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Abstract We compared the effect of propofol and saline control on intradermal test reactions in dogs with atopic
dermatitis undergoing outpatient intradermal testing (IDT). Nineteen dogs were used in this clinical study.
Patients were randomly allocated to receive either intravenous (IV) propofol or IV 0.9% saline, and IDT was performed on the right or left (randomized) lateral thorax. One investigator, unaware of the treatments, interpreted
all IDT results. Injection sites were analysed using a subjective and objective method. A value of P 0.05 was
considered significant. When all injection sites were subjectively analysed for reactions 1+ on all dogs, significantly more positive sites were apparent during propofol sedation than during saline administration. In addition,
the greater number of individual dogs experiencing more positive reactions 1+ during propofol sedation was
significant. When subjectively analysing reactions 2+, the greater number of positive reactions and the greater
number of dogs with more positive reactions observed during propofol treatment was not significantly different
from the saline control. When analysed objectively, the greater number of positive reactions observed during propofol sedation was not significant. A greater number of dogs had higher subjective scores and larger objective
measurements during propofol sedation compared with saline administration. In summary, propofol sedation
was associated with an overall greater number of positive IDT reactions compared with the saline control.
Although not always significant, this difference should be considered when choosing propofol for skin testing
dogs with atopic dermatitis.
Keywords: allergic dermatitis, allergy testing, atopic dermatitis, atopy, dog, intradermal allergy test, intradermal
skin test, intradermal test, propofol, sedation.
INTRODUCTION
Atopic dermatitis (AD), the allergic reaction manifested in response to inhaled or percutaneously
absorbed allergens, is a common skin disease in dogs.
Diagnosis of AD is based on a suggestive history, characteristic clinical signs, elimination of other causative
pruritic skin disorders and at least one positive intradermal testing (IDT) reaction.1 More importantly, IDT
is performed to determine the appropriate allergens
for immunotherapy in dogs with AD.2
Sedation is often necessary to adequately restrain
the patient and minimize stress during IDT. Unnecessary stress associated with physical restraint of patients
for IDT may cause endogenous corticosteroid release,
accidental subcutaneous injection resulting in no intradermal response, and frustration on the part of the
person conducting the test, all of which may adversely
affect the test results.3,4 Intradermal testing is commonly performed on an outpatient basis. Therefore,
any form of chemical restraint must be short-acting
with minimal residual effects. Several drugs have been
examined as chemical restraint agents for IDT, including acepromazine, oxymorphone, ketamine/diazepam,
ketamine/diazepam/atropine, tiletamine/zolazepam,
xylazine/atropine, medetomidine, thiamylal, methoxyflurane, halothane and isoflurane.3,511 On the basis of
these previous studies, acceptable chemical restraint
agents which do not significantly interfere with IDT
results include ketamine/diazepam, ketamine/diazepam/atropine, tiletamine/zolazepam, xylazine/atropine,
medetomidine, thiamylal, methoxyflurane, halothane
and isoflurane.3,511 Despite the fact that these agents
do not appear to affect the IDT results, each anesthetic
protocol has side effects making it less than ideal.
Propofol is a short-acting, noncumulative drug with
characteristic rapid induction and smooth recovery,
allowing short-term sedation with prompt recovery
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L. F. Graham et al.
169
Statistical analysis
The database analysed in this study included all of the
allergen injection sites, on each dog, that reacted during the propofol sedation or the saline control. A site
that did not react during one of the treatments, but did
react during the other, was included in the database
and was assigned a value of 0.
The scores assigned in the subjective method of assessment and the objective measurements were statistically
evaluated utilizing the paired t-test (two-tail test). The
number of sites that reacted, including the assigned zero
value for the sites where only one reaction was observed
during the two treatments, were counted and evaluated
with nonparametric statistical procedures. The chi-square
test for heterogeneity and the binomial test were used
under the assumption of equal probability (the null
hypothesis). Wilcoxons signed rank test was also used
on selected count data (one-tail test). Spearmans nonparametric method was utilized for the linear correlation analysis between the subjective and the objective
assessments.
The statistical analyses were performed using
software (SPSS, Version 11.0; Chicago, IL, USA). A
P-value 0.05 was considered statistically significant.
RESULTS
Nineteen client-owned dogs diagnosed with AD at
the University of Minnesota Veterinary Teaching
Hospital were included in the study. Six dogs were
female (three intact) and thirteen were male (three
intact). The ages ranged from 1 to 10.8 years (mean
4.9 years). Body weights were 7.843.4 kg (mean 22.6 kg).
Several breeds were represented, including Labrador
Retriever (3), Bichon Frise (3), Lhasa Apso (2), German Shepherd (2), Australian Shepherd (1), Golden
Retriever (1), Vizsla (1), Sheba Inu (1) and mixed breed
dogs (5).
To achieve a light plane of sedation, the dogs included
in this study required a mean propofol dose of 5.5 mg kg1
IV (range 1.86.6 mg kg1) for initial induction. This
dose was administered in 25% increments every 15 s
to achieve adequate sedation to perform the test. All
dogs required a minimum of four repeated propofol
injections of 0.5 mg kg1 IV (range 0.20.8 mg kg1)
given every 23 min. Four dogs required six repeated
injections to maintain an appropriate level of sedation
needed for IDT. All dogs maintained a palpebral
reflex, significant jaw tone and spontaneous respiration throughout sedation. The values for heart rate,
spontaneous respiratory rate, indirect blood pressure
and oxygen saturation during periods of propofol
sedation were within normal limits in all dogs (data not
shown). The sedation lasted for the time necessary to
complete the IDT interpretation (mean, 19.9 min,
range 12.225.1 min). All dogs recovered smoothly
and uneventfully. Recovery to standing was complete
in all dogs within 20 min after the last propofol
administration.
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L. F. Graham et al.
DISCUSSION
Although some companion animals will tolerate the mild
discomfort of IDT with gentle restraint, IDT is routinely
performed using short-acting sedation because many
dogs require sedation in order to accurately and efficiently complete the test. Many sedative drug combinations used for IDT have long recovery periods, are
controlled substances requiring record keeping, and/or
are associated with adverse physiological effects that may
not be appropriate in certain patients. Because IDT is
most commonly performed on an outpatient basis, a
171
Table 1. Average Spearmans correlation coefficient between the subjective and objective methods of IDT assessment during propofol sedation
or saline control treatment in 19 dogs with atopic dermatitis
Total number of positive reaction sites
Treatment
Propofol
Saline
r = 0.80*; n = 19
r = 0.87*; n = 19
r = 0.43; n = 16
r = 0.43; n = 11
r = 0.51; n = 18
r = 0.55; n = 19
*In each row, superscript letters indicate significant correlation between variables (P 0.05).
Number of dogs (n) is different from 19 due to inability to compute r when one or more of the variables become constant (e.g. all become equal
to 1).
2003 European Society of Veterinary Dermatology, Veterinary Dermatology, 14, 167176
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L. F. Graham et al.
173
of ketamine and diazepam is thought to have antihistaminic effects.5 Benzodiazepinedissociative combinations provide rapid and smooth induction with
adequate cardiopulmonary stability in most patients.
Unfortunately, the dissociative agents, ketamine and
tiletamine, are nonreversible and cause increased sympathetic activity, myotonia and catatonia. Recoveries
are rough, often taking hours before the dog is ambulatory. The decreased tear production and impaired
palpebral reflexes, characteristic of dissociative agents,
can result in corneal ulceration if adequate ocular
lubrication is not provided.21 Perivascular injections
are painful.21 Also, these drugs are controlled substances requiring secure containment and accurate
records. Therefore, the benzodiazepinedissociative
combinations are not ideal agents for outpatient IDT.
Clinically useful alpha-2 adrenergic agonists for IDT
include xylazine/atropine and medetomidine.3,5,10,11
These nonscheduled agents provide reliable sedation,
good muscle relaxation and analgesia, versatility in route
of administration and pharmacological reversibility.
Unfortunately, the use of xylazine has been associated
with increased mortality in small animal practice.22
Alpha-2 agonists have profound cardiovascular effects
including vasoconstriction and initial hypertension,
followed by long-lasting, centrally mediated hypotension.23 Decreased cardiac output, characteristic of
alpha-2 agonists, may be unacceptable in many older
or debilitated patients. Bradyarrhythmias are also common after alpha-2 agonist administration and may
require the administration of an anticholinergic. The
effects of anticholinergics on IDT are unknown,
although the increased intracellular cAMP levels
associated with the use of anticholinergics may stabilize
cells and prevent the release of inflammatory mediators.5 Two studies confirming the use of xylazine for
IDT in dogs have included atropine in the sedation
protocol.3,5 The sedative effects of xylazine and medetomidine last longer than is required for many IDTs.
Although xylazine and medetomidine are reversible,
antagonism increases the risk of rough recoveries and
can increase apprehension.24 Alpha-2 antagonism is
also associated with tachycardia and hypotension due
to alpha-adrenergic blockade, and the antagonist
increases the cost of the sedation.25 Additional adverse
effects of alpha-2 agonist administration include hyperglycemia, osmotic diuresis, emesis and unreliable sedation in some dogs.26,27 Temporary aggressive behaviour
has also been reported in dogs receiving alpha-2 agonists.28,29 For these many reasons, alpha-2 agonists are
most suitable for short-term sedation in young, otherwise healthy patients presenting for IDT.
Barbiturates, specifically thiamylal, do not interfere
with IDT in dogs.6 However, poor recovery quality,
sloughing from extravascular administration, transient
cardiopulmonary depression and the FDA-controlled
status make these drugs less than ideal for outpatient
procedures.
Inhalants including methoxyflurane, halothane
and isoflurane do not adversely affect IDT in dogs.6
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L. F. Graham et al.
However, the cost of vaporizers and machine maintenance, negative cardiovascular effects, public health
aspects of inhalant pollution and the difficulty of using
these agents without premedication in dogs make the
routine use of inhalant anaesthetics for IDT difficult
for many practitioners.
Owing to the desirable characteristics discussed
previously, propofol is an ideal sedative drug for IDT.
However, the results of this study showed an overall
trend for propofol to increase the IDT reactivity. Intravenous administration of propofol can cause histamine
release in a variety of species, including dogs.14,3032
Therefore, our results may be attributed to endogenous
release of histamine and known histamine release is the
reason for not using other agents, such as morphine
and meperidine, for sedation during IDT. 19 Paradoxically, propofol was shown to decrease the skin
reactivity to intradermal injections of serial histamine
dilutions in normal dogs.12 However, dogs with AD
may exhibit increased sensitivity to the histaminereleasing effects of propofol, causing an overall trend
towards increasing the IDT reactivity. Also, propofol
has been shown to cause peripheral vasodilation.33,34
This mechanism may also account for the overall trend
towards increasing IDT reactivity during propofol
sedation.
The trend for propofol to increase the number of
positive IDT reactions in atopic dogs may result in
hyposensitization to irrelevant allergens. In normal,
nonatopic dogs, six months of hyposensitization therapy to irrelevant antigens did not significantly change
the IDT reactions of subsequent tests and the dogs
remained asymptomatic.35 However, the long-term
effects of such hyposensitization protocols are not
known at this time.
In summary, this study demonstrated a significantly
greater number of positive IDT reactions during
propofol sedation, compared with the saline control,
only for subjectively evaluated reactions assigned a
score 1. However, results consistently demonstrated a
trend towards greater numbers of positive IDT reactions during propofol sedation. The tendency for propofol to increase the IDT reactivity may not be a
clinically significant problem, when weighed in consideration with the beneficial effects of this sedative over
other options currently available. Nevertheless, this
tendency must be emphasized and considered in subsequent clinical decisions.
REFERENCES
1. Scott, D.W., Miller, W.H., Griffen, C.E. Muller and
Kirks Small Animal Dermatology, 6th edn. W.B. Saunders,
Philadelphia, 2001: 5889.
2. DeBoer, D.J., Hillier, A. The American College of Veterinary Dermatology task force on canine atopic dermatitis (XV): fundamental concepts in clinical diagnosis.
Veterinary Immunology and Immunopathology 2001; 81:
271 6.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
175
APPENDIX 1
Allergens included in the intradermal test. Allergen concentrations are 1000 PNU unless specified in parenthesis
A. Controls
Histamine (1:100 000)
Sterile saline
A. Epidermals
Cat epithelia
Mouse epithelia
Sheep epithelia (wool)
A. Grasses
Corn pollen (250 PNU)
Kentucky/June bluegrass
Meadow fesque grass
Orchard grass
Perennial rye grass
Timothy
A. Household pollens and miscellaneous inhalants
Cotton linters
Dust mix (250 PNU)
Feather mix
Grain mill dust mix
House dust
House dust (250 PNU)
Kapok seed
Mixed mites (1:1000)
Pyrethrum
A. Insects
Black ant (250 PNU)
Caddisfly (250 PNU)
Cockroach mix (250 PNU)
Flea (1:1000)
House fly (250 PNU)
Household insect mix (250 PNU)
Mosquito (250 PNU)
Moth (250 PNU)
A. Mould
Alternaria tenuis
Aspergillus mix
Cephalosporium
Cladosporium
Corn smut
Fusarium mix
Helminthosporium
Hormodendrum
Penicillium mix
Rhizopus mix (250 PNU)
Rhodotorula
A. Trees
Ash mix
Black willow
Box elder
Eastern oak mix
Elm mix
Maple mix
Pine mix
Poplar, lombardy
Red cedar
White birch
A. Weeds
Cocklebur
Common mugwort
English plantain
Lambs quarter
Marsh elder/burweed
Nettle
Pigweed mix
Ragweed mix
Russian thistle
Sheep/red sorrell
Yellow/curly dock
2003 European Society of Veterinary Dermatology, Veterinary Dermatology, 14, 167176
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L. F. Graham et al.
Rsum Cette tude a valu les effets du propofol sur les intradermoractions ralises chez des chiens prsentant une dermatite atopique. Dix neuf chiens ont t inclus. Les patients ont reu soit du propofol par voie
intraveineuse soit du solut sal 0.9%. Les tests intradermiques ont t effectus, au hasard, sur la face latrale
droite ou gauche du thorax. Un investigateur, ne connaissant pas le traitement, a interprt les rsultats des tests.
Les sites dinjection ont t cts subjectivement et objectivement. Une valeur p 0.05 tait considre comme
significative. Lorsque les sites dinjection ont t analyss subjectivement pour les ractions 1+ un plus grand
nombre de zones de tests taient positives dans le groupe propofol en comparaison avec le groupe contrle. En
outre, la diffrence tait galement significative pour les chiens prsentant plus de ractions positives. En analysant les ractions juges subjectivement 2+, les diffrences ntaient pas significatives. Avec lanalyse objective,
le plus grand nombre de ractions observes dans le groupe propofol ntait pas significativement diffrent du
groupe contrle. Un plus grand nombre de chiens prsentait des scores subjectifs levs et des mesures objectives
leves pendant la sdation au propofol en comparaison avec le solut sal. En rsum, la sdation avec le propofol
tait associe avec un nombre plus important de ractions intradermiques positives en comparaison avec le contrle. Bien que les diffrences ne soient pas toujours significatives, elles devraient tre envisages si le propofol
est utilis comme sdatif pour tester les chiens prsentant une dermatite atopique.
Resumen El efecto del propofol en las reacciones de los tests intradrmicos fue comparado con la utilizacin
de la solucin control salina en perros no internados con dermatitis atpica en los que se estaba llevando a cabo
las pruebas intradrmicas (IDT). Diecinueve perros fueron utilizados en este estudio clnico. Se seleccionaron al
azar a los pacientes para recibir de forma intravenosa (IV) el propofol o la solucin salina al 0.9% y los IDT fueron
realizados en el trax lateral derecho o izquierdo (seleccionado al azar). Un investigador, desconocedor de los
tratamientos, interpret todos los resultados de IDT. Los sitios de inyeccin fueron analizados usando un mtodo
subjetivo y objetivo. Un valor de p 0.05 fue considerado significativo. Cuando todos los lugares de inyeccin
fueron analizados subjetivamente para reacciones 1+ en todos los perros, un nmero perceptiblemente mayor
de sitios positivos era evidente durante la sedacin del propofol comparada a la administracin salina. Adems,
el nmero superior de perros individuales que experimentaban un nmero mayor de reacciones positivas 1+
durante la sedacin del propofol fue significativo. Cuando se analizaron subjetivamente reacciones 2+, el
nmero mayor de reacciones positivas y el nmero ms grande de perros con un nmero mayor de reacciones
positivas observadas durante el tratamiento con propofol no fueron significativamente diferentes del control
salino. Cuando se analiz objetivamente, el nmero mayor de reacciones positivas observadas durante la sedacin
del propofol no fue significativo. Un nmero mayor de perros tuvo un ndice subjetivo ms alto y medidas objetivas ms grandes durante la sedacin con propofol comparado con la utilizacin de la solucin salina. En
resumen, la sedacin con propofol fue asociada a un nmero total mayor de reacciones positivas en el IDT comparadas al control salino. Aunque no siempre significativa, esta diferencia debe ser considerada en los si se elige
el propofol para la realizacin de tests intradrmicos en perros con dermatitis atpica.
Zusammenfassung Die Wirkung von Propofol auf Intrakutantest- (IKT-) reaktionen wurde bei Hunden mit
atopischer Dermatitis, bei denen ein Hauttest durchgefhrt wurde, mit der von physiologischer Kochsalzlsung
verglichen. Neunzehn Hunde wurden in dieser Studie verwendet. Die Patienten wurden randomisiert und
erhielten entweder Propofol oder IV 0.9%ige Kochsalzlsung intravens (IV) und ein IKT wurde auf dem rechten
oder linken Brustkorb (randomisiert) durchgefhrt. Injektionsstellen wurden objektiv und subjektiv bewertet.
Ein P-Wert von 0.05 wurde als signifikant erachtet. Wenn alle Injektionsstellen bei allen Hunden subjektiv auf
Reaktionen 1+ analysiert wurden, waren signifikant mehr positive Reaktionen whrend der Propofolsedation
feststellbar, verglichen mit den mit Salzlsung behandelten Hunden. Zustzlich war die Anzahl der Hunde mit
einer grsseren Anzahl von positiven Reaktionen 1+ signifikant vermehrt. Wenn subjektiv Reaktionen 2+
bewertet wurden, waren die grssere Anzahl der positiven Reaktionen und die grssere Anzahl von Hunden mit
einer erhhten Anzahl von positiven Reaktionen bei Sedation mit Propofol nicht statistisch signifikant. Wenn
objektiv bewertet wurde, war die whrend der Sedation mit Propofol wahrgenommene grssere Anzahl von positiven Reaktionen nicht signifikant erhht. Eine grssere Anzahl von Hunden hatte hhere subjektive Werte und
grssere objektiv gemessene Reaktionen whrend Sedation mit Propofol verglichen mit der Behandlung mit
Kochsalzlsung. Zusammenfassend war eine Sedation mit Propofol mit einer grsseren Anzahl positiver IKT
Reaktionen verbunden als Kochsalzlsungsbehandlung. Obwohl der Unterschied nicht immer signifikant war,
sollte er bercksichtigt werden, wenn Propofol fr den Hauttest beim Hund mit atopischer Dermatitis verwendet
wird.