One of the great things about the webinar bets is we can get such fantastic speakers, world authorities in their areas, coming from America, coming from Europe, coming from Great Britain, even the tops of snowy peaks. Which is where Diane is, is speaking from today. I don't think you're outside actually on the peak, you're in, you are inside, aren't you, Diane?
I am indoors, yeah. Just as well cos it could get a bit chilly, otherwise if we were outside, so we're we're inside, I'm down in London at the moment, so I'm in a hotel room, so I've got Paul hosting in case something horrible happens with my with my internet, but you know, as I say, very fortunate to have Diane Diane on, it's world renowned veterinary virologist. Going to be talking about FIP treatment, .
She came from the place which kind of invented most of these viruses anyway, which was the University of Glasgow with the Jarretts who were fabulous at finding viruses that nobody else could find. Is a member of the European Advisory Board of Cat Disease. I could go on, Diane.
You've got YouTube channels, you know, you really are somebody who's who's really pushed forward our understanding of all these viruses. I don't want to make you too bigheaded, so I'm not gonna say all the nice things I could say, because we just are dying to know how to treat this rather horrible disease called FIP, so it's over to you, Diane. Thank you very much, Anthony, and I, I really am very grateful to you all at Webinar vet for allowing this webinar series to occur.
This is the 4th in our series on FIP and today we're going to look at treatment. Unfortunately, there aren't a lot of happy endings in tonight's webinar, and I wish I'd bought shares in Kleenex before I began. It's a bit like this that here saying to the cat, bad news is curiosity, and it's a bit like saying bad news is FIP.
So, I've got rather a dark sense of humour. I hope you can bear with that, . I don't want the suicide rate to go up during the course of this webinar.
It's already too high among vets, so I'm going to, after, especially depressing stories, put in some photos like this one where one of the cat's parents is saying, Honey, did you let the cat in last night? And the other person says, no, I thought you did. This isn't my cat, by the way, they're all indoors on the other stove.
I'd like to begin by asking the participants, the veterinary surgeons out there, how often they diagnose FIP, please. Is it A once a week, B more than once every week, C 1 or 2 a month, D 1 or 2 a year, or E I almost never diagnose FIP. And please, if there are any non-vets in the audience, please don't answer this.
I'm wanting to know how often the veterinary surgeons are seeing it. Ideally, I would like to come back and ask this in the summer because it's something that we tend to see around the Christmas time, the winter time. So we're getting people voting at the moment, Diane, and .
Does just perhaps give people a couple of more seconds to vote. Obviously if you don't, as Diane said, see cases then don't contribute. So I think we'll call that a halt now.
We've got nobody seeing it weekly. Nobody's seeing it every other week. We've got about 8% who say they see one or two per month.
We've got, 79% of them to say one or two a year, and there's 13% who say, I almost never diagnose FIP, so it's very much. You know, by this 1 or 21 or 2 cases. Thank you very much, Paul.
Yes, that, that's interesting that it is so rare still. Thank goodness. I'm really pleased about that.
And second question, how do you confirm a diagnosis of effusive FRP or do you not confirm it? That would be A, B, yes, you do confirm it by RTPCR of the effusion. C yes by RTPCR of blood, D by biopsy, and Erevolta.
So again, we'll just let people vote on this, . So do you confirm your diagnosis of FIP infusion of FIP? No, yes, by RTPCR of the infusion, yes by RTPCR on blood, yes by biopsy or yes by revolta test.
And we've got . Just allowing a couple of more seconds if anybody wants to make their decision. So, we've got 25% of people say that they don't diagnose, .
They, you know, the, on the effusion, and they don't do anything. We've got 47% saying they're doing PCR on the effusion, 17% doing it on the blood, 8% making the, diagnosis by biopsy, and 3% using the Rivolta test. So the majority seem to be using, a PCR test on the effusion.
Thank you Paul. That of course is the right answer because RTPCR on the blood isn't really very helpful, but hopefully people have come to the previous webinars, or if not they can certainly access them from the website because accurate diagnosis is very important. If you haven't got the diagnosis right, your treatment won't be correct.
I'd like to begin by making the point that prevention is absolutely better than cure. And as I explain my reasons for this or for the coming hour, I hope that you will come to see why I say this. I came to this conclusion very many years ago, and these are two young cats, Lupo and Perseus, who've lived with the coronavirus carrier for a year now, and the coronavirus carrier sheds virus in her faeces every time she uses a litter tray.
And these cats have lived in the same household with her and have not become infected. Their feasts are consistently negative and they've been proven not to have even been exposed by a recent coronavirus antibody test. So it is possible, and it's not hugely high tech, it will be the subject of the next webinar.
But I just want you to bear that in mind that really is the key message of this webinar that prevention is better than cure. To understand how to treat a disease, you need to understand the pathogenesis in great detail. And I will talk about wet and dry FIP, but really it's a spectrum, it's not two distinct diseases.
In fact, it's really varied in every individual cat who has FIP, so the effusive FIP is acute, occurring within weeks of infection usually, and non-effusive is the chronic form where the cat has mounted a partially successful immune response. And therefore, the treatment that we need to use will depend where on the spectrum each individual cat is. So I'll just go through the pathogenesis very briefly.
The cat becomes infected by indirect transmission, usually by sharing a contaminated litter tray, and they probably mostly become infected when they groom themselves after using the litter tray, and they have full mites of cat litter with particles, microscopic particles of infected faeces on their paws, and from there the virus goes into the intestine. We believe that it replicates first in the epithelial cells of the small intestine. This is the small intestine of a little Persian called Poppy, who was only 5 months old when she died.
And we stained her intestine and for the virus. We stained the virus infected cells black. You can see them at the tips of the vili.
You can see that the vilie are stunted, that they're fused in places, and so you'll be able to deduce from that that she was diarrheic, which she was, she was also vomiting and this . This stage of the infection alone was enough to kill Poppy. She didn't actually have FIP, and so you can imagine that if you were to go in with an anti-Coronavirus, it's possible that you could have saved Poppy at that stage, but unfortunately there was nothing of that sort available at the time.
For those of you who do mixed, small and large animal medicine, you'll have seen this sort of picture with transmissible gastroenteritis virus, the coronavirus of pigs. So from the intestine, the virus then goes into the, into the the bloodstream, there's a systemic infection and this virus targets the monocytes and the macrophages. And you can see it here stained again black by Professor Anya Card, the world famous histopathologist, and she stained the virus in the monocytes and shown them attaching to the endothelial wall.
This is a cross section of a blood vessel. With these monocytes attaching, they were releasing matrix metalloproteinase 9, which will cause endothelial cell retraction, so that they will be able to extravasate from the blood vessels and set up an inflammatory reaction around the blood vessel, and that is the lesion of FIP. So at this stage, we would want to be supporting the monocyte to to battle the virus.
And in a recent study by the wonderful group in Belgium, and it showed that these virus infected cells actually cause local endothelial cells to exhibit more of the ligans that will bind the neutrophils and monocytes so that the infection will become worse in that area. Sorry, I didn't explain that very well. So at this stage we've got the the monocytes and the macrophages releasing not just MMP 9 tumour necrosis factor alpha and interleukin 6 that I've written here, but a whole slew of cytokines and chemokines into the into the blood vessels that will make the cat .
Have the clinical signs of fever will cause raised acute phase proteins, and numerous signs and in my cartoon here, there's the monocyte releasing all these. In chemokines and cytokines and on the right you can see the pygranuloma around the bifurcation of the cartoon of the blood vessel, and that's how you can often see it on postmortem. In real life you see an actual pygranuloma which can be just 1 or 2 millimetres across but still visible to the naked eye and in dry FIP.
No, the immune response becomes so great. That it can become quite big, even 1 or 2 centimetres across and be mistaken for a tumour. So you can imagine that you have to target each of these aspects as you treat FIP antivirals for the early stages, and supporting the immune system by the time the virus is replicating in the monocytes macrophages.
And using anti-inflammatories and immunosuppressants by the time you have a periovascular piogranuloma occurring. The problem with this virus. Is that it's not just a straightforward virus infection such as herpes viruses or caliciviruses where you go in with acyclovir for herpes virus, you kill the virus, the problem's solved.
With FYP, you've not only got the virus to contend with, but it gets into the monocyte, which is the key cell of the immune system, and then it messes with that, messes with the highly technical term. Sorry, and this, this table. It's in your notes.
So there's no need to copy it down and we'll just go through the different parts, the different aspects of treatment. We only have an hour, so although there are many more things that we could discuss than I have here, what I've zeroed in on. Is the, the ones that are available to you as practising veterinary surgeons and also the ones that you will tend to be questioned about by people who are frequent internet.
So I'd like to begin with, how do we deal with the viruses? Well, for exclusive FIT, simply drawing off the effusion, very low tech, but you remove the virus and the virus infected cells, so you remove some of the source of the inflammatory cytokines. You'll make the cat feel better immediately and as we've already seen, is better than a blood sample for diagnosing or ruling out diagnosis of FIP.
I'm grateful to Anne Claire Gannon for sharing this photo with me. This was Shalimar, and you can see that Anne Claire has been drawing the effusion off of his thorax, his thoracic cavity, and she's used clippnosis. She's just used bow clips on the scruff.
She didn't use a chemical sedation, and so immediately afterwards he was able to sit up and eat comfortably. And sleep and he presented with very bad dyspnea due to the thoracic effusion and sometimes even the abdominal effusion can be so great it presses on the diaphragm. Obviously you have to make sure you don't draw enormous amounts of fluid off and cause the cat to go into shock, so people tend to draw off 100 to perhaps 200 millilitres at a time, which is a huge amount.
Now GC 376 is an antiviral protease inhibitor that you may be getting asked about because last year, Professor Peterson. And published this groundbreaking article in the Journal of Feline Medicine and Surgery, and he reported on the 1st 20 cases treated with this in a field study, as opposed to experimental infection. And this this diagram comes from his paper.
What Professor Peterson has done is group the 20 cats into the manifestation of the FIP. So on the left you've got the, the wet, cute at the top, dry to the wet suspected FIP, dry to wet FIP, and then dry FIP. The bars in the different colours illustrate.
At the time that the cat was being treated in weeks, so the timeline is along the top up to 36 weeks. And those cats that have a a date on them are the cats that are survivors at the time of the of the publication. And you'll notice that most of these fall into the wet FIP.
Category we've got one dry FIP who has had 4 different sections of treatment and there's one wet FIP CT21 who was ongoing with a repeat batch of treatment at the time of publication. So as you would expect, this is working best among the cats who are acutely infected with the use of FIP, the, the writing at the end of the bars is the cats, is what the cats died of. They didn't make it through this trial.
So, we have 6 cats who seem to be cured and the average survival. At the time of writing was about 11 months. One cat was ongoing treatment and 13 cats who sadly had died.
This is one of the cats who died. This is Phoebe on the left you can see she's suffering from uveitis. There's visible aqueous flare in her right eye, and she responded to treatment.
Her eyes have recovered. But sadly, after 3 weeks she developed neurological signs and had to be euthanized. For me, the development of use of neuro neurological signs is where I draw the line.
It's one of the reasons for euthanizing a cat with FIP. OK, so that was a bit depressing. This little cat here that this writing says the clinic sorry, the clinicians, what am I like?
The children were feeling guilty about having shaken the box all morning to see if they could guess what was inside. Get back to work. The next antiviral I'm going to talk about is feline interferon omega.
It's better to use feline interferon ga than human interferon because interferons are very species specific. I'm not really going, I know I've just put doses up, but I'm not really going to talk about doses. I've got them all in your notes, .
So, just because I don't expect you to remember them after this, and you'll probably go to the notes to find out what the doses are anyway, so I thought I'd save time. There's been a couple of major publications on feline interferon Omega. The first was by Doctor Shida, and the second by, Doctor Ritz.
And I've made this graph here. Showing the study in red and they see a study in green and I made the number of cats into percentages so it's easier to see a comparison. And so the survival is over a period of less than 1 week on the left, then the next group's 1 to 3 weeks, 3 to 12 weeks, over 12 weeks and over 2 years, and you can see that there was.
Longevity in the Shida study but not in the rit study. And you might be wondering why. Well, the study.
In what isn't always apparent is that all the cats were biopsied. That was one reason that they may not have survived so well. The second is that they didn't have a decreasing dose of prednisolone.
They were kept on immunosuppressive doses of prednisolone throughout, and a number of the cats died of secondary bacterial infections. I believe it was 5 cats. And thirdly, they were given amoxicillin coylanate, which suppresses interferon gamma, which is a major contributor to recovery from coronavirus infection.
So although that was a controlled, placebo-controlled study, and it's referred to by many people, it has some major drawbacks and interferon omega is my personal go to for for treating FIT. This is a case of Danielleanmore and Teresa McCann, and he was called Oliver. He had pleural effusion, and the pleural effusion was positive by RTPCR presented in May 2003, and you can see his, some of his blood results.
Sorry, some of his results on the pleural effusion in May 2003 and seven months later in 2004, he was treated with a million units per kilogramme of interferon omega subcut every other day then once a week. This is the protocol that Doctor Shida pioneered. And prednisolone with a sliding dose.
So this is poor little Oliver in 2003 and Danielle kindly shared with me this photograph, which Oliver's parents sent to her at Christmas time in 2003. You can see it's very much better, and he actually survived 18 months. And then sadly, was euthanized in October 2004.
If I could just take you briefly back to this, and I can't give you a reference for this, but my feeling is that the cats with the thoracic effusions last rather longer than the cats with abdominal effusions. The prognosis seems to be a bit better. And I'm very grateful to Danielle and Theresa for allowing me to use this case, in, in.
Lectures. I think I've got it on the website. I will certainly make sure it's up by tomorrow.
If not, I think you can't get it anymore from Verbank used to be able to. For non-effusive FIP, the key to successful treatment is to catch the FIP as early as possible. You've got the doctor saying to the poor, so you should really come to me sooner.
So I'd like to show you the results of Basil, who was treated very early for FIP because he belonged to a veterinary nurse and she'd already lost some cats to FIP so she was very much on the ball. And he presented in January 2004 with Iris and back in those days we were using 50,000 units of interferon omega per cat once a day, not per kilo per cat, and now we've increased it to 100,000 units, but at that stage we're using it orally. It's it's an interferon that does survive going through the stomach acid.
So you can do that and we were using sliding doses of prednisolone, making sure that they were halved every 7, 1014 days. What I do when I'm reducing prednisolone is I look at the alpha 1 acid glycoprotein because that's an acute phase protein. It's the first thing to give you an indicator that your treatment is working or not working, so you know if it suddenly starts going up, you have to go back to the previous dose of prednisolone or meacam, whatever anti-inflammatory you're using.
Here you can see that within just 3 weeks, basil's Basil's AGP reduced from 2600 to 100, and his jaundice had resolved, and he carried on recovering and his antibody teacher declined till in February, a year later, his teacher was down to 10, which is close enough to 0, that we were able to discontinue the interferon, and we had previously already discontinued the prednisolone. Presenting his details slightly differently with a green line for normal. What I've got here in this chart is the bars grouped according to coronavirus territory AGP and so on along the bottom.
And each of the different colours represents a different date. So what I want to show you is just how dramatically AGP fell, and that's the second group of columns. And you can see if you look over to the right is lymphocytes climbing.
Lympopenia is one of the one of the key. And pathological features of FIP because the virus gets into the monocyte and it's actually trying to shut down the immune system so that the immune system can't chuck it out of the body. So it is an immunosuppressive virus and it manifests as decreased lymphocytes and we know now that that's due to TNF alpha.
So, The key messages here are the AGP is very useful for monitoring your treatment in FIP. I'm looking for a return reduction in HEP and an increase in the albumin globulin ratio due to decreased globulins is a good prognostic sign, but a very good prognostic sign is the lymphocytes climbing back up and reversal of the anaemia of FIP, which is a very serious complication, which we'll talk about more shortly. So, when you when you see a cat like Basil, And I'm afraid it won't happen very often.
But what you need to know for the for you to stop the treatment completely is that the coronavirus antibody tier has returned to 0. That way you know that there is no niis of infection anywhere in the body, otherwise the cat would still be making antibodies to the coronavirus. Coronavirus faecal shedding isn't terribly useful because about 25% of cats with FIP doesn't actually shed virus anymore.
The the infection in the gut has been transient. So, let's move on to supporting the immune system. In 2005, Hannah Dearton published a groundbreaking paper where she showed that the replication of the coronavirus in the peripheral blood monocytes was less to do with the virulence of the virus and more to do with which cat the monocytes came from.
So, the, the monocytes were controlling the amount of viral replication. In the, in, in the monocyte. I've made this cartoon showing the virus going into the monocyte.
Now, when a monocyte or a macrophage phagocytosis, a pathogen. It, it Keeps the pathogen in a vesicle and releases nitric oxide, among other chemicals into that vesicle to break down the pathogen. And then Displays pieces of antigens from the pathogen on the surface in it along with the feline leukocyte antigen in humans, we call that the major compatibility complex.
So Where does the nitric oxide come from? While nitric oxide is generated from arginine by inducible inducible nitric oxide synthase. Where does the arginine come from?
In cats, arginine comes from meat. Cats are obligate carnivores. They can't survive like I do on plants.
So it doesn't give me any joy to say this because I would rather they were all vegetarians like me. But they did need meat. Not cereal based food.
And they need plenty of variety as well. Arginine was first shown to be an essential amino acid for the cat back in 1978. Morrison Rogers actually found that you if you fed a cat an arginine free meal, you could kill that cat.
And the reason for that is that arginine is needed in the urea cycle. So he talks of harmonia. So here you see it very crudely simplified.
In as essential in your cycle. And we find that it's also essential for the functioning of M1 macrophages and then 2 micro features, and then M1 macrophages, the enzyme is is ionosyntheses, synthase. I always get that jumbled up, and then M2 is artinase 1.
The M1 macrophage is very important because it's pro-inflammatory and it also sequesters iron, and this is why you get the anaemia of chronic disease because of these M1 microphagous sequestering iron and it becomes unavailable for the bone marrow. It's doing that to try to stop bacteria using the iron. So it's part of the innate defence mechanism, but you can see from this that if the cat is lacking in arginine, it's going to first pay for the urea cycle because otherwise, the cat will develop hepatic encephalopathy and die.
So it's going to favour that over the immune system. It's going to favour the urea cycle of the immune system. And that is why cats who have FIP and indeed who have any infectious illness should be supplemented with real meat.
In Ray's recent study, they said arginine metabolism is at the centre of the M1M2 polarisation of microphages, and this diagram is from their paper. And the M2 macrophages, as you can see here at the bottom of their diagram. The M2s become anti-inflammatory and help the animal to recover from the infection.
So if you're stuck in M1, you're going to have chronic inflammation. Doctor Maggs, who is perhaps a world expert on feline herpes virus, did an experiment of feeding dietary lysine. Because in humans, people take lysine when they have cold sores, which is, which are caused by feline herpes virus, human herpes virus has probably caused a horrible panic there.
Human herpes virus is is what causes cold sores. Now, what they did was feed a basal controlled diet, which was a Purina dry food diet, and they had the same diet augmented with Llysine, and they were expecting the cats on the augmented Llysine diet to have fewer upper respiratory tract signs, and in fact they were worse than the cats that didn't have the L lysine, but in this graph from the paper, you can see that plasma arginine decreased. You see it decreasing out here to past 50 days in both groups.
Llysine is antagonistic to arginine, which is why we do not supplement the diets of cats with FIP or coronavirus infection with L lysine. In fact, I've done a 180 degree U-turn and I wouldn't use it in herpes virus either. I'm just being a little devil now.
Could the rise that we have seen over the past decades and the rise in FIP have anything to do with the rise of cereal-based cat foods that are low in arginny? So that was depressing. So here's another amusing photo, and one of the cats was saying to the other as he looks up at the big eagle, I wouldn't.
OK, feline interferon is supportive of of the immune system, . And we've covered that, so I'll now go on to polyprenal immunostimulant. Very controversial subject.
Alejandre published a paper in 2009, using polyprenal immunostimulant in 3 caps for dry FIP. And last year he published a much bigger study of 60 cats and. And they, they, the co-authors titled their their paper Poly Polyprenal immunostimulant treatment of Cats with presumptive non-infusive FIP in the field study, .
Because they, the, the diagnosis wasn't fully confirmed. So again, I've made the locks into the percentages of cats. You can see there's almost 30 cats only lived up to 100 days.
A quarter of the cats that would be 15, survive between 100 and 200 days, and we have, some cats going out to over 900 days on polyprenal immunostimulant. With presumptive manage use of FIP. In, in his first paper, Doctor Lejendre said to not use it in effusive FIP, although one of my colleagues said she does use it in that with some success.
In last year's paper, they said, they, they showed data for not using it with systemic corticosteroids, and on the left you have the survival curves in blue without corticosteroids, and in red with systemic corticosteroids, and you can see that there was a much better survival in the cats that were only treated with polyprey immunostimulant, and no corticosteroids. However, for the cats that have intraocular disease such as uveitis, it would appear that you could use ocular corticosteroids, safely and the You can see that the red one with the corticosteroids is better than the the blue survival curve there. I'm grateful to Diana Don you for this picture of of Mars, who is a cat who Who has, who was diagnosed with non-effusive FIP using the mesenteric lymph node.
Sorry, finding the aspirate RTPCR that we do at Glasgow vet school. And He is alive 25 months post diagnosis. He is about to get his dose of polyal immunostimulant, and his diagnosis was mesenteric lymph node enlargement, which seems to be a form of FIP that's very .
And conducive to successful treatment, and here are Mars results. He began PI or PPI in March 2016, and again I've grouped the dates in groups with AGP lymphocytes, hematocrit globulin and albumin globulin ratio, and the green bars indicate the normal level, but of course sometimes the normal is below the green bar, sometimes it's above. So the first, test is on the 8th of December 2015 before his PPI, and it's very, .
Very congruent with the diagnosis of FIP. He's got very high AEP over 6000. He's lympopenic.
He was yet normal. Blood red blood cells throughout. He had hypergrammoglobu anaemia, which pushed his albumen globulin level down low.
And what I'd especially like to show you here is that after his PI, his lymphocytes became of a normal level. Now that's just N equals 1. I don't have a bunch of data and I don't have a control group, so I'm not being very scientific here, just wanted to share it with you.
And if any of you out there have data like this on cats that you're treating or not treating. PPI I'd very much like to hear from you. So as I mentioned, mesenteric lymph node adenopathy is one of the most treatable manifestations of FIP, but because it's an enteric infection, it may be that they that the cats get some lymph node adenopathy in early infection.
And cats that don't have FIP, that's one of the things that you would have to watch out for, but you certainly know when you're getting a cat with dry FIP, the cat's losing weight and has all the Typical biochemical and haematological changes. If they have a very solid lymph node, raised lymph node in the abdomen, that's a quite a good candidate for trying treatment. The cat in front who looks like my cat Musa, but I assure you it isn't, is saying, I hope that fireman asks her out soon.
This is getting old. I hasten to add that these are not my cats. It's not me.
OK, let's move on to anti-inflammatories and immunosuppressants. Now, if you're going to use massive immunosuppression in the cat, you better be very sure you've got the diagnosis right. And this is where any cat that you're suspecting of of FIP should have a coronavirus antibody test using a sensitive test.
In other words, not antireness. Luca was a cat with FIP. And an erroneous negative antibody test by Antech Diagnostics caused a delay in FIP diagnosis.
For Luca. And this is his actual results and I'm grateful to Maria Bonina for sharing with me. And you can see what they call their coronavirus antibody test, which they even mislabel, they, they label it FCV which everybody knows is the abbreviation for feline calicivirus, or feline coronavirus, so they get zero marks there.
They said he was negative, which is just a beggars belief because he had his pathologically confirmed FIP. And then to top it all, they offered to confirm with the 7B Eliza and the 7B laboratory artefact has been discredited long ago, so why on earth is still offering that? I really don't know.
I'm I'm afraid that I'm rather angry with this laboratory for this. Ridiculous report. I published on a comparison of papers in Jains a couple of years ago now, and the best ones were the the coronavirus immunocom which can be used in your practise laboratory.
It comes with all the things that you need to to do the test. It's not at all complicated. And of the rapid immuno migration tests, the, the speed of corona from Bach and the fastest, from megacor did very well.
OK, so. Like, oh, sorry, my computer jumped. Also run a toxoplasma antibody test and if you were at our at the dry FIP webinar, you will have seen the misdiagnosed toxoplasma, .
Case that Cohen published. So that was all very depressing, . The fireman didn't come, but Batman did, and he said, I have to admit, Catwoman, you're not as I expected.
Prednisolone is probably the go to for, for most of us in diagnosing FIP sorry, in treating FIP. But is it really a good thing to use? In the Ritz study, they had a control group of prednisolone only.
And none of the cats survived beyond 12 weeks, but they didn't slide the dose. They just kept it at 2 makes per kick throughout the time. It seems a bit strange to me.
So you really have to decrease the dose every 7 to 10 days. The sharp hi among you will have noticed that some of the treatments turn up in more than one category. They're covered in feron gas, so let's have a look at cyclosporin A.
And Tanaka etal showed that cyclosporinate actually has some activity against coronavirus in vitro and of course it's very immunosuppressive. Doctor Tanaka published in the veterinary record details of 3 cases, but, but one in particular, 2 of them died, but one did quite well, and this is Doctor Tanaka's figure from that paper. You can see here, around the cyclosporin A that he's decreased the doses and then increased them again when the pleural fluid came back.
On the very top are the days after treatment. Underneath it, the clear triangles indicate the pleural fluid volume. And then Doctor Tanaka had to give the cat erythropoietin.
To counteract the non-regenerative anaemia. Now, the bars on the bottom are indications of the viral copies, and this actually shows that even though cyclosporin has some antiviral activity, it didn't completely get rid of the virus in this case it was treated. What I find very important about this cat is that the erythropoietin probably saved the cat's life.
And for the time that the, the cat survived, which was 264 days, which if I remember rightly brought her to 15 years old. The dog says, What's the password? The cat said, Let me in or I'll stretch your face.
And the dog said, that'll work. I just, I love that one. It's so like the attitude of cats, you know, dogs are, you come in and your dog's going, How are you doing?
How are you doing? How are you doing? And your cat goes, ah, about time I'm waiting for my dinner.
So we come to the last group here, . Of the treatments targeted modification of the immune response and a lot of these are kind of way out into the future. They're not something that you're going to be using in the practise, but I'd like to briefly tell you about a case called Rolly, and you can see him here with his effusive FIP tummy or swollen up and more clearly from above.
This is in January of last year, 2017. And his sight is resolved on. Interferon onomega proneolone and curcumaloga rhizome, in other words, turmeric, and you can see ginger on the left, which is anti-inflammatory, and I put it there just to show you the the little turmeric rhizomes, and when you cut them open they're, they're very bright yellow orange colour.
I always say to people, to vets, they're a bit like a maggot or a child's finger, but Doctor Gregor, the famous nutritionist of humans, referred to them as a little tur in a YouTube video recently, so, not very appetising. We use that as well with Roy. And on day 30, he also got anti-TNF off for monoclonal antibodies and Fliximab.
However, unfortunately, he developed non-effusive FIP. As you can see, he has annatooria here and he had uveitis of his left eye, but what tragically killed him was that he developed hemolytic immune-mediated anaemia. Which rapidly killed him.
Doctor Cai reported on 51 cases in Taiwan. And made an algorithm for staging effusive FIP. I've made a little video about that, and the link to which is in your notes.
And you can see that Sorry, I've, I've made an Excel file of the, of the staging that Doctorai and her colleagues, . Developed. And the Excel file gives you it adds up the sums at the bottom to to give you the survival time.
How you use it is, for example, Roy had a hematocrit of 27.5. So you go to the PCV and this was 27.5, which is over 26, so you put a 0 in for January 2017 when that test was taken, and you do that for each of the tests on each of the days, and you get a total at the end when you put all the parameters in.
And if the total comes to between 0 and 4, the cat's likely to survive more than 2 weeks. If the total is between 5 and 11, the survival time is going to likely be less than 2 weeks and over 12, the total of a total of the survival is less than 3 days and . Using it prospectively and raig, it did seem to work in that on the test on the 30th of March, although it wasn't over 12, he'd gone up dramatically compared to previous tests, and he was in fact euthanized on the 1st of April.
The canine among you will have noticed that these are parameters due to anaemia. And anaemia is definitely what. Kind of takes out a lot of the cats for FIP, but even in the very early days, our haematologist at Glasgow, was remarking mild regenerative anaemia, which appears to have an immune-mediated component, and even though he was on high doses of prednisolone, and even though he was on the curcuma rhizome, which is anti-IL-6 activity.
Unfortunately, we were unable to reverse that immune-mediated hemolytic anaemia. His hematocrit steadily declined, and his bilirubin rose dramatically just before he had to be euthanized. So, The parameters for me and these are personal for for stopping treatment and euthanas are the onset of neurological signs, the hematocrit falling below 20% and then onset of immune-mediated hemolytic anaemia, and there's no point in giving the latter group a blood transfusion because it's like pouring gas on a fire.
So, just to finish up. My key messages are that the best treatment is of course to treat the disease that the cat actually has. Giving the wrong treatment can be worse than giving no treatment.
Prevention is better than cure. I hope that by now you will have seen how highly complex this disease is. And that really if we can prevent it, we, we have a lot better chance than than trying to understand this incredibly complex disease and target the treatment towards all these different aspects of the immune response as well as to the virus.
I, I'm so grateful to the guardians who sent me their cat stories, their photographs, and allowed them to be used to help others and to their veterinary surgeons who supplied details and samples. You people have just been absolutely fantastic in helping this research. Got to thank my friends and colleagues at the veterinary diagnostic Laboratory at Glasgow.
The word laboratory splits into labour and oratory. I've done the oratory, and these are the guys that are doing all the work back on the ranch. I want to thank the people at Webinar vet who are always incredibly efficient and for hosting this series, and Anthony has permitted me to come back and gave me such a lovely introduction.
And I think I hope we still got some minutes for questions, have we? Yeah, and yeah, that's fine, Diane. So I'm, I'm gonna lead with those.
I think we, I can see them, but I'll just check, see if there's any questions coming through. Just before we do that, because there's no questions at the moment, . I've just been asked by one of the team to, to remind you all about the mood series that we're doing at the moment.
That's not how to get into a mood, it's how to get out of a mood, and it's how to be positive about things. It's Mike Scanlon who did our mindfulness and our sleep series, which have been really well received. I know you've probably heard me go on about it before, but I just think.
You know, we do have a stress problem within the profession. And that, you know, unfortunately sometimes, you know, these things get really serious and it's very much part of our remit webinar that with the, you know, helping to support all the great work that the Royal College are doing with the Ryan Mass initiative to, to just give people that option of there is some really good stuff out there and, you know, how can we be more positive. You know, being grateful about life.
Loads of different techniques there just to help us to, to realise we're fortunate to have this fantastic job that we can do, which obviously sometimes, you know, as with all jobs probably gets us down, but. You know, I don't know what about you, but I, I just feel very fortunate that I've been able to do the job that I wanted to do from when I was 8, because there's a lot of people out there who, you know, don't have those opportunities and don't enjoy the jobs that they do, so. It it's there, you know, hopefully to, to help.
I was . On another webinar. I'm trying to think, I think it was yesterday, so if you haven't seen it, there was also a fantastic webinar on Cabalabean by Nick Beckfield, sponsored by sponsored by Protein.
And Diane, I don't know if you, you're old and crumbly enough to remember when, you know, every animal came in and got a jab of of antibiotic and a, and a pink injection which was B12. And they sting. I, I've got that in the notes that they should all get the carbalamine injection.
Yeah, but we're doing all wrong because we're now being told, you know, how good it is, and, and this is a protectin's product is an oral carbalamine, cos obviously slightly less painful than being jabbed once a week. I'm not sure if if it can be used in cats, but it's certainly, can be used in dogs, but I think it can be used in cats, but it's a, it's a fairly new product and . Obviously we'll see how that develops, it's always difficult I suppose to get tablets into, but .
Paul has put that URL up about the the wellbeing course. I think that's wonderful. Is this, yeah.
Yeah, when the, the vets that are dealing with this are, it's, it's a terribly soul destroying condition to be dealing with FIP. It can really drag you down. So I think it's wonderful that you're addressing that webinar vet.
We all as much as we try not to get attached to our patients, and it, you know, we just hate these horrible diseases that we don't. Yeah vets we kind of want to sort things and get them better and. You know, lots of great work there, Diane, I mean, the, the beauty of this is that, you know, you've probably seen it in your career, how, you know, FIP is.
Thanks to all the great work that you and others have done is, is, is more treatable now, and I love that, that first one, the first slides of the, the two cats living in a household with an FIP cat, or a. She's not a FIP but she's a carrier. Yeah just by understanding the disease more, we can then think of strategies to avoid, you know, one of those cats going down with the disease, so, you know, really.
Yeah, and I've got a wonderful group on Facebook called the NFIP Group who are actually subscribing to support me, to support my research. And they're actively doing things like designing posters to make people aware of coronavirus, to try to pressure breeders into breeding coronavirus negative kittens and and to actually take action against the spread of this virus. There's a tremendous amount of support now happening through the internet so that people can get sorry.
But don't know I've finished really, carry on, Paul. We just can't catch ours, that's the only problem, isn't it? No, I, you know, obviously you've very kindly done these webinars for us, so if, if people, you know, come in on this one and perhaps missed others, the, the website should be a lot more searchable now.
So if you put FIP in, we should get most of those webinars showing up. We are going to do, perhaps even next week, let's set ourselves a target next week to have a 10 minute, look over the website, because there's so much good stuff in the new one that even I'm just sort of getting to grips with, so it would be good to, to pass some of that on and, and help you in, in finding stuff and, and also doing some of the multiple choice quizzes that have been set up to really see, you know, have we. Have we grasped some of the stuff that er Diane and other lecturers have talked about?
We have got a few questions now. I've, I've sort of droned on for a bit, Diane. It was good to hear you because I began to wonder halfway through if I actually still had the connection I was talking to myself, so I was so relieved when you came on.
And everybody stayed on as well. In fact, the, the audience has grown during the webinar, so it's always a good sign. Oh, that's a bad thing.
But did you say the audience has grown G R O W N or that they growed G R O A N E D? I, I definitely think it was the first one, but. I think my terrible jokes must have made them groan.
I'm sorry. So Alexandra is saying hello, and just, you know, as I say, you don't hear the tumultuous applause at the end, as you would usually do, Diane. So great webinar, thank you very much.
How to prepare a household after cat with FIP before introducing new cats. So I think, you know, perhaps either a carrier or a cat that's obviously had the disease. Potentially shedding into the environment, how long do those viruses stick around before you can introduce a new cat?
Well, provided there are no cats, you can introduce a new cat in 7 weeks. The virus survives in dried up 4 mites for 7 weeks up to 7 weeks. So after 7 weeks, it's safe to introduce a new cat, and we'll be dealing with that in the next webinar and it's also on my website.com and in my book for Guardians.
FRP and coronavirus, which is available from Amazon. So lots of if we're looking on Amazon, what's the name of the book? It's FIP and Coronavirus, a guide for cat guardians.
If there is a cat in the household, so, they'll need to send faeces from that cat to see if the in contact cat was shedding coronavirus, and they tend to shed for 2 or 3 months, mostly, but some cats do shed for longer and you do get asymptomatic carrier cats. And some of them might develop disease, but some of them might not as well. Yeah, usually if they've had virus for over a year and a half, they don't develop the disease and they can be quite stressed.
And I was given a carrier cat, so she, she had a new home at 10 years old and had to travel from England to Scotland to come to the home and didn't get FIP but we do see FIP again re-emerging. In geriatric cancers as their immune system ages and becomes poor, and then the virus can just get the upper hand. So we can almost see that 2nd level where it comes, but that cap that maybe is shedding for 3 months.
We, we then do another test maybe up to 3 months and that's negative. We're then almost having to still add the other 6 or 7 weeks on before we introduce a new cast. Yes, that's a good point, yes.
OK, another question from Alexandra. a second question is for how long should we use Infe on every other day dose before switching to once a week? Well, the, the Shia protocol was just once a week, but, Danielle and I, when we were discussing Oliver, we regretted going to once a week, and we wondered if we should have stuck it twice a week for him.
And, and We should have really clocked that his AGP hadn't reduced back to normal. It came down a bit, but the AGP really should be in the normal range before you start tailing off the interferon. For me.
I know it's difficult if you're not in Britain, it can be difficult to get the AGP levels in other countries. I know Italy does because of course Paltrinieri in Italy is kind of the world expert on AGP, but I'm not sure which laboratory would do it in the United States. Yeah.
But we do get samples at Glasgow from all over the world. Well, this is the thing, I mean, presumably now we can send samples up to you, they get, they get there, you know, we send them in the right way, we can get them to Glasgow pretty quickly, can't we? Yeah, they don't even have to be on ice.
Yeah, so just ordinary package over to you. Greg is asking, is there any work on a vaccine being done? Yes, fellow cell FIP, is available, and I'll be talking about that in the next webinar and actually giving some information that isn't very readily available as to why I think it's a good vaccine.
And his veil is that the Zettis vaccine? Is it the sorry. Yes, it is, it's the latest.
Oh probably said Pfizer didn't I? Yeah. They're all the same.
They keep on changing to confuse us. They do. Gordon.
Gordon said he embarrassingly laughed out loud at your Batman joke. That was sent to me by Professor William at Glasgow, and I think it was personal. I, I think Gordon's rather worried that people are wondering why he's laughing at a, at a, you know, a, a computer screen with his headset on.
They probably think he's, he's going into some sort of meltdown, but, no, it was, it was a good joke. I did like that one as well. The, the corny ones are the best.
So, so, before we finish, anybody got any other questions, . When are we doing the next one, Diane? Have you got a date for that with us?
It's the 4th of October. Alright, so we'll have to wait, but good things come to those who wait, I suppose, so it's worth waiting for. But it, it, you know, it's been a great series bringing it together.
I'm just so grateful that you're making this possible because it was something I've wanted to do for years and didn't know how to on my own and And then, you know, I got the email. Would you like to? And I said, would I?
And then you've been fantastic about allowing me to come back and just pick up where I left off. Well, this is really one of the great beauties of, you know, of using webinar technology which we've now been doing for, for 8 years is, it's just that being able to get, you know, the world authorities on these conditions. You know, to, to actually try and do that on a weekly basis by bringing people into the country or, you know, to Liverpool or Manchester or London or wherever, it, it, it would become very, very difficult and, you know, it's one of the reasons I think when we, when we look at the surveys asking people how we're doing, you know, the quality of what we do is fantastic, and that's, you know, that's obviously testimony to, to people like yourself and.
And all the other great speakers we get, so it's, it's us that should be thanking you, not the other way around, but you know, thank you for your kind words nevertheless. Well, I think I'm going to need a crowbar to get my head out the door. Well, it, it's the cats will always bring you down to a low level, won't they?
They, they will tell you who the boss is in the household and it's definitely not you, is it? No, is a status here. So Diane, thank you once again.
Thanks everyone for listening, . You know, a fantastic webinar, looking forward to the next one, you know, I don't like wishing my life away, but, looking forward to October to hearing more about the, the vaccine options and, and, and other things. Thank you and everybody a lovely summer.
Thank you all again. Cheers. Good night, bye bye.