Combination Therapies for Protein-Losing Enteropathy: Which is Best?

Protein-losing enteropathy (PLE) can arise as a consequence of chronic enteropathy in dogs and, if so, usually carries a guarded prognosis. Immunosuppressive therapy with prednisolone and azathioprine is commonly recommended; however, azathioprine is associated with undesirable effects. Chlorambucil, by contrast, is widely used in treating chronic enteropathies in cats and has been well tolerated and efficacious. This case study compared efficacy of azathioprine versus chlorambucil versus both in combination with prednisolone for treatment of PLE in dogs (n = 27). Dogs in group A (n = 13) received prednisolone (2 mg/kg PO q24h) and azathioprine (2 mg/kg PO q24h), and group C dogs (n = 14) received prednisolone (1–2 mg/kg PO q24h) and chlorambucil (4–6 mg/m2 PO q24h). Treatment response was assessed and immunosuppressive medication tapered gradually at 2–4 week intervals. Response was significantly better in group C than group A. After 2 weeks, serum albumin concentration increased by 36% in group A and 56% in group C. Clinical signs (including body weight) improved in 6 dogs in group A and 12 in group C. Median survival time for group A was 30 days whereas median survival time was not reached in group C. At study end, 2 dogs from group A were still alive compared to 10 from group C. Results suggested combination therapy with chlorambucil and prednisolone is more effective in treating PLE in dogs than azathioprine and prednisolone.

Commentary

PLE treatment can be quite frustrating because of the guarded prognosis. After diagnosis, the decision of which drug combination to initiate can be difficult. This study is relevant because the combination of chlorambucil–prednisolone has steadily gained popularity because of the perceived improved efficacy. This study provided more evidence that the combination is likely more effective than azathioprine–prednisolone; however, the role of cyclosporine in PLE treatment was not addressed. Multimodal therapies are often necessary in severe cases, and 3 immunosuppressant medications are typically required for disease control. Still, determining medication order can be a challenge, but based on these results and other anecdotal evidence, I recommend the combination of chlorambucil–prednisolone as the initial therapy in severe cases of PLE.—Dara Zerrenner, VMD, MS, DACVIM

Source

Comparison of a chlorambucil-prednisolone combination with an azathioprine-prednisolone combination for treatment of chronic enteropathy with concurrent protein-losing enteropathy in dogs: 27 cases (2007–2010). Dandrieux JR, Noble PJ, Scase TJ, et al. JAVMA 242:1705-1714, 2013.