Tacrolimus for the Treatment of Inflammatory Bowel Disease in a Dog

doi:10.4236/ojvm.2012.23025

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Open Journal of Veterinary Medicine, 2012, 2, 158-162

http://dx.doi.org/10.4236/ojvm.2012.23025 Published Online September 2012 (http://www.SciRP.org/journal/ojvm)

Tacrolimus for the Treatment of Inflammatory B owel

Disease in a Dog

Masashi Yuki*, Yosiaki Oota, Noriaki Nagata

Yuki Animal Hospital, Nagoya, Japan

Email: *[email protected]

Received July 12, 2012; revised August 18, 2012; accepted August 24, 2012

ABSTRACT

A 2-year-old intact female Toy poodle was referred with a 2-week history of diarrhea. Blood examination findings in-

dicated thrombocytosis, severe hypoproteinemia, and hypoalbuminemia; endoscopy revealed duodenal mucosal irregu-

larity and increased graininess. Based on these results and additional histopathological findings, we made a diagnosis of

protein-losing enteropathy caused by lymphocytic-plasmacytic enteritis with lymphangiectasia. The dog was initially

treated with prednisolone. Improvement was only observed with high-dose prednisolone; its dose could not be reduced

without relapse. When cyclosporin, methotrexate, and chlorambucil were combined with prednisolone, no further bene-

ficial effect was observed. When tacrolimus was combined with prednisolone, improvement was seen and the dose of

prednisolone could be reduced. Tacrolimus is both a calcineurin inhibitor and a multi-drug-resistant inhibitor, so it may

be an effective treatment choice for a dog refractory to standard inflammatory bowel disease treatment. This is the first

report of tacrolimus for the treatment of inflammatory bowel disease in dogs.

Keywords: Dog; Inflammatory Bowel Disease; Tacrolimus

1. Introduction

Canine inflammatory bowel disease (IBD) is a chronic,

immunologically mediated intestinal disorder resulting

from the complex interaction of environmental, genetic,

and immune factors [1]. Variations in the histologic ap-

pearance of the inflammation suggest that IBD is not a

single disease entity and the nomenclature merely re-

flects the predominant cell type present. Lymphocytic-

plasmacytic enteritis (LPE) is the most common form

reported, eosinophilic gastroenteritis is less common, and

granulomatous enteritis and neutrophilic infiltration are

rare in IBD [2]. Protein-losing enteropathy (PLE) may

occur secondary to conditions such as chronic inflamma-

tion in small intestinal diseases and is often caused by

intestinal lymphangiectasia following LPE [3].

The development of LPE is thought to originate as a

consequence of a deregulation of mucosal immunity in

predisposed animals. The immune-mediated basis of the

disease can be inferred by the response to the administra-

tion of immunosuppressive drugs [4]. Immunosuppres-

sive drugs such as prednisolone, azathioprine, chloram-

bucil, cyclosporin, and methotrexate are often used in the

treatment of this disorder [5], but achievement and main-

tenance of remission may be difficult using these agents.

Tacrolimus is an immunosuppressive macrolide iso-

lated from the fermentation broth of Streptomyces tsu-

kubaensis. It potently inhibits helper T lymphocyte acti-

vation [6]. Tacrolimus is the primary immunosuppressive

agent developed for organ transplantation. In recent re-

views of human refractory IBD, tacrolimus had therapeu-

tic efficacy, whereas prednisolone did not [7]. Recently,

in veterinary medicine, tacrolimus in ointment form has

begun to be used in the treatment of immune-mediated

skin diseases and keratoconjunctive disease [8-12].

In the present case, despite using a combination of

prednisolone and cyclosporin, methotrexate, and chlo-

rambucil, which is a potent, immunosuppressive agent, the

expected effect was not obtained. However, improve-

ment was confirmed when tacrolimus was substituted for

the trio of cyclosporin, methotrexate, and chlorambucil,

and rapid remission was achieved and maintained.

2. Case Description

A 3.5 kg, 2-year-old intact female Toy poodle was re-

ferred to our hospital with a 2-week history of diarrhea.

Upon physical examination, the dog had a temperature of

38.1˚C, a heart rate of 144 beats per minute, and a respi-

ratory rate of 30 breaths per minute; all were within

normal limits. The dog had a body condition score of 2

out of 5 and revealed a pendulous abdomen. Examina-

tions of the mucus membranes and heart sounds were

*Corresponding author.

M. YUKI ET AL. 159

normal.

Blood examination data at the time of admission re-

vealed thrombocytosis of 81.3 × 104/μL (reference range

20 to 50 × 104/μL), moderate hypocholesterolemia of 68

mg/dL (reference range 111 to 312 mg/dL), moderate

hypocalcemia of 7.9 mg/dL (reference range 9.3 to 12.1

mg/dL), severe hypoproteinemia of 3.2 g/dL (reference

range 5.0 to 7.2 g/dL), severe hypoalbuminemia of 1.3

g/dL (reference range 2.6 to 4.0 g/dL), and elevation of

C-reactive protein of 2.3 mg/dL (reference range 0 to 1.0

mg/dL). Total bile acid level was normal.

Fecal examination for internal parasites was negative.

Urinalysis was normal. Plain chest radiography was

normal. Plain abdominal radiography showed a loss of

intraabdominal detail and an abnormal colonic gas pat-

tern. Abdominal ultrasound showed ascitic fluid and in-

testinal wall thickness was normal. Ascitic fluid was

clear with a specific gravity of 1.004, total protein of 2.0

g/dL, and a few mononuclear cells that formed transu-

date.

Treatment with amoxicillin (Tatumi Kagaku Co., Ltd.,

Kanazawa, Japan) (10 mg/kg, periorally (PO), q 12 hr),

metronidazole (Shionogi & Co., Ltd., Osaka, Japan)

(12.5 mg/kg, PO, q 12 hr), and hypoallergenic Royal

Canine Veterinary Diet (Royal Canine Japan, Inc., Tokyo,

Japan) was begun to counter the possibility that the diar-

rhea was caused by bacteria, protozoa, or food allergy.

Furthermore, the antiparasitic drug combination of pra-

ziquantel/pyrantel pamoate/febantel (Bayer Yakuhin, Ltd.,

Osaka, Japan) was administered. However, the total protein

and albumin levels continued to remain low and diarrhea

resumed on the 20th day (Figure 1).

On the 21st day, an endoscopic examination was per-

formed for a definitive diagnosis. The gastric mucosa

was normal. The duodenal mucosa exhibited mucosal

irregularity and increased graininess. Histopathological

review of biopsy specimens confirmed normal gastric

mucosa and duodenal mucosal inflammation consistent

with moderate to severe lymphocytic-plasmacytic infil-

tration and hydropic degeneration. The lymphatics of

these areas were slightly dilated. A diagnosis of PLE

secondary to LPE was made at this point.

Administration of prednisolone (Shionogi & Co., Ltd.,

Osaka, Japan) (1 mg/kg, PO, q 12 hr) was begun. In-

creases in the total protein and albumin levels were con-

firmed and diarrhea improved in 1 week. On the 38th day,

however, when prednisolone was reduced to 0.75 mg/kg

q 12 hr, total protein and albumin levels decreased (Fig-

ure 1) and alanine aminotransferase level increased.

Treatment with cyclosporin (Novartis Pharma K. K.,

Tokyo, Japan) (5 mg/kg, PO, q 24 hr) was begun to en-

able the tapering of prednisolone. Prednisolone was re-

duced gradually again, but the total protein and albumin

levels remained stable and no diarrhea was observed. On

the 130th day, prednisolone was reduced to 0.15 mg/kg q

12 hr. Total protein and albumin levels decreased and

diarrhea returned (Figure 1). Prednisolone was increased

to 0.5 mg/kg twice a day again, but no increase in total

protein and albumin levels was observed.

On the 144th day, treatment with prednisolone and cyc

TP, Total Protein; ALB, Albumin

Figure 1. Clinical course of treatment with prednisolone, cyclosporin, methotrexate, chlorambucil and tacrolimus in a dog

with protein-losing enteropathy caused by lymphocytic-plasmacytic enteritis with lymphangiectasia.

M. YUKI ET AL.

160

losporine with methotrexate (Wyeth, Tokyo, Japan) (0.5

mg/kg, intramuscularly, once a week) was started. Diar-

rhea improved, although no increases in total protein and

albumin levels were observed. Vomiting, which is a side

effect of methotrexate, was observed. On the 151st day,

cyclosporin was discontinued because it did not produce

sufficient effect and its cost was a problem. On the 158th

day, chlorambucil (Glaxo Smith Kline, Bern, Switzerland)

(0.35 mg/kg, PO, q 24 hr) was substituted for meth-

otrexate. Vomiting, which is a side effect of chloram-

bucil, and diarrhea were observed.

On the 178th day, a severe decrease in total protein

and albumin levels was seen, tacrolimus (Astellas Pharma

Inc., Tokyo, Japan) (0.13 mg/kg, PO, q 12 hr) was sub-

stituted for chlorambucil, and prednisolone was increased

to 1 mg/kg q 12 hr again. The increase in the total protein

and albumin levels was confirmed and diarrhea improved

after 1 week (Figur e 1). On the 194th day, moreover, pred-

nisolone was discontinued 4 days into the course due to a

bite wound, no decrease in total protein and albumin lev-

els was seen, and a temporary increase of globulin was

observed (Figure 1). On the 219th day, prednisolone

dosing was gradually reduced to a low-dose level (0.15

mg/kg, PO, q 12 hr) while maintaining an increase of

total protein and albumin levels. In addition, the trough

level of the tacrolimus at this point was below 2 ng/mL

(Mitsubishi Chemical Medience Corporation, Tokyo,

Japan). On the 290th day, the total protein and albumin

levels reached the reference ranges and it was possible to

get a complete remission (Figure 1).

Tacrolimus dosing was gradually reduced to 0.065

mg/kg every other day from the 401st day to the 467th

day. However, decreases in total protein and albumin

levels were observed clearly (Figure 1). On the 467th

day, tacrolimus dosing was increased again to 0.065

mg/kg q 24 hr. On the 509th day, total protein and albu-

min levels improved into the reference ranges. On the

538th day, tacrolimus dosing was reduced to every other

day again to relieve the burden of its cost. However, a

decrease of total protein and albumin levels was ob-

served and tacrolimus was again increased to q 24 hr

(Figure 1). More than 800 days have passed since tac-

rolimus treatment was begun; no adverse effect has been

observed and treatment progress is good.

3. Discussion

The mechanism of action of tacrolimus is similar to that of

cyclosporin, even though their chemical structures differ

greatly [6]. Tacrolimus binds to immunophilins, which are

cytoplasmic binding proteins. While tacrolimus binds to

immunophilins called FK-binding proteins (FKBPs), cyc-

losporin binds to immunophilins called cyclophilins. The

immunophilin-drug complex binds competitively to and

inhibits calcineurin, a phosphatase whose activity is de-

pendent on its being bound to calcium and calmodulin.

Inhibition of calcineurin is believed to mediate the im-

munosuppressive activity of both tacrolimus and cyc-

losporine [6]. Tacrolimus has been shown to inhibit the

transcription of the early activation genes for cytokines

such as interleukin 2, tumor necrosis factor α, and interferon

in T cells [7]. Although its mode of action is similar

to that of cyclosporin, the immunosuppressive effect of

tacrolimus is 30 - 100 times greater in vitro and 10 - 20

times greater in vivo than that of cyclosporin [7].

In recent reviews of human refractory IBD, the cal-

cineurin inhibitor tacrolimus had therapeutic efficacy [7].

In recent reviews of veterinary medicine, the calcineurin

inhibitor cyclosporin was also effective in dogs with re-

fractory IBD. The anti-inflammatory effect of cyclosporin

in human and dogs IBD are belived to be due to suppres-

sion of activated T cells infiltrating the mucosa [13].

In this case, it was insufficient, but the use of tac-

rolimus with the same mechanism was tried because

some effect of cyclosporin was seen. In human IBD, tac-

rolimus is used at a rate of 0.025 mg/kg given orally

every 12 hours, with a trough level of 5 - 15 ng/mL [7].

In dogs, a high dose of 0.4 - 2.0 mg/kg seems to be

needed to get this trough level [14,15]. However, severe

adverse effects including body weight loss and pneumo-

nia may result from the high dose of 0.4 - 2.0 mg/kg [15].

Clinically, the therapeutic dose of tacrolimus for dogs

has not been determined, so we used as a reference the

dosage in human organ transplantation [6].

The trough level in this case was below 2 ng/mL, low-

er than the recommended therapeutic dose for human

IBD. However, effectiveness was observed. All cytokine

production was inhibited completely at a blood level of 1

ng/mL in a basic study of tacrolimus in humans; the 50%

inhibitory concentration was 0.02 - 0.11 ng/mL and an

inhibitory effect was indicated by a low concentration

[16]. The trough level was not recorded in a report on

tacrolimus for the treatment of sterile panniculitis in a

dog, but the effect was observed at a low dose of 0.06

mg/kg/day [17]. Therefore, there is a possibility that even

a low dose and a low trough level can be effective in

dogs. However, because in this case, tacrolimus was

given every other day, the resulting lower total protein

and albumin levels indicated the need for daily admini-

stration.

Recently, the high expression of p-glycoprotein was

confirmed in lymphocytes from duodenum mucous mem-

brane lamina propria after treatment with prednisolone in

dogs with IBD and possible drug resistance by p-glyco-

protein was suggested [18]. Presently, p-glycoprotein and

cytochrome P-450 3A4, 3A5 manifested in the small

intestine and liver appear to be cooperatively functioning

as the cause of the absorption barrier of tacrolimus [19].

On the other hand, cyclosporin and tacrolimus can block

M. YUKI ET AL. 161

the p-glycoprotein of resistant cells and are viewed as

multi-drug-resistant inhibitors that obstruct the multi-

drug resistance function [20]. It is thought that calcineurin

inhibitors have different actions and that these actions are

manifested early at low concentrations [20,21]. An insuf-

ficient effect was observed from the use of cyclosporin in

this case. However, with tacrolimus, an immediate effect

was observed with its low dose, so its multi-drug resis-

tant inhibitor actions may be involved in this case.

In humans, the most common adverse effects seen

with tacrolimus include headache, tremors, insomnia,

hyperesthesia, and musculoskeletal complaints [6]. In

this case, low-dose tacrolimus has been given for more

than 2 years, but no adverse effect has been observed.

However, attention will be necessary for the sign because

adverse effect include body weight loss and pneumonia

in the dogs [15].

In conclusion, because tacrolimus is both a calcineurin

inhibitor and a multi-drug-resistant inhibitor, it may be

an effective treatment choice for dogs refractory to IBD

treatment. More studies about the effect on IBD and the

clinical dose of tacrolimus in dogs are needed. To the

best of our knowledge, this is the first report of tac-

rolimus for the treatment of IBD in dogs.

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