猫特应性皮炎综合征的治疗-系统性回顾（4）

王帆

Treatment of the feline atopic syndrome – a systematic review

猫特应性皮炎综合征的治疗-系统性回顾

作者：Ralf S. Mueller* , Tim Nuttall† , Christine Prost‡, Bianka Schulz* and Petra Bizikova§

翻译：王帆

Discussion

讨论

To the best of the authors’ knowledge, this is the first systematic review of therapeutic interventions for the feline atopic syndrome, both for FASS and feline asthma. Such reviews are standard practice in similar human and canine conditions, where the evidence is used as a base for treatment guidelines. The data evaluated in this review have been used to provide a summary of treatment recommendations (Table 10). Clinicians should note that these recommendations do not imply that all of the listed treatments should be used in all patients, nor that they should be considered in this order.

据作者所知，这是首次对猫特应性皮炎综合征，包括FASS和猫哮喘的治疗干预进行系统性回顾。在类似的人医和犬疾病中，这种回顾是标准惯例，证据被用作治疗指南的基础。本综述中数据评估已用于提供治疗建议总结(表10)。临床医生应该注意到，这些建议并不意味着所有列出的治疗方法都应该用于所有病例，也不应该按此顺序考虑。

Clinical manifestations of FASS are common problems that decrease the QoL of affected cats and their owners. They appear to be chronic conditions that require long-term management. It is therefore important to eliminate fleas, Demodex gatoi, and other ectoparasites and endoparasites, food allergens, bacterial skin infection/pyoderma, yeast overgrowth and differential diagnoses before making a final diagnosis. It also is likely that FASS and feline asthma have a multifaceted aetiology. As in cAD and human asthma, treatments may need to be combined to optimise the outcome for each cat. Clinical trials usually are designed to evaluate the efficacy of a single treatment and therefore may underestimate the efficacy of combination treatment.

FASS的临床表现是常见问题，常降低患猫及其主人生活质量。它们似乎是需要长期治疗的慢性疾病。因此，在作出最终诊断之前，必须排除跳蚤、戈托依蠕形螨、其他体外寄生虫和内寄生虫、食物过敏、皮肤细菌感染/脓皮病、酵母增殖和其他鉴别诊断。FASS和猫哮喘也可能有多方面的病因。就像CAD和人哮喘一样，可能需要联合治疗已达到对每只猫有最佳效果。临床试验通常是为了评估单一治疗的疗效，因此可能会低估联合治疗的疗效。

Treatment should be tailored to each cat, taking into account the severity, type and distribution of the lesions, and stage of the dermatitis and airway disease. It is likely that most cats will require more potent treatment (e.g. systemic glucocorticoids, topical and inhaled glucocorticoids, ciclosporin or oclacitinib) initially to induce remission.

治疗应针对每只猫，考虑病变的严重程度、类型和分布，以及皮肤病和呼吸道疾病的分期。很可能大多数猫最初需要更有效的治疗(如全身性糖皮质激素、外用和吸入糖皮质激素、环孢素或奥拉替尼)来诱导缓解。

Treatment can then be tapered and/or switched to less potent treatments (e.g. ASIT, essential fatty acids and antihistamines) to maintain the remission.

然后可以逐渐减少治疗和/或转向效力较弱的治疗(如ASIT、必需脂肪酸和抗组胺药)以维持缓解。

These treatment recommendations should not be read as a “diktat”, particularly considering the facts that many products are not approved for cats, pharmacokinetic data and dose-finding studies are lacking for most products,and safety data beyond the studies discussed here also are not available for most drugs. Not every treatment will be effective, tolerated or suitable in every cat. It is up to the individual clinician to evaluate their patient and discuss the advantages and disadvantages of each treatment option with the owners. This will include potential adverse effects, ease-of-administration, and cost as a single treatment or in combination. The owners’ preferences as well as concurrent conditions and medication also will have to be accounted for. Nevertheless, the treatments recommended in this review should be considered before moving to alternatives with less evidence of efficacy and safety in FASS or feline asthma.

这些治疗建议不是“绝对”的,特别是考虑到许多产品没有批准用于猫的事实,对大多数产品来说缺乏药代动力学数据和有效剂量研究,除了这里讨论的研究之外，大多数药物的安全性数据也无法获得。并不是每一种治疗方法对每只猫都有效、耐受或适用。这取决于临床医生对单个病例的评估，并与宠主讨论每种治疗方案的优点和缺点。这将包括潜在的副作用、管理的方便性以及单一治疗或联合治疗的费用。宠主的偏好、并发症和联合药物也必须考虑在内。然而，在使用对FASS或猫哮喘疗效和安全性证据较少的替代疗法之前，本综述中推荐的治疗方法应予以考虑。

The recommendations in this review were derived largely from the results of clinical trials reporting statistically significant changes in various outcome measures. Following best practice, the recommendations were based on SORT scores7(Table 1), which are a simple and robust way of evaluating patient-orientated outcomes. However, clinicians should note that statistically significant improvements do not necessarily mean that these are clinically significant (i.e. lead to an acceptable improvement in clinical signs and in the QoL for the patient and owner). Moreover, individual animals may have a better or worse response than the mean outcome reported in a clinical trial. In addition, most studies performed on feline asthma utilised small numbers of cats experimentally sensitised to HDN, Bermuda grass or A. suum and more studies are urgently needed assessing treatment options for naturally occurring feline asthma, as well as evaluating adverse effects of those therapies with long-term use.

本综述中的建议主要来源于临床试验的结果，报告了各种结果衡量指标在统计上的显著变化。根据最佳临床结果，这些建议是基于SORT评分7(表1)，这是一种简单而有力的评估以病例为导向的结果的方法。然而，临床医生应该注意到，统计上显著的改善并不一定意味着临床意义显著(即导致临床症状和病例和宠主的生活质量得到可接受的改善)。此外，个别动物的反应可能比临床试验报告的平均结果更好或更差。此外，大多数关于猫哮喘的研究使用了少量对HDN、百慕大草或猪蛔虫敏感的猫，迫切需要更多的研究来评估自然发生的猫哮喘的治疗方案，以及评估长期使用这些疗法的副作用。

This review highlights the limited evidence for some treatments in FAS. The analysis of the clinical trials was variously affected by small group sizes, uncontrolled studies, retrospective studies, deficient data reporting, and variable and nonvalidated outcome measures. Compared to the dog, where a rapidly increasing number of randomised, controlled trials are being published, fewer studies of lesser quality are found evaluating allergic cats and more randomised controlled trials are urgently needed. Wherever possible, the quality of clinical trials should be improved by designing double-blinded RCTs, using power calculations to determine adequate treatment cohorts, and using validated outcome measures (e.g. the SCORFAD and pVAS scales or lung function studies), similar to those published for dogs with atopic dermatitis and in human asthma. Other outcome measures relevant to the clinical significance of therapeutic interventions include a QoL score, and global scores for efficacy, tolerance and ease-of-administration. Minimum datasets should include intention-to-treat data with means or medians and an appropriate measure of variance (e.g. standard deviation or 95% confidence intervals). Additional useful outcomes include the proportion of cats reaching certain clinical thresholds (e.g. >50% and >75% improvements in pruritus and lesion scores or in lung function). Statistical tests should be appropriate to the data and, where necessary, advice from a statistician should be sought during design of the study.

这篇综述强调了一些治疗FAS的证据有限。临床试验的分析受到小组规模、不受控制的研究、回顾性研究、缺乏数据报告、可变的和未经验证的结果措施的不同影响。与犬相比，越来越多的随机对照试验被发表，较少的质量较差的研究被发现评估过敏患猫，迫切需要更多的随机对照试验。只要有可能,应该改进临床试验的质量通过双盲设计相关,使用功率的计算来确定适当的治疗组,并使用验证结果的措施(如SCORFAD和pva评分或肺功能的研究),类似于发表的犬特应性皮炎和人哮喘。其他与治疗干预的临床意义相关的结果指标包括生活质量评分、疗效、耐受性和易管理性的整体评分。最小数据集应该包括用平均值或中位数和适当的方差度量(例如标准差或95%置信区间)来处理数据的意向。其他有用的结果包括达到特定临床阈值的猫的比例(如瘙痒和病变评分或肺功能改善＞50%和＞75%)。统计测试应适用于数据，必要时，在研究设计期间应征求统计学家的意见。

The recommendations in this review are derived from an evidence-based consensus supporting use of an intervention and do not imply endorsement of specific therapeutic options or products. Furthermore, these recommendations do not consider availability or licensing specifics in individual countries. Clinicians should therefore choose individual treatments based on legal and ethical standards in their own country of practice.

本综述中的建议来自以证据为基础的共识，支持使用干预措施，并不意味着支持特定的治疗选择或产品。此外，这些建议没有考虑个别国家的可用性或许可细节。因此，临床医生应该根据自己国家的法律和道德标准来选择个人治疗方法。

This systemic review of therapeutic interventions has provided evidence for treatment recommendations in FAS (Table 10). It is hoped that these will aid clinicians in designing treatment plans to improve the QoL of their patients and their owners. The review highlighted shortfalls in the quantity and quality of published data. Clinicians are therefore encouraged to publish good quality clinical trials assessing the efficacy of existing and novel treatments. Future reviews including such data will improve the strength and breadth of treatment recommendations for FAS.

对治疗管理的系统性回顾为FAS的治疗建议提供了依据(表10)。希望这些将有助于临床医生制定治疗计划，以改善他们的病例和主人的生活质量。该评论强调了已发表数据在数量和质量上的不足。因此，我们鼓励临床医生发表高质量的临床试验，以评估现有和新疗法的疗效。包括这些数据在内的未来审查将提高FAS治疗建议的强度和广度。

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