Hello, it's Anthony Chadwick from the webinar vet. We're so fortunate today to be talking to Danielle Gunmore, who's going to be talking about an update on infectious peritonitis in cats. Obviously a really topical disease.

We were very much ahead of the game when coronavirus hit because we had a disease that was so similar in many ways, but now we're benefiting from all of the money that's been spent on COVID research and treatments, which I know Danielle's going to talk about. I, I think everybody knows who Danielle is. We had a great time, didn't we just recently in Rhodes at the ISFM conference.

As, as Danielle says, the cats are the, are the greatest species of companion animals that we will treat and . Who's to disagree with her? I, I, Danielle, I think told you the story about being adopted by a cat over the pandemic.

That's for a story another time, but, I'm really looking forward to the presentation. Danielle, over to you. Thank you.

Thank you, Anthony. And, yeah, and I go back a long way. We're, we're, we're great buddies, but we're also great admirers of what each other does, and, and that makes for a great working together.

Thank you. And you picked a great topic. This is so important, and yeah, we're getting something positive out of COVID, which is gonna be something good.

And my apologies ahead of time. I, I look pretty rubbish. I feel pretty rubbish.

I think it's probably last week catching up on me. I've done a lateral flow, it's negative, plus you can't catch it through the airwaves. So, I'm not my normal sparkling self.

My apologies. I do have a wee bit of medicine here and . I'll help take OK, so, update on feline infectious peritonitis, and actually we went renaming things in Rhodes, and one of the ones that I can't remember who asked we should rename because this is the wrong name and this really confuses people because people think it's a disease of perneum.

I was sent a letter to the vet record because I'm on the editorial board. And it was a letter from someone in Asia, and they had seen that this is feline infectious peritonitis, and they had seen that, in some types of paritonitis in people and in some rat studies, they infuse, it was like heavy water. It was very, very strange, but it's basically like washing out the, the, the parrot name and they thought this would be a good thing.

But of course, The names are wrong. It should be called feline infectious phlebitis because what it actually affects is the vein. And the beans are obviously everywhere.

If I keep looking over here, that is because that's where my screen is. Shall I move you over a. OK, right.

Now, The stuff that I'm citing, the work that we're doing, it isn't me. It's a team of us, 5 of us doing this. The lead is Sam Taylor, and she has been Amazing.

The work that lady is doing is just stunning. Also Amy Barker, let me see I get a better point that point is kind. There you go.

Amy Barker is really heavily involved. So Tasker, well, obviously you can't do anything on the cats without having said in there. Also, Steph Sorrell, you might not know her so much, but you might do the BSAVA stuff, previous resident of mine, brilliant freelance specialist, and then myself.

So it's the 5 of us, and we make up the FIP advice team, and we're doing it all for free, so be gentle. Oh what I should have said here, the ABCD, ABCD is the, it's advisory board for cat diseases, the European Advisory board. They've updated all the FIP stuff, brilliant.

Go look there and obviously obviously the international I is all up to date as well. I don't think I need to introduce you to Coronaviruses. They are fabulous, exciting viruses, much more exciting now, hey, who knows that pick up the world literally, what I did my PhD on and most people thought I was being weird and playing in dusty back quarters of you.

I'm gonna show you that's not actually. So what we know is that the coronaviruses make up the, the enteric coronas, they don't do very much. And then once they've mutated, they become more vicious ones.

So if you're looking for how common they are in the normal enteric ones are, well, about, you know. Yeah, a single cathold up to about 40% are gonna be positive, but you know, they really don't get sick very much. Where you get, a very heavy antibody presence is when you've got lots of cats, and that's when you get the mutations.

And I'm not gonna go into all the how the mutations occur, because I want to spend more time on diagnosis and treatment. But ultimately the mutations increase the ability of the viruses to live within the macrophages and within each macrophage you've got multiple, multiple, multiple viruses because these viruses are so huge, as is obviously coronavirus or be like human coronavirus get there yeah that every daughter virus is different from the mother. So you get what's called a quasi-species cloud of viruses and from those you get these extra mutations that make them particularly virulent.

And it's when you get this happening, that's when you get death from FIP, not that much in the general cat population, but when you've got lots of cats together, that's the problem. And you can really look at, you've got the enterics over here that really don't cause any disease. You've got some lab strains, you know, they were wild strains once, but they got lab because they are just so nasty.

They'll go to like every cat I put into kittens, isn't it? But most field strains are somewhere in the middle, and then it depends on the host immune system. If you've got a very poor immune system, you're going to develop cycles, so the classic peritonitis form that people expect to see, and these poor cats always look they feel miserable.

I feel like like I did this morning. Whereas if you've got a moderate cell-mediated community, then you'll get the dry form and you can see you've got a pretty good UVI starting here. And if you've got good eyesight, you can see these little brown splodges on the inside of the cornea.

These a carratic precipitate. So I know it's a good picture because it's like, is this kitten gonna die or not. So the factors that are gonna affect it, so the strain isn't usually much of a player.

What I would say is there are very occasional hot strains that will move from cat to cat. Usually, the virulent strain that causes FIP is inside the cat and so yes, it's still shedding coronavirus, but it's shedding the unmutated one. That's not pathogenic, you know, that's not gonna cause FIP, and very occasionally does the virulent one actually get back to the bowel and spread that.

Very rare. But the dose is really important, and this is or a faecal, so where you've got a lot of diarrhoea all over the place, lots of chickens that's when you want to get FIP. Age is incredibly important.

We know that, more than 50% of cats with FIP are less than 2, 90% are less than 4. You can get a few in geriatrics as their immune system goes. So age incredibly important.

The immune system can't just can't hold off the virus and they're much more likely to be lots of kittens in one place together, diarrhoea, difficult to clean them, big dose of virus. Genetics plays a significant role. We know that 70% of these cats are pedigree cats, OK, you got more likely to get lots of pedigre cats in one place.

That's true. Certain breeds, Bengal would be one, Persian. It tends to be lines of cat breeds of cats, but certain breeds like like Benny, we do see a problem with them.

But is it because they're kept in bigger groups it's getting. We certainly know that stress plays a major, major role. So stress weaning, vaccination, rehoming, neutering, all of those things, bang bang bang bang, and the poor cat's immune system thing, you know, it's, it's, it's tough for them to cope with it.

And disease. So you know if they are lucky enough to have cancer risk of having a field that might be 4, it might be. So what is the possible outcome?

Well, lucky lucky cat will be a resistant. It's only less than 5%. Not many.

Most vast majority of transient infections that get infected, make antibodies, they clear it. They lose the antibodies, they get infected. They make antibodies, they clear it rinse and rub it.

Persistent carriers about 15%, and they're the kind of typhoid Mary. They're the ones you want to find in a breeding unit because they're the ones that keeping everybody else. And so that leaves the rest which is up to 5 to 10% getting FIP.

Let's do a bit of math. We've got about 10 million pet cats in the UK. About 12% had greed before lockdown.

One study says it's 24% because breeders, bad breeders really bred their their queens in a big way to get lots of kittens out, so we'll stick with them. Third counts are young. And up to 5 to 10% get FIP but obviously it counts in a rescue situation or at risk as well, so can you do the math.

Maybe 30,000 cats a year. I don't think that's right. Even if it's called that.

15,000 10,000. And you, what you're getting is an immune-mediated high granulomas, phlebitis minus rosy. And we've got the dry form here.

It's one in his brain. His eyes are not like the eyes are not inflamed but aquarium. Here, we've got this poor little cat, which has got uveitis.

And then this one didn't make it because both kidneys, but what you can see is you've got these oculate vessels over the surface of the cat's kidneys and you can see lots and lots of granulomatous tissue on the blood vessels. You can see it really lines on the blood vessels and it really shows you how how that works. So most common form this is about between 60 to 75% depending on the studies of the wet form, so most common and typically presenting with this.

Acetic depressed cats tends to be rapid. basically, high protein fluid into body cavities is what you're looking for. Not difficult to die.

A difficult one is the drawing. So this is gonna be my 30% or so of which will be 5% will be CNS and another 5% or so will be neurological. So variable failure to thrive is biggie, you'll see kittens, one is a normal size and one is smaller.

Fever not responding to antibiotics is a biggie on the dry and the wet form. And actually a colour change in viruses is a really good indicator of what we're dealing with. It could also be neurological.

This is a neurological case. Eyes are fine, but it's in his brain. He's paralysed.

Conforming in the abdomen. This is where you get particularly colic function. It's a good place for this course that's also a good place for lymphoma.

So it can be hard to tell these two apart, and the kidneys. So here we've got, back of an eye, and you've got these granuloma forming along the veins, and here you've got, hy femurs blood in the anterior chamber because the UVitis is, is so severe. It's much more chronic and insidious.

Diagnosis is challenging. Hence we've got Sherlock. It's a jigs puzzle.

There is no simple here. We've got tick, we've got diagnosis. It's just not that simple.

What we really need is to show the, the virus. In the same place as we've got the high granulomatous cells. So what we're wanting to see ideally would be immunostochemistry or immunocyto cytochemistry so actual.

Highlighting the cells that are infected. And then, that's perfect. But if you're not actually gonna highlight the cells affected, then the other way of doing it is looking at cytology, and showing that you've got higher granuloma granulomatous fluid or, FNA and then doing quantitative RTPCR, quantitative bit is necessary because you know there's lots of it, just a little bit, I'm not excited.

A whole lot and I or you could do the specifics and we'll come back to that. There are all sorts of things we can look at and we're gonna have a look at each of these, and Sherlock Cat will help us. Haematology, yeah, not very useful.

Not specific Lympropenia, anaemia, sometimes the anaemia is usually anaemia stomach disease. Sometimes you can get quite a marked anaemia, you know, down to like 13, 15%, and it can be mediated. So it can look like an IMHA.

On biochemistry, depending which tissues are affected, but expect to see raised bilirubin, which then when you've got the anaemia, you're thinking, oh, it is my NHA. Raised globulin and then albumin usually goes down as a negativity phase protein. So you end up with an AG ratio, typically it's going to be less than 0.4.

If it is. 8 or above, it's really unlikely to be. And look for acid one, alpha glycoprotein AGP this is acute phase protein.

Normal is less than 500, and in FIP it's usually less, it's like more than 1500, often more than, 3000. And here you see high protein in the back of this capsti and the veins are looking like sausages because they're having. What do.

Fluid. If there's any fluid, look at the fluid. If there appears to be no fluid.

Then do an abdominal suffage, OK? Because it usually is affecting the abdomen. They do it all lava and 20 mLs of saline, which it, put it in just the same way you do, I fluid in the lamb.

You can all remember my alarming day and then you can just be like the . And then squish it around and then stick it back. You only need half a mil back if you won't get very much back and then you can look up everything you need in that fluid.

That's a really good tip you can come to me from one of my team and the ECC, and yes, I am on medicinal. Right. What can we look out in the field?

Well, it's likely to be yellow, slightly pink that might be coming from the from the plural. Froy. It's high protein.

Look at the AG ratio. It's gonna, we got the test. Some people swear by this.

All this test tells you is you've got high protein, and you can do that on a refractometer. If you want to know how to do this test, you just take 20 mLs of water, drop of acetic acid, vinegar, and then. Juggle that up and then drop it.

The body fluid on top and it kind of forms this little droplet. It might separate and drop down but it won't defeat just shows it's quite. Cell count doesn't tend to be that high, but what's juicy and non-toxic neutrophils.

And macrophages, so we've got macrophages and non-toxic neutrophils, the non-septic exit. And the AGP Do that on the fluid as well. The things that you can do on the fluid, this is where the immunocyto chemistry comes in.

Most of the labs, actually all the labs in Britain aren't offering immunocyte chemistry. What they do is they take the fluid and spin it down. They start to spin it and then they treat it like it's immunochemistry because that reduces the false positive.

So if you think that then decent lab and the ones in Britain are, you've got a confirmation. And then histoca, which is a gold standard, It's really good when you see it, you've got these infected macrophages, you know, you've got all these infected macrophages and all these microphages all together. Mina has to camp tends to be not as sensitive as the quantitative art to PCR.

It tends to be a bit more expensive, although in my university, we're doing it much cheaper now. I'm proud to say. What about the RTPCR?

Well, the standard RTPCR, all you're doing is saying coronavirus is there, and it'll pick up, probably it would pick up COVID. Good thought. I'm not sure and looked at it.

It probably could, not very specific. It's just looking at spike. I hope it wouldn't.

Good thought. I think about it. But people will use this for trying to look for coronaviruses and poo, you know, this is not, for diagnosing FIP.

And if anyone says, oh, it's MIP because you found it in the poop. No, you didn't. OK.

That's not a way of diagnosing it. The quantitative art to PCR. It's what you want.

So go do it, Glasgow, Langford, Finlabs, and Finai. You are looking for really, really high level, and you want to see what cells with it. Take care because it's normally reported as a cycle threshold CP, and it's a low number didn't take many amplifications in order to.

And then you've got the real FIP test from IDEX and it is detecting spike mutations which do make up 70% of the mutations from it is not as sensitive as this data which appear to show and actually in real time, people find it not as sensitive as quantitative RTPCR so they tend to go to that first. So quantitative or the IDEX is better than the neurocytochemistry. There's not very many cells, and then the IDEX got low sensitivity, so we tend to go to the ant.

What about serology? Well, serology, you may as well hear in its ear for the usefulness of this. All it tells you is the cat has met the coronavirus.

Oh, what kitten hasn't, so do not tell me that that is on the profile, OK? I don't care. I really, really don't care.

You know, tell me it's positive. I'm going to say, well, of course it's had a good kitten, a young kitten from rescue centre. Tell me it's negative.

I don't care because some wet cases, then you know what, that's got all these immune complexes in it in its societies. And they're out of its blood. So really, I don't care.

And imaging can be useful when you're looking at CT here. You've got this fat stranding. He is a normal perineum, and here's the fat stranding.

It just shows the way you get the this protein is is oozing out of the inflamed the sys on the. MRI of the brain can be can be really good. It's can be pretty pahonemonic.

You see pictures like this and it's really. So, but that's obviously pretty specialist. I know this is too weak.

You'll not be able to see it, but I'm gonna go talk you through it. This is the ABCD guidelines. The presents a practise, physical exam, you've got routine blood signs.

Yeah, and you might get the FIP suspected on up here is FIP possible. So just on the presenting oh it's possible, do few bloods you're gonna be suspected. Then if you can find this granu which is inflammation, you're gonna go lightly.

If you can search for coronavirus, then it's found by quantitative ITP then it's gonna be very likely and in a histocam, then it's likely confirmed and it tends to be FIP very likely confirmed that that's where we're we're treating, but I'm gonna make a comment about. Because important is be pragmatic. There is no point whatsoever using up all the money, getting a diagnosis.

And then have nothing left to treat. All right, don't do that. Please don't do that.

Don't be pragmatic. Just the history and the signalment and the clinical signs and the biochemistry that they all fit. So the fluids fit and send off for culture and sensitivity really important because we have had quite a few of these cats that appear to be FIP turn out to be septic abdomen, sometimes both.

But then send your fluids off and start treatment pending the diagnosis because the 45678 days it takes to get your results back, the cat could be doing very much better. And with organomegaly, you're gonna do FNAs. OK, here is a wee tip.

Get a little little tube, you know, a little bus tube, one with a little pointy bottoms off whatever you've got in practise, there are, and then do 2 or 3 FNAs from that kidney or from that lymph node, whatever it is that's. And put it into maybe 250 microliters of barrel saline, i a drop, and keep doing FNA's until you can make that fluid cloudy. If you can do, make it really quite thick, that'd be brilliant because that will get you your diagnosis and you can separate it.

You could do a 300 or 400 microliters, then you can divide that and then you can go for the histopathology for cytopathology and pathology. I can go for a confirmatory diagnosis. I'll put the cost up here just to give you some ideas.

The RTPCR, there's Axio and Fin, so, there you are. At 72, these are the costs when did I do this at the end of last year, go 36 was the cheapest at that point goes up. They're doing tissues, spike mutation from IDEX at that point of 47.60.

Immunocytic chemistry, Liverpool, Glasgow and Edinburgh do this and basically we all sell pellets. So look at it for immunochemistry. Liverpool is 19, but it needed to be confirmed and that has gone up.

I haven't got any costing. Glasgow was . 38.

I didn't update this fine, silly me, as is now 35, ours is not cheap. Yeah, so, check on the costs. These were a nap from time.

What I'm showing you is they vary. So think about what materials you can get and then go. And I do want you to think about.

Differential diagnosis. It's very easy to have a young pedigree kitten with a big belly and you're gonna go, I pee, isn't it? Of course.

Oh, not always. We had quite a few pancreatitis. The pancreatitis, septic abdomen, or that, a few of those as well.

Lymphocytic cholangitis is oxoplasmosis. Generalised lymphoma definitely had some TBs, always a bit of fun, like those, congestive heart failure. Oh, Bartlosis, absolutely we've had one that fits Bartonlosis and it looks at everything like I can have my feet.

And it's treated with the the drugs and sort of got a bit better and relapsed again and eventually, OK, well, let's treat for what else it could be and gave him a a decent course of, of, doxycycline and got back. So yeah, don't forget, don't be led astray because you're excited it's now a treatable disease, OK? And of course, it can be two things going on.

If things are, if the case is not going as well as you want it to, think back, I got my diagnosis right. So that takes us to the rema. So I hope you've got the nugget of the diagnosis, diagnosis.

Just to make sure that we want to be really pragmatic. Diagnosis, history, ignorant, clinical signs. That raised alpha AGP.

And don't forget about quantitative RPCR and FNA your lumps and bumps. Don't forget about abdominal lavage as a way of getting some fluid to do more investigation. And then send your fluids off and start treatment.

Mm This is where we were, kind of before COVID. We had some options, but mostly we just sleep the worst. Got to take it around some of the dry ones to see if we try things.

We try to mean a suppression. Hm yeah, we tried to immunomodulation interferon interferon andcortic steroids was make it as a good combination at one point, but then. When repeated as a proper study fell apart for preline immune stimulant I will talk about doxycycline, actually, doxycycline, it does have activity against feline coronavirus.

Just you need to give up a high dose that would be, toxic for doxycycline. And when you know when people have got thalidomide on this, people are getting desperate are they and then they had combination. That's the one that proved this combination pretty useful.

So what about poopreal imines, you know, we've had this for years. It is licenced in the US for treatment of what they call rhinotracheitis virus, feline rhino, herpes, so we call it herpes virus thing. Separated by a point.

So, we've got this study, this is about 60, probable dry cases, some confirmed ones and some others, and basically you've got about 10% living to a year, but dry cases would never make it to a year, so you know this is doing something. Then we've got long term survival data we've been looking at, but actually we've really put this paper in the confirmed cases reviewers really didn't like a presumptive case, the ones that were so close, but we didn't have confirmation, so we put it back in confirmed just those ones, and we're looking at ones that have already lived a year. So if they live a year, what's their prognosis from there?

And the prognosis from there is they'll be very well. So, the ones that didn't do so well were the ones that still had a low ageing AGP. Oh, sorry, yeah, not that true, a low, is probably a ratio or had anaemia, negative indicators by way of costs per month works out at about 500 pounds.

So, it can certainly, it can give you time, all right? So if you are trying to decide whether or not you are going to use the antivirals, this is a very, very safe drug, ship it in from the states. Expensive, very safe.

You can use it to treat herpes flu. You can also use it, to treat, other viral, quite a few other viral problems. So it's, it's a good job, we keep on.

Then C3 like protease inhibitor came on. This was published in 2019, so just before COVID. This is an antiviral, given by injection, painful, and treatment was for 12 weeks.

And 19 out of 20 cats in Peru, which was just like. What? No, I remember reading this like, oh, that that's not possible.

And then they, some of them occurred and, particularly, neurological, but ultimately 30% that's better than the, the PPI was giving us or PI as it tends to be called now, . First the teeth if they're babies. It's not legally available at the moment.

Plenty of legalgal versions, but I do not recommend you go back. There is word on the street that there may be a legal version coming along. So this is kind of where we were and then COVID hit.

So we kind of had fleas, and then COVID repurposed a lot of drugs. I loved it when they started talking about dexamethasone. Wow, who would have sunk it, dexamethasone steroids might actually help an inflammatory condition.

Whoa, I'd never thought of that. And then we've got antibiotics, doxy and azithro, I said the doxy, well, with both, all of these listed here show, in vitro, efficacy. They work in the in the the lab, but can you get them up to a big of those to treat catsitroconazole.

So here we've got, antifungal. And there's certainly a case where a kitten was treated with that and interferon and initially got better but came back with seizures and was euthanized. Ivermectin, of course I said Mr.

Trump was very into that. It's very big in Brazil where they treated everybody for COVID with Ivermectin. I'm sure it got rid of everybody's worms.

Badly, it didn't keep them alive. It has some efficacy but not enough. And then we've got the the anti-malarials.

In fact, hydroxychloroquine was used 10 years ago in kittens and there was some efficacy, . But it caused hepatopathy. And then mefloquine and GS I want to talk a bit more.

So mefloquine, this is larium, this is an anti-malarial. And it's not a licenced drug for cats at all. There's really not masses of work on it, but our counterparts in, Sydney Uni who have been working ahead of us, so they're about a year ahead of us.

They've been doing more work on this, and we're all feeling it's got some efficacy. So particularly if cost is a real problem or you're having relapses. Don't forget about Lariium.

The dose that's a little bit tricky to do because it's a big tablet, and takes ages to get it reformulated. But this lab will reformulate it. It takes a long time.

But you can see it's cheap, look. That's only 54 quid for 12 weeks, so it is, it is very cheap, so it's a cheap add on. Don't, don't forget about it.

You do need to give it with food, GS without food. Mefloquine with food, otherwise they're gonna throw up, all right. It can cause a lot of nausea, laptopathies, but it is something to be considered, all right, do not forget about this little book.

So then we start with the nucleide analogue. His work was actually this is all Neil Peters, of course, the god of FIP, and he had started working with these because he's in California, which is where Gilead is. Now it's an unfortunate name for a company if anyone's ever read Handmaid's Tale.

And so they were already working with this was published in 2018. And this experimental study, interestingly, very low doses, only for 2 weeks. And such an impressive effect.

Oddly, we can't get that anymore. Are we already seeing viral mutation? Yeah, yeah, I reckon we already are.

But yeah, it looked really amazing. Yeah, so good, it really made you want to swear. It did sweat.

And then this this paper, 26 cats, they've got wet and neurological, same low dose for 12 weeks. 70% remission, but when they repeated treatment and or increase the dose, 96%. Quite a lot of cats, not all of them, but some cats, they think we quite sore when you're injecting them, yeah, to the point where they're actually screaming for a minute and screaming for a minute is really not nice, but some don't seem to worry at all and others will just their shoulders and it's really weird.

And they did get some open source with this formulation. This is not the same formulation as we now have available. Then this is, yeah, then they redid the neuro cases and they got.

Not surprisingly. Everybody is paying for it at this point. Everybody around the world is going, we need this drug.

I've got cases of FIP. I need it. I want to save these cats.

The owners are desperate, you know, we need to save the cats. It's not surprisingly, illegal companies were poor. We can help, you know, well there's a legal chemist out I went yes, there's no we can do.

First paper, one of the first, one of these illegals was, came about Diana Ady published this case we found them, Norwegian forest game, and he had ocular, and you can see here he was given his vaccine, uveitis, he got some prednisolone, and they gave him mutin for the 6 days. About 50 days and then they put it in you see his weight gain. Look at this, wait, wait.

Over over 1 kg and then he went on to interferon, and some people do suggest having a long course of interferon at the end may help, it may help. We don't know yet, but it may help if you've got funds to. And then FIP Warriors and many other websites that set up.

FIP Warriors certainly was initially, somebody who was really trying to help, coordinate things, but they've been really hijacked by the these illegal drug. Producers and the people, some of the people on their worries are being paid as intermediaries. They're giving a lot of advice.

They're giving a lot of time. I can absolutely see why, but it means that there's definitely, it's not altruistic anymore. But they showed that in, these counts, 24 counts and 96.

So we've got this study. Jones was last year. Lots of different versions now available, because lots of different companies out there making it and the companies drop out, new one pops up.

They're like this. Like whack a mole, crowdsourced almost 400 cats and at the point of of submission, almost 90 significant improvement within a week. When these cats improve, improve, you've got a kitten that's literally dying to the kittens next morning crying for food, quite spectacular, really magical, really magical, the point where everybody in the ICU is dancing around hugging each other and just going, wow, look at him, look at him.

So yeah, it's a. These are magic drugs. They really are.

I never thought they'd happen in my lifetime. When I did my PhD in FIP, I really thought, you know, this is just the best. That's why I did it.

I saw so many kittens with it. I wanted to try and do something to help. So at the point of publication, most of us still alive, 50% cured, some still on treatment, and we've got about 12% relapse.

What is terrifying, truly terrifying. Less than 9%. And really any veterinary help.

This is all being done by the owners, by these drug companies. There's no vets involved. There you go.

That's just a selection. And when you get the high doses for neurological cases, they put B12 in it. Seems to help.

But there you can see there's all these different drug brands. We've got tablets. So hero is the big runner.

This one is from, the Warriors is the second Slovak branch. This guy is actually really helpful, lovely guy. I go to their website.unning research he's doing.

On these we're getting so much really, really good, so you can see that this is not this name hero will will come back to that. And you can see here Mishan is actually tiny. It's interesting how different brands flare in different countries.

So these illegal black market versions, the problem is you don't know what's in there. You receive a clear, colourless, sometimes pink. File, no label on it.

Don't know, there's been times, there's been evidence of toxicity. There's been evidence of contamination. There's been suggestions of sabotage.

They're all from China. These are the same companies who are doing illegal drugs, you know, these are not nice players. And so we know that there are kickbacks involved as well, so you're not being given straight advice if you go.

We know, and VMD is very, very quick to point this out. As a vet, even suggesting the website to an owner. If you are found out, You'll lose your MRCV.

I, I want you to keep your ass. You guys are good guys, but do not recommend using the illegal potions. Make sure that you write in your notes that you did not recommend them.

The owners are usually already found them and bring them to you and say, OK, I want this drug. You have to make it very, very clear that not only you would be doing something legal, they would be doing something illegal because injecting an animal is an act of veterinary, act and act of veterinary medicine. It has to be done under the auspices of the vet.

Yes, we can send them with insulin, etc. But we train them beforehand. So, yeah, there's a lot to worry about the illegals risk of injection, damage, to the owner, to the cat, side effects missed, all sorts of sorts of terrible things that we, we don't want to.

But Most countries don't have an option. Us, we're lucky, as in Australia and now a few other countries as well, which I'll tell you about. So what about us?

What about us? Well, we are lucky enough that we actually have two sources of reazir, which is pro-drug, and then you've got the, the parent so it's really weird, the relationship. Let's just say we've got I think I'm gonna change this side because it is too confusing.

Basically, whengaze breaks down into GS 44, 1524, which I will now call just GS. And what we have, I'm not allowed to tell you their names or the, the companies that make them because that's against advertising restrictions, but we've got one the one called Fee, which is the patented one. This is the one that is patented for the treatment of coronavirus in people, .

So it has to be sold at the same, same cost per file, and it's only available in Britain, and to be honest, they did it for us because we didn't have these, reformulated ones. Now we have the reformulated ones, I think that would be very reticent to let us have any anymore unless it's so much more expensive that, there's no one would go to them now that we've got the, the veterinary special. But because the veterinary special, is, it's more concentrated, so it's a smaller volume, and it is, water-soluble rather than oil soluble.

So it's less painful, which is good. They're 10 mL vials and if you you know, alcohol swab, etc. And you need a lot of time in theory you could 10 months.

You're never gonna need to and decide which rules. Our our CBS rules say you've got to dispose of them after a month, but you don't need to. They usually used up in a in a.

In a wet form that you'd be used up in in a week or so and in a dry form, particularly in a bigger gap, you might need a vial a day anyway. But if someone has that somehow it's got that out there, these files need to be disposed of after a day, don't, that is only the human product. So Australia has had the, the veterinary version since November 20 November 2020.

We got it in August 2021 and we've now got that number with bigger now, but, you know, somewhere up to 2000 cases now. We're looking at looks about 85% success, but Sam is fabulous. Sam Taylor is pulling together 200 cases or more that she's got lots and lots of data on, and that's gonna be a stunning paper and she deserves, .

A knighthood. But paperwork is just horrible. Less painful than injection.

It's good. If, it, if the disease recurs at less, usually recurs it works brilliantly which is what you. Just.

And so long as you keep increasing the dose as increasing the amount as per the increased weight to the cat, then you're absolutely fine. But it's, if you don't keep increasing the dose, so you start at the dose for a 2 kg pack, and now the kitten is, 5 kg and you're still on the same volume, you say that's when it fall apart. But we do have some that are quicker and you ate, harder to treat.

And they tend to be what they, they just never quite get cold or they've been quite good but then start falling apart later in treatment. But it's unusual for them to fall apart. Significantly after you stop treatment.

So what we say is you do 12 weeks of treatment, and then if you can just stop at that point because they're doing OK, then watch for another 12 weeks, but they rarely fall apart after that, as far as we've seen. But this is all new, guys, all new. We have not been doing this November 2020.

Is when the first got this in the world. So, you know, we are still learning. We don't know that the FIP is not gonna come back when all.

We just don't know. So we need to make it very, very clear to the owners. We don't know.

We're doing the best we can, but we don't know. And the dose, sadly, we have to keep increasing the dose and this worries me. So look at the dose, got 10 to 12 now, make the cake for a few if we start from 2 to 4.

I know it's worrying me. What about 15 and then if it's in CNS at 20, but divide that by 10 makes a cake twice a day, otherwise the absorption is just rubbish. Initially, IV in the severe cases and that will make the effusion get worse.

So they'rec from really flat cats, you know, there's no way that kittens not gonna eat anything you couldn't tell them. So go IV initially. And, we have, we've had the oral GS for a while.

It's little, it quarters nicely, so it's very, very, very, very useful. So by way of costs, this was the cost they go from last September, really should take this not change much actually, but that's the cost for vile for the rende beer for the human product, whereas the veterinary special is here, so you can see the difference. What is really important is make sure your practise is not charging the standard 100% markup.

Because if it is, you're gonna make these drugs too expensive, and that means the, these owners are gonna go to the black market. All the cats are gonna get euthanized and the practise loses out either way. So we've got, a 10% markup in our clinic, which I'm very proud of.

For, for both products. So talk to your practise, explain it, but we, we can't do a big markup on this. We're going to get money for even a little markup 10%, make plenty of money these expensive drugs, right?

And the insurance companies mostly are. So if we, we've got down here we've got twins a 2 kg cat and here we're using a 10 megs per kilo, which is a wet one, and there the costs of change. So emission tablets at this 0.3000 without fat and without markup, remember these you've got fat and markup on top of these.

The injection, about 5.5. Yeah, you're not gonna use the human product because it it.

So, don't even think. The veterinary product 3.5 for the injectable and about 1.5 for the tablets, so the tablets are significantly cheaper.

What we're recommending, I think I'll come to it anyway, but we're recommending, if it's sick like so 5 days of injectable and then switching to to tablets. If the kitten's eating and Bret and bony then let's put it straight on. I just put this up as for cost, so we've got a 2 kg cat.

On the price as it was at this point, so we'll work it out, yeah, that's that 3.2, remember, plus that, plus markup, dry ocular CNS +63 kg cat. Significantly more expensive, whereas if we're using the GS 2 kg cat.

On a wet, it's gonna be much cheaper. So really be thinking about these ballpark figures, you need to kind of have them in there. There's a new article that Beth So, Sea, my brilliant, brilliant.

She was my project student. She's just qualified. I'm so proud of her, and I'm not gonna slaughter her surname.

I must practise it now. I'm sorry, I haven't said your surname. And myself wrote a companion practise article and we've got costings in there so it's worth going.

Importing. So if you're someone watching this in a different country or you've got contacts in another country who want to know what to do, then, contact both the vein specials. There is the export orders is the contract and what the company, what the country has to do is they need to have the Their governing body, so in our case that RCVS have to say yes, we're OK with this.

Once their governing body says yes and they provide a piece of paper over so they say yes, then the, the same signature, this is very important, the same vet in the practise that contacted over and set up the system set up the link on the website must be the same person you signed, really, really important. Lending ship. So far, Sweden, Germany, Finland, the Netherlands, South Africa, France, and looks like Singapore is starting pretty good, but we want to take over the world.

Practical notes, it's with potassium. They are dosed at the same dose. I know you're gonna say, oh, hang on, but ones and one's oral, but it, it works out in the wash, believe me, .

If anything tends to be going higher, if you're going orally, if you can go higher. Really, really important. I should put this in red.

Increase the dose with the cats, increasing body weight, because if the cat responds, it's going to be growing and where so many kittens are falling apart and got to again, it's because they weren't dosed body weight. Those are important. Try and convince the owners to spend the 20 quid to buy, you know, get, baby slash pet scales, weighing scales, you put them on the bar, you know, the flat things, you see if they can get them.

Because, obviously these ones aren't quite there with raised ones, but you get flat ones much cheaper, that way they weigh it on a weekly basis so that the dose can be adjusted. So initially we were doing 14 days of rendezair, but it looks as though 5 days works just as well. You can do just oral GS and certainly if I I can't find renta painful, then switch to the oral.

As I said. Mefloquine On a full stomach, GS on an empty stomach, give them a tiny bit of liculic, something like that, and then just give them their proper food 30 minutes later. Discomfort's really variable.

Some of them just don't notice. Others treats in a cuddle is enough. Most them either use gabapentin or Travadone, and that is 50, or 100 mix for a cat 2 hours before.

Local Eler can help, you needle, . Room temperature. I was thinking, what does RT mean?

Room temperature. So let's don't use it cold and then put my on the skin. If, IV could certainly make them feel pretty rubbish, but then they're feeling pretty rubbish at that point anyway.

And remember, it will likely make the flu so we get worse. We don't only for the first two days, so you're gonna need to redrain. We, it's hard to work out what side might be drug side effects and what might be the effect of the disease, but it looks like increased ALT drug doesn't make them feel bad and it stops as soon as you stop the drug, so we pretty much ignore that.

Potentially anaemia, we're still playing with that one, we're not sure. Some have had raised, SDMA which have responded to some fluids, and sometimes we've got raised EOs which kind of ignore. Monitoring, you can monitor just increasing body weight, demeanour.

Effusion's going down, eyes clearing. Ideally, ideally, ideally, then it would be nice to get haematology, biochemistry, and HP at the time of diagnosis, and then after 2 weeks and then monthly. If you can't afford it, remember, better to spend the money on the drugs, just globulins, bilirubin and .

You know, Micro micro micro microma tube which will give you the PCB, the total protein and the colour of plasma. I should put a picture of that, yes. Ultrasound to monitor for effusions and nodes going down and then ideally you're gonna be stopping after 12 weeks.

And at that point, what you want, you don't want to stop until everything's normal. OK, you can forget the ALC because that's often not because of the drug, but I definitely want the AGP to be normal. I want the anaemia to be resolved.

So you really want things to be normal for at least 2 weeks, the year before and then stop. You can feel so much more confident to keep stress and I think, OK, he's normal now, but let's do another month. The globulins, they will go up initially if there's a lot more fluid, or abdominal fluid because the globulins in the fluid back into the body and that makes the globulins go up.

Don't worry about that. The AG ratio usually gets normalised by about 6 to 8 weeks, and it goes up with relax. So watch out for that.

If you see that, increase the dose by 3 to 5 mg per week on top of the daily dose. OK, so if you're on 10 megs per kick, then go to can afford it 15. And then again.

To be normal for these two. And then if you, if you're losing control, adjunct treatment, what about mefloquine? What about, actually, of course, added in, immuneo stimulant as well.

So mefloquine, interferon, and PI are all your friends here. Mefloquine is an antiviral, so two antivirals are good, and then interferon and or, pre polypyreal immune stimulant are going to be a boosting immune system. Right What's next?

Well, we've already got Monrovia for people, and it is sold legally by the company Hero, which I mentioned. It is still a nucleoside analogue, but it's a different amino acid. It's a cytosine rather than adenosine, and this company, I've done a field trial, it looks pretty good.

Side effects looks a little bit rougher, but it's got different antiviral profile. So if you're losing control with de GS 44, once we get legal mov, it looks like the Americans might. Get this one first, which seems only fair given that they've been jumping up a bit, and we, they haven't had the legal versions.

They have to be doing illegal. So it looks like they're gonna get money but they're first, working out of Colorado with, Mike Lapin's group. Got to see him two nights ago, which was great.

Save for the golf is love your life. So what we need more studies. We need more studies.

We need to do what what Taylor is doing, because her and feet are pulling this stuff together, and we need everybody else to be looking at it too. And ultimately, I think it's gonna be a combination. This is what happens in people, you know, the heart rate for H88 lots of, about each part, for, HIV in people.

It's got antivirals, immuno stimulants, etc. So I think it's gonna be reair and Moree, and or mefloquine, . Then polyprenol, immuno stimulant, and interferon, etc.

So it's gonna be combinations. I'm just gonna, I'm going to skip this because I'm almost out of time. This is just the first cat, that was treated in Britain with the legal one.

This is, Lara, sister. Thank you, Lara, and here is gorgeous Ninja, and he was about as bad as could be and He was positive. He was really sick.

He went septic and he was, you know, vomiting blood or coughing up blood rather, you know, it's only, it was only because they'd already got deze, coming that day that they didn't euthanize it. And so he was treated. Yeah, it was 9 parts dead.

And it took a while. There you go. Normalising by 5 days, discharged at 10.

So he was a slow one, but that's because he was so bad. Yeah he is. And this is some more of the data from the this website, fabulous man who shares his data with me.

And so most counts are better day 3, but there is this other second blip, really sick ones it can take. It's a case from Australia, really sick kitten, still a happy kitten, sick kitten, kitten. So, by way of diagnosis, be pragmatic, OK.

Try to get immunoche. You can quant or and or RTPCR quantitative. The quantitative RPCR is a really simple one, remember how I said how to get the fluids.

It's really, really helpful. We have got the legal versions. You can get really, really good responses.

There is our advice line, but be gentle with us, so we're all doing it for free. And I have to admit the others do. I do very little on it.

I'm doing the TB one at the same time. So all of it much, to be honest, but we're, we're all trying to do it and we're trying to do it for free, because this is important for us. And I think at that point I shall stop and hand back to Anthony.

I saw that picture, I just loved it. Thank you so much, Danielle. That's been really useful to go over what is available and there is so much good stuff going on, which is fantastic.

I even had my own cat, or, no, I should say the cat that adopted me during the pandemic who sat on my lap, watching with interest, although he is not an FIP sufferer, but he obviously cares about other cats as well. So he's, he's learned a bit as well. I think it's probably the red dot, you know.

Yes, he's chasing those. Yeah, my, my kitten, if he comes over, he sees the red dot in my screen. So any questions from anyone, it's obviously, .

So exciting and and great to see. I think I can say, and I will get struck off over doing a great job. Bringing it into the country as well and to be honest, if you want importing, then that's who you go to.

I just, and if it's, if you're asking me a question I can answer a question, but I can't directly put out. I can't print it. Yeah, I, I know we've We've spoken to Bova and of course it's such a fabulous drug, but because of BMD rules and everything, it's just seems to be falling within the cracks, doesn't it, which makes them not be able to tell the story to people.

And as you say, this is a common disease, so or a relatively common disease, so people are, are seeing these cats, and this news doesn't necessarily get through to everybody right away and It's sad if somebody has the cash and things that a cat is put to sleep when it perhaps had a good chance of surviving, isn't it? Yeah, cause what some people are doing, if they, if they know they've only got, say 1000 pounds, then they go, OK, then, you know, we keep it as simple as we can, and then they go, OK, well, let's, can we, can we even do a week of high dose, antiviral. Then add in, you know, soredaze they keep high dose twice daily.

So if you're saying. 2, you're taking 10 meta of GS 44 twice a day for. League.

With mefloquine and Interferon, and let's try, you know, and so you try and work out what way you can go with it. Some kittens have had their treatment crowdsourced, all sorts of things have been happening, and to be honest, a good thing to consider is try and, you know, it's If the kitten is not going to respond. It hasn't responded, you know, it certainly it's not responded by day 3 at all, then either, like, you've got the wrong diagnosis, it could be something else.

You know, and, but if it's done really well by day 3, then you go, OK, yeah, this is worth keeping going. Yeah, and I think as you said, there's a lot of them have really done well by day 3 and then there's a bunch that take 2 or 3 weeks, but Obviously, it's a, it's a smaller number compared to the ones that do well in the 1st 3 to 5 days. Yeah.

Do you want me to stop sharing? Yeah, that's, although it, it looks like it's an interesting, magazine there, so maybe send me a copy because the cat is obviously enjoying this, isn't it? He is.

I can't remember where I think. Oh, yes, I did. It's a website that is actually an FIT website which I should have put on there.

Bad me, bad me, my bad, definitely. I will put the, the link on there. It's, I haven't quite worked out who's doing it, but it's a, it's a very it's very funny, isn't it?

It's It's interesting. There's, there's no questions. Just, to let people know, one of our recent improvements is that you can actually get a live transcription.

If you do struggle with hearing or, or with any other issues. So at the bottom of the screen, you may not have noticed that next to raised hands, there should be a live transcription button just for people that if they, if they find that helpful, that's something we're going to bring into the recorded ones, but it's actually A bit difficult at the moment, but we're working towards it with some of our new, upgrades of the, of the website and so on. But certainly one of the advantages is of being at the live one, if you do struggle, we now do have that ability to turn captioning on for the webinar.

How accurate is it? It's a bit like the BBC one. If you've ever seen BBC with transcription, it, it always makes me laugh a bit.

So it's entertaining, but it will of course get better as it recognises people and so on. I think it's the very technical words, the very medical words that. It potentially struggles with.

But if any of you are using it, please do feedback and, it's obviously an area that we're looking at and trying to improve on because, you know, I, I do know some people, struggle with hearing and things. Particularly sometimes the link's not quite good and we've all got different accents and things, and yeah. But at least, at least you can see my face, not you might not want to, but for lip reading, reading things.

I've got reasonable lip movement. Yes, no, very good. And I did take issue with you when you were saying you were looking in a bad way because even though you're sick, you still look very good, so .

You know, I'm, I'm going to take issue with you on that comment that you made at the beginning of the webinar. Well, we do have a question. How long does it take to import the Remdesvi via bova?

That's from Jane. Once, once they've got the, it's a case of whatever country you're in, go, you know, emailing your, MRCVS people. And saying, look, there's this compound and you can pull all our papers and stuff and, and actually over just contact over.

They'll give you all the documents that you need to send to your people, you know, your, gra granting body. And once there's an email back that says yes, it's fine, you can import this, that email then goes to Bova and they can import, they can export straight away. So it, it can be pretty quick.

And obviously, it presumably is, you know, even quicker. Yeah, absolutely. And what, what there is is so in Scotland, for example, it's certainly if you order on a Monday, you get it on Tuesday, Tuesday you get it on Wednesday, da da da.

But a Thursday you'll get it on Friday, but order it on Friday, you might not get it, well, you won't get it till Monday. And that's too long. That's.

Yeah. Yeah. So we keep both in stock.

We are, we, so we can do emergency supplies. It's only as an emergency supplies. So if got a cat in Scotland and you obviously haven't got a stock, then you can contact us and we keep emergency stocks.

Brilliant. And, and obviously with the UK and Bovi, you don't have to first of all, get in contact with the Royal College because obviously it's accepted. So that it takes that out of the, out of the equation.

So it sounds, Jane, as if you can get it in very quickly. And I've similarly heard of some really great cases that are, are doing well. So it's, as we see from Danielle's stats, it really is a little bit of a wonder drug, isn't it?

It, it is stunning. It really is one of those. They had a still going, it's British Blue, or British Blue, she is called Toby.

And, Ivan Sanchez, one of our interns, and now a resident, was looking after this little kitten, and he's he's a big man, muckle big man, and you know this little tiny kitten and he's saying FIP, this disease is so bad, and I, we can try and treat this really can we, you know, and it's just the way he was so gentle with this little kitten and she just turned around literally it was like she's all. And then the next morning, and you know, got tears and everyone's hugging each other and and each time she comes back for assessments and she's just growing and growing and growing, and he just cuddles his kit and it's just a pleasure and it's this is, this is magic and that he's here at this point in his life that he gets to see this, this mirror. And if it's, I think, .

Ex-president Trump had some of it, and if it's good enough for ex-President Trump, it's good enough for the kittens, isn't it? I'll keep it for the kittens. What, what I would say is it's not going to last.

I the the the doses are already going up. We need more of these drugs coming through and we need to find out what the best combinations are. Is a fast moving situation, isn't it?

Well, the problem is with coronaviruses, you know, they mutate, so whatever you do, they're just moving away from you. It's always going to be an arms race. And this is why it's probably going to be difficult.

With cats who are obviously You know, that We're not going to spend the, not the same amount of money is going to be spent on cats as on humans, that vaccines will always be. In the same situation, we've never created really an effective vaccine, have we? Well, premium cell is a, I worked on that during my PhD and you really you might as well pee in the ear, which is why we don't in Britain.

But the, the word on the street is there is at least 2 companies that are working on potential feline coronavirus vaccines. What they They don't want is to, because it's all back, it's all based on the technology of that they've learned COVID, and they want to repurpose, you know, they pour this money into these, MRNA vaccines. So they're gonna be looking around for other diseases.

And it's straight away you go, Oh, hang on, cats get a coronavirus disease, should we do that? But of course, what they don't want is to Use a vaccine that could be better used in people. So that's, that's what's held up, Gilead from releasing rendeir to cats other than, the small number of cats in Britain that, that have had their product, before the, the veterinary special came along, and it's because they didn't want.

They didn't want people to say, hey, kittens in Britain get the vas or get redes, and yet there are people dying in, in Africa. Yeah, of course. But then they, they charge the same price regardless.

So there was partly that, but then they just don't want side effects to be seen in cats that might then suggest that, oh, hang on, might be a problem in people. So it's just a little bit reticent. But the work is started and I, I really have little doubt that I think.

I'm going to be hopeful, and I'm gonna say within the next 5 years, certainly 10. Within the next 5 years, we are going to have a lot more understanding of what, what the stage play of the vaccines are. I think that we should be looking at, at least, you know, in vivo testing by 5 years.

Maybe we might even have the vaccines by then, but we will get them. I have little doubt about that. And this is where I think at the beginning of the pandemic, you know, as a vet, we, we understood a lot about, or, you know, understood a lot about epidemiology, but also we're aware of this, how strange coronavirus in cats could be, and of course it's been a really strange virus in, in humans and I suppose now we're beginning to also learn from what the medics have done with, with this treatment.

So it's, it's a lovely. One health story and that we can help each other if we listen to each other. Yeah, it is.

I, I just, I did find it heartbreaking that the that the government specialists, you know, health specialists, you know, like the, the one for Scotland, cardiologist. Cardiologists don't know about immunology. They just wouldn't speak to the vets and epidemiology.

Yeah, he needed epidemiology, virology, you know, was the, virology, and we've got all of that in the coronavirus work that's already been going. And when they kept saying, you know, there's never been a vaccine for coronavirus and, and you have. Yeah.

Try the chicken one, try the cat one, the, you know, there's lots of coronaviruses as well. Yeah, the Coronavirus in dogs is starting to become a much bigger thing in France. They they're recognising it much more than we are here.

But yeah, there's doggy coronavirus as well, and these are big viruses. Every single, remember, every single virion is different to every other virion, and that's pretty terrifying because it means the speed of mutation is stunning. Hm.

That's why we've got Omicron and his friends playing with us. Danielle, it's been fabulous speaking to you. We we have promised everyone listening that .

ISFM was really exciting. It's always a good conference to go to if you have an interest in cats and renaming of conditions which When the clinicians do it, it's much more fun because when the microbiologists do it, they always change it to a name that's even more. Unpronounceable.

So clinicians tend to make things more simple, whereas I think the microbiologists, if there are any microbiologists, I'm sorry, I didn't think you'd be on, but they do make life more difficult with changing of nomenclature of viruses and fungi and things. So we're looking forward to perhaps pulling some of our great feline specialists that we have together to share that with you soon. So do look out for that.

For that roundtable pod webinar as well. So, Danielle, thank you as always. Enjoy the rest of your medicine.

It is important. Hopefully it will get you better very soon, but who would know you were even ill, you look amazing. I raise a glass to you, my love.

Thanks, Danielle, thanks everyone for listening and hopefully see you soon. Bye bye, bye bye bye.