2016 HILL’S GLOBAL SYMPOSIUM PROCEEDINGS

Copyright (c) VeFoilo Licensed for use on publications wholly owned by NAVC.com 3D Issue version 7. Copyright (C) 2016 Trinity Innovations LTD. All rights reserved. This application is protected by copyright law and international treaties. Visit www.3dissue.com. Unauthorized use of this program or any portion of it, may result in severe civil and criminal penalties and will be prosecuted to the maximum extent possible under law.

00:00

Discussing Nutrition in Terms of Derm Defense 2016 HILL’S GLOBAL SYMPOSIUM PROCEEDINGS

APRIL 26TH-27TH | HOLLYWOOD, CALIFORNIA, USA Discussing Nutrition in Terms of Derm Defense 2016 HILL’S GLOBAL SYMPOSIUM PROCEEDINGS 2 Quotes & Quotables STATE OF THE ART LECTURE 4 A Physician’s View of One Health: Challenges and Opportunities Barbara Natterson-Horowitz, M.D. TREATING ATOPIC DERMATITIS 8 Clinical Presentations and Diagnosis of Canine Atopic Dermatitis: Listen, Look, List, Learn Douglas J. DeBoer, DVM, DACVD Christina Restrepo, DVM, DACVD 16 Pearls of Wisdom and Pitfalls in the Treatment of Atopy Darren Berger, DVM, DACVD Allison Kirby, DVM, DACVD 22 Nutritional Management of Dogs with Adverse Food Reaction Dana Hutchinson, DVM, DACVN INNOVATIVE SOLUTIONS FOR DERM PATIENTS 28 Disrupting Veterinary Medicine Leanne West with Jason Zutty 34 Innovation in Nutritional Management of Canine Atopic Dermatitis Jennifer M. MacLeay, DVM, PhD, Dip.ACVIM COMMUNICATIONS IN PRACTICE 42 Does Your Pet Owner Get It? Justine A. Lee, DVM, DACVECC, DABT 46 The M(illennial) Factor and G(eneration)s Lidiya Alaverdova, DVM 52 Diffusing the Angry Client Andrew Roark, MS, DVM CLICK ON ANY TITLE TO ACCESS ARTICLE

Clinical Presentation and Diagnosis of Canine Atopic Dermatitis: Listen, Look, List, Learn The evaluation of a pruritic dog requires a step-by-step thought- process and approach that should lead to a deﬁnitive diagnosis. Pearls of Wisdom and Pitfalls in the Treatment of Atopy The successful management of canine atopy centers around 1) client education, 2) disease directed therapy and 3) management of secondary infections or ﬂares. The M(illennial) Factor and G(eneration)s While a front desk staff member may or may not be the appropriate person at the clinic to address a particular client’s complaint or concern, all front desk staff members should have the ability to receive a complaint, begin the process of addressing this complaint, and improve the practice’s strategic position within a given encounter. 2| HILLS GLOBAL SYMPOSIUM 2016 DERM DEFENSE

Disrupting Veterinary Medicine Vetrax is a medical device and information platform designed to more quickly alert veterinarians and pet owners to potential health concerns as part of an ongoing monitoring program. Does Your Pet Owner Get It? The intricacies of workplace communication— what we say, how we say it and what our choices say about us—have become increasingly complex as each group brings a different set of experiences and expectations to the table. A Physician’s View of One Health: Challenges and Opportunities The convergence of the ﬁelds of human and animal medicine has the potential to generate novel scientiﬁc hypotheses, create effective new therapies and potentially transform how physicians, veterinarians and their patients understand health and disease. Nutritional Management of Dogs with Adverse Food Reaction So why is canine pruritus such a challenging clinical sign to treat? Many factors likely play a role, including, but not limited to, identiﬁcation of an accurate diagnosis,thoroughness and clarity in communication of the therapeutic plan, which an owner must take to fully control their dog’s clinical signs, and likely a need on our part to better exploit multimodal therapy when managing these patients. HILLS GLOBAL SYMPOSIUM 2016 DERM DEFENSE |3

STATE OF THE ART LECTURE Credit: Joanna Brooks A Physician’s View of One Health: Challenges and Opportunities Barbara Natterson-Horowitz, M.D One Health is one of the most important movements and emerging concepts in health today. The convergence of the ﬁelds of human and animal medicine has the potential to generate novel scientiﬁc hypotheses, create effective new therapies and potentially transform how physicians, veterinarians and their patients understand health and disease. Despite this potential, One Health has not yet gained signiﬁcant awareness or traction in human medical communities. From its inception, One Health, sometimes also called One Medicine, has been piloted primarily by leaders from the world of veterinary medicine. Although the speciﬁc term was coined perhaps 10 years ago, comparative medicine has been quietly evident on university campuses with veterinary and medical schools for decades longer. Although a few physicians have played major leadership roles in One Health, in the United States, despite over 10 years of the movement’s robust growth, many have still not heard of it. Furthermore, physicians with some awareness of One Health often believe it to be primarily and exclusively about zoonotic infections and global health. The much broader scope and potential of One Health as also including comparative physiology and medicine is not being communicated effectively. Consequently, the human medical community remains 4| HILLS GLOBAL SYMPOSIUM 2016 DERM DEFENSE

STATE OF THE ART LECTURE largely disengaged. This is problematic because without signiﬁcant engagement from physicians, nurses and other human health care professionals, the potential of One Health cannot be realized. To advance One Health it is imperative that we ﬁrst understand the roots of under-engagement of the human medical community. This, in turn, can guide the development of novel and engaging opportunities for physician which demonstrate the power relevance of One Health’s comparative, collaborative and cooperative approach. One of the most fundamental challenges to bringing individual physicians into One Health is to demonstrate that it is relevant to their daily practice of medicine. It is important to remember that the vast majority of physicians are not infectious disease specialists or public health offi cials. They are internists, pediatricians, obstetrician-gynecologists, cardiologists, dermatologists, and oncologists, among others. There are countless connections between the physiology and pathology of humans and animals in all of these ﬁelds. Yet, an informal survey of One Health conferences and journals over the past two years reveals content that is dominated by infectious disease, zoonoses, food safety, and environmentally- related concerns. 1,2 While these issues are tremendously important to human populations, the relative paucity of content from other HELPING PHYSICIANS RECOGNIZE THAT THE DISEASES THEY TREAT IN THEIR PATIENTS ARE OFTEN NOT UNIQUELY HUMAN AND THAT ANIMAL HEALTH EXPERTS HAVE IMPORTANT INSIGHTS TO SHARE WILL ADVANCE THE ONE HEALTH CONCEPT. comparative medical ﬁelds is a lost opportunity. Demonstrating the many intersections between animal and human health which are non- infectious is essential to counter physician under-engagement in One Health. How can the human medical community’s awareness and engagement in One Health be strengthened? I faced this question 10 years ago as I became increasingly aware and interested in One Health. At the time, I was a faculty cardiologist at the David Geffen School of Medicine at UCLA. I became fascinated by the intersection of human and veterinary medicine. Through my lecturing about One Health to groups of medical students and physicians, I found that while there was mild interest in the topic in general, interest surged when I focused the on comparative studies of the diseases they were dealing with in their human patients. I began tailoring my One Health lectures HILLS GLOBAL SYMPOSIUM 2016 DERM DEFENSE |5

STATE OF THE ART LECTURE Zoobiquity: A Species-Spanning Approach to Health Discussing shared clinical medical challenges in human and non-human animals will lead to: ■ Broader consideration of the epidemiology and evolution of disease including implications for shared environmental triggers and exposures; ■ Potential for new approaches to diagnose and treat diseases in people and non-human animals; ■ Exploration of new collaborations and novel hypotheses for investigation. to their areas of focus and interest. Indeed, when speaking with cardiology fellows, I would discuss hypertrophic cardiomyopathy in cats, mitral regurgitation in Cavalier King Charles spaniels, and ventricular tachycardia in boxers. 3–5 When speaking with psychiatry residents, the discussion would focus on compulsive disorders in Doberman pinchers, feather plucking in parrots and separation anxiety in young dogs. 6–8 I began targeting the content of my lectures to help these physicians-in-training recognize the deep connections between the two medical ﬁelds. This tailored, specialty-speciﬁc approach led to many requests by students for clinical and research opportunities in One Health. The increased interest that followed these lectures led to the creation of the Zoobiquity Conferences in 2011. 9 The conferences are designed to bring together physicians and veterinarians taking care of the similar diseases in different species. The past four U.S.-based conferences cases have included sessions about breast cancer, obsessive-compulsive disorder, heart failure, melanoma, self-injury, infertility and many others. The Zoobiquity Conferences are designed to feature the beneﬁts of the comparative method and to formulate models of interdisciplinary collaboration. For example, a veterinarian 6| HILLS GLOBAL SYMPOSIUM 2016 DERM DEFENSE presented a case of glioblastoma multiforme in a Rhodesian ridgeback; a physician also presented a case of glioblastoma in a high school principal. They shared with one another imaging, histology, treatment protocols and outcomes through an engaging discussion about similarities in people and non-human animals. The audiences at the conferences comprised of nearly equal distributions of professionals from clinical human and veterinary medicine. The conferences also include a medical ﬁeld trip in which attendees are led “on rounds” by leading academic and zoological veterinarians at local zoos and on veterinary school facilities. Developing programs and educational opportunities tailored for physicians is crucial to the development of One Health in the coming years. Helping physicians recognize that the diseases they treat in their patients are often not uniquely human and that animal health experts have important insights to share will advance the One Health concept. Programming which exposes practicing physicians to veterinarians taking care of the same disorders in their patients is one effective way to drive this point home. These conversations and debates provide a necessary boost to pull One Health from

STATE OF THE ART LECTURE the periphery of the human medicine to the central position where it belongs. There is so much opportunity, yet the gap between the two professions persists. Taking stock of where the barriers are and developing programming to remove them, will do much to promote One Health across the health professions. References 1. One Health Initiative. “Events”. Available online: http://www.onehealthinitiative.com/events.php (accessed on 28 January 2015). 2. One Health Initiative. “Publications”. Available online: http://www.onehealthinitiative.com/ publications.php (accessed on 28 January 2015). 3. Kittleson, M.D.; Meurs, K.M.; Munro, M.J.; Kittleson, J.A.; Liu, S.; Pion, P.D.; Towbin, J.A. Familial Hypertrophic Cardiomyopathy in Maine Coon Cats: An Animal Model of Human Disease. Circulation 1999, 99, 3172–3180. 4. Borgarelli, M.; Savarino, P.; Crosara, S.; Santilli, R.A.; Chiavegato, D.; Poggi, M.; Bellino, C.; La Rosa, G.; Zanatta, R.; Haggstrom, J.; Tarducci, A. Survival Characteristics and Prognostic Variables of Dogs with Mitral Regurgitation Attributable to Myxomatous Valve Disease. J. Vet. Intern. Med. 2008, 22, 120–128. 5. Basso, C.; Fox, P.R.; Meurs, K.M.; Towbin, J.A.; Spier, A.W.; Calabrese, F.; Maron, B.J.; Thiene, G. Arrhythmogenic Right Ventricular Cardiomyopathy Causing Sudden Cardiac Death in Boxer Dogs: A New Animal Model of Human Disease. Circulation 2004, 109, 1180–1185. 6. Dodman, N.H.; Karlsson, E.K.; Moon-Fanelli, A.; Galdzicka, M.; Perloski, M.; Shuster, L.; Lindblad- Toh, K.; Ginns, E.I. A canine chromosome 7 locus conﬁrms compulsive disorder susceptibility. Mol. Psychiatry 2010, 15, 8–10. 7. van Zeeland, Y.R.A.; Spruit, B.M.; Rodenburg, T.B.; Riedstra, B.; van Hierden, Y.M.; Buitenhuis, B.; Korte, S.M.; Lumeij, J.T. Feather damaging behaviour in parrots: A review with consideration of comparative aspects. Appl. Anim. Behav. Sci. 2009, 121, 75–95. 8. Flannigan, G.; Dodman, N.H. Risk factors and behaviors associated with separation anxiety in dogs. J. Am. Vet. Med. Assoc. 2001, 219, 460–466. 9. Zoobiquity. Conference Overview. Available online: http://zoobiquity.com/conference- research/conference/conference-overview/ (accessed on 28 January 2015). Editor’s Note: This article was originally published in Veterinary Sciences (ISSN 2306-7381), an international, scientiﬁc, open access journal on veterinary sciences published quarterly online by MDPI. To access the original article please visit http://www.mdpi.com/journal/vetsci. ABOUT THE AUTHOR Barbara Natterson-Horowitz, M.D., is a Professor of Medicine in the Division of Cardiology at the David Geffen School of Medicine at UCLA. In addition to patient care, she is actively involved with medical education and research. Dr. Natterson-Horowitz holds a professorship in the UCLA Department of Ecology and Evolutionary Biology and is Co-Director of the Evolutionary Medicine Program at UCLA. She serves as a cardiovascular consultant to the Los Angeles Zoo as a member of its Medical Advisory Board and is Chair of the Zoobiquity Conference, a national educational program that facilitates interdisciplinary discussions between physicians, veterinarians and others in the health professions. In 2012, Dr. Natterson-Horowitz co-authored the New York Times bestselling book, Zoobiquity: The Astonishing Connection Between Human and Animal Health. Zoobiquity was named Discover Magazine’s Best Book of 2012, The China Times Best Foreign Translation of 2013, and a Finalist in the American Association for the Advancement of Science Excellence in Science Books 2012. Her work has been featured in the New York Times, The Guardian, Wall Street Journal, Nature, Scientiﬁc American, and New Scientist, among others. Dr. Natterson-Horowitz completed her undergraduate studies at Harvard College and received a Master’s degree from Harvard University. She received her medical degree from the University of California, San Francisco. HILLS GLOBAL SYMPOSIUM 2016 DERM DEFENSE |7

TREATING ATOPIC DERMATITIS Clinical Presentation and Diagnosis of Canine Atopic Dermatitis: Listen, Look, List, Learn Douglas J. DeBoer, DVM, DACVD Christina Restrepo, DVM, DACVD The diagnosis of canine atopic dermatitis (AD) is based on meeting clinical criteria and ruling out other possible causes with similar clinical signs. A sub-group of the International Committee for Allergic Diseases in Animals (ICADA) was tasked with the development of a set of practical guidelines that can be used to assist practitioners in the diagnosis of canine AD. 1 The guidelines generated focus on three aspects of the diagnostic approach: 1 1. Ruling out of other skin conditions with clinical signs that can resemble, or overlap with canine AD. 2. Detailed interpretation of the historical and clinical features of the condition. A new tool to assist with interpretation of these ﬁndings is the application of clinical criteria known as “Favrot’s criteria”. 2 3. Assessment of skin reactivity by IntraDermal Testing (IDT) or detection of IgE by Allergen-Speciﬁc IgE Serology (ASIS) testing. Use of any one of these approaches in isolation can result in misdiagnosis, so it is important not to rely on any of them as a sole diagnostic principle. 1 The evaluation of a pruritic dog requires a step-by-step thought-process and approach that should lead to a deﬁnitive diagnosis. The 8| HILLS GLOBAL SYMPOSIUM 2016 DERM DEFENSE

TREATING ATOPIC DERMATITIS diﬀerential diagnoses and role of complicating factors (Table 1) need to be narrowed down using information derived from the history, the ﬁndings on physical examination, diagnostic tests (where necessary), and response to treatment. Basic sampling methods and diagnostic tests, which may be required to rule out most of the common diﬀerentials, are ﬂea combing, skin scraping, hair plucking and cytological examination of skin and ear samples. 1 A clinical diagnosis of canine AD, based on exclusion of other possible pruritic dermatoses and Favrot’s criteria, is required 1 . Because reactions to food components can present clinically as canine AD, or serve as a ﬂare factor in canine AD, dogs with cutaneous adverse food reaction (CAFR) may be indistinguishable clinically from canine AD. 3-5 Depending on the allergens involved, the pruritus may be seasonal (e.g., pollen) or non-seasonal (e.g., dust mites, food). 11 The presence of gastrointestinal signs, such as diarrhea, vomiting, tenesmus, soft stools, ﬂatulence, and increased number of bowel movements, is more typically seen with food-induced canine AD. 5,6 In any canine AD case that has year-round clinical signs, CAFR can only be ruled-out by eﬀective strict elimination diet trials, since accurate diagnostic commercial tests are not currently available. 1 Many laboratories oﬀer food 1. IMPORTANT DIFFERENTIAL DIAGNOSES FOR PRURITIC SKIN DISEASES IN DOGS 1 Ectoparasitic skin diseases: Fleas Scabies (Sarcoptes scabiei) Demodicosis Cheyletiellosis Pediculosis Otoacariasis (Otodectes cynotis) Trombiculiasis Nasal mites (Pneumonyssus caninum) Microbial skin infections: Staphylococcal pyoderma Malassezia dermatitis Allergic skin diseases: Flea allergy dermatitis Atopic dermatitis Food intolerance/allergy Insect bite hypersensitivity Contact dermatitis Neoplastic disease: Cutaneous lymphoma HILLS GLOBAL SYMPOSIUM 2016 DERM DEFENSE | 11

TREATING ATOPIC DERMATITIS 2. SEVERE FACIAL INFLAMMATION IN AN ATOPIC FRENCH BULLDOG. SELF- TRAUMA CAN SOMETIMES BE SO SEVERE AS TO LEAD TO CORNEAL DAMAGE OR EAR HEMATOMAS. FAVROT’S CRITERIA 2 Ectoparasitic skin diseases: 1. Age at onset < 3 years 2. Mostly indoor 3. “Alesional” pruritus at onset 4. Aﬀected front feet 5. Aﬀected ear pinnae 6. Non-aﬀected ear margins 7. Non-aﬀected dorso-lumbar area Use to evaluate the probability of the diagnosis of canine AD 5 criteria should be fulﬁlled Do not use alone for diagnosis of canine AD, and rule-out resembling diseases Reliability ■ 5 criteria: Sens. 77.2% Spec. 83% ■ 6 criteria: Sens. 42% Spec. 93.7% allergen-speciﬁc IgE panels despite the fact that several studies have suggested that intradermal (IDT) and Allergen-speciﬁc IgE Serology (ASIS) are not reliable in diagnosing CAFR [7-10]. Thus, IDT and ASIS should not be used to make a diagnosis of CAFR. 1 A new tool to assist with the interpretation of the clinical ﬁndings when confronted with a pruritic dog is application of clinical criteria known as “Favrot’s criteria” (Table 2). 2 Allergy testing Once a clinical diagnosis of canine AD has been made, several factors may play a role in deciding whether an allergy test and allergen- speciﬁc immunotherapy (ASIT) is indicated. Severe clinical signs, duration of clinical signs for more than 3 months per year, and insuﬃ cient management with symptomatic therapy, justify in most cases allergy testing. 1 These can be performed by IDT and ASIS. ASIS only measures circulating allergen- 10 | HILLS GLOBAL SYMPOSIUM 2016 DERM DEFENSE WHEN INFLAMMATION PERSISTS FOR A VERY LONG TIME, THE SKIN MAY BECOME LICHENIFIED AND HYPERPIGMENTED, AS SHOWN IN THIS ILLUSTRATION. A PATIENT WITH THIS APPEARANCE OFTEN ALSO HAS SECONDARY YEAST OVERGROWTH ON THE SKIN, WHICH SHOULD BE EVALUATED VIA SKIN CYTOLOGY.

TREATING ATOPIC DERMATITIS PINNAL DERMATITIS IN A DOG WITH ATOPIC OTITIS. NOTE THE ERYTHEMA, HYPERPIGMENTATION, AND SCALING THAT EXTENDS OVER MOST OF THE CONCAVE SURFACE OF THE PINNA, YET SPARES THE EAR MARGINS. CHRONIC INFLAMMATION AND SELF-TRAUMA OFTEN LEAD TO POST-INFLAMMATORY HYPERPIGMENTATION, AS SEEN ON THE VENTRAL ASPECT OF THIS WEST HIGHLAND WHITE TERRIER. PODODERMATITIS IN TWO ATOPIC DOGS. THE PEDAL PRURITUS AND INFLAMMATION CAN BE MILD AND RESULT ONLY IN SOME HAIRLOSS OR SALIVARY STAINING (LEFT), OR CAN BE SEVERE WITH INTERDIGITAL TRAUMA AND SECONDARY BACTERIAL AND YEAST OVERGROWTH (RIGHT). HILLS GLOBAL SYMPOSIUM 2016 DERM DEFENSE | 11

TREATING ATOPIC DERMATITIS ERYTHEMA AND ALOPECIA ON THE MUZZLE OF AN ATOPIC DOG WITH FACIAL PRURITUS. speciﬁc IgE, does not take into account other allergic pathways, and often shows positive reactions in non-allergic dogs. 12, 13 Both tests are not recommended as screening tests and should only be used to conﬁrm the clinical diagnosis of canine AD. The results of these tests are used to identify the oﬀending allergen(s) that may be avoided or treated with allergen speciﬁc immunotherapy (ASIT). 1 IDT is considered the preferred diagnostic method among dermatologists. References VENTRAL ERYTHEMA AND EXCORIATIONS FROM SCRATCHING AND BITING ON THE ABDOMEN OF AN ATOPIC GOLDEN RETRIEVER. THE FEET, FACE, AND VENTRUM ARE THE MOST COMMON AREAS OF PRURITUS IN ATOPIC DERMATITIS. 12 | HILLS GLOBAL SYMPOSIUM 2016 DERM DEFENSE 1. Hensel P, Santoro D, Favrot C, Hill P, Griﬃ n C. Canine atopic dermatitis: detailed guidelines for diagnosis and allergen identiﬁcation. BMC Veterinary Research 2015;11(196):1-13. 2. Favrot C, Steﬀan J, Seewald W, Picco F. A prospective study on the clinical features of chronic canine atopic dermatitis and its diagnosis. Vet Dermatol. 2010;21(1):23–31. 3. Olivry T, Deboer DJ, Prelaud P, Bensignor E. International Task Force on Canine AtopicDermatitis. Food for thought: pondering the relationship between canine atopic dermatitis and cutaneous adverse food reactions. Vet Dermatol. 2007;18(6):390–1. 4. Jackson HA, Murphy KM, Tater KC, Olivry T, Hummel JB, Itensen J, et al. The pattern of allergen hypersensitivity (dietary or environmental) of dogs with non-seasonal atopic dermatitis cannot be diﬀerentiated on the basis of historical or clinical information: a prospective evaluation 2003–04. Vet Dermatol. 2005;16:200. 5. Picco F, Zini E, Nett C, Naegeli C, Bigler B, Rufenacht S, et al. A prospective study on canine atopic dermatitis and food-induced allergic dermatitis in Switzerland. Vet Dermatol. 2008;19(3):150–5. 6. Favrot C, Steﬀan J, Seewald W, Picco F. A prospective study on the clinical features of chronic canine atopic dermatitis and its diagnosis. Vet Dermatol. 2010;21(1):23–31. 7. Hillier A, DeBoer DJ. The ACVD task force on canine atopic dermatitis (XVII):intradermal testing. Vet Immunol Immunopathol. 2001; 81(3-4):289–304. 8. Jeﬀers JG, Shanley KJ, Meyer EK. Diagnostic testing of dogs for food hypersensitivity. J Am Vet Med Assoc. 1991;198(2):245–50. 9. Mueller R, Tsohalis J. Evaluation of serum allergen-speciﬁc IgE for the diagnosis of food adverse reactions in dogs. Vet Dermatol. 1998;9(3):167–71. 10. Jackson HA, Jackson MW, Coblentz L,

TREATING ATOPIC DERMATITIS Recognizing and diagnosing canine atopic dermatitis is more straightforward when a logical framework is used. We listen to the client for a detailed history look at the pet for physical clues consult a list of known diagnostic criteria to help us Hammerberg B. Evaluation of the clinical and allergen speciﬁc serum immunoglobulin E responses to oral challenge with corn starch, corn, soy and a soy hydrolysate diet in dogs with spontaneous food allergy. Vet Dermatol. 2003;14(4):181–7. 11. Zur G, Ihrke PJ, White SD, Kass PH. Canine atopic dermatitis: a retrospective study of 266 cases examined at the University of California, Davis, 1992-1998. Part I. Clinical features and allergy testing results. Vet Dermatol. 2002;13(2):89–102. 12. Hensel P, Bauer CL, Austel M, Keys D. Serological and intradermal test reactivity patterns among six species of house dust and storage mites. Vet Dermatol. 2009;20:228. 13. Marsella R, Sousa CA, Gonzales AJ, Fadok VA. Current understanding of the pathophysiologic mechanisms of canine atopic dermatitis. J Am Vet Med Assoc. 2012;241(2):194–207. and then learn what we can about alternate possible diagnoses through using some quick in-offi ce diagnostic tests. SEVERE CLINICAL SIGNS, DURATION OF CLINICAL SIGNS FOR MORE THAN 3 MONTHS PER YEAR, AND INSUFFICIENT MANAGEMENT WITH SYMPTOMATIC THERAPY, JUSTIFY IN MOST CASES ALLERGY TESTING 1 . HILLS GLOBAL SYMPOSIUM 2016 DERM DEFENSE | 13

TREATING ATOPIC DERMATITIS ABOUT THE AUTHORS Douglas J. DeBoer, DVM, is a graduate of the School of Veterinary Medicine, University of California-Davis, and completed postgraduate training at Michigan State University and at UC Davis. In 1986, he joined the faculty of the School of Veterinary Medicine, University of Wisconsin-Madison, where he is currently Professor of Dermatology. His research and clinical interests center on the immunology of recurrent and chronic skin diseases, with a focus on canine allergic skin disease. He is a diplomate of the American College of Veterinary Dermatology and has served on the scientiﬁc editorial boards of the American Journal of Veterinary Research and Veterinary Dermatology, and is outgoing chair of the International Committee on Allergic Diseases of Animals. Christina Restrepo, DVM, DACVD, graduated in 2003 from the University Of Florida College Of Veterinary Medicine. After graduation, Dr. Restrepo completed a one year internship in small animal medicine and surgery at the renowned Animal Medical Center in New York City. She then practiced small animal medicine and surgery in Miami, Florida where she gained further experience in dermatologic conditions and utilized her ﬂuent Spanish language skills. This led to her acceptance of a dermatology residency position at the University of California at Davis, in 2005. During the residency program, Dr. Restrepo received the American College of Veterinary Dermatology Resident Research Award for her clinical research which she also presented in Germany and Italy. In 2009, Dr.Restrepo reached the culmination of extensive training and became a board certiﬁed Diplomate of the American College of Veterinary Dermatology. She has practiced dermatology in California, Florida, and Australia. Currently she practices at the Animal Specialty Hospital of Florida in Naples, near her hometown. Dr. Restrepo enjoys lecturing to national and international audiences regarding the ﬁeld of dermatology. 14 | HILLS GLOBAL SYMPOSIUM 2016 DERM DEFENSE

TREATING ATOPIC DERMATITIS HILLS GLOBAL SYMPOSIUM 2016 DERM DEFENSE | 15

TREATING ATOPIC DERMATITIS Pearls of Wisdom and Pitfalls in the Treatment of Atopy Allison Kirby, DVM, DACVD Darren Berger, DVM, DACVD The successful management of canine atopy centers around 1) client education, 2) disease directed therapy and 3) management of secondary infections or ﬂares. Client education is the key to long-term success or failure for an individual patient. Client education should include: a discussion about management vs. cure; quality of life for both owner and pet; empathy regarding owner frustration; ﬁnancial considerations; the potential for more than one allergic hypersensitivity to be present; and that no single, safe, cheap, give-it-and-forget-it therapy exists (individual therapy is KEY). The goal of therapy is to make the patient comfortable, which may mean completely eliminating itch, but this is not always the case. Therapeutic intervention consists of a multimodal approach using supportive therapies (antihistamines, fatty acid supplementation, and barrier restoration) combined with more disease speciﬁc options (steroids, cyclosporine, Interleukin-31 inhibitors and allergen speciﬁc immunotherapy). Supportive care provides a relatively safe and inexpensive option to manage canine atopy, but in the vast majority of patients is minimally effective. In addition, supportive care is not effective in the acute management 16 | HILLS GLOBAL SYMPOSIUM 2016 DERM DEFENSE

TREATING ATOPIC DERMATITIS of atopic ﬂares and should be considered more as a preventive measure. 1 Every dog should have the opportunity to fail supportive therapy on their ﬁrst allergy related examination, so that stronger therapies are not utilized for more mildly affected patients. However, where supportive care’s role really lies, is in the potential drug sparing effects it may offer. Several studies have highlighted that dogs on concurrent antihistamines or high dose fatty acids are able to use less of more potent medications (cyclosporine and/or steroids) and obtain the same clinical response. 2,3 Antihistamines commonly used include diphenhydramine, cetirizine, and fexofenadine, which are given once or twice daily. Fatty acid supplementation is achieved through supplementation of Omega-6 (vegetable and seed oils) and Omega-3 (marine ﬁsh oils) fatty acids. The exact ratio of Omega-6 to 3 needed is unknown and studies suggest that essential fatty acid enriched diets may be better than supplementation via oral capsules. This provides an ideal opportunity to make a diet recommendation to clients and incorporate the overall health of the patient. Topical therapy is a mainstay for the management of any atopic patient. Atopic patients may be bathed weekly to every other week. Bathing serves three purposes; 1) to remove trapped allergen from the hair coat, 2) to soothe and rehydrate the skin, and 3) to deliver topical medications and barrier replacements (Ceramides and phytosphingosine). In addition, there are a variety of mousses, pads and sprays available for those clients unable to bathe their pet frequently. Glucocorticoids remain a mainstay of therapy in veterinary dermatology, speciﬁcally in the management of allergic and pruritic dermatoses. Currently, steroids are one of two therapeutic options that will relieve pruritus quickly (<1 day) when used at appropriate dosages. 4 Unlike newer drugs Cyclosporine capsules USP (Atopica®, Novartis, USA), Oclacitinib maleate (Apoquel®, Zoetis, USA) with more targeted therapeutic effects, steroids have a generalized mechanism of action affecting THE GOAL OF THERAPY IS TO MAKE THE PATIENT COMFORTABLE, WHICH MAY MEAN COMPLETELY ELIMINATING ITCH, BUT THIS IS NOT ALWAYS THE CASE. HILLS GLOBAL SYMPOSIUM 2016 DERM DEFENSE | 19

TREATING ATOPIC DERMATITIS THERAPEUTIC INTERVENTION CONSISTS OF A MULTIMODAL APPROACH USING SUPPORTIVE THERAPIES COMBINED WITH MORE DISEASE SPECIFIC OPTIONS. a greater number of inﬂammatory pathways and as a result have a greater potential for adverse events. With regards to the management of atopy, the use of oral prednisone derivatives is preferred. The starting antipruritic/anti- inﬂammatory dosage for prednisone/ prednisolone and methylprednisolone is 0.5- 1mg/kg/day, which is then tapered over time based on the patient’s response to the lowest alternate day dose that controls the patient’s symptoms. 2 The key to responsible use of steroids is avoiding long-acting injectable formulations, educating the owner on the difference between “comfortable” and pruritus-free, and realizing that there is a large variability in individual tolerance. Glucocorticoids offer several advantages as they are readily available, inexpensive, and work relatively quickly. Their main drawbacks are they possess the greatest potential for encountering an adverse event and they have a societal stigma attached with them. Glucocorticoid therapy is an appropriate long-term option for patients with ﬁnancial constraints, in cases where other options have failed, short-seasonal duration, and in cases where the owners have been informed of all Topical Therapy: Bathing delivers topical medications and barrier replacements (Ceramides and phytosphingosine) soothes and rehydrate the skin 18 | HILLS GLOBAL SYMPOSIUM 2016 DERM DEFENSE removes trapped allergen from the hair coat

TREATING ATOPIC DERMATITIS their options and still elect it as their option of choice. When used as a management strategy, they should always be combined with supportive options as a method to decrease the overall steroid dose needed for therapeutic control. Cyclosporine is available as the FDA labeled product Cyclosporine capsules USP (Atopica®, Novartis, USA) approved for the control of canine atopic dermatitis in dogs. Cyclosporine is a potent calcineurin inhibitor that primarily affects T-lymphocyte populations via decreased production of IL-2 and IL-4. These interleukins have a vital role in the proliferation and survival of lymphocyte subpopulations and the production of IgE, both of which play a role in the pathogenesis of atopic dermatitis. 5 Cyclosporine should be administered at an initial starting dose of 5mg/kg orally once a day until clinical signs have abated and then tapered to the lowest alternate day regimen that controls clinical signs. 2 It is important to realize many patients will not be able to tolerate alternate day therapy and still be comfortable and infection free. It is preferred that patients be given cyclosporine on an empty stomach as food impacts the oral absorption of the drug and decreases the already poor bioavailability of the medication. With continued use of cyclosporine in veterinary medicine, a growing list of adverse events associated with the medication is now known. The most common and predictable of these adverse events is gastrointestinal disturbance occurring in up to 40% of cases during the initial period of administration. 5 Full effi cacy may not be observed for up to 6 weeks. During this time it is essential that all secondary ﬂare factors continue to be controlled as concurrent secondary infections may mask the beneﬁcial effects of the medication. Interleukin 31 inhibitors at this time include the FDA approved product Oclacitinib maleate (Apoquel®, Zoetis, USA) and the USDA conditionally licensed product Canine Atopic Dermatitis Immunotherapeutic (CADI). Oclacitinib maleate (Apoquel®, Zoetis, USA) is approved by the FDA for the control of pruritus associated with allergic dermatitis and control of atopic dermatitis in dogs at least 12 months of age. Oclacitinib maleate (Apoquel®, Zoetis, USA) is the ﬁrst selective Janus kinase (JAK) inhibitor developed for the dog. JAKs play a key role in cytokine signaling and the signal transduction of pro-inﬂammatory, pro-allergic, and pruritogenic cytokines. Although multiple JAKs exist, Oclacitinib maleate (Apoquel®, Zoetis, USA) preferentially inhibits JAK-1, which is involved with the signaling pathways for IL-2, 4, 6, 13, and 31. Oclacitinib maleate (Apoquel®, Zoetis, USA) has the greatest affi nity for inhibition of JAKs involved with IL-31 signaling, the cytokine recently demonstrated to play a central role in the development of pruritus. 6 Oclacitinib maleate (Apoquel®, Zoetis, USA) is administered twice-daily for the initial two weeks and then decreased to once-daily for long-term use. This medication has been shown to have a rapid onset of action, signiﬁcantly decreasing pruritus within the ﬁrst 24 hours of administration. 7 The USDA conditionally licensed product, CADI, is a caninized anti-IL-31 monoclonal antibody developed by Zoetis. Monoclonal antibody therapy works by one of two mechanisms; either binding a soluble molecule preventing it from interacting with a cell surface receptor or by targeting ALLERGEN SPECIFIC IMMUNOTHERAPY (ASIT) IS THE SAFEST THERAPY OPTION FOR ATOPY AS IT LACKS ADVERSE EFFECTS ASSOCIATED WITH CHRONIC USE. HILLS GLOBAL SYMPOSIUM 2016 DERM DEFENSE | 19

TREATING ATOPIC DERMATITIS Allergen speciﬁc immunotherapy is beneﬁcial in 60-70% of patients with improvement noted between 6-18 months after starting therapy. 9 the cell surface receptor directly. CADI works by “soaking up” circulating IL-31 produced by lymphocytes preventing it from activating cell receptors. It is administered as a subcutaneous injection given no more frequently than every 30 days. CADI therapy offers several advantages in that it is a very targeted therapy whose adverse event proﬁle appears to be very narrow at this time, it can be administered to any age of dog, and may be given with any concurrent medications. Initial ﬁeld studies evaluating the effi cacy and safety of CADI compared to placebo revealed treated dogs had a signiﬁcant reduction in owner assessed pruritus compared to placebo treated dogs, no dogs developed serious adverse reactions, no dogs developed immediate post-injection reactions, and the most commonly reported adverse events were vomiting, diarrhea, and lethargy. 8 Since both of these medications are very new in the veterinary ﬁeld, long-term side effects have not been established and owners must be prepared that we are still gathering information regarding these products. Allergen speciﬁc immunotherapy (ASIT) is the safest therapy option for atopy, as it lacks adverse effects associated with chronic use that accompany most other treatment options. ASIT is beneﬁcial in 60-70% of patients with improvement noted between 6-18 months after starting therapy. 9 If after this time no improvement is seen, therapy is usually stopped or switched to an alternate route of administration. In patients that respond, treatment is usually lifelong. Intradermal testing is the preferred method 20 | HILLS GLOBAL SYMPOSIUM 2016 DERM DEFENSE for identifying relevant allergens in atopic patients. In cases where intradermal testing is not an option, serum testing may be an acceptable alternative. Selection of allergens for ASIT is based on the potency of the positive allergen, the length of the allergen’s season, the amount of allergen produced, allergen buoyancy, allergen cross- reactivity, allergen prevalence and patient history. The presence of a positive reaction or the strength of the reaction should not be the sole determining factors for choosing a particular allergen. There are several methods for administering ASIT with subcutaneous injections or sublingual immunotherapy being the two most commonly chosen. Based on limited studies at this time, there does not appear to be a difference in the percentage of patients who respond to either method. However, a recent investigation revealed a percentage of patients that previously failed ASIT through injections did have a positive treatment response following a switch to the sublingual route. With injections, serious adverse reactions such as anaphylaxis, urticaria, and angioedema are extremely rare and most clients administer injections at home. These reactions appear even less of a concern with sublingual immunotherapy, which may be used in patients who have had severe reactions to injections. The primary adverse events with sublingual immunotherapy appear to be transient facial pruritus and mild GI upset. During the initial induction course of ASIT, symptomatic therapy will often be needed and concurrent use of

TREATING ATOPIC DERMATITIS glucocorticoids, cyclosporine, Oclacitinib maleate (Apoquel®, Zoetis, USA), or CADI is usually required. The goal of managing an atopic patient is not only to decrease overall pruritus but also prevent recurrent infections. It is important to note adequate assessment of drug effi cacy cannot be assessed while active infection is present. In addition, if a patient’s pruritus is controlled it does not mean their infection rate has decreased. References 1. Olivry T, DeBoer D, Favrot C, et al. Treatment of canine atopic dermatitis: 2010 clinical practice guidelines from the International Task Force on Canine Atopic Dermatitis. Vet Dermatol 2010; 21: 233-248. 2. Olivry T, Foster A, Mueller R, et al. Interventions for atopic dermatitis in dogs: a systematic review of randomized controlled trials. Vet Dermatol 2010; 21: 4-22. 3. Olivry T, Bizikova P. A systematic review of randomized controlled trials for prevention or treatment of atopic dermatitis in dogs: 2008- 2011 update. Vet Dermatol 2013; 24: 97-117. 4. Gadeyne C, Little P, King V, et al. Effi cacy of oclacitinib (Apoquel®) compared with prednisolone for the control of pruritus and clinical signs associated with allergic dermatitis in client-owned dogs in Australia. Vet Dermatol 2014; 25: 512-518. 5. Archer T, Boothe D, Langston V, et al. Oral cyclosporine treatment in dogs: A review of the literature. J Vet Intern Med 2014; 28: 1-20. 6. Gonzales A, Bowman J, Fici G, et al. Oclacitinib (Apoquel®) is a novel Janus kinase inhibitor with activity against cytokines involved in allergy. J Vet Pharmacol Therap 2014; 37: 317-324. 7. Cosgrove SB, Wren J, Cleaver D, et al. A blinded, randomized, placebo-controlled trial of the effi cacy and safety of the Janus kinase inhibitor oclacitinib (Apoquel®) in client-owned dogs with atopic dermatitis. Vet Dermatol 2013; 24: 587-597. 8. Michels GM, et al. Proof of concept effi cacy and safety study of an anti-IL-31 monoclonal antibody for the treatment of atopic dermatitis in client-owned dogs, in Proceedings. 29th NAVDF 2015; 219. 9. Loewenstein C, Mueller R. A review of allergen- speciﬁc immunotherapy in human and veterinary medicine. Vet Dermatol 2009; 20: 84-98. ABOUT THE AUTHORS Allison Kirby, DVM, DACVD, earned her Bachelor of Science in Animal Biology from the University of California, Davis, in June 2001. She went on to attend veterinary school at UC Davis and graduated in 2005. Dr. Kirby went on to complete a small animal rotating internship at PetCare Animal Hospital in Santa Rosa, California before completing her dermatology residency in 2009 at Animal Dermatology Clinic, in Marina Del Rey, Tustin and Pasadena, California. Since then she has worked at the clinic primarily at the Marina del Rey location as a full time dermatologist. Dr. Kirby’s research experience includes several studies focused on atopic dermatitis including: a clinical study that evaluated the use of Oclacitinib in canine patients for the treatment of atopic dermatitis; and a double-blinded placebo controlled study evaluating the clinical effi cacy of cerenia in the treatment of atopic dermatitis. Darren Berger, DVM, DACVD, received his BS in chemistry from the University of Iowa in 2003 and his DVM from Iowa State University in 2007. Following graduation, Dr. Berger worked as a general practitioner and emergency veterinarian in Des Moines, Iowa for 2 years. He then went on to complete a 3-year residency program with Dermatology for Animals in Gilbert, Arizona and became a Diplomate of the American College of Dermatology in 2012. Dr. Berger is currently Assistant Professor of Dermatology at Iowa State University’s college of veterinary medicine in Ames, IA. He is the author of several textbook chapters, multiple peer-reviewed journal articles and is an Associate Editor for the Journal of Small Animal Practice. His research interests include clinical pharmacology, the clinical management of canine atopic dermatitis and equine hypersensitivity disorders. HILLS GLOBAL SYMPOSIUM 2016 DERM DEFENSE | 21

TREATING ATOPIC DERMATITIS Nutritional Management of Dogs with Adverse Food Reaction Dana Hutchinson, DVM, DACVN The client complaint of an itching dog is a common one. Nonetheless the pruritic dog is frequently a challenging appointment for the veterinary healthcare team (VHCT) and followed by frustration on both the part of the VHCT and client as we work together to improve the quality of life for these pets. Dermatologic diseases rank third and fourth among the most common conditions affecting dogs in the United States and is the most common reason dog owners submit a pet insurance claim. 1,2 Many of these appointments are the result of pruritus due to allergic skin disease, and in dogs this is most commonly caused by one of three conditions: Adverse food reaction (AFR), ﬂea allergy dermatitis, or canine atopic dermatitis (CAD). Adverse food reactions can be further broken down into food allergies which are caused by an aberrant immune response to a food and food intolerance, which is an abnormal physiologic response to a food which is not immune mediated. So why is canine pruritus such a challenging clinical sign to treat? Many factors likely play a role, including, but not limited to, identification of an accurate diagnosis, thoroughness and clarity in communication of the therapeutic plan which an owner must take to fully control their dog’s clinical signs, and likely a need on our part to better 22 | HILLS GLOBAL SYMPOSIUM 2016 DERM DEFENSE

TREATING ATOPIC DERMATITIS exploit multimodal therapy when managing these patients. Nutritional modulation of dermatologic conditions is often passed over despite its potential to play a safe, eﬀective, and owner-friendly role in the management of many dermatologic conditions. Diagnosis - Deﬁnitively diagnosing AFR in a canine patient requires clinical signs and patient history consistent with the condition, a thorough diet history and an exclusive novel or hydrolyzed food trial. Clinical signs in dogs with AFR most commonly manifest as focal, multifocal, or generalized non- seasonal pruritus, but may also manifest as otitis, seborrhea, superﬁcial pyoderma or even as atopic dermatitis in some dogs. 3 Since the clinical signs of dogs with AFR can be diverse, it is also important to consider the age and other, non-dermatologic signs present in the patient. Some dogs with AFR are ﬁrst presented with signs at a young age and have both dermatologic signs as well as gastrointestinal signs. Furthermore, the importance of a thorough diet history in the diagnosis of canine AFR is frequently underestimated. While time- consuming a detailed diet history gives the VHCT clues as to the likelihood that AFR is a probable diﬀerential diagnosis for the patient. The patient history may provide additional information suggestive of another diagnosis such as reported seasonality of the dog’s pruritus likely caused by an environmental allergy or frequent dietary indiscretion or excessive use of treats and human foods likely the underlying cause of owner-reported episodes of gastroenteritis. The diet history taken from a client with a dog with suspected AFR should be detailed and thorough. In order to consistently report all important diet history details it is helpful to utilize a Diet History Form such as the one that can be found at wsava.org/nutritiontoolkit. There are several important questions that should be included when taking a diet history from an owner with a dog with suspected AFR (Table 1). These questions include not only speciﬁc foods and treats fed but also inquiries examining other sources of foods eaten by the dog including dog walkers, toddlers, grandparents, and other individuals who have contact with the pet. It is frequently helpful to allow the owner to ﬁll out the Diet History Form at home so as to be as accurate as possible when recording foods and treats given. Speciﬁc and open ended questions are encouraged when taking a diet history to ensure that the owner feels comfortable sharing openly. For example, it may be useful to state, “What treats does Teddy get when he comes in after going to the bathroom?” rather than, “Does Teddy get any treats?” HILLS GLOBAL SYMPOSIUM 2016 DERM DEFENSE | 25

TREATING ATOPIC DERMATITIS 1. with a food allergy resulting in gastrointestinal signs, and contain a limited number of ingredients to limit possible antigenic exposure. Current and previous diets of patient Most food allergens are proteins Flavored medications, supplements, tooth paste, preventative medications greater than 10,000 Daltons in size. 4 Hydrolyzed therapeutic pet foods Access to other pets’ food and feces ideally contain one protein source Access to wild animal feces (deer, rabbit, etc) which has been hydrolyzed (broken Treats, human foods, digestible toys (rawhides, etc) down) to polypeptides less than 10,000 Daltons which reduces the Possible access to treats or human foods from toddlers, grandparents, dog potential allergenicity of the protein. walkers, doggie daycare, trainer, mail carrier, neighbors, etc In theory this results in a protein that cannot accommodate cross linking of IgE receptors on mast cells necessary for mast cell degranulation to take place and When owners feel that it is assumed their pet therefore should not be capable of initiating receives treats they are more likely to share an immune response to an offending antigen openly. An effective dietary elimination trial in an allergic pet. The value of a hydrolyzed hinges on a complete diet history so that an protein pet food when conducting a food trial appropriate food may be identified for the is multifold. Since it is the size rather than the trial and all other foods may be addressed uniqueness of the protein that prevents an with the owner. An appropriate food for a immune response a protein can be fed with dog undergoing an elimination trial contains which the pet has been previously exposed to. a single, novel (new to that particular dog) or hydrolyzed protein source identified based on This can be of particular use in pets that have that dog’s unique diet history. been adopted. Many pets today are adopted, which frequently makes obtaining a complete Novel and Hydrolyzed Therapeutic Foods diet history impossible. While adoption is The rationale for the use of a single, novel or undoubtedly a wonderful thing this can hydrolyzed protein food to which the dog present a challenge to the VHCT planning an has not been previously exposed during a elimination trial to rule out AFR. Fortunately dietary elimination trial for food allergy is that a valuable solution to this common situation an immune response to a food component exists for the VHCT: Hydrolyzed therapeutic can only occur if the dog has previously been foods. With therapeutic hydrolyzed pet foods in contact with the offending food allergen. the patient’s diet history is no longer critical This is due to the fact that the dog’s immune to an effective elimination trial. In these cases system will then respond to the allergen a hydrolyzed protein food is most appropriate which it has been sensitized to at subsequent for an elimination trial. Hydrolyzed foods are exposures. There is nothing intrinsically also highly digestible which may be beneficial hypoallergenic about novel proteins, they are for some pets with gastrointestinal signs due simply used because they are novel to the to AFR. particular pet’s immune system. DIET HISTORY FACTORS FOR CONSIDERATION PRIOR TO AN ELIMINATION DIET TRIAL For this reason, commercial therapeutic novel protein pet foods ideally contain one, intact protein not commonly eaten by pets. These foods are typically highly digestible and therefore appropriate for many dogs 24 | HILLS GLOBAL SYMPOSIUM 2016 DERM DEFENSE Many commercial and therapeutic novel and hydrolyzed food options exist. Whether a novel or hydrolyzed therapeutic food is chosen for a particular pet undergoing an elimination trial should depend on the

TREATING ATOPIC DERMATITIS diet history, owner and pet preferences, concurrent conditions, as well as response to therapy. One contemporary topic often on the minds of owners considering an elimination trial is whether over the counter limited ingredient foods may be used for this purpose. Countless over the counter limited ingredient foods are now available to consumers, many of which contain exotic protein sources and therefore may at initial inspection appear appropriate for a dog undergoing a food allergy diet trial. Interestingly, a study published in 2011 found that when tested such over the counter pet foods contained trace amounts of common protein sources including soy and beef, which were not disclosed on their ingredient list. 5 For this reason, owners willing to invest the time and resources required to conduct an elimination trial should be counseled as to the importance of utilizing either a commercial therapeutic novel or hydrolyzed food or a homemade novel protein diet formulated by a board certified veterinary nutritionist to ensure that the trial is valid. In addition to the value of knowing that the food is not contaminated with protein sources the pet has previously been exposed to some therapeutic foods developed for pets with food allergies also contain other nutritional SPECIFIC AND OPEN ENDED QUESTIONS ARE ENCOURAGED WHEN TAKING A DIET HISTORY TO ENSURE THAT THE OWNER FEELS COM- FORTABLE SHARING OPENLY. characteristics beneficial to pets suffering from AFR such as supplementation with omega-3 and 6 fatty acids, as well as use of highly digestible ingredients which may benefit dogs with gastrointestinal signs related to AFR. Dietary Adherence and Trial Success - Client-education is a critical component of a successful elimination trial. Owners should be made aware that not only must the prescribed food be fed exclusively but the elimination trial will also require exclusion of all additional treats and human foods other than those specifically approved during the 8-12 week trial. A recent review of available evidence found that when an elimination diet trial was followed closely more than 90% of pets with cutaneous adverse food reaction undergoing an elimination diet trial responded by 8 weeks. 6 Owners should be warned that even seemingly minimal exposure to other foods (such as treats given by a friend or occasional Treating Canine Pruritus ■ The clinical signs of skin disease, most frequently manifested as pruritus, are among the most common reasons pet owners visit veterinarians. ■ Allergic skin disease in dogs is most frequently due to either ﬂea allergy dermatitis, adverse reaction to food, or atopic dermatitis. ■ Ruling out adverse reaction to food as the cause of a pet’s pruritus is a challenge for the veterinary health care team (VHCT) since diagnosis requires strict adherence to an 8-12 week diet elimination trial. ■ A successful elimination trial hinges on a thorough diet history, firm owner adherence to the prescribed therapeutic or homemade food, and clear communication between the VHCT and owner. HILLS GLOBAL SYMPOSIUM 2016 DERM DEFENSE | 25

TREATING ATOPIC DERMATITIS kibbles snatched from another pet’s food) could potentially inhibit the VHCTs ability to interpret the results of their pet’s elimination trial. Treats appropriate for pets undergoing a novel or hydrolyzed food trial include the dry form of the food being used in the trial given from a treat box or jar and Prescription Diet Hypoallergenic Treats. Prior to instituting an elimination trial owners should be counseled on appropriate substitutions for any ﬂavored medications, supplements and preventatives they are currently administering to the pet which are inappropriate for use during an elimination trial for AFR. During an elimination trial it is also critical that the owner addresses the other individuals that have contact with the pet. These are often the individuals identified during the diet history such as grandparents, dog walkers, etc. While it is important that these individuals are also aware of the pet’s food restrictions during the trial it may be helpful to provide appropriate alternatives if treats are given to ensure compliance such as those listed above. Although undoubtedly challenging for the family of a pet undergoing an elimination trial it is important to recognize that no other currently available diagnostic test is able to accurately diagnose a food allergy. And while laborious at times, adequate compliance during an 8-12 week elimination trial will allow the VHCT to definitively rule out a food allergy in a pet that has not demonstrated resolution of clinical signs despite strict adherence to the prescribed trial, or diagnose food allergy in a pet that has shown resolution of clinical signs during the trial with recurrence of signs upon provocation testing. Regardless of the outcome, strict adherence to an exclusive elimination trial for 8-12 weeks provides the VHCT with invaluable information that may be used towards the identification of the underlying cause, and management of, clinical signs in pets with pruritus. References 1. Banfield Pet Hospital Web site. “ State of Pet Health 2015 Report”. Available at: http://www. banfield.com/state-of-pet-health/common- conditions. Accessed February 18th, 2016. 2. Veterinary Pet Insurance Web site. “Top Ten Reasons Pets Visit Vets”. Available at: http:// www.petinsurance.com/healthzone/pet-articles/ pet-health/Top-10-Reasons-Pets-Visit-Vets.aspx. Accessed February 18th, 2016. 3. Olivery Thierry. Letter to the Editor: Food for thought: pondering the relationship between canine atopic dermatitis and cutaneous adverse food reactions. ESVD and ACVD 2007, 18: 390- 391. 4. Cave NJ. Hydrolyzed protein diets for dogs and cats. Vet Clin Small Anim Pract 2006, 36; 1251- 1268. 5. Raditic DM, Remillard RL, Tater KC. ELISA testing for common food antigens in four dry dog foods used in dietary elimination trials. J Anim Physiol Anim Nutr (Berl) 2011, 95; 1: 90–97. 6. Olivry T, Mueller RS. Critically appraised topic on adverse food reactions of companion animals (1): duration of elimination diets. BMC Vet Research 2015; 11: 22. ABOUT THE AUTHOR Dana Hutchinson, DVM, DACVN, is a part-time Small Animal Clinical Nutritionist at Angell Memorial Hospital for Animals, Jamaica Planes, MA as well as an Associate Manager Scientific Insights at Hill’s Pet Nutrition. Her work focuses on meeting the unique metabolic needs of patients with a wide variety of medical conditions. She has a particular interest in canine and feline geriatrics, critical care nutrition and renal disease. Dr. Hutchinson graduated from North Carolina State College of Veterinary Medicine in 2008 and received her specialty training at Tufts Cummings School of Veterinary Medicine. 26 | HILLS GLOBAL SYMPOSIUM 2016 DERM DEFENSE

TREATING ATOPIC DERMATITIS HILLS GLOBAL SYMPOSIUM 2016 DERM DEFENSE | 27

INNOVATIVE SOLUTIONS FOR DERM PATIENTS Disrupting Veterinary Medicine Disruptive Technologies in Human Medicine Leanne West with Jason Zutty A disruptive technology is one that has the ability to change the way we live, work, and play. For example, we are starting to be connected to anything and everything through the Internet of Things (IoT). Sensors are being built into our clothing, our cars, and our home goods. Soon, the world around us will know everything that is going on—our clothing will be taking a steady stream of health and activity data; our cars will know when and where to go and perform the driving for us; and our home will know what room we are in and what activity we are doing. We see some of these devices on the market now, but eventually we will see these devices working together with each other, with others in the population, and with our environment. We have become dependent on technology. In a study performed by Braun Research, Inc. for Bank of America in 2015, 80% of people reach for their mobile phone first thing in the morning, (often ahead of coffee and their toothbrush!) 1 , and 44% could not last a day without it. 2 Gallup says that 81% of us keep our smartphone with us all day. 3 Focusing on medicine, wearables are starting to appear with mobile health sensors, smart fabrics, precision medicine, and medical decision-making, where data is generated 28 | HILLS GLOBAL SYMPOSIUM 2016 DERM DEFENSE

INNOVATIVE SOLUTIONS FOR DERM PATIENTS and sent to enterprise systems to give a complete picture of the wearer’s health and environment. Twenty percent of people either already own or would consider buying wearable technology. In addition, the top three reasons people want wearables are health-related. 77% want them to assist with exercise; 75% want them for tracking medical information; and 67% want them to assist with better eating habits. 4 In addition, “62% of smartphone owners have used their phone in the past year to look up information about a health condition.” 5 wearable, it is a mobile means of tracking your pet’s health data. How Vetrax is different? Vision for Veterinary Medicine Vetrax is a medical device and information platform designed to more quickly alert veterinarians and pet owners to potential health concerns as part of an ongoing monitoring program. On the surface, activity monitoring sounds similar to what Whistle and other companies offer. However, the sensor data is taken at a higher frequency than others on the market. The higher frequency allows a better and more complete understanding of the data. Do pet owners feel the same way about health data for their companion animals as they do about health data for themselves? The answer is yes. In 2014, according to Grand View Research, the worldwide pet wearable market was valued at 837.6 million dollars, and the compound annual growth rate specifically for medical applications is estimated to grow 20% from 2015-2022. Most of these wearables, such as WUF, FitBark and Whistle, are for GPS tracking or energy-level monitoring, while some, like Voyce and PetPace, track vitals such as temperature and heart rate. 6 For example, look at the data given in the Figure 1. Data for a given behavior might look like the sine wave given in (a). A standard signal coming from standard energy-level monitors might look like (b) where much of the features of the data are missed because the data is taken at a low frequency intervals represented by the red dots. Because Vetrax samples at a much higher frequency, the data signal features are collected and analyzed using all of the characteristics of the signal, as shown by the blue dots in (c). In February of this year, Merck Animal Health announced a diabetes tracker for pets, allowing the pet owner to set dose reminders and track insulin given. 7 While it is not a In addition, currently-available sensors for pets use a single number to determine low, medium or high energy levels. Vetrax is collecting data in three axes. The three axes and higher HILLS GLOBAL SYMPOSIUM 2016 DERM DEFENSE | 29

INNOVATIVE SOLUTIONS FOR DERM PATIENTS FIGURE 1. (a) (b) (c) frequency together allow differentiation of behaviors that would otherwise be missed by Whistle and others. In the Figures 2 and 3, real data collected from dogs with the Vetrax sensor is shown for one axis data (a) and three axis data (b). When comparing single axis data with the three axis data, it is clear that different behaviors are discernable. Some of the visible differences are that the three axes data are farther apart for excreting than they are for drinking; Scratching has a stronger periodicity than walking. With one axis data, these differentiators are not visible. To optimize algorithms that can differentiate between the various behaviors with the Vetrax data, Georgia Tech is leveraging a unique genetic programming tool with its roots in military algorithm development, Georgia Tech Multiple Objective Programming (GTMOEP). Genetic programming is a bio-inspired approach that allows computers to create algorithms. Traditional genetic programming only supports the use of arithmetic and logical operators on scalar features. The GTMOEP framework builds upon this traditional programming by also handling feature vectors, allowing the use of signal processing, and machine learning functions as primitives in addition to the more conventional operators. GTMOEP is a novel method for automated, data-driven algorithm creation, capable of outperforming human derived solutions. 8 Based on an analysis of frames of collected data, Vetrax is implementing a “rejection FIGURE 2. (A) SINGLE AXIS DATA TAKEN WITH THE VETRAX SENSOR Barking 30 | Chewing Drinking Eating Excreting Jumping HILLS GLOBAL SYMPOSIUM 2016 DERM DEFENSE Laying Running Scratching Shaking Unnating Walking

INNOVATIVE SOLUTIONS FOR DERM PATIENTS FIGURE 3. (B) TRIPLE AXIS DATA TAKEN WITH THE VETRAX SENSOR Drinking Eating Excreting Running chain” algorithm, or series of algorithms (Figure 4). For each definitively identifiable behavior, such as shaking or scratching, the Vertax system will classify the behavior. Using this chain of algorithms, the identified behaviors are picked off, leaving the data to go through the identifying algorithm for the next behavior. This process repeats until all data has been specifically classified. If there is data left after passing through all behavior algorithms, this data will be identified as walk, rest, and run based on the overall energy of the data. This last step of identifying walk, rest, and run behavior from a magnitude of the data is where other companies begin and end their analysis. Scratching Shaking Unnating Walking Overall, the AGL has collected data on over 500 dogs. Algorithms were generated from datasets resulting from over 1,500 man- hours of detailed annotation work. Behavior Algorithm performance using these datasets have achieved a validated positive predictive value of approximately 79%. These algorithms should produce reliable trends to enhance the veterinarian’s capabilities in managing the health of their patients. Note, the Vetrax system is not a tool for diagnosing diseases. The system supports managing chronic health and wellness programs. The veterinarian will baseline an animal’s quantified behavior before a prescribed intervention (nutritional and/or pharmaceutical) and then observe the FIGURE 4. Shaking Classiﬁer Shaking Frames Not Shaking Frames Scratching Classiﬁer Scratching Frames Neither Scratching nor Shaking Frames Run, Walk, Rest Running Frames Walking Frames Resting Frames HILLS GLOBAL SYMPOSIUM 2016 DERM DEFENSE | 31

INNOVATIVE SOLUTIONS FOR DERM PATIENTS Trackers for Pets animal’s quantified behavior trend after the intervention. In use, veterinarians prescribe Vetrax for dogs that need to be regularly monitored due to chronic illness or another health condition. The owner aﬃ xes the lightweight Vetrax sensor to the dog’s collar. The sensor collects detailed data used to classify behaviors 32 | HILLS GLOBAL SYMPOSIUM 2016 DERM DEFENSE the dog is exhibiting—such as basic levels of activity (resting, walking, running) and more advanced activities such as shaking, scratching or drinking—and regularly transmit the information wirelessly to the Vetrax information cloud where the data can be reviewed by the veterinarian to see if the prescribed intervention is working as intended.

INNOVATIVE SOLUTIONS FOR DERM PATIENTS References 1. Bank of America, “Trends in Consumer Mobility 2015.” http://newsroom.bankofamerica.com/ files/doc_library/additional/2015_BAC_Trends_ in_Consumer_Mobility_Report.pdf. Accessed March 29, 2016. 2. SocialTimes, “79% Of People 18-44 Have Their Smartphones With Them 22 Hours A Day.” http://www.adweek.com/socialtimes/ smartphones/480485. Accessed March 28, 2016.) 3. Gallup, “Most US Smartphone Owners Check Phone at Least Hourly.” http://www.gallup.com/ poll/184046/smartphone-owners-check-phone- least-hourly.aspx. Accessed March 28, 2016. 4. PricewaterhouseCoopers. “PWC: 1 in 5 Americans owns a wearable, 1 in 10 wears them daily.” http://mobihealthnews.com/37543/pwc-1- in-5-americans-owns-a-wearable-1-in-10-wears- them-daily. Accessed March 2016. 5. PewResearch. “U.S. Smartphone Use in 2015.” http://www.pewinternet.org/2015/04/01/us- smartphone-use-in-2015/. Accessed March 30, 2016) 6. BIONIC.LY. “13 Wearable Tech Products for Pets.” http://bionic.ly/13-wearable-tech-products- pets/?hvid=48f3c. Accessed March 28, 2016. 7. Merck Animal Health. “New Pet Diabetes Tracker from Merck Animal Health Helps Owners of Diabetic Pets Manage the Disease.” http://www. merck-animal-health-usa.com/news/2016-2-11b. aspx. Accessed March 28, 2016. 8. “Multiple Objective Vector-Based Genetic Programming Using Human-Derived Primitives,” GECCO ‘15 Proceedings of the 2015 Annual Conference on Genetic and Evolutionary Computation, Pages 1127-1134, ACM New York, NY, USA ©2015 ISBN: 978-1-4503-3472-3 doi>10.1145/2739480.2754694. ABOUT THE AUTHOR Leanne West is a principal research scientist at the Georgia Tech Research Institute in Atlanta, Georgia. Ms. West has participated in several optical system design, development, and evaluation projects in her career. She is author of a book chapter in “Technology for Aging, Disability and Independence: Computer and Engineering for Design and Applications,” published by John Wiley & Sons and has written a number of papers and given several presentations on assistive technology device development and remote sensing. She has licensed her invention of a wireless personal captioning system and brought it to commercialization through her company, Intelligent Access, LLC. Ms. West was recognized for her work when she was named one of Georgia’s “40 Under 40” by Georgia Trend magazine in 2004, a listing of the 40 “Best and Brightest” inﬂuential Georgians in the business and political communities under 40 years old. She was also selected for the 2008 Leadership GA class, which recognizes leaders for the state of Georgia. Ms. West is an active participant at her organization, having served on numerous campus committees and having been the twice-elected Chair of the Georgia Tech Executive Board. HILLS GLOBAL SYMPOSIUM 2016 DERM DEFENSE | 33

INNOVATIVE SOLUTIONS FOR DERM PATIENTS Innovation in Nutritional Management of Canine Atopic Dermatitis Take Home Messages Jennifer M. MacLeay, DVM, PhD, Dip.ACVIM “Atopic dermatitis is a chronic skin disease which requires permanent treatment” Dr. Andreas Wollenberg The purpose of this presentation is to share important insights we have gained concerning canine atopic dermatitis in regard to pre- treatment, proactive management and the use of Prescription Diet® Derm Defense™ Canine food. ■ Early intervention in canine atopic dermatitis results in very low mean peak skin health and pruritus scores. ■ Incorporating Prescription Diet® Derm Defense™ Canine into a pre-treatment protocol, as part of a multimodal strategy to manage dogs with atopic dermatitis, may result in delayed or reduced use of medication. ■ By implementing pre-treatment and early intervention as best practices clients feel more empowered over a disease that is uncomfortable for the pet and disruptive to the family and the home. Background Canine atopic dermatitis is a disease that encompasses all the elements of the art of veterinary medicine; diagnosis, management and communication. Diagnosis requires knowledge of how environmental allergies, ectoparasitism, infection and adverse reaction to food or drugs may coexist and/or be differentiated from each other. Management requires knowledge of the considerable number of over the counter 34 | HILLS GLOBAL SYMPOSIUM 2016 DERM DEFENSE

INNOVATIVE SOLUTIONS FOR DERM PATIENTS and pharmaceutical treatments available. One must understand the nuances of where and when to implement more intensive therapy because of potential side effects. Further, veterinarians must be excellent communicators in order to educate pet parents about the nature of the disease, how to control triggers within the home and discuss therapeutic options without inducing recommendation fatigue. It can be a challenge to communicate how management of allergies takes trial and error to find the most appropriate combination of therapies and then convey that a particularly effective therapy may change over time, depending upon the season and other environmental influences. Pre-Treatment and Proactive Therapy Physicians will often recommend beginning allergy medications in advance of allergy season in order to mitigate the severity of seasonal allergies. This is known as pre- treatment. Pre-treatment or proactive therapy is the long term treatment concept of choice for human atopic dermatitis management. 1 This approach involves intense therapy, until lesions have mostly cleared, followed by long term intermittent topical or, if necessary, systemic therapy, resulting in fewer flares and increased quality of life for affected individuals. 1,2 According to Wollenberg THE GOAL OF NUTRITIONAL MANAGEMENT FOR CANINE ATOPIC DERMATITIS IS TO INHIBIT THE INFLAMMATORY RESPONSE, STABILIZE THE SKIN BARRIER AND SUPPORT SKIN AND COAT HEALTH. and Ehmann, pre-treatment should be “immunobiologically based, time contingent, low dose anti-inflammatory treatment with behavioral therapeutic background”. Behavioral therapeutic background means teaching the fundamental reasoning behind therapeutics such that patients understand why, how and how often treatments are to be applied. Recently Lourenço et al published a study showing the effi cacy of proactive therapy in dogs using a hydrocortisone spray to extend the remission period in dogs with atopic dermatitis. 3 New Prescription Diet® Derm Defense™ fulfills these criteria, especially when used as part of an overall pre-treatment strategy, as it is formulated to contain ingredients chosen for their ability to help modify skin barrier dysfunction and the immunodeviations found in canine atopic dermatitis. HILLS GLOBAL SYMPOSIUM 2016 DERM DEFENSE | 37

INNOVATIVE SOLUTIONS FOR DERM PATIENTS BY IMPLEMENTING PRE-TREATMENT AND EARLY INTERVENTION AS BEST PRACTICES CLIENTS FEEL MORE EMPOWERED OVER A DISEASE THAT IS UNCOMFORTABLE FOR THE PET AND DISRUPTIVE TO THE FAMILY AND THE HOME. Goal of Nutritional Management of Canine Atopic Dermatitis The goal of nutritional management for canine atopic dermatitis is to inhibit the inflammatory response, stabilize the skin barrier and support skin and coat health. Invisible inflammation is present in patients who have skin barrier dysfunction and can be addressed using nutrition and pharmaceuticals. Unhealthy skin, including the ear canal, can be addressed externally through the use of topical anti-inflammatory medications and gentle cleansing. Unhealthy skin can also be addressed through nutrition to support healing and growth of a strong, resilient hair coat. HistaGuard Complex™ Prescription Diet® Derm Defense™ contains a proprietary blend of whole egg, antioxidants and sources of polyphenols, which together is Hill’s® HistaGuard™ Complex. This combination of ingredients is formulated to help modulate the immune response to allergens. The functional goal of the inclusion of these nutrients is to help stabilize mast and inflammatory cells, thereby decreasing histamine and cytokine release. 4 Components within eggs have been shown to have immunomodulation and anti-oxidant activity among other benefits. 5,6 In a study conducted by Jewell et al, three groups of 5 dogs were exposed to the novel antigen keyhole limpet hemocyanin during weeks 9 and 11 of feeding 1 of 3 foods. 7 One group ate a food that did not contain egg, one consumed a food 36 | HILLS GLOBAL SYMPOSIUM 2016 DERM DEFENSE containing egg and one consumed the food without egg and was also treated with daily, immunosuppressive doses (2.2 mg/kg body weight orally per day) of prednisone. After 12 weeks, all dogs had similar antibody titers to the novel antigen supporting that humoral immunity was not affected and they could mount a normal immune response. However, when the dogs underwent intradermal skin testing, dogs consuming the food with egg and the dogs treated with prednisone had similar, statistically significant reductions in the acute (15 min) and delayed (24 hour) cell mediated immune response as measured by skin wheal diameter and thickness. This study showed a benefit from consuming egg in the inflammatory skin response that was similar to prolonged prednisone therapy without any clinical side effects. 7 Plant based foods such as green tea, fruits, some herbs and green vegetables are rich in polyphenols which act as antioxidants, induce antioxidant enzymes such as glutathione peroxidase and superoxide dismutase and have been found to modulate cell signaling pathways.8 In human and laboratory animal studies, polyphenols have been found to play an inhibiting role in the presentation of allergens to the immune system and an inhibitory role in T cell release of cytokines, inhibition of B cell production of IgE and inhibition of degranulation by mast cells. 9 In addition, polyphenols have anti-oxidant activity limiting the free radical cellular injury which may occur during allergic insults. 10 In pilot studies performed at the Hill’s Pet Nutrition Center in dogs with atopic dermatitis we have seen lower levels of IL-31, IL-12p40 and other cytokines, reduced itching, hair loss and skin erythema when we fed botanicals containing anti-oxidants and polyphenols. 11 Vitamin E, antioxidants and omega-3 fatty acids also play a role in the HistaGuard™ Complex. Vitamin E plays a vital role in protecting skin lipids from peroxidation

INNOVATIVE SOLUTIONS FOR DERM PATIENTS secondary to exposure to UV radiation, inflammation or infection. Vitamin E was also studied in a canine mastocytoma cell line as a model for canine atopic dermatitis and was found to reduce histamine, prostaglandin D2 and chymase release. 11 In a random sample of 2633 adults, researchers found an inverse relationship between dietary vitamin E intake and serum IgE concentrations which in turn were associated with the frequency of skin allergen sensitization. 13 In 2014, Plevnik et al reported low plasma vitamin E levels in dogs with atopic dermatitis. Dogs were supplemented with 8.1 IU/kg once daily orally with vitamin E. Supplemented dogs were found to have lower CADESI-03 scores than non-supplemented dogs. 14 In work performed by Hill’s Pet Nutrition, we found that dietary alpha tocopherol increases serum vitamin E levels and serum vitamin E correlates with skin levels of vitamin E. 15 Prescription Diet® Derm Defense™ contains vitamin E in excess of the above recommended amount and also contains other anti-oxidant sources including vitamin C, green tea as source of catechins and lipoic acid. It is well known that omega-3 fatty acids result in less inflammatory cytokines and as the relative amount of omega-3 fatty acids in the diet increases, more prostaglandins of the 3 series and leukotrienes of the 5 series are produced in cells. 16 Gene Expression and Metabolic Pathway Analysis Gene expression and metabolic pathway analysis are useful techniques to identify ingredients and nutrients which positively affect pathways of interest for a particular disease. Metabolic pathway analysis uses complex modeling of network-based pathways to interpret gene expression and metabolite data. In the case of canine atopic dermatitis, we identified ingredients that target inflammation, the immune system and histamine related pathways. Therefore Prescription Diet® Derm Defense™ also contains beneficial fats and complex carbohydrate sources shown in cell culture studies to have a positive effect on metabolic pathways associated with inflammation, the immune system and histamine. Healthy Skin and Hair Coat Achieving healthy skin and hair coat requires a complex balance of macro and micronutrients. Protein, Vitamins A and E, omega-3 and omega-6 fatty acids and their ratio to one another, and minerals such as zinc and copper all contribute to growth and healing of the epidermis, dermis, collagen and pigmentation. Book chapters exist on the contribution of nutrition to basal skin and hair coat health and the reader is directed to those for a comprehensive review. 17,18 Both omega-6 and omega-3 fatty acids play important roles in skin and systemic health. The essential amino acids, cis-linoleic and alpha-linolenic represent omega-6 and omega-3 fatty acid families respectively. In canine atopic dermatitis, both omega-6 and omega-3 fatty acids are important in skin healing and its resistance to producing inflammatory cytokines in the face of allergic insult. Often the total quantities of either omega-6 or omega-3 are considered important or their relative ratio to one another. In fact both are important, a relatively low total omega-6:omega-3 ratio is considered anti- inflammatory while total omega-6 intake can be important for correction of epidermal lipid defects and decreasing transepidermal water loss. 19 Clinical Studies We conducted two clinical studies in dogs with a history of seasonal atopic dermatitis. The first was a controlled, masked trial in dogs, without clinical signs, in advance of the spring allergy season. in order to mitigate the severity of seasonal allergies discussed as pro-active therapy above. The second clinical study was a case series of dogs already exhibiting clinical signs. Both were multicenter studies to determine the impact of Prescription Diet® Derm Defense™ on clinical signs of seasonal HILLS GLOBAL SYMPOSIUM 2016 DERM DEFENSE | 37

INNOVATIVE SOLUTIONS FOR DERM PATIENTS atopic dermatitis. Dogs were recruited from 11 general practices in the United States. Consistent with accepted standards of care, treatment was not withheld, therefore, prescribed medications and dosing information was collected; only oclacitinib, which was not uniformly available to all practices, was disallowed. Medications dispensed were categorized as a topical containing a glucocorticoid, a systemic antihistamine, a systemically administered glucocorticoid and/ or an immunosuppressive agent. Veterinarians graded skin lesions using a standardized visual score (0: absent - 4: severe for erythema, alopecia, excoriations and lichenification for 27 body sites, max score of 432) and pruritus score (0:absent - 4:severe). Both veterinarians and dog owners filled out a comprehensive questionnaire concerning skin and coat health and owners additionally evaluated atopy related behavior with a visual scale of “none” to “all of the time” on a continuum and this was converted to a 0-100 score. Symptomatic Case Series Clinical Study Twenty dogs with clinical signs consistent with seasonal atopic dermatitis were recruited to participate in the clinical feeding study. After initial veterinary examination and consent agreement by owners, dogs were switched to Prescription Diet® Derm Defense™ Canine therapeutic nutrition for 8 weeks. Both veterinarians and owners recorded clinical and behavioral observations throughout the feeding period. Veterinarians elected to dispense medications to 19/20 (95%) dogs. Veterinarian mean scores improved for hair coat shine, texture, shedding, skin healing, dander, hair regrowth, overall coat and skin quality from baseline to week 8. Mean owner scores improved for skin redness, itching, licking, head shaking, pet’s condition as disruptive and improved quality of life since beginning the study. Food was part of the multi-modal therapy elected by the participating veterinarians and sixty-five percent of both veterinarians and owners believed the food was somewhat to highly effective in reducing licking and scratching and 70% of owners wanted to continue feeding the new food. Controlled Proactive Presymptomatic Clinical Trial Dogs with a history of, but without current clinical signs were randomly assigned to either Prescription Diet® Derm Defense™ food or to a control food that was nutritionally balanced but did not contain the same actives as the test food for a 12 week feeding period. FIGURE 1. COMPARISON OF MEAN SKIN HEALTH SCORE BETWEEN DOGS IN THE PRE-SYMPTOMATIC CONTROLLED STUDY AND THE SYMPTOMATIC STUDY. DOGS EXPERIENCING EARLY INTERVENTION IN THE CONTROLLED STUDY HAD LOWER PEAK MEAN SKIN HEALTH SCORES. 25 ■ Baseline ■ 4 Weeks 20 ■ 8 Weeks ■ 12 Weeks 15 ■ 16 Weeks 10 5 0 38 | Pre-Symptomatic HILLS GLOBAL SYMPOSIUM 2016 DERM DEFENSE Symptomatic

INNOVATIVE SOLUTIONS FOR DERM PATIENTS Forty-four adult dogs (22 Test, 22 Control) were enrolled and completed the controlled proactive clinical study. The recurrence rate of clinical signs consistent with canine atopic dermatitis was high as 82% of dogs developed a positive skin health and/or pruritus score at some point during the 12 weeks of feeding. Interestingly, dogs enrolled before they developed clinical signs of atopic dermatitis had lower peak mean skin health (Figure 1) and pruritus (Figure 2) score than dogs enrolled in the Symptomatic Case Series Study. This was likely due to the close veterinarian-client relationship and frequency of veterinary visits that was established by the study protocol. As a result of close monitoring, dogs were placed on therapy as clinical signs appeared and when clinical signs were less severe. The first day of topical medication use was similar between groups in the controlled study but antihistamine and systemic glucocorticoid use occurred later and less often in dogs fed Prescription Diet® Derm Defense™ (Figure 3). FIGURE 2. COMPARISON OF PRURITUS SCORES BETWEEN DOGS IN THE PRE- SYMPTOMATIC CONTROLLED STUDY AND THE SYMPTOMATIC STUDY. DOGS EXPERIENCING EARLY INTERVENTION IN THE CONTROLLED STUDY HAD LOWER PEAK MEAN PRURITUS SCORES. 2.50 ■ Baseline ■ 4 Weeks 2.00 ■ 8 Weeks ■ 12 Weeks 1.50 ■ 16 Weeks 1.00 0.50 .000 Pre-Symptomatic FIGURE 3. DAY OF FIRST SYSTEMIC GLUCOCORTICOID ADMINISTRATION IN THE CONTROLLED STUDY. GENERALLY, DOGS ON PRESCRIPTION DIET® DERM DEFENSE™ WERE ADMINISTERED GLUCOCORTICOIDS LATER AND LESS OFTEN THAN CONTROL FOOD FED DOGS. Symptomatic First Day of Treatment Control Test 0 20 40 60 Days 80 100 120 ■ Systemic glucocortocoid HILLS GLOBAL SYMPOSIUM 2016 DERM DEFENSE | 39

INNOVATIVE SOLUTIONS FOR DERM PATIENTS In the Controlled Proactive Presymptomatic study 94% of the control dogs versus 68% of the Prescription Diet® Derm Defense™ dogs developed a positive skin health and/ or pruritus score and were prescribed medication. When data were summarized, 53% of control food dogs versus 32% of the Prescription Diet® Derm Defense® fed dogs received multiple medications. Conclusion Early intervention in canine atopic dermatitis results in very low mean peak skin health and pruritus scores. Veterinarians and pet owners noted improvements in various measures of skin health, hair coat appearance, and pet behaviors associated with the pet’s dermatologic condition. Dogs with signs of atopic dermatitis improved when Prescription Diet® Derm Defense™ was added to their overall management plan. Further, incorporating Hill’s® Prescription Diet® Derm Defense™ into a pre-treatment, proactive protocol, to manage dogs with atopic dermatitis, may result in delayed or reduced use of medication. References 1. Wollenberg A, Ehmann LM. Long Term Treatment Concepts and Proactive Therapy. Ann Dermatology 2012;24:3:253-260. 2. Bieber, Thomas. Atopic Dermatitis. Annals Dermatology 2010;22:2:125-137. 3. Lourenço AM, Schmidt V, São Braz B, Nóbrega D, Nunes T, Duarte-Correia JH, Matias D, Maruhashi E, Rème CA, Nuttall T. Efficacy of proactive long-term maintenance therapy of canine atopic dermatitis with 0.0584% hydrocortisone aceponate spray: a double blind placebo controlled study 4. DeMora F, Puigdemont A, Torres R. The role of mast cells in atopy: what can we learn from canine models? A thorough review of the biology of mast cells in canine and human systems. British Journal of Dermatology 2006;155:1109-1123. 5. Mine Y, D’Silva I. Bioactive Components in Egg White. In: Yoshinori Mine ed. Egg Bioscience and Biotechnology. Hoboken, NJ: John Wiley & Sons, Inc., 2008;141-184. 40 | HILLS GLOBAL SYMPOSIUM 2016 DERM DEFENSE 6. Hatta H, Kapoor MP, Juneja LR. Bioactive Components in Egg Yolk. In: Yoshinori Mine ed. Egg Bioscience and Biotechnology. Hoboken, NJ: John Wiley & Sons, Inc., 2008;185-238. 7. Jewell D, Fritsch D. The Effect of Egg on Selected Immune System Parameters of the Dog. Data on File. Hill’s Pet Nutrition, Inc., Topeka, KS 2015. 8. Tsao R. Chemistry and biochemistry of dietary pholyphenols. Nutrients 2010;2:1231-1246. 9. Singh, A, Holvoet, S and Mercenier, A. Dietary polyphenols in the prevention and treatment of allergic diseases. Clinical & Experimental Allergy 2011:1-14. 10. Gonzalez R, Ballester I, Lopez-Posadas R, Suarez MD, Zarzuelo A, Martinez-Augustin O, Sanchez- DeMedina F. Effects of flavonoids and other polyphenols on inflammation. Critical Reviews In Food Science and Nutrition 2015;5:4:331-362. 11. Panicker K. Role of Polyphenols in dogs with atopic dermatitis. Data on File. Hill’s Pet Nutrition, Inc., Topeka, KS 2016. 12. Gueck T, Aschenbach JR, Fuhrmann H. Influence of vitamin E on mast cell mediator release. 2002;13:301-305. 13. Fogarty A, Lewis S, Weiss S, Britton J. Dietary vitamin E, IgE concentrations and atopy. The Lancet 2000;356:1573-1574. 14. Plevnik KA, Salobir J, Levart A, Tavcar-Kalcher G, Nemec-Svete A, Kotnik T. Vitamin E supplementation in canine atopic dermatitis: improvement of clinical signs and effects on oxidative stress markers. Veterinary Record 2014;175:22:560. 15. Jewell D, Shiguang Y, Yoshi D. Effects of serum vitamin E levels on skin vitamin E levels in Dogs and Cats 2002;3:3:235-243. 16. Wander RC, Hall JA, Gradin JL, Du SH, Jewell DE. The ratio of dietary (n-6) to (n-3) fatty acids influences immune system function, eicosanoid metabolism, lipid Pperoxidation and vitamin E status in aged dogs. J. Nutr. 1997; 127: 1198-1205. 17. Roudebush P, Shoenherr W. Skin and hair disorders. In: Thatcher C, Remillard R, Roudebush P, Novotny B Hand M eds. Small Animal Clinical Nutrition. Topeka, KS: Mark Morris Institute, 2010:637-670. 18. Nutritionally Responsive Dermatoses. In: Hayek M, Daristotle L, Foess-Raasch M Case L. eds Canine and Feline Nutrition. Maryland Heights, MO: Mosby-Elsevier, 2011, 31. 19. Marsh KA, Ruedisueli FL, Coe SL. Effects of zinc and linoleic acid supplementation on the skin and coat quality of dogs receiving a complete and balanced diet. Veterinary Dermatology, 2000;11:277-284.

INNOVATIVE SOLUTIONS FOR DERM PATIENTS ABOUT THE AUTHOR Jennifer M. MacLeay DVM, PhD Diplomate ACVIM, received her DVM from The Ohio State University in 1993. She completed an internship in Charlottesville, VA and a residency and PhD at The University of Minnesota. She is boarded in the American College of Veterinary Internal Medicine in Large Animal Internal Medicine. At the University of Minnesota Dr. MacLeay studied and published on the effects of nutrition on equine exertional rhabdomyolysis (“Tying Up”) and polysaccharide storage myopathy. Dr. MacLeay then joined the faculty at Colorado State University holding positions in both the equine and food animal hospitals as an Assistant and then Associate Professor in the Department of Clinical and Biomedical Sciences. While at CSU she developed a collaborative research program studying nutrition and dietary induced metabolic acidosis in sheep as a model for human osteoporosis. Results of that work have been presented internationally. Dr. MacLeay joined Hill’s Pet Nutrition as a Medical Director in January of 2009. Since that time she has led numerous external clinical studies for Hill’s and also in conjunction with the University of Minnesota and Michigan State University. She has been responsible for several patents in the field of urinary tract health through her collaborative work with other Hill’s scientists. In her current role she works closely with Predictive Biology, Early Research, Global Professional Veterinary Affairs and Global Marketing to develop and promote nutritional solutions for dogs and cats. HILLS GLOBAL SYMPOSIUM 2016 DERM DEFENSE | 41

COMMUNICATIONS IN PRACTICE Does Your Pet Owner Get It? Justine A. Lee, DVM, DACVECC, DABT A recent DVM360 study found that of the professional fears that veterinarians have, 15% fear having state board intervention and/or being sued for malpractice. 1 One of the top reasons veterinarians get these complaints is often due to poor communication. Here are 10 simple steps to focus on when it comes to communicating with your pet owner. After all, you want your pet owner to get it. More importantly, you want to get your pet owner. Are you understanding their primary concern? Are you taking the time to actually listen to what they are asking for? Are you providing appropriate options for them? So, why are there breakdowns in client communication? ■ Rushed: Everyone feels rushed! 53% of working parents with kids under 18 have diﬃ culty with balancing work and family responsibilities (Pew Research Center, DVM360). 3 Spend time with your pet owners while doing so in a non-rushed manner. 4 ■ Trust: Only 59% of Millennials say their veterinarian takes “time to know them,” compared to 64% of Baby boomers. How do we build that trust? 3 ■ Accessibility: According to a recent study by Trone Brand Energy, 78% of 42 | HILLS GLOBAL SYMPOSIUM 2016 DERM DEFENSE

COMMUNICATIONS IN PRACTICE Better communication in 9 1. 2. MAKE AN APPROPRIATE INTRODUCTION LISTEN: ACTIVELY LISTEN TO WHAT YOUR CLIENT IS SAYING. REFLECT ON IT AND REITERATE IT. HEAR THE PET OWNER’S RESPONSE AND FOLLOW UP TO MAKE SURE NOTHING IS MISSED (E.G., DID I MISS ANYTHING ABOUT MOLSON’S PAST MEDICAL HISTORY)? 3. SINCERITY: BE SINCERE IN HOW YOU RESPOND TO PET OWNER 4. EMPATHY: ACKNOWLEDGE WHAT HAS BEEN SEEN AND HEARD 2 (E.G., AFFIRMATION, SHARING YOUR STORY) 5. 6. COMPASSION: NOT ONLY SHOULD YOU SHOW SINCERITY, BUT SHOW COMPASSION TO HOW THE PET OWNER MAY BE FEELING, OR HOW THE PROBLEM MAY BE AFFECTING THEM. CHUNK AND CHECK HILLS GLOBAL SYMPOSIUM 2016 DERM DEFENSE | 45

COMMUNICATIONS IN PRACTICE 7. ASK: ASK OPEN ENDED QUESTION 8. EFFORT: MAKE AN EFFORT TO UNDERSTAND TO BUILD AN EFFECTIVE WORKING RELATIONSHIP 9. PARTNERSHIP: OFFER A PLAN ON HOW TO CARE FOR BOTH THE PET OWNER AND TEH PATIENT. JOIN TOGETHER TO CREATE A SOLUTION AND OFFER OPTIONS. Baby Boomers feel their veterinarian is accessible, compared to only 47% of Millenials. 3 How do we provide more “access” to our pet owners? ■ Transparency: Today’s pet owners want to be able to price shop for the best price or product. They like to comparison shop. 4 Be transparent on where they can get the product, and they may trust you more and buy more from you in the end!). 3 References 1. DVM360 website. State of the Profession: What’s keeping veterinarians up at night? February 2016. Available at: http://veterinarynews. dvm360.com/state-profession-whats-keeping- veterinarians-night. Accessed March 1, 2016. 2. Hunter L, Shaw J. Raising Awareness of Diversity. Veterinary Team Brief 2016;27-28. 3. DVM360 website. Today’s veterinary clients just aren’t the same – and they want it all. February 2016. Available at: http://veterinarybusiness. dvm360.com/today-s-veterinary-clients-just- aren-t-same-and-they-want-it-all. Accessed March 1, 2016. 4. DVM360 website. Pet owner 2.0: Your millennial veterinary clients. February 2016. Available at: http://veterinarynews.dvm360.com/pet-owner- 20-your-millennial-veterinary-clients?pageID=2. Accessed March 1, 2016. APPROPRIATE COMMUNICATION WITH THE PET OWNER CAN ENSURE THE BEST TREATMENT PLAN FOR THEIR PET. ABOUT THE AUTHOR Justine Lee, DVM, DACVECC, DABT is a double board-certiﬁed emergency critical care specialist and toxicologist who is passionate about all things animal and veterinary medicine! She’s the CEO and founder of VETgirl, a subscription-based podcast and webinar service oﬀering RACE approved continuing education (CE). Dr. Lee is a world-renowned veterinary speaker, scientist, blogger and author. More, she’s an avid dog and cat lover and hopes to make you laugh and learn about keeping your pets safe in her dog and cat books. 44 | HILLS GLOBAL SYMPOSIUM 2016 DERM DEFENSE

COMMUNICATIONS IN PRACTICE HILLS GLOBAL SYMPOSIUM 2016 DERM DEFENSE | 45

COMMUNICATIONS IN PRACTICE The M(illennial) Factor and G(eneration)s Lidiya Alaverdova, DVM Welcome to life in the new workplace. As people live and work longer than ever before, the modern veterinary oﬃ ce houses multiple wildly diﬀerent generations under one roof— and it can be a melting pot for problems. Baby Boomers (1943-1960), Generation X (1961-1981), and Generation Y or Millennials (1982-2004) grew up in diﬀerent times, have wide-ranging value sets and often employ conﬂicting communication styles. And then there are CUSPERS—persons born within 3-5 years of a generational divide who may favor and display characteristics from both relative generations. They are the folks who cement the generations together. They function as mediators, translators, and mentors. A generational identity is a state of mind shaped by many events and inﬂuences, such as: ■ How you are parented. For example: Boomers grew up with stay at home moms, while Generation X grew up in families with both parents busy working or divorced, and kids often unsupervised. ‘Special’ Millennials were sheltered and overprotected by both parents, including much more involved dads. ■ Events that occur during your childhood years and society’s reactions to those events. For example: American High for Boomers, consciousness revolution for Generation X and 90s boom for Millennials. 46 | HILLS GLOBAL SYMPOSIUM 2016 DERM DEFENSE

COMMUNICATIONS IN PRACTICE ■ Events that occur as you ‘come of age’ and your individual reaction to these events. For example: consciousness revolution for Boomers, 90s boom for Generation X, and Sept. 11 and the Great Recession for Millennials. The intricacies of workplace communication— what we say, how we say it and what our choices say about us—have become increasingly complex as each group brings a diﬀerent set of experiences and expectations to the table. All age groups must individualize their approach by learning their coworkers’ preferences and attempting to meet in the middle. The solution won’t come from any one person or generation. The solution is really simple: Flexible approach and mutual respect. Being BOOST YOUR GENERATIONAL IQ AND LEARN THE WHY BEHIND THE WHAT, WHEN LIVING AND WORKING IN MULTIGENERATIONAL ENVIRONMENT. FIND OUT ABOUT THE MISSING LINK IN GETTING YOUR POINT ACROSS WHEN COMMUNICATING WITH NON-MILLENNIAL GENERATIONS. aware of the diﬀerences is a good start. More than that—talk about your team and demystify what’s unknown or misunderstood. Go out of your way to learn from each other. Older workers can lend their vast industry knowledge and experience. Younger workers can shed light on new ways of doing things and technology trends. Getting along with Boomers ■ Show respect. Acknowledge that you have less experience and can learn from them. ■ Choose face-to-face conversations. ■ Give people your full attention. Stop multitasking while someone is talking. ■ Learn the history. Find out what has gone wrong and right in the past before making suggestions for changes. HILLS GLOBAL SYMPOSIUM 2016 DERM DEFENSE | 47

COMMUNICATIONS IN PRACTICE 1. G(ENERATIONAL) SNAPSHOT Baby Boomers (1943 – 1960) Generation X (1961 – 1981) Millennials (1982-2004) Overall Work-centric, goal-oriented, competitive, free-spirited, relatively optimistic, social cause oriented. Formal. Follow protocol, tend to build processes and procedures around everything. They live to work. Independent, self-reliant, resilient, risk-taker, cynical, ﬂexible, technologically adept, and resourceful. Challenge the status quo. Value personal time and strive to achieve work-life balance. They appreciate fun in the workplace and have a work hard/play hard mentality. Deeply aware of social issues, entrepreneurial, comfortable with change and a fast pace, open- minded, conﬁdent, self- expressive, upbeat. Task oriented, want options & choices, and expect attention. Think “digital”, want to make a diﬀerence and value life over work. My work is… An exciting adventure A contract = obligation A means to an end – have to pay those bills My Work Ethic Workaholic Eliminate the task What’s next? Words that motivate me at work are… You are needed/valued Let’s do it your way! You will work with other brilliant, creative people. My thoughts on meetings… I love to have meetings! Another meeting? Ugh What’s a meeting? In-person? Job Strength Service Oriented/Team Players Adaptable and Techno-Literate Multitaskers and Techno-Savvy Outlook Optimistic Skeptical Hopeful View of authority Love/Hate Whatever… Polite Leadership By Consensus By Competence By Pulling Together Relationships Personal Gratiﬁcation Reluctant to Commit Inclusive Time on the job Visibility is key “Face Time” As long as I get the job done, who cares It’s quitting time – I have a real life to live Diversity Integration began Integrated No majority race Feedback Once a year with documentation Interrupts and asks how they are doing Wants feedback at the push of a button Work/Life Balance Balances everyone else and themselves Wants balance now Need ﬂexibility to balance activities 48 | HILLS GLOBAL SYMPOSIUM 2016 DERM DEFENSE

COMMUNICATIONS IN PRACTICE Getting along with Generation Xers ■ Get to the point. Avoid jargon and buzzwords that obscure your point. ■ Use email. Take advantage of technology and only have face-to-face meetings when required. ■ Give them space. Xers crave autonomy. ■ Get over the notion of dues paying. ■ Lighten up. Remember it’s OK for work to be fun. Getting along with Millennials ■ Challenge them. They want to do work that really matters. ■ Ask for their opinion. They love to collaborate and be a team player. ■ Encourage ﬁnding a mentor and become their champion. ■ Provide timely feedback. They are used to ■ ■ ■ ■ ■ Here are a few ideas to consider if you not only work in multi-generational environment, but also tasked to lead and motivate a diverse team: ■ Understand what makes each generation tick—oﬀer diﬀerent options to best meet the needs of a multi-generational workplace. Adapt your attitudes about rewards, work styles, communication preferences and motivators to match generational expectations. ■ Make an eﬀort to start conversation. Run educational sessions about generations and consider implementing reverse-mentoring getting feedback instantaneously and need positive motivation. Lighten up. Remember it’s OK for work to be fun Be transparent. Allow them to experiment and rethink traditional ways of doing things. When communicating with millennials, frame everything as a story—or even better—visualize it for them. Millennials value authenticity. Show them your personality. program. ■ Leverage the strengths of each generation—pursue and encourage a multiplicity of perspectives and ideas. This leads to innovation and will help your clinic be progressive. ■ Build bridges between generations—build on strengths and encourage people to become more of who they are rather than pushing them to conform. ■ Communicate uniquely with each generation—observe and discover ways to meet the diﬀerent communication styles of your team. HILLS GLOBAL SYMPOSIUM 2016 DERM DEFENSE | 49

COMMUNICATIONS IN PRACTICE ■ Support the values of each generation— make a point to ask people about their individual needs, views and preferences. A successful veterinary oﬃ ce or a clinic should be a melting pot of diﬀerent generations, personalities and talent (not problems!), all coming together toward a common goal—save and transform lives of pets. That is the only way to bring fresh perspectives to oftentimes common problems within multigenerational environment. The next time you bump into someone from another generation to whom you don’t relate to, stop and remember that no one is right or wrong, we’re just diﬀerent. Resources 1. Ypulse.com 2. Lancaster L, Stillman D. When Generations Collide. Who they are. Why they Clash. How to solve the generational Puzzle at work. HarperBusiness; Reprint edition, 2003 3. Zemke R, Raines C, Filipczak B. Generations at Work: Managing the Clash of Boomers, Gen Xers, and Gen Yers in the Workplace . AMACOM; Second Edition edition, 2013 4. Howe N, Nadler R. Millennials in the Workplace. LifeCourse Associates, 2010 5. Caraher L. Millennials & Management: The Essential Guide to Making It Work at Work. Bibliomotion, 2014 6. Generational Conﬂict in the Workplace. Available at: http://www.cellaconsulting.com/ blog/generational-conﬂict-workplace/ Accessed on Feb 18th, 2016 7. Leadership in the Multi-Generational Workplace. Available at: http://www.cellaconsulting.com/ blog/leadership-in-the-multi-generational- workplace/ Accessed Feb 19th, 2016 8. Cross-generational mentoring. Availabe at: http://www.cellaconsulting.com/blog/cross- generational-mentoring/ Accessed on Feb 19th, 2016 9. How To Communicate In The New Multigenerational Oﬃ ce. Available at: http:// www.forbes.com/sites/jennagoudreau/ 2013/02/14/how-to-communicate-in-the-new- multigenerational-oﬃ ce/#5b19502450d8. Accessed on Feb 21, 2016 ABOUT THE AUTHOR Lidiya Alaverdova, DVM, graduated as a veterinarian from the National University of Life and Environmental Sciences of Ukraine in 2007. She has always been passionate about making a diﬀerence in the veterinary profession and improving pets’ lives globally, which motivated her to join leading industry corporations. She worked in the marketing team for Pﬁzer Animal Health division in Ukraine and as chief editor for a professional veterinary magazine, VETZOOPROFY, before joining Hill’s Pet Nutrition™ in 2007 as Veterinary Aﬀairs Manager for Central Eastern Europe and Russia. Since then she occupied roles of increasing responsibility and was relocated to European Hill’s™ Headquarters in Prague, Czech Republic in 2009. Her main responsibility was to build professional relationships with vets in Central Eastern Europe and Russia and lead Hill’s educational eﬀorts in traditional and digital spaces. She pioneered and organized many Hill’s European webinars, professional FB groups for veterinary technicians in Poland and Czech Republic, led Hill’s conference presence in close partnership with veterinary associations. In 2012, she was promoted to a brand manager role at Hill’s Global Marketing Innovation Team, Topeka, USA, where she currently leads innovation strategy in gastrointestinal, recovery and dental categories for the Hill’s Prescription Diet brand. Lidiya has strong passion for collaborative communication, creative thinking, innovation, leadership and anything digital. She has been awarded ‘The Future of Veterinary Medicine Award’ by Ukrainian Veterinary Association and ‘Hill’s You Can Make A Diﬀerence Award’ for leading a company wide eﬀort to understand and engage with Millennial Female Veterinarians. 50 | HILLS GLOBAL SYMPOSIUM 2016 DERM DEFENSE

COMMUNICATIONS IN PRACTICE HILLS GLOBAL SYMPOSIUM 2016 DERM DEFENSE | 51

COMMUNICATIONS IN PRACTICE Diffusing the Angry Client Andrew Roark, MS, DVM Customer service is a critical part of the medical experience provided by veterinary clinics. As the primary point of contact with pet owners who are calling the clinic, arriving for appointments, voicing concerns and departing after a medical interaction, front desk staﬀ members commonly come into contact with angry or upset clients. While a front desk staﬀ member may or may not be the appropriate person at the clinic to address a particular client’s complaint or concern, all front desk staﬀ members should have the ability to receive a complaint, begin the process of addressing this complaint, and improve the practice’s strategic position within a given encounter. When facing an angry or complaining client, here are a dozen tips for people serving clients— regardless of their position within the hospital—to remember. 1 “Remain calm. When a customer starts yelling or being otherwise rude, there is nothing to be gained by responding in a similar manner. In fact, that will probably escalate hostilities. Maintain control of yourself, even if the customer’s tirade makes you feeling like yelling yourself.” 1 52 | HILLS GLOBAL SYMPOSIUM 2016 DERM DEFENSE

COMMUNICATIONS IN PRACTICE 2 “Repeat their concerns. Once he’s had time to explain why he’s upset, repeat his concerns so you’re sure that you’re addressing the right issue. If you need to, ask questions to make sure that you’ve identiﬁed the problem correctly…Repeating the problem shows the customer you were listening, which can help lower his anger and stress levels. More than this, it helps you agree on the problem that needs to be solved.” 2 3 “Phones are great diﬀusing tools. If a [client] emails you and you don’t respond for minutes (or hours) it can seem like they’re being ignored. You, in fact, may be busy helping other folks or even investigating their issue. But if the user reaches a boiling point, real- time communication can help to reassure them that you’re actually taking their issue seriously. In addition, it’s easy to dehumanize people you interact with on the web; all they are is a faceless email address. Hopping on the phone reminds users that they’re dealing with a real person, and they should perhaps be nicer.” 3 4 “Don’t take it personally. Remember, the customer is not angry with you, they are displeased with the performance of your product or the quality of the service you provide. Your personal feelings are beside the point.” 1 5 “Use your best listening skills. The ﬁrst thing an angry customer wants is to vent. To do so, they need someone to listen—and, for better or worse, you are that person. Listening patiently can defuse a situation, as long as the customer feels acknowledged in his or her complaint. Hear them out. When they are done talking, summarize what you’ve heard and ask any questions to further clarify their complaint. Body language can be critically important here. Keep eye contact. Stand or sit up straight. Keep your arms uncrossed. Show how closely you’re paying attention to their problem.” 1 6 “Actively sympathize. After the customer vents, he wants to know you understand where he’s coming from and how he or she feels. Express sympathy for their unpleasant customer experience. Respect and understanding go a long way toward smoothing things over.” 1 WHEN A CUSTOMER STARTS YELLING OR BEING OTHERWISE RUDE, THERE IS NOTHING TO BE GAINED BY RESPONDING IN A SIMILAR MANNER. HILLS GLOBAL SYMPOSIUM 2016 DERM DEFENSE | 53

COMMUNICATIONS IN PRACTICE LISTENING PATIENTLY CAN DEFUSE A SITUATION, AS LONG AS THE CUSTOMER FEELS ACKNOWLEDGED IN HIS OR HER COMPLAINT. 7 “Never argue back. It is natural for upset customers to express their anger, but some customers can take things too far and your reaction may be to defend yourself. However, as a professional customer service specialist, you should never argue back. Maintain your integrity and be the better person. If customers begin to abuse you verbally, let them know that you understand their frustration and that being rude will not solve their problem. Let the customer know that you are there to help, but you cannot do so until they calm down.” 4 8 “Apologize gracefully. Whether the customer’s complaint is legitimate or not is really irrelevant. If you want her to stay a customer, you need to express an apology for the problem they are having (or perceive to be having). A simple, straightforward statement is often all that’s needed: ‘I’m sorry you’re not happy with our product. Let’s see what we can do to make things right.’” 1 9 “Kill them with kindness. If your angry customer refuses to calm down, then kill them with kindness. Be sincere, respectful, and understanding. Show sympathy for their situation and express empathy for their frustration. By keeping calm and controlling your own anger, you may ﬁnd that your customer will ease up a little too. Try to make a joke to lighten the mood or share a story to show that you can relate.” 4 10 “Present a solution. Now you need to present her with a solution. There are two ways to do this. If you feel that you know what will make your client happy, tell her how you’d like to correct the situation…If you’re not sure you know what your client wants from you, or 54 | HILLS GLOBAL SYMPOSIUM 2016 DERM DEFENSE if they resist your proposed solution, then give her the power to resolve things. Ask her to identify what will make her happy. For instance, you could say, “If my solution doesn’t work for you, I’d love to hear what will make you happy. If it’s in my power I’ll get it done, and if it’s not possible, we can work on another solution together.” 2 11 “Take action and follow-up. Once you’ve both agreed on a solution, you need to take action immediately. Explain every step that you’re going to take to ﬁx the problem to your client If she has contacted you by phone, make sure that she has your name and contact details. This gives her a feeling of control because she can get hold of you again if she needs to. Once the situation has been resolved, follow up with your client over the next few days to make sure that she’s happy with the resolution. Whenever you can, go above and beyond her expectations. For instance, you could send her a gift certiﬁc0ate, give her a great discount on her next purchase, or send her a handwritten apology.” 2 12 “Use the feedback. Your last step is to reduce the risk of the situation happening again. If you haven’t already done so, identify how the problem started in the ﬁrst place… Find the root of the problem and make sure it’s ﬁxed immediately... Also, ensure that you’re managing complaints and feedback eﬀectively, so that you can improve that way that you do things” 2 References: 1. 7 Steps for Dealing With Angry Customers. Forbes.com. http://www.forbes.com/sites/ thesba/2013/08/02/7-steps-for-dealing-with- angry-customers/ 2. Dealing with Unhappy Customers: Turning a Challenge into an Opportunity. Mind Tools. http://www.mindtools.com/pages/article/ unhappy-customers.htm

6 COMMUNICATIONS IN PRACTICE Tools for Managing Angry Clients 1. 5. Timeliness – How quickly we respond to complaints. Credibility – What we will do to ensure that others are not affected similarly. 2. Facilitation – How easy we are to complain to. 6. Attentiveness – Communicating with empathy. 3. Redress – What we do to “make it right.” 4. Apology – How and when to say “I’m sorry.” These six tools for managing angry and complaining clients can be applied to nearly any situation. They are based on extensive studies conducted in the airline industry and are easily adapted for use in a veterinary practice. HILLS GLOBAL SYMPOSIUM 2016 DERM DEFENSE | 55

COMMUNICATIONS IN PRACTICE 3. Hamilton, E. 5 Tips for Dealing With Angry Customers. UserCentered. https://community. uservoice.com/blog/angry-customers-tips/ 4. Wolﬀ, M. 7 Tips on How to Handle Angry Customers Without Losing Your Cool. Velaro. com http://www.velaro.com/blog/how-to- handle-angry-customers ABOUT THE AUTHOR Andrew Roark, MS, DVM, is an associate veterinarian, author and speaker. He practices at Cleveland Park Animal Hospital in Greenville, South Carolina and is the founder and managing director of veterinary consulting ﬁrm Tall Oaks Enterprises. Dr. Roark has received the Outstanding Young Alumni Award from the University of Florida’s College of Veterinary Medicine, as well as being named Practice Management Speaker of the Year at NAVC, one of the world’s largest veterinary conferences. In 2013 and 2015, practices where Dr. Roark works were named as ﬁnalists in the American Animal Hospital Association’s Practice of the Year Contest. Dr. Roark was also named one of the “25 Veterinarians to Watch in 2013” by Veterinary Practice News. 56 | HILLS GLOBAL SYMPOSIUM 2016 DERM DEFENSE

COMMUNICATIONS IN PRACTICE HILLS GLOBAL SYMPOSIUM 2016 DERM DEFENSE | 57

NEW ENVIRONMENTAL ALLERGIES The best offense is a good defense Hill’s FIRST & ONLY NUTRITION with HistaGuard™ Complex — formulated to reduce signs of environmental allergies by: n Disrupting the internal allergy response n Creating a barrier against future episodes NEW PRESCRIPTION DIET ® Derm Defense ™ HistaGuard with ™ Complex Your first defense against future allergy outbreaks with HISTAGUARD COMPLEX , a proprietary blend of bioactives and phytonutrients Continuously NORMALIZES IMMUNE RESPONSE TO ALLERGENS with natural sources of polyphenols Supports SKIN REJUVENATION with vitamin A, zinc and essential fatty acids ©2016 Hill’s Pet Nutrition, Inc. ®/™ Trademarks owned by Hill’s Pet Nutrition, Inc. HillsVet.com