Dr. Angie Krause (00:00)
Welcome back to Tails of Truth, where we tell the truth about veterinary medicine. I'm Dr. Angie, and this is my co-host and veterinary nurse extraordinaire Jojo. And today we are hanging out with Dr. Darren Dell, who is a veterinary dermatologist at Wheat Ridge Animal Hospital in Wheat Ridge.

and I email Dr. Dell every single day with something, maybe not every day, at least once a week.

Darin Dell (00:28)
It's not every day.

Maybe it's once a week, but that's okay.

Dr. Angie Krause (00:32)
Once a week over.

JoJo (00:32)
They're really funny.

love these emails between you two. It's Dr. Angie's like, help. WTF, what is this? And then Dr. will respond, my God, a Frenchie. That's what those emails look like.

Dr. Angie Krause (00:40)
lol

Hehehehehe

Darin Dell (00:47)
Well, you know, again, we have to have a little fun. That's why

we got into this job. We wanted to help pets and have fun. we should never stop doing that.

Dr. Angie Krause (00:56)
Yes.

But I mean, I think our email relationship has been going on for well over a decade. It's yes.

Darin Dell (01:02)
It's been quite some time. It's been quite some time, but that's

great. I again, I want to help more people and I know that a lot of veterinarians don't get any dermatology experience, like in school. ⁓ And then dermatology CE is pretty limited as well. So I love when people ask questions, like, let's get your questions answered. Let's fill those voids in your knowledge because that means you can help more pets.

Dr. Angie Krause (01:15)
Yeah.

Yes, I appreciate that because I want every single patient that comes into my exam room to get the best that they possibly can. And I don't know a lot and all the things.

Darin Dell (01:31)
Absolutely.

you do too. You know more than you think.

It's just, it's weird. ⁓ I mean, whole thing that dermatology should be easy, right? Because you just look at it. People are like, that all you're going to do? Yeah, I'm just going to look at it. That's what I do. I look at things. But it's not, right? Because so many things look the same. That's where the struggle comes in. And then really taking into account everything else about that pet. So the Derm exam is relatively easy.

Dr. Angie Krause (01:45)
Mm-hmm.

JoJo (01:45)
⁓

yeah.

Dr. Angie Krause (01:54)
Mm-hmm.

Darin Dell (02:00)
going through the history and what's the rest of the physical exam and what are the comorbidities and what are the other drugs and that's where it gets really complicated.

Dr. Angie Krause (02:07)
Yes, and I see itchy dogs every day. All year round, I have itchy patients.

Darin Dell (02:10)
yeah. Yeah. Well we didn't have winter

this past year. We never got it. So that doesn't help. And then spring started really early. I've never paid so much attention to pollen counts as I have since I've become a dermatologist. And I can tell you that they are bad right now. Very bad. Yeah. Yes, it does. Yeah.

Dr. Angie Krause (02:17)
Yeah. Yes.

Okay, that reflects my schedule. That reflects my schedule.

JoJo (02:29)
that's good to know.

Dr. Angie Krause (02:33)
And a lot of times I get into trouble when I do all the things I know to do and I'm not getting results. And that's when you get the email with the title or the subject SOS. Please help me now. Yes.

Darin Dell (02:44)
I get very fair, very fair. Because that's

JoJo (02:43)
You

Darin Dell (02:47)
when everybody gets frustrated and what we don't want is for clients to give up.

Dr. Angie Krause (02:51)
And I think if you have

JoJo (02:51)
Well, and Dr. Angie,

that's really evidence, just so you know, of how much you advocate for your patients, that you're not afraid to ask for help. I'm just gonna put my two cents in there. Yeah.

Darin Dell (02:59)
Right. That's a good point. ⁓

Dr. Angie Krause (03:00)
Yeah.

Darin Dell (03:03)
I really think that we don't teach veterinarians how to ask for help or how to ask for a consult very well. Like your emails make a lot of sense. You put all the pertinent information, you give me everything I need to know, and you send me a picture or two. You know, that gets me a long ways. But if you don't know how to speak that language, it's really hard to get help. So I think

You know, veterinary schools could do a lot more. Obviously, they don't have time or money for it. But explaining how to refer a patient or how to talk about a patient would go a long way, I think.

Dr. Angie Krause (03:30)
Yes. Well, I graduated in 2007 and at that time we were taught you're going to lean heavily on specialists. And so I came into medicine at a time where you did, there were a lot of phone calls and I feel like as things evolve, I don't have access to specialists. You're one of the very few specialists that I can reach out to and know that you're probably going to get back to me and help me. But most of the time you just, hard to either get them on the phone or they just.

They don't talk to veterinarians anymore. And so it's kind of lonely out here.

Darin Dell (04:01)
Yes, I I get that. I understand. So a little background on me. So I graduated at Illinois in 2001. I worked in general practice for six years, started a residency in dermatology at a private practice. After a year and a half that residency was closed, not my fault, I had to find a job. So I worked overnight ER for two years and then finished my dermatology residency. So the big joke at that time was that I was the dermatology resident doing overnight ER.

I had a criticalist to ask questions of and you know, other friends to talk to. But I get it. I know how lonely it can feel out there. Even though you've got other people around you, just some of these big questions are the things that don't make sense. Yeah, you're out there doing it on your own.

Dr. Angie Krause (04:39)
Yeah. So I appreciate every time you've answered my email and all my questions, but a lot of questions I get from clients when they come in with their itchy dogs and we're trying to figure out, it food or is it environmental? talk about itch suppression. And so I tell them like, no matter what we need to rescue your dog from their itchy states, no matter if it's a bacterial infection and allergy, whatever's happening. And when people Google Cytopoint, Apoquel,

Darin Dell (04:42)
Of course!

Dr. Angie Krause (05:07)
I guess we have some like new kids on the block now.

Darin Dell (05:09)
We do,

yes. We have new drugs, Zenrelia Numelvi soon-to-be-Benfrelia, yep, lot's of stuff.

Dr. Angie Krause (05:15)
And people are scared of them. What would you say to those people?

Darin Dell (05:17)
Yes. So

many things. So it is important to rescue them from their discomfort, right? So some folks do feel that allergy is not that important, but for those of us who have allergies ourselves or you've watched a dog scratch all night, you know that that's, you know, it is a severe thing. ⁓ I also like to talk about symptoms ⁓ since we have so many drugs, you know, that's

I want to know the pet's None of them are wrong or bad. It's just we need to know the symptoms so we can pick the best medication. But why would we not want to make their lives more comfortable? they make our lives better. We're here to make their lives better. Why would we not do that? I think on the veterinary side, we get hung up sometimes on arguments about side effects and what this could mean. These drugs, whether it's Cytopoint or Apoquel or the new ones, they're all very similar to human medicine that have been out for

decades. we're just lagging behind. There's a good chance that a lot of your clients are taking one of these nib drugs for something, or they know somebody who is. So they have personal experience with it probably with a similar drug. They just don't have the same fears for themselves, which is funny, right? ⁓ These drugs are very safe and very well tested. And it's just the new class of medicine that we're all being exposed to.

Dr. Angie Krause (06:27)
Mm-hmm.

Yes. Well, and when I got out of school, a lot of times we were just still suppressing with prednisone or cyclosporine. So we were just doing this really broad immunosuppression. so now suppressing it just safer than ever. Like we've come so far.

Darin Dell (06:47)
Absolutely, yeah.

We have come a really long ways, and again, that's why I like to talk about symptoms, because most allergy dogs do scratch, but not all of them. ⁓ And then I think you also have to take into account the breed. I know you're excited about the Frenchies, but some breeds, like I see a lot of Mastiffs and Newfoundlands, St. Bernards, those dogs that barely show any pain, they also don't show a lot of itch sometimes, right? They just, meh. they've been bred to live their lives.

just taking whatever comes out them I think they're tough dogs and so your little dogs that were bred to be to look a certain way or to just be in your purse or on your lap they don't quite have that same ⁓ i'm not sure the right word there grit i like grit grit is a good word yeah yeah let's go with that so anyway we got a long ways from what itch is but

JoJo (07:24)
Great. Yeah. Yeah.

Well, if is not having

that, if the dog is not presenting with itch, like these breeds that you just mentioned, what is bringing them to your office?

Darin Dell (07:40)
Ah, something is wrong. So keep in mind that what I tell clients is that allergy at its root is inflammation in the skin. Nobody can argue that. It is inflammation in your skin. A lot of dogs are going to scratch because they don't know what else to do with it. But sometimes inflammation is a rash. Sometimes it's hair loss. Sometimes it's dry skin. Sometimes it's odor. Sometimes it's a swollen foot, swollen lymph node, anal gland problems, ear problems. It can be a myriad of skin issues.

Dr. Angie Krause (07:47)
Mm-hmm.

Darin Dell (08:03)
So I see a lot of people that come in not knowing how all these things fit together and oftentimes allergy is that underlying trigger that sparks that inflammation and causes a bunch of problems.

Dr. Angie Krause (08:14)
Okay. And so what would you say for the guardian of the three year old Frenchie who has allergies and you're and we're probably, this dog's probably going to be on Cytopoint maybe for the next 10 years. Are, are we worried that Cytopoint is going to increase our risk of cancer?

Darin Dell (08:21)
Mm-hmm.

No, I'm not worried about that whatsoever. So the the good and bad thing about Cytopoint ⁓ is that it is not a drug, right? So it's a monoclonal antibody. It was our first ever monoclonal antibody in veterinary medicine, which is pretty cool. We don't give that enough props. But that means that it does one thing. It stops the feeling of itch very very safely. It's not metabolized by the liver. It doesn't get excreted into the kidneys. It is a very very safe product. That's why there's no age restrictions. There's no

comorbidity restrictions, you can give it to anyone anytime. I do not worry at all about Cytopoint causing cancer or life threatening problems. I do, however, worry that Cytopoint is masking a symptom and not treating the allergy. That is what usually gets us in trouble. Because again, it's stopping the feeling of itch, the allergy inflammation in the skin, still there.

JoJo (09:18)
Hmm.

Dr. Angie Krause (09:23)
Right.

JoJo (09:24)
my dog's no longer itching, therefore problem solved.

Darin Dell (09:27)
Correct. We still

Dr. Angie Krause (09:27)
Yes.

Darin Dell (09:28)
thought

a lot when it first came out. We'd see them back for re-checks and the owner would be, yeah, this is great. And you'd look at their feet and they would be disgusting or they'd have an infection there or they just wouldn't notice because they thought, no, I'm done. ⁓ But the good thing is, as you mentioned, when in 2007 we only had steroids and cyclosporine and immunotherapy, we should get to that, but all we had was blanket suppression.

Dr. Angie Krause (09:41)
Right, right.

Yes.

Darin Dell (09:52)
So until Cytopoint and Apoquel came out, I don't think we fully understood just where that division was going to be, you know? Because it's true, when dogs scratch, obviously they make it worse, right? So the theory was that if we just stop scratching, it wouldn't be worse. And that's true, but when you pull out the itch, then you get to see the inflammatory part for what it is. And that's what I think, we're still missing some products to treat that, so.

Dr. Angie Krause (10:13)
Right.

What products do you think will be developed for that?

Darin Dell (10:20)
I think that we'll see some JAK inhibitors that focus more on that than the itch. So all the ones we have now really focus on stopping the feeling of itch because that's right or wrong in America. We feel that allergy causes itch and we want itch to stop as fast as possible. Again, right or wrong. ⁓ So that's where all these drugs are focused on because they want to sell drugs. ⁓ But I think the more that we see

Dr. Angie Krause (10:25)
Okay.

Darin Dell (10:46)
there's still this symptom. there's still this swollen foot. there's still this ear infection. We're going to see some shift away from that and go towards the allergy inflammation part. So I'm hoping.

Dr. Angie Krause (10:54)
Okay.

JoJo (10:55)
And Dr. Dell, are you using the newer classes Zenrelia and the new Numelvi

Dr. Angie Krause (10:55)
And what do you think? go ahead. Yeah, that's what I was going to ask.

JoJo (11:00)
that's coming out? Well, the Nu Melvi is out, right?

Darin Dell (11:01)
⁓ that's... New Numelvi

is out. It's been out like two weeks, I think. ⁓ So I've been using Zenrelia for the last year and a half with good success. I've actually been very happy with dogs that were no longer responding to Apoquel responding well to Zenrelia. Safety is the same. Side effects are the same. It's a very good product. Nu Melvi just came out, so I don't have as much experience with it just because our shipment hasn't shown up yet. But it should be safer based on the science.

JoJo (11:27)
Okay, because the Zenrella had some some warnings that I saw that had been removed. So I wondered if that ever comes into play. Yeah, okay.

Darin Dell (11:27)
So I'm excited about it.

Dun dun dun. Okay, that's a great thing.

If you could just share this with anyone who gets Zenrelia that'd be great. So the original study, keep in mind that the drug study to get Zenrelia approved happened during COVID. So I can say that because I participated in it and it was terrible. Normally during a drug study, you have a person that comes in and talks with you every week and they go over all your stuff and they kind of guide you through it. Because it was COVID, we did that remote and it was...

not the same. It was a challenge. And the complications they found were kind of similar. So in their study, their toxicity study where they were giving puppies a 5X labeled dose, those puppies got vaccinated and two of those puppies in that group got sick. So we've already got puppies, which it's not labeled for, taking a 5X dose, which you would never do, and you vaccinated them and two got ill. I'm not very surprised by that at all, but

It happened during a study, the coordinator couldn't be in there kind of helping in person. And so it is. And anything that happens during a drug study is reported as a side effect. That's why you see so many things on the side effect. You know, if the dog has GDV while it's on the study, then GDV is a side effect. If it gets hit by a car, then being hit by a then death is a side effect. I mean, it's meant to be strict so you don't miss anything, but it also can go too far.

Dr. Angie Krause (12:44)
Yeah.

Darin Dell (12:48)
there was a follow-up study that showed that dogs achieved adequate vaccine titers after being vaccinated while they're on Zenrelia and then the FDA removed that virus activation label warning. So I don't worry about any of that.

Dr. Angie Krause (12:59)
great. Okay. So I can use Zenrelia can vaccinate my patients and we're not worried. Okay. So you would, you would think it's safe for me to use Zenrelia because usually I wait, a year, but you've done the year for me and you've used it a lot.

Darin Dell (13:11)
Yeah, I've

been very happy with it. Again, dogs where Apoquel stopped working or isn't working as well, or maybe those dogs where you send home the prescription and the owner is giving twice as much as you said. Does that happen? Yeah, that happens to you too. Well, I give it twice a day because it works better. like, I don't want, I don't really want that, ⁓ for you. So that's a great, that's where I started using Zenrelia for those patients where your dose is a little higher than I want. I know it works, but I don't want to do that. Try this instead.

Dr. Angie Krause (13:23)
Yes. Yes. Yeah.

Yeah.

Darin Dell (13:40)
⁓ I've also found more success with using Zenrelia for patients who have otitis externa. I've never found Apoquel very good at preventing that, whereas Zenrelia seems to do a decent job. Not as good as cyclosporine, but ⁓ again, pros and cons. So I would definitely use it.

Dr. Angie Krause (13:54)
Okay. Okay.

JoJo (13:55)
And is it accurate that

that needs to be given separately from vaccines? Is that inaccurate?

Darin Dell (14:00)
well, so it's still a warning. It's still on the warning label, so I'm obviously not going to go against the FDA, but ⁓ I am not worried about vaccinating patients while they're taking Zenrelia. I do not recommend personally any changes to their vaccine protocols or Zenrelia dosing.

JoJo (14:02)
Okay.

Yeah

Okay.

Okay, cleared all that up.

Dr. Angie Krause (14:16)
Nice.

Darin Dell (14:16)
Okay,

yeah, I get asked ⁓ five times a day. So, yes. I'm like, please, please. And I even told Elanco, I'm like, could you please keep telling people about this? Like, the follow-up studies are very good. So, please share. Yeah, and so the new product, the NU Melvi is a selective JAK inhibitor, meaning that there should be less side effects because it'll hit other, it's less likely to interfere with other cytokines.

Dr. Angie Krause (14:21)
Do you really? Okay. You're like, please distribute this information.

Okay.

Darin Dell (14:42)
So I definitely don't want to talk about cytokines today more than that. ⁓ But realize that your side effects from Apoquel come from the impact on other cytokines that are responsible for red blood cells or white blood cells, those sorts of things. So Numelvi shouldn't interact with that. I just haven't used it much. So we'll see.

JoJo (15:01)
I told Dr.

Dr. Angie Krause (15:01)
don't

see a lot of side effects.

JoJo (15:02)
Angie they're going to sell a ton of it just from their fantastic marketing.

Darin Dell (15:05)
The marketing is pretty cute, I have to admit. Resting itch face.

JoJo (15:07)
It's so, the resting itch

Dr. Angie Krause (15:08)
the resting itch face?

JoJo (15:10)
face

Dr. Angie Krause (15:10)
Ugh, so good.

JoJo (15:11)
is so fantastic. I mean, if that's sitting on a shelf, somebody's gonna want it.

Darin Dell (15:15)
Yeah.

Dr. Angie Krause (15:15)
Yeah.

Well, and I don't see a lot of side effects with Apoquel. Have I missed something? I just don't. Okay. Okay.

Darin Dell (15:19)
No, you shouldn't. So it's really only about 4%. ⁓

So, and the same for Zenrelia So 4 % means you might see it in 10 years or you might not. ⁓ Again, those side effect dogs come to Wheat Ridge. So I either see them or they maybe they're seeing internal medicine because they're worried about the bone marrow or something. ⁓ So yeah, in practice, you're not going to see it much.

Dr. Angie Krause (15:30)
Yeah. Yeah.

Okay. Okay. Okay. Well, that's great.

Okay. Well, a lot of people come to me because I'm an integrative veterinarian and they come to me with their itchy dogs and they're like, we want to get to the root cause. And they come to me like, I'm trying to heal my dog's gut. And, and I'm like, well, I know exactly who you need to see for the root cause. And I think I say your name once a day. It's yours. Yes. I was like, you need to see.

Darin Dell (16:01)
Aww. Hopefully it's me.

Yay, hopefully it's me. I'm like, this

would be so embarrassing if it wasn't me.

JoJo (16:08)
Yeah.

Dr. Angie Krause (16:08)
It would be so embarrassing.

Yeah, Darren Dell at Wheat Ridge. was like, this is the pinnacle of root cause treatment where we don't need to heal your dog's gut necessarily. We don't need to do all of these things. We need to, you know, work at the level of the immune system. So tell us when I send, when I send the Frenchie to you, tell me what you're doing.

Darin Dell (16:26)
Absolutely.

Yes,

the three-year-old Frenchie, absolutely. So ⁓ first I just give them little background of food versus environmental allergy, kind of cut through some of the garbage that's out there because there's so much ⁓ inaccurate advertising. So we kind of cut through that. And then I'll talk about the choices. So I always talk about drug choices first because they work faster. So my theory is that if we need to use a medication to make the dog comfortable, then we should do that first.

Dr. Angie Krause (16:33)
Yes.

Darin Dell (16:57)
⁓ Nobody wants their dog to be uncomfortable. And then we pivot to immunotherapy and allergy testing. allergy testing is the allergy testing and immunotherapy, I should say. Immunotherapy is our only way to treat allergy without using a medication and to get to the root cause. So we're really trying to reverse that hypersensitivity because allergy is just a hypersensitivity to something like oak pollen or maple pollen, especially right now. ⁓ So if you're allergic to that, can make that go away. And that's the really cool thing.

that we can make you not sensitive. There also is this thing called blocking antibodies, so you're less likely to react. And if you do react, it's going to be less and slower. So immunotherapy does a lot of great things. ⁓ It can also, it's the only treatment that can stop your allergy from progressing over time. So just like in people, in people that have a fancy name, they call it the atopic march. And it just means that as you age, your allergy gets worse. ⁓ It happens in dogs too. Most people will eventually

live long enough to age out of their allergy. They sort of desensitize themselves over 40 years. Dogs, unfortunately, don't have that option. So immunotherapy helps us get there faster and can really get to the root cause. So yeah, that is by far my favorite thing. I do have a lot of, I don't want say I scare people, but I really try to make sure that they know what they're getting because nothing annoys me more than someone who says, I did an allergy test and then nothing happened.

I don't want you to pay for something if you're not going to do the next thing, right? So, ⁓ I got a lot of folks that think, I'll just do an allergy test and then I'll know. That's actually not going to help you.

Dr. Angie Krause (18:24)
Right.

JoJo (18:31)
Dr. Darren, can you break that down too? Because allergy test is a little bit confusing because what you do for allergy testing is not the same thing as the boxes that people are sending out to all of the online sellers of those.

Darin Dell (18:34)
Absolutely.

Dr. Angie Krause (18:35)
you

Darin Dell (18:41)
Correct, correct, correct. Oh, this

is fun, I love this. So, what dermatologists typically do is an intradermal test or a skin test, or the skin prick test if you were a person. So it's the same thing that a person gets. For people, they do it on your arm or maybe on your back. And what we're doing is we're exposing the skin to numerous different allergens and then we're watching the skin respond. And that is the gold standard test because there's, I like to say, no middleman. I'm exposing you to juniper pollen and I'm going to see right there.

Dr. Angie Krause (18:45)
Yeah.

Darin Dell (19:09)
Is that a thing for you or not? So it's a very simple, very direct test. ⁓ For dogs, we do give them a light sedation. So it's a little twilight sedation so they don't remember. And of course we have to shave a patch. But ⁓ I think it's the sedation that ⁓ is important because our test is 70 different things because I think you need to go big or go home. ⁓ So the skin test is preferred. The secondary test that we do is a blood test where they're measuring an inflammatory protein in the blood.

Dr. Angie Krause (19:28)
wow.

Darin Dell (19:37)
Blood tests are still good. ⁓ The confusion there is that there's so many different companies and they're not all quite equal. But blood testing is useful. I do it when, you know, maybe I can't sedate the dog because it's a Frenchie and it doesn't breathe well. Or it's a show dog and I can't shave it. Or they just drove four hours to see me and I can't logistically get through while, you know, doing that. So blood testing can still be useful. It does matter which lab you use. And then there's the other stuff.

which is not useful. there are of course hair and saliva tests that you can find on Instagram and Facebook and even Groupon once I found one of those. And those are not even rooted in science. I'm sorry, there's actually no science to that. Several years ago, a dermatologist did a study where he took hair and saliva from healthy dogs, from allergic dogs, and then he took hair from stuffed animals and sterile saline.

and he submitted that to those companies. And those stuffed animals were very allergic. That saline was very, very allergic. And it sparked off this kind of argument where the company complained and he wrote a letter back and they complained back to him. And it went around and around a little bit. And the truth was that, if you can find allergies in sterile saline, then you don't have a test. That's not...

JoJo (20:36)
my God.

Dr. Angie Krause (20:58)
Wow.

Darin Dell (20:59)
That's not a thing. So it's a very funny

Dr. Angie Krause (20:59)
Yeah.

Darin Dell (21:01)
paper because they talk about all the stuffed animals that they bought and they kept them in sealed plastic bags and they just, you trimmed off the fake fur and...

Yep. So no practical use from those hair or saliva tests. There's no science. Nope.

JoJo (21:10)
Wow.

Dr. Angie Krause (21:11)
Yeah.

None. Yeah. And

people spend a lot of money on them. I see those test results every day and I have to just say, I'm so sorry that this isn't helpful. You know, I just, I'm so sorry this happened to you. They get so mad at me.

Darin Dell (21:20)
they

Yeah, right.

JoJo (21:27)
I think they get so mad at you for that too. They want, they

really want that to be the answer.

Darin Dell (21:33)
I'll send you a copy of that paper. It's quite funny because you just can't argue with that. great. And then we do something else. ⁓ But the reason that I go through all that with clients that you send me or anybody sends me is that allergy testing is just one piece, right? We do need to know what you're allergic to, but it's very rare that they could go home and change something. The dogs still has to go outside. They're not going to, you know, even if they...

JoJo (21:36)
That would be great.

Dr. Angie Krause (21:37)
Okay. Yeah, yeah, not helpful. And then I send them to you. And then we, then we use something else. Yeah.

Darin Dell (22:00)
xeri scape their entire yard the neighbor isn't going to you just can't get away from all this pollen there are times you know i had i had one client who had the dog was allergic to feathers and they had several birds and they actually made the choice to get rid of the birds surprisingly ⁓ i had one client who ⁓ ran a kennel and the dog was allergic to other dogs and so she stopped taking her dog to her kennel and that helped but that's two cases in twenty five years so

Does it happen? Yeah. Is it going to happen for everybody? No. ⁓ So the test itself is really just to get us to immunotherapy, which is where the magic happens. And unfortunately, just like in people, that treatment can take months and months, up to a year to even work. So I really want to make sure that I prepare people that we're investing in the future. We're doing this now so that next year is better, so that the next five years are better, so that your dog's whole life is better. And definitely for those young Frenchies, that's

that is the absolute best time to do it. Let's do it when they're three, because then they could have 12 years of benefit versus 12 years of whatever drug it happens to be.

Dr. Angie Krause (23:07)
Yes. Yeah. I see great results. I see really great results with what you do. Yeah.

Darin Dell (23:09)
Yeah, yeah, it's, ⁓

it does work. ⁓ The other thing that I harp on people, and hopefully not too much, ⁓ I harp on them that communication is key. So if you were a person taking immunotherapy, if you know anyone who has, they make you go into the doctor every week or sometimes twice a week for your shot. Right, so that's also the time for the nurse to ask you questions. How are you feeling? What happened this week? Yada, yada, yada, yada.

So I really harp on my clients that I need to know everything like you gave the shot and you were itchier you went to Breckenridge and you were itchier or you went wherever like all those little facts helped me adjust therapy and make it unique to that pet so that's where I get really excited because I can tailor it specifically to that animal but The other side of that is when I have clients who disappear for six months and don't tell me anything. I can't tailor it to your pet so

Dr. Angie Krause (24:05)
⁓

okay. So you're in a lot of contact with everybody.

Darin Dell (24:06)
You know? I-

that's- it works best that way. There's so much- Yes. Yes.

Dr. Angie Krause (24:11)
Are they emailing you too?

How much time do you spend every day in your email box?

Darin Dell (24:18)
goodness, two hours or so? Yeah, but again, that's how you tailor it and make it work better.

Dr. Angie Krause (24:22)
Wow, amazing.

Right.

So they'll say, Hey, I went up to Summit County and my dog was itchier. so you, so do you know what's growing in Summit County then?

Darin Dell (24:33)
So you

can check pollen counts by zip code. So if you know where they went and when they went there, you can do the work and find out, what was that? And then I can look at their allergy test and say, okay, do I have that ingredient in your allergy serum or did I choose something else instead? Because our allergy serum doesn't contain everything you're allergic to. That doesn't actually work. We try and keep it around 10 or 12 ingredients. So we just try and

Do we have the right mixture of things? And knowing, again, if they flared when they flared where helps me adjust that next time.

Dr. Angie Krause (25:08)
Okay. And what would be the investment for the testing and the year of immunotherapy?

Darin Dell (25:14)
that's a good question. ⁓ Right now it's probably closer to 2000, which feels like a lot to me, but when you think about a year of medicine, it's actually not. I'm still, again, graduated in 2001, so I still struggle. ⁓

Dr. Angie Krause (25:16)
Yes.

Okay.

Yes. We'll compare it to every

JoJo (25:29)
And is insurance covering that

ever?

Darin Dell (25:31)
So if they bought insurance before they have allergy symptoms, yes. A lot of it will. Just like anything else, if they get insurance after they've got a diagnosis, then probably not.

Dr. Angie Krause (25:41)
Well, compared to every other specialty, that's actually, that's really good. Yeah. Yeah.

Darin Dell (25:44)
no we're very reasonably prized right just again

you in my heart it it hurts a little bit but

Dr. Angie Krause (25:49)
Yeah. Yeah.

JoJo (25:51)
But

if you think about the return on investment over a lifetime, if you broke that down over the next 10 years, that's actually not that much.

Darin Dell (25:54)
yeah!

Yeah, it's a big benefit to the pet. And again, if we can stop the allergy from getting worse, if we can freeze it in time right there and not have new symptoms, that's a big thing, especially for these Frenchies and the English Bulldogs too. And the Bull Terriers. my gosh, Bull Terriers are terrible too. I mean, they're sweet dogs. I love them. I do love Bull Terriers, but their allergies are bad.

Dr. Angie Krause (26:11)
Mm.

Yes.

Yes. What's the most allergic dog you see?

Darin Dell (26:20)
I would probably have to be the English Bulldog. Yeah. They're always the worst. I think the bull terriers are just sad when it happens, because they're just... I don't know. I don't know if they think a lot, those bull terriers. I don't know what's... how much is going on out there. They're sweet though, I love them.

Dr. Angie Krause (26:22)
Yeah. Yeah.

Aww.

you

Yeah, yeah. What dog do you think I could get that you would feel pretty confident is less likely to have allergies?

Darin Dell (26:42)
Ooh, boy, that's a tough question. What don't I see? You know, I don't see a lot of English springers. That's one that I've always really admired, because I think they're a good, I feel like they're a medium-sized dog that can do a lot. It could hike with you, it could run with you, but it's not, you know, gonna take up your whole bed. And it's rare that I see an English springer.

Dr. Angie Krause (26:50)
Okay. I'm writing this down.

JoJo (26:51)
Wait, are you taking notes, Dr. Angie?

Dr. Angie Krause (27:05)
What about cavies?

Darin Dell (27:07)
Cavies

are sweet as well. ⁓ They're more likely to have ear problems. then you get into the primary secretory otitis media and then all their neuro stuff. And their heart disease. But again, adorable dogs.

Dr. Angie Krause (27:13)
Okay.

Right. And their hard stuff, yeah.

Yes. Okay.

So you're, you're for the, the springers. Okay. Okay.

Darin Dell (27:28)
I think. mean, I

had a collie myself and this is, she's shopping. Okay, the other breed that I would suggest. I love this, I love this. We could have a whole podcast on that. ⁓ My other thought would be a smooth collie.

JoJo (27:31)
This is personal. Dr. Angie is shopping right now for a dog. Yes. I'm like, she doesn't take notes. She's taking notes right now. Yeah.

Dr. Angie Krause (27:45)
⁓ I would never, yeah, yeah.

Darin Dell (27:47)
you know? Pretty rare

to see those in my office. ⁓ A little bigger, probably. Depends on how big a dog you want, I think...

Dr. Angie Krause (27:55)
Yeah. What about a border

Collie Do you see a lot of border Collies They're so healthy.

Darin Dell (27:58)
I do not see a of border collies. So I think that's another... They're so healthy, they're just, see the behavior, folks, right? So that's... So...

JoJo (28:05)
Yeah, exactly. I'm like, don't

put that one on your list. Oh, okay.

Darin Dell (28:09)
It depends on your lifestyle. It's

Dr. Angie Krause (28:09)
No, I won't.

Darin Dell (28:11)
like anything else. mean everyone makes their own choice, but you have to decide what's best for you.

Dr. Angie Krause (28:15)
Yes. Okay. So if someone wanted an itchy dog, they would get a bulldog. Yep. Okay.

Darin Dell (28:20)
Bulldog. Yeah. If

they wanted to always wipe their dog somewhere, they would get a bulldog. If you want a constant infant, bulldog is your thing. I know, but that's... Those of us who are parents understand, but... Okay. There's a wiping the face, wiping the back end, just... Every day, wiping.

JoJo (28:25)
Totally.

Who? ⁓

Yeah, yeah, that was the moment right there you've unsold

Dr. Angie Krause (28:35)
Yes, yes.

JoJo (28:42)
Yeah.

Dr. Angie Krause (28:43)
Just constant wiping. Yeah.

Darin Dell (28:45)
That's not wiping. I know, they should

probably do that for kids in high school instead of giving them like a bag of flour like they used to. Here's a Frenchie. Just do your best. Keep it clean. Go to the bag of wipes. We're gonna judge you in three days how clean this dog is and that'll decide if you can take care of a baby. Yeah.

JoJo (28:50)
Yeah, with a bag of wipes. Here you go. Every

Dr. Angie Krause (29:00)
Here's your dog's medicated wipe

JoJo (29:00)
fold.

Darin Dell (29:03)
Right,

every fold has to be wiped.

JoJo (29:05)
Yes, which is what freaked me out because you AI is a thing now Have you seen this this mixed breed that I cannot figure out if it's AI or not? What what was it? And you Sharpei a and Frenchie? Yeah, ⁓

Darin Dell (29:17)
⁓ dear. dear.

Dr. Angie Krause (29:18)
I mean, that could keep

you in business,

Darin Dell (29:19)
⁓

JoJo (29:21)
I mean, if it's a real thing,

I've been to research before this, if it's a real thing, but, man.

Darin Dell (29:26)
I hope not.

I sure hope not. mean, that's... It'll be... Right, could just see those two breeds, really. That'd be it, yeah. It's just, the sad part is that in getting the appearance that people want, my biggest concern is that we've made the ear canal so small. ⁓ Especially in the Sharpeis the...

JoJo (29:30)
Yeah, your wait list will become very, very long.

Yeah. Talking about folds. Yeah.

Dr. Angie Krause (29:49)
Yes.

Darin Dell (29:52)
ears are just the canals are so tiny they're smaller than the cats ear canals and so it just doesn't work right

JoJo (29:58)
Do you ever

see Sharpeis I haven't seen a Sharpeis in practice in so long. ⁓

Darin Dell (30:02)
yeah, we see quite

a few. For ear problems, mostly. I mean, they have allergies. Yeah, they have allergies too, but they typically manifest the ears go bad first because again, there's such a small space that it doesn't take much inflammation to close them off.

Dr. Angie Krause (30:05)
I bet you do.

JoJo (30:08)
yeah, maybe you see more than the average.

Dr. Angie Krause (30:10)
Yeah, I hardly can.

Hmm.

JoJo (30:21)
So painful too.

Darin Dell (30:22)
Yeah.

Dr. Angie Krause (30:23)
Well, speaking of cats, of having ear canals as small as cats, I...

JoJo (30:26)
I was going say, I think

Darin Dell (30:26)
I love cats.

JoJo (30:27)
we need to do a whole episode separate for the cat people, but I don't even.

Dr. Angie Krause (30:30)
Yes, we

Darin Dell (30:31)
I love cats.

So, I've become a cat person. I have six cats. Which is actually too many cats. I've, yeah.

Dr. Angie Krause (30:32)
do. I am a cat person and I see... ⁓ You too?

JoJo (30:37)
you're not joking. Yeah.

Dr. Angie Krause (30:40)
Yeah,

it's a lot of litter.

Darin Dell (30:42)
It is. It is a lot of litter, but it didn't, it wasn't intentional. That's what everyone with SixCat says. It wasn't intentional. It just happened this way.

Dr. Angie Krause (30:52)
It's

a slippery slope to six cats. Yeah.

Darin Dell (30:55)
Thank you. Thank you. I tried to stop at four

and then I have two daughters who love cats and my wife loves cats and then the most recent one is missing a foot so I mean he had to come home with me. ⁓

JoJo (31:06)
Of

Dr. Angie Krause (31:07)
Well, I mean, it's a hazard. It's a occupational hazard. But I see so many more itchy cats recently and I, I don't know what to do anymore. And so I do email you but, and send them to you. And what are we, why are cats itchier? What's happening?

Darin Dell (31:10)
It is an occupational hazard.

JoJo (31:10)
You

Darin Dell (31:23)
I think, I don't think it's necessarily that cats are itchier, I think everyone's itchier. I think it's really what we're seeing. ⁓ Because pollen counts are higher, the air is dry, our weather's been strange. So I think it's just everyone in Colorado is itchier, and cats get affected by that too. ⁓ Cats can have food allergy just like dogs, usually they have environmental allergy, just like dogs do. And they're typically non-seasonal because they're in the house, right? Under the bed, where you can't dust or...

Dr. Angie Krause (31:28)
Mmm.

Darin Dell (31:51)
you down in the basement hiding behind the toilet or something so they're cats it's the same thing it's just cats are harder to treat because we have fewer options

Dr. Angie Krause (31:52)
Right.

We have Apoquel and then...

Darin Dell (32:02)
we do.

So here I'm going to ask you a quiz question that's in one of my lectures. Are you ready? ⁓ Okay. Do you know what AMDUCA stands for? Or even what it means? What does AMDUCA do? Okay. So AMDUCA is a law that came into place in 1996 that protects veterinarians like us and allows us to use drugs off label. So before

Dr. Angie Krause (32:08)
Okay. I am.

No.

⁓ I probably

learned about this in a CE one time and forgot about it.

Darin Dell (32:32)
I'm sure you did. it just, I mean, and to me that kind of blows my mind to think that in the early 90s, even though that was forever ago for most of your viewers, probably listeners, it was illegal for us to use drugs off-label, but we almost always had to. Even today, we use stuff off-label all the time. So AMDUCA is what makes that legal for us to do that. Anyway, the long story short is that part of that law says that if there's a drug labeled for that disease, you have to talk about that drug first.

Dr. Angie Krause (32:33)
Yeah.

Mm-hmm.

Darin Dell (32:58)
before you use something off-label. So, Apoquel is off-label in cats, and always will be, so it's not wrong to talk about it, but you should talk about Atopica first, because that is the only label-approved drug for cats for allergy.

Dr. Angie Krause (33:11)
Okay.

Darin Dell (33:12)
So my talk usually goes through, A, this is definitely manageable, but it's harder for cats because as much as we love cats, they don't get as much love back. Atopica is the approved drug, and if your cat will take it, it's probably gonna work and they're gonna do great. The downside is that most cats hate the flavor of atopica and will not take it. And so then we might think about Apoquel I find the chewable actually very easy to give cats.

But most of the time cats need a much higher dose than dogs, so it can get pricey. Sometimes we result, or we end up giving them steroids, you know, because that's what we have. ⁓ Cats can do well on steroids for a long time. Sometimes antihistamines work, not very often. Your success, your chance of success with antihistamine is only about 15%. So for those folks that say, well I'm just going to try some Benadryl, okay, well.

Dr. Angie Krause (34:00)
Mm-hmm.

Darin Dell (34:04)
Enjoy your 15 % chance of success. I don't bet on 15%. That's just not going to be a thing. And then we talk about immunotherapy, ⁓ which I think, again, cats get the short end of the stick there, but immunotherapy works great in cats. You just have to get people kind of in the mindset of it. Because a lot of people think, ⁓ I couldn't give my cat a shot, or I couldn't do that. But it works really, really well in cats.

Dr. Angie Krause (34:06)
Okay. Yeah.

Mm-hmm.

Okay, just as well

as dogs, like same. ⁓ okay.

Darin Dell (34:31)
I think better, personally, I think it works better in cats.

And I don't know if that's just because they have less variation, like they're not running outside, most people don't take their cats to Breckenridge, right, or Moab, like, oh, me and the cat are going to Moab, you don't hear that. So I don't know if they respond better just because there's variation, but I do think they respond better than dogs. So, there is hope.

Dr. Angie Krause (34:41)
Yeah.

Yeah.

Okay, that's good to know. So there's some hope for the itchy cats.

Darin Dell (34:56)
every year dermatologist meeting we have a conference and we complain about not having cat drugs so every year the drug companies tell us us ⁓ we're we're working on something so maybe this is maybe we're getting close i hope so it would be nice to have another choice besides atopica and apoquel

Dr. Angie Krause (35:02)
Yeah.

I hope so. I hope so.

Yes.

Yes. And then trying to figure out what food allergy they might have in cats. It's really hard because they don't like hydrolyzed diets. It's they're disgusting. And then you're just like, I don't know, maybe rabbit or this or that. And I feel like more and more it just doesn't work. I'm just kidding.

Darin Dell (35:19)
goodness.

Yes.

Agreed. I tell clients

I start way more diet trials than I finish.

Dr. Angie Krause (35:34)
Yeah.

Darin Dell (35:35)
We'll start it, and, you know, just to kind of give them a way out, because some people get really upset with themselves when they can't do it, and I don't want that to be the case. Some people get mad at the cat, and like, no, no, let's not get mad at anybody, it's just the reality of their cats, like you said, we don't have a ton of choices, so... If you started it, you tried it, and it didn't work, okay, move on. Move on. Don't, don't, don't linger and be sad.

Dr. Angie Krause (35:44)
Yeah.

Yes.

Yeah.

Darin Dell (36:00)
Keep on moving, keep on making progress, forward progress.

Dr. Angie Krause (36:00)
Right.

Forward progress. Okay. Well, Jojo, is there anything else while we have a million things? Yeah. Part two. Cause at some point I want to talk to you. No.

JoJo (36:07)
A million things. I feel like we need a part two. Yeah. We can't keep going here because I don't have that kind of editing skill. But

Darin Dell (36:11)
Ooh, okay.

Okay.

Okay, alright. Fair

enough.

JoJo (36:21)
I want a part two because there, I do have so many questions still.

Darin Dell (36:25)
Okay, I can come back if you have me.

Dr. Angie Krause (36:25)
Yeah, next time we have to,

yeah, we need to talk about Ultimino, my favorite diet in the world. I love it so much.

JoJo (36:28)
yeah.

Darin Dell (36:30)
is it really your favorite?

JoJo (36:31)
Yeah, we need to talk diet. She loves it so

much.

Darin Dell (36:34)
okay. I love it too. If people can pay for it and dogs will eat it, I love it too.

Dr. Angie Krause (36:40)
Right?

JoJo (36:40)
Yeah, we still have diet to talk about supplementation to talk about. I want to hear that. I want to hear your emu story live on this recording. So yeah, I think we need to do a part two. That's my thought.

Dr. Angie Krause (36:42)
Yes.

Darin Dell (36:44)
yeah!

Dr. Angie Krause (36:47)
Yeah.

Darin Dell (36:48)
Okay. Okay, that sounds

good to me. Happy to do it.

Dr. Angie Krause (36:53)
Yeah.

Yeah. Part two. And then for those of you that are listening and you want to ask a question next time we have Dr. Dell on I leave a comment below. If you're watching this on Instagram or YouTube, tell us about your itchy dog or cat and what you struggle with. And Darin thanks so much for hanging out with us. Like I have wanted to hang out with you for so many years because you just, yes.

Darin Dell (37:13)
You're welcome.

JoJo (37:17)
This was so fun. Yeah.

Darin Dell (37:19)
It was a lot of fun. Thank

you for having me. And just the more we can educate people and veterinarians, the better it's going to be. So I'm all for it. And it's super fun. You guys are so fun to talk to.

Dr. Angie Krause (37:25)
Yes. Yes.

⁓ good. You too. Okay. See you later. Bye.

JoJo (37:29)
We enjoyed this. Bye.

Darin Dell (37:32)
Awesome, right? Bye!