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Introduction

[00:01:07] If your dog has been seen by a veterinarian for itching sometime since 2014, there’s a very good chance you’ve been prescribed a medication called Apoquel, or at least you’ve heard of it. Apoquel is a daily oral medication for treatment of itch associated with allergies. I’ve been really looking forward to doing this episode because pet owners are constantly looking for more information about this medication. The misinformation that is circulating on the internet regarding Apoquel is a huge reason why I started the show. I want to give you an evidence-based resource of reliable information regarding this drug.

Russell Sprout, the Grinchiest allergic dog.

[00:01:46] I’ve talked about my dog Russell Sprout on the previous episode of environmental allergies. And yes, this very special looking dog, who is the mascot for Your Vet Wants You to Know has also taken Apoquel. He’s been a challenging allergic case, but he’s definitely been worth it. He actually won top prize in the “So ugly I’m cute” category at a local American Cancer Society fundraising walk. The most insulting part though, is that we didn’t even enter him into the competition. Like most pet owners, I have a concern about the medication I give my pets. As you’ll hear me say over and over again on this show, I needed to assess the benefit versus the risk, because there’s a risk with absolutely every decision we make for our pets. For today’s episode, I’d like to talk to you about the benefits and the risks of Apoquel and why as a dermatology specialist who has spent three years of my residency researching and publishing data regarding this medication and its long-term effects, I feel very comfortable using Apoquel in my patients with allergies.

[00:02:51] Full disclosure, Zoetis, the makers of Apoquel, previously provided me with an honorarium to present my research at a global expert panel of veterinary dermatologists. However, they were in no way involved in the research study prior to its publication and they are not a sponsor of today’s episode.

Symptomatic Therapy for Itch

[00:03:11] Apoquel is an excellent therapy for itchy dogs, but it doesn’t cure allergies. Let me say this again. Apoquel does not cure allergies. Allergies are a lifelong medical condition that we strive to manage, but will rarely cure. As I discussed on the previous episode of environmental allergies, treatment falls into two categories. 1) is symptomatic relief with medications like Apoquel, Cytopoint, Atopica, and steroids that will help to relieve the itch, or 2) desensitization with allergy shots, which is the only treatment that actually works to fix the underlying disease. Having said that Apoquel will stop the itch when it’s being given, but if you stop giving the medication and you’re not addressing the underlying disease another way, the itch is just going to come back. So the medication is an excellent tool to provide our pets with relief while you’re working with your veterinarian to search for the underlying cause of the pet’s allergies, whether that’s food allergy or environmental allergy or flea allergy. In other words, a prescription of Apoquel is not going to fix the problem. It’s a helpful tool in our allergy treatment plan. A team based, cooperative, communicative relationship with your veterinarian is your best bet for long-term success. 

redness on the neck of an allergic dog

Redness, swelling, and itching on the neck of an allergic dog before receiving Apoquel at his initial consult has completely resolved at his first recheck exam a few weeks later.

Benefits

[00:04:36] When your pet needs fast relief from itch, Apoquel starts working very quickly, as fast as four hours after the first dose is administered. Compared to Atopica, which is another commonly used allergy medication, which can take up to six weeks to start working, this is a really big benefit. Apoquel has an excellent safety profile compared to steroids. Prior to its development, veterinarians were relying on steroids if we wanted fast relief from itch. Steroids carry many side effects, including increased thirst and urination increased hunger, increased panting, increased liver enzymes, increased risk of urinary tract and skin infections increased blood pressure, muscle wasting, weakening of the joints and ligaments just to name a few. Now don’t get me wrong, I use steroids and they work. As I’ve already said earlier this episode, every decision that I make involving my patients is a matter of risk versus benefit. For some diseases, the benefit of using steroids will outweigh the risk. But when I’m treating itch associated with allergies, Apoquel has a better safety profile than steroids, both short-term and long-term, and it works just as quickly.

[00:05:48] The incidence rate of adverse reactions was very rare, less than one in 10,000 dogs treated with the medication, and the adverse reactions included things like vomiting, diarrhea, lethargy, anorexia, and blood work changes. That’s an extremely low rate of adverse effects. To kind of put this in perspective, according to National Geographic, that’s the same odds as you would have being injured by a toilet at some point this year. For patients who are receiving Apoquel long-term I do recommend blood work prior to starting, and then at least every six to 12 months, just to make sure that nothing is trending in a concerning direction. Physical exams are required at least every 12 months in order to legally continue prescribing medications.

[00:06:33] I mentioned earlier, the Apoquel can be used to provide relief from itch while you’re searching for the underlying allergy. This is great because the idea is to use Apoquel as a bandaid while you’re searching for the underlying cause. I like using this medication during an elimination diet trial to determine if the pet has food allergies, since it can take up to two months for itch associated with food allergies to improve. Once a pet has started a prescription diet, I typically use Apoquel during those two months to make sure that the pet is comfortable. As I get closer to the end of the diet trial to determine if there are food allergies, before I introduce new foods into the pet’s diet, I’ll have the pet owner stop giving the Apoquel to see if the animal is itchy. If the itch is still there, then I know that I have a component of environmental allergies that I need to deal with, but if the itch is gone, then I talk to the pet owners about challenge feeding with the original food that the pet was on before the diet trial to determine if food allergies are present. When the itch comes back when we introduce other foods, I’ll have pet owners restart the Apoquel to provide fast acting itch relief. Apoquel can also be used when you’re investigating environmental allergies. So unlike steroids and anti-histamines, the dog doesn’t need to stop Apoquel prior to doing skin or intradermal allergy testing to determine what in the environment is causing the allergy. After doing the allergy testing, the pet can remain on Apoquel while those allergy shots are starting to take effect, which can be up to a year in some dogs. The long-term goal is to use the allergy shots to desensitize the pet to the underlying allergy so that eventually I can stop using the Apoquel or only use Apoquel during really bad allergy seasons for a certain proportion of dogs.

[00:08:27] Cost can actually be a benefit. As far as Apoquel is concerned, other allergy medications, such as a Atopica and Cytopoint can be cost-prohibitive for a pet owner that has a large or giant breed dog.

Drawbacks

On the other hand, cost can be a drawback for some clients. Apoquel is more expensive than steroids. 

[00:08:47] It also may not be as effective for reducing swelling associated with allergies as it is with reducing itch. So if I have a pet that has allergies, where their ears are completely swollen shut, or their paws are horrendously swollen, a lot of times I’m going to reach for steroids and Atopica over Apoquel to provide better relief. Because Apoquel can affect the immune system. There is a possibility of an increased risk of infections. I have seen pets receiving Apoquel develop infections with demodex, a type of mange mate. However, most of the common flea and tick preventatives on the market nowadays are actually effective against demodex, and if your pet has any type of allergies, it really should be on an effective flea and tick preventative anyway to keep any exposure to flea saliva from causing a flare of allergies. I recommend talking to your veterinarian about what flea prevention is right for your pet. In addition, dogs with allergies will benefit from frequent bathing to help remove pollens they get exposed to, and to repair their skin barrier, which is often abnormal. That bathing goes a long way towards helping reduce skin infections that they may be predisposed to because of the medications they’re on. Side-effects with Apoquel, as I said before, are rare in dogs. However, if your pet is one of the few that does experience side effects, that may be a drawback to using this medication and different allergy therapy may be recommended.

Misconceptions

[00:10:13] The biggest misconception regarding Apoquel I hear is that it causes cancer and this is simply not true. I feel really confident saying this. Let me start by addressing the reason behind this misconception.  Apoquel is in a class of medications called Janise kinase inhibitors. These medications stop the transmission of signals called cytokines from outside of the cell into the cell. In the case of Apoquel, the signal that it inhibits is one that causes the sensation of itch. Apoquel is the only Janise kinase inhibitor that’s currently being used in veterinary medicine. However, there are other Janise kinase inhibitors being used in human medicine. One of these drugs has been shown to increase the risk of cancer and the other has not.

[00:11:04] So because they all share a similar mechanism of action, or the way that it works within the body, there’s a concern that Apoquel could potentially alter the immune system in a way that allows cancer to develop. I recently published a large scale research study in the Journal of the American Veterinary Medical Association that answered this very question. One of the reasons I took on this study is because people were concerned and looking for answers. For a while I was using this medication in Russell Sprout, my allergic dog, and I wasn’t satisfied with the information that was currently available in primary literature. So instead of taking to the internet and trying to wade through what’s good information, and what’s a bad information, I actually sat down and did my own research study. That study looked at dogs who had received Apoquel for a very long period of time, the minimum was six months, but some of these dogs were taking this medication for over five years.  I compared that group of dogs to other allergic dogs who had never received Apoquel, but whose allergies are managed on other medications. One of the challenging and really cool things about the study was that I actually age and breed matched all of the dogs, which gave me some control over two of the biggest risk factors for cancer, which are age and breed. I wound up including 660 dogs in this study, which is almost unheard of to have a veterinary study this large. Generally most veterinary studies look at maybe a few dozen pets at a time, so 660 is a huge undertaking. After reviewing all of the records for skin masses and diagnosis of cancer, I compared the two groups and found that there was no statistically significant difference in the development of cancer between the two groups of allergic dogs. Now when pet owners are concerned that they read on the internet that Apoquel causes cancer, I can confidently tell them that I have actually done the research and I have not found that this is the case, but because every decision I make in my patients weighs the risks versus the benefits, I still do things to minimize the risk. So for Apoquel, that includes regular blood work and physical exams to make sure that I catch anything that’s concerning before it actually becomes a problem, as well as working on finding the underlying cause of the allergy so that I can decrease the amount of Apoquel that the animal is taking throughout the course of its life.

Apoquel and Cats

[00:13:40] I would like to make a brief mention about the use of Apoquel and cats. There has been some investigation into the use of this medication as a therapy for cats with allergies. It is not currently FDA labeled for use in cats. So it’s considered an off-label use, which is allowed under the animal medicinal drug use clarification act or AMDUCA. We just don’t have as many studies looking at Apoquel in cats. Of the studies that we do have, they found that cats typically require higher doses of Apoquel to be effective compared to dogs. The medication doesn’t last quite as long, which results in cats needing to receive the medication twice a day, and for a lot of cat owners, that’s a big drawback because of difficulties they may have in giving a pill to their cat. For some cat owners, giving a pill one time a day is hard enough. Twice a day may lead to a cat revolution in the household. The higher dose and more frequent administration also significantly increases the cost of this medication for cat owners. So at this time, because there are only a few studies that have been published, because of the twice daily dosing needed for Apoquel to be effective in cats, and because I have other FDA labeled products that work well for allergies in cats, I still recommend other therapies such as steroids, Atopica, and allergy shots.

Summary

[00:15:01] Apoquel overall has been a revolutionary medication for treating itchy dogs while investigating their underlying allergies. Overall, it is a safe medication to use both short and long-term, as long as FDA guidelines are being followed and pets are being monitored with blood work and physical exams. If you have concerns about potential side effects for your specific pet, I highly recommend you call your family veterinarian and discuss what is happening with your animal to come up with a plan as a team.

Scratching the Itch

[00:16:55] Today’s “Scratching the itch” is a shout out to moms who are veterinarians. Since becoming a mother, I’ve joined a Facebook group of remarkable women who are veterinarians and mothers. Over the years that I’ve been a part of this group, it has grown to over 14,000 members all across the world. It’s a really special place to share stories that are unique to women who are doctors, as well as mothers and provide support in many different forms, whether that’s through shared laughter, sadness, or just having someone to be there for you to talk to at any given hour of the day.

[00:17:28] One story I read recently warmed my heart and I reached out to the mother to ask her if it was okay for me to share this, and I hope it warms your heart as well. She had struggled with being able to produce milk for her first baby and as she approached her delivery date for her second child, her anxiety about being able to nurse her child was overwhelming. She reached out to the veterinary mothers group and asked if any other moms had some extra breast milk to spare. The result was a deep freezer, fully stocked with breast milk that a local veterinary mother was unable to use because her baby was sensitive to dairy and she had been eating dairy when she produced that milk. That veterinarian donated an entire deep freezer full of milk to a veterinary mom in need. And the best part? That mom in need got the breast milk on her birthday. That’s our show for today. I look forward to your next visit with Your Vet Wants You to Know.

References:

  1. Cosgrove SB, Cleaver DM, King VL, et al. Long-term compassionate use of oclacitinib in dogs with atopic and allergic skin disease: safety, efficacy and quality of life. Vet Dermatol. 2015;26(3):171-179.
  2. Lancellotti, BA, et al. (2020) Age- and breed-matched retrospective cohort study of malignancies and benign skin masses in 660 dogs with allergic dermatitis treated long-term with versus without oclacitinib, Journal of the American Veterinary Medical Association, 257(5), pp. 507–516.
  3. Lopes NL, et al. “A Blinded, Randomized, Placebo-Controlled Trial of the Safety of Oclacitinib in Cats.” BMC Veterinary Research, 2019;15(1):1–9.

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