My clinical experience with Apoquel (oclacitinib), updated 7/11/19
Dr. Melissa Eisenschenk, DVM, DACVD
Apoquel® is the brand name of oclacitinib, an FDA approved immune suppressant drug in the Janus Kinase (JAK) inhibitor class made by Zoetis. This drug inhibits primarily JAK-1 and -3 signaling that would normally occur when a cytokine binds to a receptor on the surface of the cell. This includes blocking the effects of inflammatory cytokines released from activated lymphocytes (IL-2, -4, -6, -13) as well as IL-31, a cytokine directly involved in the sensation of itch. JAK signaling is important to the function of the bone marrow as well. Apoquel works differently than steroids, antihistamines, or cyclosporine.
Apoquel works rapidly, usually within 24 hours, to diminish itching. It is very rare to have GI upsets with Apoquel like we can see with cyclosporine. The antipruritic effects of the Apoquel wear off quickly, within 12-24 hours, so the medication needs to be given daily in most cases.
The dose of Apoquel is 0.4-0.6 mg/kg every 12 hours for up to 14 days, then 0.4-0.6 mg/kg once daily thereafter. Apoquel is not FDA approved to use twice daily longer than 14 days. The dose range is very strict, I do not recommend going above the recommended dose due to immune suppression, below the range and it doesn’t seem to work in most cases. I have seen 2 cases, both collies, where they were able to have half or less their regular dose and do ok.
Apoquel works rapidly, most pets see complete relief within 2 days. We typically give it twice daily for 7 days if the pet is very uncomfortable, then go to once daily. If it has not worked after 2 weeks, it is very unlikely to work better with continued use in my opinion. Zoetis reports that 60% of moderate to severe atopic dermatitis cases are controlled long term, likely because severe cases would do better on twice daily dosing. It is rare that Apoquel once daily controls pruritus in dogs whose allergies were so severe that they require daily steroids.
In humans, it is not recommended to give some of these JAK inhibitor drugs with CYP3A4 inhibitors like ketoconazole. I have not seen bad side effects giving almost any drug with Apoquel, including ketoconazole. I recommend using caution with other drugs that may affect the bone marrow however.
Long term studies of giving Apoquel along with other immunosuppressants like steroids and cyclosporine have not been done. My clinical experience would suggest that steroids at anti-inflammatory doses of 0.5mg/kg twice daily and taper is seems to be safe for the short term. If steroids are needed with Apoquel, evaluate how well the Apoquel is actually working for the patient. Apoquel is effective very quickly, so there is no need to transition slowly from steroids to Apoquel. Obviously a short transition may be needed to prevent an Addisonian crisis in a pet who has been on high doses or daily steroids for more than a month.
Apoquel is only FDA approved for dogs who are greater than 12 months of age. The reason for this is that below 1 year of age, demodicosis and pneumonia were seen at an unacceptable level when Apoquel was given at 3 x and 5 x the regular dose. In my clinical experience, Apoquel just does not seem to work well in puppies for allergies.
Other drugs in the same drug class as Apoquel include drugs for humans for rheumatoid arthritis, psoriasis, and cancer. In humans, the side effects of drugs in the JAK inhibitor class of drugs include: neutropenia, anemia, thrombocytopenia, increased liver values, increased cholesterol, UTI, weight gain, herpes zoster.
Apoquel side effects listed for dogs in the product insert include: vomiting, diarrhea, lethargy, anorexia, SQ or dermal masses (unspecified), decreased leukocytes, decreased globulins, and increased cholesterol and lipase. Low numbers of dogs in the studies developed demodicosis, neoplasia, pneumonia, bloody diarrhea, skin and ear infections, UTIs, and histiocytomas.
Interestingly, in early studies, a few dogs developed polydipsia, increased appetite, and aggression, similar to what may be seen with steroids- I have not seen these issues with a proven link to Apoquel.
I have started over 1000 dogs on Apoquel. It is rare to see side effects while a pet is on Apoquel. Bone marrow suppression is the most concerning side effect, but we have only seen this in about 1% of pets on Apoquel. No outward signs were seen in these dogs who had bone marrow suppression, only changes on bloodwork were discovered. This is why we recommend bloodwork at the 2-3 month point after starting Apoquel. After decreasing the dose of Apoquel, the bone marrow recovered rapidly, within a few weeks. Even in cases where the CBC values do not go below normal, it is common for the values to sink towards the low end, the clinical significance of this is not known. Other allergy medications do not cause bone marrow suppression even at extreme doses.
Ear infections seem at an unusually high rate in my opinion, at least compared to what I have seen with steroids or cyclosporine- drugs which tend to prevent ear infections. Sometimes we also see urinary tract infections while pets are on Apoquel, however, I am suspicious this type of infection is more common in patients who have allergies anyway.
Similarly to the side effect of weight gain seen in humans on JAK inhibitors, I have seen weight gain in dogs on Apoquel, not to the degree seen with prednisone. I have not had owners report an increased appetite. Perhaps they are getting less exercise from not scratching as much. It would be nice to perform a study with normal dogs, who (like humans) may tend to gain weight over time no matter what drugs they are on.
Very rare dogs have become manic on Apoquel- the owners say the dogs have a “funny look on their face” and run around the house and can’t settle down. I have seen 3-4 of these cases and really can’t explain how the drug causes this. This condition instantly resolved in all cases when the Apoquel was stopped.
Interestingly, I have seen Apoquel improve mobility in dogs with arthritis. I am not sure if this is just because they overall “feel better” when their skin is not inflamed or if some dogs with allergic inflammation of the skin also have inflammation of the joints as well.
Apoquel can be used in cats with some success, however this use is not FDA approved, high doses are needed, and more than once daily dosing is often needed. Some cats respond well to this therapy, others do not respond at all. We monitor bloodwork on all cat patients on Apoquel and thus far have not seen issues, but there are no long term studies in cats. I recommend a veterinary dermatologist manage feline cases that need to use Apoquel.
It doesn't appear there are long term side effects of Apoquel use in dogs, at least no studies have shown any concerning issues so far. The product insert warns that Apoquel may exacerbate neoplastic conditions. There is no good evidence of this as of yet, we will keep monitoring. I often see terrible skin disease in dogs who have internal disease like cancer, so keep in mind that many of the internet reports of "I started my dog on Apoquel and he got cancer" are, in my experience, likely to be dogs with skin itchiness and infection of that was triggered by an internal cancer was treated with Apoquel just before the cancer was actually discovered. I would recommend Apoquel over cyclosporine in a dog with previous cancer. Comfort and quality of life are absolute considerations when deciding which medications to use.
Our protocol for Apoquel monitoring in dogs who are on once daily dosing is to check a CBC/Chem6 prior to starting Apoquel, then at 3 months, then once yearly. The CBC is the most important piece of information for monitoring. It is important to make sure the dog does not have liver disease prior to starting the Apoquel. The only exception to this would be liver elevations caused by steroids. Time will tell if urine monitoring is important- I do not monitor urine samples.
I like Apoquel. The benefits of Apoquel include: rapid onset of action, low likelihood of GI side effects, rare side effects with long term use, no withdrawal needed for skin testing, and decent price. The downsides include: monitoring needed for bone marrow suppression, does not work for some pets, and we do not have long term data. It is a wonderful option for most dogs with allergies. Allergy testing and shots remains the only effective management of allergies that does not involve some type of immune suppression.
Monitor blood work prior to administering this medication (especially in older animals), at 3 months, and then annually thereafter until we have more information about long term use in dogs. Read the drug insert for more information and FDA recommended use.
Report all adverse side effects to the company or to the FDA: Link Here
If you have questions about Apoquel, please contact your veterinarian or call ZOETIS as we cannot give medical advice for patients we have not seen at our clinic.