Likewise, some patients can have severe ileus (from analgesics, GI disease, etc) and do need some type of pro-kinetic. Use your discretion based on each patient.
  28. What is your recommendation for treating parvo in a shelter? How often do you retest after successful treatment?
    Dr. Lee: I like to treat parvovirus, and would hate to think that dogs are being euthanized due to this treatable disease (80‒90% survival). Obviously with the infectious nature, this is a big problem for shelters. That said, aggressive IV fluids and antiemetics have been very successful and I encourage shelters to work with fosters or organizations who can potentially treat these on an outpatient basis!

Insulin Therapy in Diabetic Dogs and Cats

Patty Lathan, VMD, MS, DACVIM

  1. I have a 12-year-old cat on Lantus® (glargine) with probable insulin resistance with possible acromegaly with elevated growth factors. Should I increase insulin or what further can I do?
    Dr. Lathan: Assuming that you’ve done a workup to rule out other causes of insulin resistance (UTI, pancreatitis, neoplasia, etc), treating acromegaly is a challenge. Unfortunately, if the owners are not willing to do radiation therapy, increasing the insulin dose is the only option. Some endocrinologists recommend a maximum dose of 15‒20 units/injection, as higher doses can cause hypoglycemia. (GH is secreted episodically, so when it’s low at a given point in time, hypoglycemia is more likely.) Home monitoring of BG is optimal in these cases, particularly when hypoglycemia is suspected. Measuring BG prior to giving each insulin dose would be ideal (see Niessen S. Feline acromegaly: An essential differential diagnosis for the difficult diabetic. J Feline Med Surg. 2010;12:15-23 for additional info).
  2. If you are not able to culture the urine, do you still start on antibiotics when first diagnosed with diabetes?
    Dr. Lathan: That’s a tough question. I might be more inclined to wait to put them on antibiotics when there’s an indication that the patient is insulin-resistant. However, since we’re dealing with less than ideal circumstances, I don’t have a strong recommendation.
  3. In general, what are your monitoring recommendations for the fractious cat whose owners are unable or unwilling to home monitor?
    Dr. Lathan: Monitoring the urine glucose is a crude way of monitoring, but it’s better than nothing. Some people recommend increasing the dose slowly until there’s no glucosuria, and then backing off the dose until there is glucosuria again (changing the dose no more than every week or two, obviously unless there’s suspicion of hypoglycemia). However, this method of monitoring will not catch hypoglycemia as readily as BG curves, so the owner needs to be strongly warned that life-threatening hypoglycemia may occur.
  4. What is the shelf life of an open bottle of Lantus?
    Dr. Lathan: Anecdotally, people have used it for up to 6 months as long as it doesn’t get cloudy or change colors. Make sure the owners know that it is going against the label recommendation, and the safest thing is to follow the label. That said, most patients won’t use an entire bottle in 1 month (or even two), and many cats have been treated successfully with bottles of glargine that have been used for several months.
  5. What are your monitoring recommendations for newly diagnosed dogs with diabetes mellitus?
    Dr. Lathan: I’d start with an exam, discussion of the clinical signs (including weight), and blood glucose curve every week or two. I try to get them between 100 and 250 mg/dL when regulated, but often settle for a wider range if the patient is clinically controlled.
  6. What insulins are available with the VetPen®?
    Dr. Lathan: Only Vetsulin®.
  7. When do you decide the pet is not well controlled? After how may glucose curves? If they are not controlled, what do you recommend? Change insulin or refer or rule out other issues?
    Dr. Lathan: Technically, insulin resistance is defined as the patient requiring >2U/kg per injection, but I start getting suspicious when the dose is over 1 U/kg. If the dose is over 1 U/kg (although I might allow a little higher for NPH), I would do a workup to rule out concurrent disease (CBC/Chem/UA/urine culture, +/- quantitative PLI, abdo/thoracic imaging, etc). If I can’t find anything and I reach around 1.5 U/kg, I’d probably change the insulin. Some cats and dogs simply do much better on one type of insulin versus another.
  8. What is the conversion formula for going from U40 to U100 insulin or syringes?
    Dr. Lathan: I absolutely do not recommend using U40 syringes for U100 insulins, or vice versa, as it gets very confusing and mistakes can be made easily (I’ve seen it). However, 1 unit of U40 insulin is 0.025 mL, whereas 1 unit of U100 insulin is 0.01 mL. So each unit on a U40 syringe is 2.5 times as much as a unit on a U100 syringe.
  9. Glargine is not FDA approved in cats.  Would you discuss off-label use with clients?
    Dr. Lathan: I mention it, but truthfully don’t have long conversations about it.

Update on Demodex

Wayne Rosenkrantz, DVM, DACVD

  1. Is Demodex cornei similar to Demodex gatoi?
    Dr. Rosenkrantz: In two studies, morphologically distinct mites, the long-bodied mite (D canis) and one with a short, blunted abdomen (D cornei) were determined both to be D canis based on molecular characterization. D gatoi in the cat is a different species than D cornei but shares similarities in the area of the epidermis that it targets which is the stratum corneum.
  2. I found Demodex injae on an ear cytology. The dog only had otitis in one ear. The other ear looked normal and no mites were found. The rest of dog/skin is normal. How would you treat?
    Dr. Rosenkrantz: You could consider one of the topical ivermectin drops or place the dog on either Bravecto® (fluralaner) or NexGard® (afoxolaner), both of which would likely work. This could have been a resident mite and have no clinical significance but could also indicate mites in other body locations that you just didn’t find.
  3. When you sample a lesion by plucking hair, do you need to collect hair from the periphery of the lesion like we do with scraping?
    Dr. Rosenkrantz: Yes, the technique on site sampling would be the same as you would do for a skin scraping. Sampling both the center and margins of lesions is recommended. Make sure you gently pluck the hairs to obtain the hair bulbs; the mites are often found proximal to the bulb areas.
  4. What do you do with refractory cases?
    Dr. Rosenkrantz: Refractory cases of demodicosis are now being treated with either Bravecto or NexGard. To date, I have not seen a case not respond to either one of these options.
  5. If treating with oral ivermectin, should monthly heartworm prevention be discontinued?
    Dr. Rosenkrantz: Yes, there’s no need to have a pet on monthly heartworm prevention when giving oral ivermectin. You can discontinue heartworm preventives until you have completed the ivermectin therapy.
  6. What is the soonest that you skin scrape after a dose of Bravecto?
    Dr. Rosenkrantz: One month; many dogs will be negative within one month. In one study population ~87% were mite negative at the one-month recheck exam.
  7. Do you ever find Demodex on dogs that are already on Bravecto?
    Dr. Rosenkrantz: No, I haven’t.
  8. Please give the dosage regimen for Bravecto.
    Dr. Rosenkrantz: The dosage regimen is the same as used for flea and tick control, once every 12 weeks.
  9. How do you prep a hair pluck on a microscope slide? 
    Dr. Rosenkrantz: Hair plucks for Demodex exam are typically taken with a mosquito forceps and the collected hair is placed on a glass slide with a small amount of mineral oil. It’s best to examine under 4-10x to scan slide with microscope condenser turned down for best contrast viewing.
  10. Have you used Bravecto on dogs younger than label claim?
    Dr. Rosenkrantz: It is labeled to be used at 6 months of age or older. I have used it in dogs less than 6 months of age but this use is off label. In a margin of safety study it was given to 8- to 9-week-old puppies at standard, 3x, and 5x recommended dosages. There were no clinically relevant treatment effects on exams, body weights, food consumption, clinical pathology, gross and histopathology and organ weights. Diarrhea was the most common side effect but occurred at the same incidence as the control group.
  11. What about growing puppies?
    Dr. Rosenkrantz: For larger breed dogs where weight gains are likely to increase during the first few months of therapy, NexGard is another option, as the dose can be adjusted on a monthly basis compared with using Bravecto for 12 weeks.
  12. Are the doses of Bravecto and NexGard used for Demodex the same as the label dose for fleas and ticks?
    Dr. Rosenkrantz: Yes, exactly the same dosing and intervals.
  13. Would you use Bravecto to treat for scabies?
    Dr. Rosenkrantz: Yes, I have successfully treated a case of scabies with both Bravecto and NexGard
  14. Is Bravecto effective on lice or Cheyletiella?
    Dr. Rosenkrantz: I cannot answer this question as I have no data or personal experience to confirm this statement regarding its use for lice or Cheyletiella. My suspicion would be yes but I do not have data to support this.
  15. For a dog that is on Bravecto for Demodex, what heartworm prevention would you recommend? What if the dog is reactive to ivermectin?
    Dr. Rosenkrantz: Any of the commercially available heartworm preventives—such as Heartgard®, Sentinel®, and Interceptor®—are fine to use with Bravecto. If a dog is reactive to ivermectin, use the milbemycin based products or you could also use topical selamectin (Revolution®) or moxidectin (Advantage Multi®).  


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