Clinician's Forum: Incorporating Apoquel® Chewable Tablets into Practice

Sponsored by Zoetis

PARTICIPANTS

Andrea Gonzales, PhD, Zoetis, Veterinary Medicine & Research, Kalamazoo, MI

Andrew Hillier, BVSc, MANZCVS, DACVD, Zoetis, Companion Animal Veterinary Professional Services, Parsippany, NJ

Jill E. Maddison, BVSc, DipVetClinStud, PhD, FACVSc, MRCVS, Professor, The Royal Veterinary College, United Kingdom

Ralf Mueller, Prof. Dr. med. vet., MANZCVSc (Canine Medicine), DACVD, FANZCVSDc (Dermatology), DECVD, Veterinary Dermatologist, University of Munich, Germany

John Scotton, BVSc, MRCVS, Veterinarian, E C Straiton & Partners, Ltd., Stafford, UK

Emily Shaw, BS, Training & Service Manager, Animal Dermatology Group, Irvine, CA

Mary Beth Spitznagel, PhD, Professor, Department of Psychology, Kent State University, Kent, OH

Laura Stokking, PhD, DVM, DACVD, Veterinary Dermatologist, Veterinary Specialty Hospital, San Diego, CA

Andrea Wright, DVM, MVSc, MBA, Zoetis, Outcomes Research & Healthcare Economics, Dublin, Ireland

MODERATOR

Karen Aiken, DVM, CEO & Founder, Embark Consulting Group, San Diego, CA

Apoquel tablet provides fast relief of clinical signs associated with allergic skin disease, with >15 million dogs having benefited from its antipruritic and anti-inflammatory effects since its launch in 2013.¹ However, delivery of oral medications can be challenging for some pet owners. Apoquel Chewable tablets provide the same benefits in a formulation that is readily accepted by dogs with allergic and atopic dermatitis,² making it a clear first-choice treatment for many itchy allergic dogs.

How Apoquel Is Being Used in Practice

Dr. Aiken: How do you use Apoquel tablets in your practice today? How has that evolved in the last 10 years as your level of comfort and experience with it has grown?

Dr. Stokking: I use Apoquel in most of my allergic patients. I also recommend it for patients that come in with flea allergy, especially those that are not going to tolerate steroids well. I love using Apoquel tablets during diet trials. Apoquel is also very helpful while dogs are undergoing immunotherapy for allergy treatment. For my patients on Cytopoint®, I make sure they have Apoquel at home just in case they can’t return for their next injection at the prescribed interval and their itch comes back before they can get back to the clinic.

Dr. Scotton: In my general practice, probably 95% of the pruritic dogs I see just need itch relief and respond well to Apoquel or steroids. Since we’ve had Apoquel, I’m using fewer antihistamines, fatty acids, shampoos, and other modalities because we’ve got a medication that is effective 80% to 90% of the time in my hands, with fewer side effects. Apoquel has made it so much easier to treat canine allergic dermatitis in general practice.

Incorporating Apoquel Chewable Tablets into Practice

Dr. Aiken: Dr. Hillier, tell us about the chewable formulation. Are there differences between Apoquel tablet and Apoquel Chewable, other than the fact that it’s chewable?

Dr. Hillier: Apoquel Chewable tablets are a flavored formulation of the original Apoquel tablet formulation. The original Apoquel tablets and Apoquel Chewable tablets have the same indications, and the dosing instructions and tablet strengths are the same. No additional safety studies were required for the approval of Apoquel Chewable tablets in the US. Both provide rapid relief and start controlling allergic itch in 4 hours.^3,4a No clinically relevant difference in efficacy is expected to be detectible between the formulations after the first dose, once a veterinarian has made the decision to treat with Apoquel, we anticipate that most clinicians will default to Apoquel Chewable tablets. The formulation for the chewable tablet has pork liver powder added to increase palatability and voluntary acceptance by dogs. I can think of 2 exceptions when I’d choose the Apoquel film-coated tablet: the first is a food trial, when we would prefer to avoid anything that’s flavored, which could complicate assessment of response to a food trial, and the second is for a food-allergic dog that you know has a hypersensitivity to pork. These 2 circumstances would account for a minority^5,6 of dogs being treated, so essentially, Apoquel Chewable tablets are going to be the treatment for most dogs.

Dr. Aiken: Dr. Stokking, you took part in the clinical trial with Apoquel Chewable tablets.² Would you share some of your experiences?

Dr. Stokking: First, even the most effective drug will not work if it is not given, if doses are skipped, or if doses are administered but not consumed. If a couple doses of Apoquel are missed with once-daily dosing, you’re well beyond the range where you’re going to have much of an effect. Then the owner is going to say, “Well, Apoquel doesn’t work anymore,” but Apoquel probably would be working if the dog actually got it. So, how can we help? I was an investigator in a 2-week trial to determine whether the chewable Apoquel would be readily accepted by dogs (see Clinical Trial of the Oral Acceptance of Apoquel Chewable Tablets).² We had quite a range of patients, which was important because all dogs are different. All the patients had to have been on routine flea management and had to have been diagnosed with allergic or atopic dermatitis. Some of the patients did have a component of food allergy. The inclusion criteria for this study were that Apoquel was required for management and that Apoquel could be safely administered twice daily for 2 weeks. We didn’t have a single refusal to consume the Apoquel Chewable among the patients at my clinic. Most accepted the medication without assistance every time, meaning the owner didn’t have to hide it in food or try multiple times; the dog ate it out of their hand or from a bowl with only the tablet in it. None of my patients developed an aversion after 1 or 2 weeks of dosing. The chewable tablets are also scored in half, just like the original tablet, so we could safely and accurately dose to a half tablet. These dogs had been well-controlled already taking Apoquel and required dosing twice daily to manage their clinical signs. They had to have been withdrawn from Apoquel for 7 days prior to being enrolled in the study. All owners liked the ease of administration and were pleased with the results. In my study population, the chewable was readily accepted by 100% of my patients, and none of my clients reported any noticeable difference in efficacy.

Dr. Aiken: Now that Apoquel Chewable tablets are available, what choice will you make when prescribing for new patients or patients already on Apoquel, knowing that the cost of each formulation is the same?

Dr. Scotton: For my patients, my default setting is to go for whatever is easier for the client and better accepted by the dog, so I’d suggest trying the chewable unless the patient is already on the tablets and that is working well. I think it also helps open up that conversation with the client if you have an option to offer.

Dr. Stokking: If it becomes available for me to prescribe in my specialty dermatology practice, I would most likely reach for the chewable formulation first, as long as I wasn’t concerned about a patient having a pork allergy and if I wasn’t actively conducting an elimination diet trial. If I wanted to transition a patient from the tablet to the chewable, I would ask the client to monitor for any GI signs or a flareup. But I didn’t see any of that during the trial.

Dr. Wright: Do you think owners might perceive it as a more pleasurable experience than the original?

Dr. Stokking: Yes, my clients in the study² thought the experience was more positive than when administering other medications. You can watch the dog chew, enjoy, and swallow it, so you can be comfortable that the medication was actually taken.

Dr. Hillier: I don’t see why one wouldn’t go with the chewable tablet if they understand the potential upsides we’ve talked about today. There’s some powerful new research from Human Animal Bond Research Institute and Zoetis showing that, among >16,000 pet owners globally, 89% of people described their dog as like a child, family member, or companion.⁷ The research showed a clear correlation across cultures between the strength of the bond and better veterinary care for pets, and we know that chewables ease caregiver burden, increase compliance, and place less stress on that bond.

Dr. Aiken: How do you feel about giving Apoquel Chewable to dogs with allergies to foods other than pork?

Dr. Stokking: In my study group, I was fine doing it, as long as we monitored and made sure there were no adverse reactions.

Prof. Mueller: With food-allergic animals, starting the chewable is like a re-challenge. If the dog gets itchier after a few days, then we switch back to the nonflavored tablet. If it’s not getting itchy over the next 2 weeks, then no worries. To put this into perspective, consider that food allergy occurs in about 20% of allergic dogs,⁶ but only 2% of food-allergic dogs are allergic to pork.⁵ That means that <1% (about 1 in 200) of all allergic dogs will not tolerate pork.^b More than 99% of all allergic dogs will not react to pork, either in the diet or in flavored medications.

Caregiver Burden & Compliance

Dr. Aiken: What is the benefit to you personally in practice by being able to prescribe Apoquel Chewable?

Dr. Scotton: When clients are stressed, they pass that along to the veterinarian and staff, and everyone is unhappy. If I can prescribe something that makes their life easier, it’s a win–win. I have seen it work with other chewables (eg, worming).

Dr. Wright: There’s been such a focus in recent years on mental health and wellness. How do you see this helping veterinarians and pet owners if we can reduce the burden of care for dog owners?

Dr. Spitznagel: We found in our work that a burdened owner is calling or emailing at about twice the rate as compared with a nonburdened owner. So, if Apoquel Chewable tablets reduce the level of burden that an owner is experiencing, that’s potentially fewer phone calls, right? Think of it this way: for the owner, it’s an act of self-care to be giving your dog a "treat" rather than a medication.

Dr. Aiken: Dr. Wright, what have you found in your studies that illustrated some of the difficulties owners have in administering medications to their dogs?

Dr. Wright: Apoquel and Cytopoint are great, innovative therapies, but they can be more expensive for pet owners than steroids, so they may not be used in all cases. We’ve found that’s especially likely in cases of acute pruritus because veterinarians and pet owners may be more concerned about long-term tolerability of steroids yet are open to using them for short periods. A study evaluated 1590 pet owners’ willingness to pay for therapies for canine pruritus,⁸ with the goal of identifying key drivers in dog owner preference when considering flavored chewable therapies such as Apoquel Chewable tablets versus conventional tablet/capsule-based therapies. From the responses, we are seeing a willingness to pay for the chewable that holds up across cultures and countries. It’s been interesting to see the challenges and mitigation strategies pet owners use to administer pills to their dogs, like hiding or disguising the tablets in food ranging from cream cheese to ham and cheese. Pet owners may put the Apoquel in a treat and then find the Apoquel on the floor hours later when they notice their dog is itching. We also found that it makes it difficult for owners of these chronic dogs to go on vacation when they worry about the pet sitter not being able to administer the medication to them. We asked owners what was most important to them and found that the ability to bond with their pet and enjoy life with them was rated quite high, as well as wanting to be a good pet parent. They want to be successful in completing the full course of therapy, and they worry they’re not getting the positive effect of the treatment when missing doses. Our interviews with veterinarians have confirmed these findings from pet owners. Pilling difficulties are often discussed with veterinarians, particularly if owners are anxious from a previous experience or have a dog that is difficult to pill. A pet owner made this closing remark: “I would have paid whatever to get a tablet that was chewable.” Dog owners are really hoping for a way to make this process easier.

Dr. Hillier: Maybe veterinarians need to change their mindset from one of an expectation that most owners can do this to a more realistic mindset that most cannot or will have difficulty. That will make a difference for everybody for whom pilling is a challenge. We can certainly provide a better solution for many.

Dr. Aiken: Dr. Maddison, in your work on compliance, you cite 2 canine studies in which only 27% of owners gave the prescribed number of doses at the correct time each day during short-term antibiotic treatment.⁹ How does the caregiver burden impact compliance?

Prof. Maddison: As veterinarians, we’ve been guilty of saying “give these tablets 3 times a day” without really considering whether this is going to be feasible for this client. There’s some evidence that there are clients who won’t tell the veterinarian about these issues but might tell a veterinary nurse or a technician. We need to use a shared decision-making model—what we call the “negotiated agreement,” which involves discussing what is feasible for them, whether it’s being able to administer a medication or afford diagnostics or treatment—rather than the traditional paternalistic model where we just tell clients what to do.

Dr. Aiken: Why do you think veterinarians would not ask owners if they’re having difficulty pilling?

Dr. Scotton: Veterinarians in general practice generally don’t have the time to ask all those questions in a 10-minute consultation.

Prof. Maddison: I also think veterinarians are focused on the solution. We also may assume that, because we can do it, the pet owner can do it. When I first began lecturing about compliance, I found that veterinarians don’t think it’s an issue for their clients. The evidence, however, shows quite clearly that veterinarians cannot predict which clients are going to be compliant.

Dr. Aiken: The need for palatable medications in veterinary medicine has been cited,¹⁰ but most medications are still not palatable or chewable. What are the benefits of palatable medications?

Dr. Stokking: Certainly compliance and a better human–animal bond, because you’re not trying to force the animal to do something.

Dr. Spitznagel: I would add reduced caregiver burden; the owner is giving a "treat," instead of trying to figure out how to give a pill.

Dr. Scotton: If the pet enjoys taking something, it’s positive reinforcement for the owner to remember to give the medication. It’s so easy to forget things that are inconvenient or you don’t really enjoy doing.

Dr. Aiken: Prof. Maddison, how do you tie palatability, acceptance, and routes of administration into your work with compliance?

Prof. Maddison: Studies in pediatric medicine have shown that 1 factor that contributes to poor compliance with parents giving their children medication is the child’s reaction to the medication.¹¹ It’s the same thing with pet owners; they don’t want to stress their pet, and they feel really bad if they have to give them something the pet really doesn’t like. Medications developed with palatability and ease of administration in mind tend to be more readily accepted and more widely used.

Ms. Shaw: We have more dermatology tools than ever before, but atopic dermatitis is a long-term condition for these patients. Having a palatable, chewable medication that you can use on a daily basis could become a daily ritual between the owner and pet. I can see this as a game changer in the same way the original Apoquel was.

Apoquel® and Apoquel® Chewable Indications

Control of pruritus (itching) associated with allergic dermatitis and control of atopic dermatitis in dogs at least 12 months of age.

Important Safety Information for Apoquel® and Apoquel® Chewable

Do not use Apoquel in dogs less than 12 months of age or those with serious infections. Apoquel may increase the chances of developing serious infections, and may cause existing parasitic skin infestations or pre-existing cancers to get worse. Consider the risks and benefits of treatment in dogs with a history of recurrence of these conditions. New neoplastic conditions (benign and malignant) were observed in clinical studies and post-approval. Apoquel has not been tested in dogs receiving some medications including some commonly used to treat skin conditions such as corticosteroids and cyclosporines. Do not use in breeding, pregnant, or lactating dogs. Most common side effects are vomiting and diarrhea. Apoquel has been used safely with many common medications including parasiticides, antibiotics and vaccines. For more information, please see the full Prescribing Information at Apoqueltabletandchewablepi.com.

^aData for Apoquel Chewable is based on a model study for canine flea-allergic dermatitis.

^bCalculation: 0.2 × 0.02 = 0.004 × 100 = 0.4%

^cResponses based on owner review of Apoquel tablet and Apoquel Chewable product profiles in a survey.

^dData for Apoquel Chewable is based on a model study of canine flea-allergic dermatitis.