Nathalie DowgrayHello, welcome to the third episode of Chattering With ISFM. This month we have the second of our two episodes on feline infectious peritonitis from ISFMs own Sam Taylor, joining professors Danièlle Gunn-Moore and Séverine Tasker in discussing the latest developments in the diagnosis and treatment of FIP. We hope you enjoy the second part of their discussion.
You've been involved in it, you know, sort of from the beginning, do you think you could just tell us a little bit about those treatments? I suppose the Australians had it before us. What did we hear from them that made us excited that we wanted to get the drug?
Well, I guess, take a little bit further back. Because we've got both of the cat world's professors, we've got the majority of the world's cat specialists, we really, really targeted Gilead who make remdesivir and we were the only country where they allowed us to use their remdesivir in cats. And then we targeted Nick Bova, and he has this specials company. So we all targeted him saying look please, we really, really need these drugs. And his company works in
Australia and here. The rules for the veterinary medicines directorate are much tougher in Britain, a little bit easier in Australia. So he managed to get remdesivir. And then the GS, got me doing it now, 44 15 24, into Australia first, we got it second. So that was all started, year and a bit ago something like that. The take up has been much more in Britain, which I thinks interesting because they've had them for a year
longer. And yet we're about neck and neck in number of cases, we're 700 cases, as far as I know, in each. So it's, we've got a lot more in GS 44 than we've got on remdesivir. They're much more gung ho than we are. They go with bigger doses earlier. And they've taught us a lot. There's certainly differences between the doses of the original papers. And what we're now finding really you need, which is, this is typical
of most studies. So the lowest doses are just standard wet form, then up a bit for dry form, up a bit more for eyes, up a bit more for brains. And when you're getting up to those high doses, you need to give it, divide the dose because otherwise you just don't get enough absorbed. We're finding side effects. Do you want me to, shall I bounce that one too?
Yeah. Bounce that one back.
Yeah, side effects that we've seen. Yeah. I mean, generally, they're doing okay, aren't they? I mean, from the point of view of injectable, the remdesivir, the injections are painful. So we sometimes need to sort of help with that side of things, it can be given subcutaneously as well as intravenously. So there's things like using Gabapentin and new needles, there's lots of things.
And again, we've got a guide for treatment, haven't we, that I'm sure we can link to this podcast as well, so that you've got all of that information. In terms of monitoring, these things that we're talking about are coming up because they're being monitored. And obviously, it's really nice. We want to see the globulins come down, we want see the AG ratio better. But don't forget to weigh the cat. They're young cats, they're often growing. The fact that they're putting on weight is fabulous.
So, that's brilliant. And it's very cheap to weigh the cat as well. But also just remember about adjusting the amount, the dose that you are giving to preserve the dosage that you've prescribed for that cat. Yeah.
So how do you monitor them? What would, what advice do you give about monitoring? Are there, depends how sick they are, of course, but are there any points that you would want to have them in and do bloods? Or?
I'm not sure we've got any gold rules. It does depend a lot, some of them really aren't that bad to start with, you start the GS and they go in brilliantly, and you just go okay, fine. Particularly if money's limited. If I could, I would like to have them when they go home, after two weeks, a month. And then ideally, I'd love every month, but they've got to have good insurance or a lot of money for that. Yeah. But it means I can really monitor
them. And you can then, particularly as you're coming up to the 12 weeks, you want to know everything's normal, other than the ALT. I'll accept that the ALTs still being up. But I want to know that particularly the AGP, so the acute phase protein, I want to see that normalised. And the AG ratio, I want that normal and I want the anaemia gone.
Yeah. And I agree. And I think you know, if money is an issue, preserving it for towards the end treatment, because you want to be as confident as you can be taking them off, because there are cases that do need longer, and that, those are the really important ones. If they're doing clinically brilliantly, then try and preserve that cost for the proteins towards the end.
Therapeutic drug monitoring may be a good way to go. But then it's other drugs that you can either add in or switch to. At the moment, we tending to add in aren’t we, either Mefloquine and or Polyprenyl Immunostimulant. There's certainly a good argument for, if you've got one that's just swithering, it's not doing as well as you'd like. Then add in either Polyprenyl Immunostimulant, or Interferon-omega, because they would both be an immune modulator, which that makes sense, an antiviral with an
immune modulator. If the antivirals really not working, then mefloquine is where we're going, although sometimes we're using those two together, aren't we? Trying to look for a synergistic effect?
Yeah,
We can treat them just orally
Yes.
Because thats another question we get asked.
Absolutely,
absolutely.
Yeah, absolutely. I mean, we, you know, we've gone for the remdesivir to start with, because we've learned so much from the Australians, but there are quite a lot of publications out there with just oral treatment with the oral GS, and that is cheaper.
If they weren't neuro or opso cases, then I think that's very appropriate. Yeah.
Because I guess we don't know, we don't have the data to say that there's a benefit of using two weeks of remdesivir
No, no, no, no, no, no, there's no publish, to compare oral GS with, you know, I think sometimes when they're really sick and hospitalised, you know, the injectable to start with
Because they're too poor to swallow. Also, there is the concept, you know, that remdesivir, because of how different it is, only a little bit, but it is more bioavailable to cells. So it gets into cells better, isn't it? So on that reasoning, it's more side effects, but more potency. So therefore, when you're trying to get into difficult places, then let's go as potent as we can.
But if finances are an issue, then I think the oral GS straight off is definitely a valid way to go.
And I've also found that sometimes people, they’re very anxious about giving tablets.
Yeah
i know it's really, really hard.
If they're really not sure I’ve said, ‘let's try it, let's see where we are in three days’, you know, you're not saying ‘this awful, sick, poorly cat has got to have 12 weeks of treatment’. And they're just going ‘oh, he couldn't take it’. Your going ‘Look let's just see, just give me three days.’ And you go ‘well, let's just get to the end of the week’, and then they can go actually 12 weeks won't be too much trouble.
And I think just one last thing, just about a client without too much money is just remembering that you, like you said, you’ve just got to make sure you've documented in the notes, your conversations because
Actually around all of this treatment because it's not guaranteed. And yes, it's really successful. And we've seen great success, but not every cat. I would, I'd hate owners have the impression this is guaranteeing you a cure
We have had some that have presumed that
You spend 6000 pounds, and you're going to have your kitten back, just like it doesn't work with any other disease really. But I think in this one it’s, you’ve got to write it down Absolutely So they understand the limitations of the treatments.
It's not a guarantee. But we're doing our best, especially when we can't do the full course. Yeah,
We don't want to shy away from it. You can buy these drugs on the internet. And we know that they have widely been used from internet sources. And we'll have people watching from all around the world. How do you handle that situation? Or how do we advise vets?
Yeah, I mean, it's really hard, isn't it? And I know we've got a global audience, I think, I think it's a matter of, you know, reaching out and finding out what the regulations are in your country, what is available, what is, if there is anything legal to use, you know, there's been publications out there with
those black market drugs. So we know that they work, the problem is that we have no data on what's in them, the amount that's in them, people aren't allowed to buy them because they're importing them as a medicine and that is illegal, and where we can't prescribe or use them ourselves. So that is pretty clear in terms of the legalities of it.
It's not just we, it's all British vets.
Yeah,
We can't touch it, we can lose our MRCVS, it's that serious.
So I think the thing is that if somebody does come across, I mean it depends where you are, but I mean in the UK, we have got some, we are very lucky that we've got access to legally available products now and that is absolutely the
route that we should go down. If you are a vet that is dealing with a client that is, off their own back, ordered them online, have got the drug, you know there is an argument for you being able to monitor and help with the welfare of that cat because I think pushing it to the back, even when you've talked to the owner in that way, and they don't get any veterinary care is almost worse, you know.
Nathalie DowgrayThank you for listening to Chattering with ISFM. The full version of this roundtable discussion is available to ISFM veterinary members, along with an additional interview from Dr. Dottie Laflamme. To access that and all other ISFM member benefits, including recordings from Congress's, monthly webinars, the discussion forum and much more, do login to portal.icatcare.org. If you're not an ISFM member, then please do visit icatcare.org to learn
more. Tune in next month for the first of our JFMS Clinical Spotlight Interviews and an interview with Dr. Jessica Quimby.