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Feline Infectious Peritonitis (FIP)

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We are dedicating our efforts to raising awareness and understanding about various aspects of feline wellness, with a particular emphasis on a topic of critical importance: Feline Infectious Peritonitis (FIP).

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If you are a vet and need to speak to a specialist then fill out this form to go to our  RCVS Recognised Feline Specialist, please indicate if your query is urgent

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Bova Group have formed an exclusive partnership with Stokes Pharmacy to offer a U.S.-made compounded oral treatment for feline infectious peritonitis (FIP). This treatment is supported by Bova’s unique drug formula, which has been utilized in clinical research studies across the globe and is currently in use in the UK and Australia.

Stokes Pharmacy’s compounded preparation will be available by a veterinarian prescription only. For more information please visit: https://www.stokespharmacy.com/

FIP Research papers

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Coggins, S. J., J. M. Norris, R. Malik, M. Govendir, E. J. Hall, B. Kimble and M. F. Thompson (2023). “Outcomes of treatment of cats with feline infectious peritonitis using parenterally administered remdesivir, with or without transition to orally administered GS-441524.” J Vet Intern Med37(5): 1772-1783.

Outcomes of treatment of cats with feline infectious peritonitis using parenterally administered remdesivir, with or without transition to orally administered GS-441524 – PubMed (nih.gov)

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Green, J., H. Syme and S. Tayler (2022). “A case series of 25 cats with effusive and non-effusive feline infectious peritonitis treated with a combination of remdesivir and GS-441524 (Research Communications of the 32nd ECVIM-CA Online Congress).” Journal of Veterinary Internal Medicine36(6): 2498.

A case series of 25 cats with effusive and non-effusive feline infectious peritonitis treated with a combination of remdesivir and GS-441524 | Journal of Veterinary Internal Medicine; 36(6):2498, 2022. | EMBASE (bvsalud.org)

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Taylor SS, Coggins S, Barker EN, Gunn-Moore D, Jeevaratnam K, Norris JM, Hughes D, Stacey E, MacFarlane L, O’Brien C, Korman R, McLauchlan G, Salord Torres X, Taylor A, Bongers J, Espada Castro L, Foreman M, McMurrough J, Thomas B, Royaux E, Calvo Saiz I, Bertoldi G, Harlos C, Work M, Prior C, Sorrell S, Malik R, Tasker S.

Retrospective study and outcome of 307 cats with feline infectious peritonitis treated with legally sourced veterinary compounded preparations of remdesivir and GS-441524 (2020-2022). J Feline Med Surg. 2023 Sep;25(9):1098612X231194460. doi: 10.1177/1098612X231194460. PMID: 37732386; PMCID: PMC10812036.

FAQs for veterinary team

General

How does coronavirus cause FIP?

In infected cats, a mutation in the coronavirus triggers an abnormal immune response, allowing the virus to replicate within macrophages and evade the cat’s natural defences. This dysregulated immune system activity, involving a runaway polymerase chain reaction of inflammatory signals, ultimately leads to the development of FIP. For more details see https://www.mdpi.com/1999-4915/15/9/1847.

Are cats in contact with a cat with FIP at risk of the disease?

In-contact cats have likely also been exposed to coronavirus already and are unlikely to also develop the disease. Genetically related individuals may share risk factors for the development of the disease. During treatment with antivirals, cats are unlikely to be shedding coronavirus so do not need to be separated from cats in the home.

Diagnosis

What are the best diagnostic tests to perform to make a diagnosis of FIP?

Appropriate tests will vary according to the case and a diagnosis is a combination of thorough physical examination, blood tests, imaging, effusion analysis (if the effusive form), fine needle aspirates, histology and specific testing for coronavirus (PCR or immunofluorescence). Generally, looking for, and sampling effusions is very helpful. See https://www.abcdcatsvets.org/portfolio-item/factsheets-tools-for-feline-infectious- peritonitis-fip for useful charts and https://journals.sagepub.com/doi/10.1177/1098612X221118761 for in-depth diagnosis guidelines

Are coronavirus antibody tests useful?

The majority of cats will have antibodies to FCoV and these can be a high levels and last for months without the cat developing FIP. Additionally, they can be low or negative in confirmed cases. Therefore, antibody testing (blood or effusions) is generally not useful for a diagnosis.

Can you start treatment before you have made a definitive diagnosis?

Yes, treatment trials are appropriate in some situations where further testing is costly/invasive for example. However, other diagnoses should be excluded as much as possible (eg examining effusions) before considering them. Objective measures should be used to assess response (eg normothermia, improved appetite and demeanour, serial neurological examinations) and an improvement seen in 3-5 days, sometimes sooner.

Treatment

There are now legally available antiviral treatments in many countries, and they have been studied in peer- reviewed publications from Taylor, S. et al, 2023, Coggins, S. et al, 2023, Green,J. et al 2023. Antivirals remdesivir (injection SC or IV) and GS-441524 (tablets or suspension) have been shown to be effective in 85%+ cases. Email [email protected] for information on ordering medication in your region.

If the cat has commenced treatment on illegal, black-market drugs are they able to transition on to legally available products?

Yes, they can transition, however, it would be prudent to start the course again so that the correct drug concentration is given for the full treatment period.

How should oral GS-441524 be given?

GS-441524 can be given in a small amount of food, ideally after a period of fasting (which can also increase appetite and acceptance of medication) and at least an hour before a main meal to help the absorption of the drugs. The tablets (crushed) or suspension can be put into liquid treats for example or other tasty food. Avoid putting it into a main meal. Support owners to give tablets directly into a cat’s mouth if needed (demonstrate and direct owners to https://icatcare.org/advice/how-to-give-your-cat-a-tablet.) Suggest owners make giving medication a positive experience by following with a treat (without medication), a brush or playing with a toy (depending on the cat’s preference).

Do cats need to be treated for 84 days?

For most cats, an 84 day/12 week treatment course remains recommended. However, shorter courses of 42 days at 15mg/kg q24hrs (6 weeks) have been used successfully to treat cats with effusive FIP in a recent study (Zuzzi-Krebitz, AM, Buchta K et al, 2024). Importantly, these cats almost all responded rapidly, with clinical (including effusion resolution), haematological and biochemical (including AGP) parameters returning to normal in most cats within 28 days. This is not true of all cats with the disease and hence treatment duration should be decided on the basis of the cat’s response. Shorter courses may be suitable if treated cats respond rapidly, with resolution of clinical signs (including effusions), normalisation of biochemistry abnormalities (and if available normalised serum AGP at 4 and 6 weeks). Cats should be closely monitored for relapse. AGP is not available in many countries and it may be that serum amyloid A (SAA) can be used similarly, but further studies are needed. Communication with owners should discuss that, currently, most published response rates and outcomes are for cats treated for 12 weeks.

What adverse effects might occur with remdesivir/GS-441524?

The medication is well tolerated. Changes in blood results include mild ALT elevations, eosinophilia, and lymphocytosis which do not require specific treatment. Urolithiasis has been reported with black-market medications. Remdesivir injection may cause pain SC and should be diluted and given slowly IV with hypotension and reduced demeanour possible.

What is the risk of relapse and when it is most likely to occur?

The risk of relapse is around 10% and relapse generally occurs shortly after the treatment course is completed but can occur during treatment. Note that relapse can result in different clinical signs from the original presentation. Late relapse (or reinfection) is possible but current research suggests this is a rare occurrence. Relapses can be successfully treated.

How often should I re-examine a cat on treatment?

Re-examinations and repeat blood tests are tailored to the individual cat and owner according to clinical condition, response and finances. Clinical improvement should be noted in 3-5 days so contact with owners at this point is recommended along with examination at 6 weeks and before stopping therapy.

Is it essential that I give the medication twice daily?

No, evidence shows that over 85% of cats respond to once-daily treatment. However, therapeutic drug monitoring (TDM) (unpublished studies) suggests a benefit of twice-daily treatment. For cats challenging to medicate, focusing on consistent once-daily treatment is reasonable, with monitoring of response.

What dosage should I prescribe in mg/kg?

This varies according to type of FIP with ocular and neurological cases requiring higher dosages than cats with the non-effusive or effusive form. However, response is individual and should be adjusted according to clinical and biochemical improvement. Access the document for dosage information and remember to adjust the dosage as the cat gains weight and kittens grow (encourage owners to monitor weight at home).

The cat I started treating has not improved as expected, what next?

In this scenario start by reviewing the diagnosis and considering if another condition could be responsible for the clinical signs. If you remain confident of the FIP diagnosis, then a dosage increase may be required. Access the document for further information.

What other treatments apart from antivirals should I prescribe?

In many cases, no other treatment will be needed, and clinical improvement will be rapid. However, cats with FIP may benefit from supportive treatment such as fluid therapy, nutritional support (including feeding tubes in some cases), analgesia, antiemetics and appetite stimulation. Neurological and ocular cases may require specific treatments such as topical ocular medications and anti-seizure drugs respectively.

Can I give vaccinations, neuter or treat for fleas and worms during or after FIP treatment?

Vaccination and neutering should only be considered during the second half or after treatment when the cat is clinically well. Vaccinations should be given according to lifestyle and risk of disease. Relapse after vaccination or neutering has not been reported but is understudied. Stress should be minimised using Cat-Friendly Clinic/Practice principles and analgesia post-neutering optimised. Parasite treatments can be given.

What else can I do to support owners?

For many owners, the diagnosis is an upsetting one. Direct them to appropriate information about FIP and the antiviral treatment (see below). Support them by giving medications and checking in with them after 24-48 hours to see how they are getting on. Advise on the importance of nutrition and encouraging the cat to eat.

FAQs for pet owners

General

What is FIP?

FIP is a condition in cats (not people) caused by a coronavirus. While the virus often doesn’t cause serious issues, it can, in rare cases, mutate and interact with the cat’s immune system, leading to this disease. Depending on which parts of the body are affected, the disease can cause a range of symptoms.

What signs do cats with FIP show?

Cats can show different signs depending on which parts of the body are affected, but the most common signs are eating less, seeming very tired, losing weight, and having a high temperature. Other signs include a swollen abdomen (belly), wobbly walk, fits, changes in the eyes and a yellowing of the skin.

Is it contagious to other cats?

Feline coronavirus is contagious among cats, but most infected cats do not develop serious illness. While it’s uncommon, FIP can sometimes occur in more than one cat within the same household, particularly if the cats are related.

Diagnosis

How is it diagnosed?

Diagnosis can be challenging and require several different tests including blood tests, tests of fluid in the abdomen (belly) or chest, X-rays, ultrasounds and in some cases MRI/CT scans or even surgery.

Can you start treatment before a definitive (final) diagnosis?

Yes, in some situations it can be appropriate to start treatment if FIP is strongly suspected, further tests are not possible and other conditions have been ruled out as much as possible. Cats will generally respond to treatment within 48-72 hours if they have the disease, sometimes sooner, and monitoring temperature, appetite and blood test changes can help confirm response to the treatment.

Treatment

How is it treated?

Anti-viral medications are now legally available from your veterinarian as injections, tablets and a suspension. The course of treatment is 84 days. Cats may also need other treatments such as pain relief, fluids and eye drops depending on the signs.

Can my cat be cured?

Yes, research studies and experience have shown that anti-viral treatment can cure the disease with around 85% of cats responding to treatment.

Should you give cats shedding coronavirus in their faeces or cats exposed to other cats with FIP, anti-viral drugs?

No, as it is our only major treatment tool, and it can potentially cause resistance. We need to reserve these medications for patients requiring lifesaving treatment.

If the cat has commenced treatment on illegal, black-market drugs, are they able to transition to legally available products?

Yes, they can transition, however, it would be prudent to start the course again so that the correct drug dosage is given for the full 84 days.

How do I give the antiviral medication?

Your veterinarian will decide the dosage (amount) of medication to give and how often. This varies according to the type of FIP and the cat’s response to treatment. Generally, the injectable antiviral (remdesivir) is given once a day, and the tablets or suspensions are given once or twice a day. It can be given in a small amount of food, ideally after a period without food and at least an hour before the main meal to help absorption of the drugs. The tablets (crushed) or suspension can be put into liquid treats for example or other tasty food. Avoid putting it into a main meal. Tablets can be put directly into a cat’s mouth if needed (ask your veterinary clinic for a demonstration and see https://icatcare.org/advice/how-to-give-your-cat-a-tablet.) Try to make giving medication a positive experience by following with a treat (without medication), a brush or playing with a toy (depending on the cat’s preference).

How quickly will my cat get better?

Most cats will start to feel better and have a normal temperature after 3-5 days. It can take longer for changes in blood tests to resolve.

How will my veterinarian monitor my cat’s treatment?

Your veterinarian will decide when they need to examine your cat after starting treatment and monitoring appointments will vary depending on how your cat is responding to treatment. Generally, it is recommended to review the cat’s progress after 2 weeks, at 6 weeks and before stopping treatment but further checks may be needed. You should contact your veterinarian if you have any concerns about your cat between check-ups. Visiting a clinic accredited as a Cat-Friendly Clinic or Cat-Friendly Practice can help reduce the stress of examinations. (www.catfriendlyclinic.org, https://catvets.com/cfp/cfp).

How long is the course of antiviral treatment?

Current recommendations are to treat for 84 days (12 weeks) but some cats may be cured with shorter courses. Further research may alter advice so discuss with your veterinarian.

What can I do at home to help my cat?

At home, the most important thing is to give the medication as directed by your veterinarian. You can also monitor your cat’s signs and weight (baby scales can be useful). It is important your cat eats well, so monitor their appetite and don’t change their diet unless directed to as this can put them off eating. No other supplements are needed in most cases. Avoiding stress is important, so see https://icatcare.org/advice/making-your-home-cat-friendly and ensure your cat has all they need at home.

Can my cat have a vaccination or be treated for fleas and worms during or after treatment for FIP?

Vaccination is important to prevent other severe illnesses, so vaccinations should be given as recommended by your veterinarian. However, cats should only be vaccinated when they are well so this may be postponed until towards the end of treatment or afterwards. Relapse after treatment for fleas or worms has not been reported so should be given as advised by the veterinary team.

Can my cat be neutered (desexed/castrated/spayed) during or after treatment for FIP?

Surgery should be postponed until a cat is well, so during the second half of the treatment period, or afterwards. Stress should be minimised as much as possible.

How are tablets administered?

Directly into the mouth or with a small amount of food, ideally on an empty stomach for better bioavailability. Round tablets up to the nearest quarter, never round down.

Can you crush the tablets?

Yes, tablets can be crushed.

Monitoring during treatment

Weighing the cat

The cat should be weighed routinely (minimum every 2 weeks), and the dose should be adjusted accordingly.

Do NOT leave cats on a set dose for the duration of the treatment. They need to be on mg/kg dose as they will gain weight as they begin to thrive.

What happens at 84 days?

The cat should be examined before stopping treatment. All assessments should ideally be normal. The cat should be re-examined approximately 4 weeks after stopping treatment or sooner if any clinical signs re-appear.

Concurrent medications and neutering

Concurrent medications:

Nothing has been formally tested, however, opioids and NSAIDs have been used beneficially when clinically needed. Drugs such as maropitant may benefit cats when feeling nauseous and inappetent. Corticosteroids are contraindicated during treatment. However, cats with uveitis may need topical corticosteroids. Cats with severe neurological signs occasionally require short-term systemic corticosteroids to reduce inflammation.

Are there any contraindications to routine worming and flea treatments?

No.

Are there concerns about vaccinating the cat during treatment?

No information is available on response to vaccination of cats receiving treatment for FIP although analysis of treated cases suggests that cats can be safely vaccinated after or during successful treatment without causing relapse. Vaccines should be administered as is normally recommended for the cat depending on its environment and risk (see WSAVA or ABCD Vaccination Guidelines). If urgent vaccination is required whilst the cat is being treated, due to the risk of infectious disease, vaccines can be given if the cat is well.

When is the ideal time to neuter?

A month after treatment is completed, however, if leaving the cat unneutered is causing stress, neutering can be performed with at least 4 weeks of treatment remaining.

For more information, please read the latest guidance (February 2024) ‘Feline Infectious Peritonitis (FIP) Information for Cat Owners’.

If you have a query about availability or ordering of medication to treat FIP please email [email protected]

Contact your territory manager direct for the quickest response.


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