Apoquel vs. Atopica: comparison of two medications to control atopic dermatitis and itch in dogs

By Jon Plant, DVM, DACVD

Atopica® (cyclosporine) and Apoquel® (oclacitinib) are separate and distinct medications. Both are used for controlling the signs and symptoms of atopic dermatitis (“allergies”) in dogs. They are two of the most effective allergy treatments for dogs. Let’s see how they compare.

Availability of Atopica and Apoquel

Atopica was FDA approved more than 10 years ago and is widely available as a prescription drug through veterinarians.

Apoquel was launched in January 2014, but the demand quickly exceeded the manufacturing capacity of the manufacturer, Zoetis. This has led to very limited availability and backorders. Most veterinary clinics are unable to order any Apoquel at all. Zoetis anticipates that production will be able to keep up with the demand in the spring of 2015.

Cost of Atopica and Apoquel

Atopica comes in four sizes: 10, 25, 50 and 100 mg capsules. It is dosed based on your dog’s body weight. Each size is priced differently and larger dogs may require more than one capsule. Depending upon your dog’s weight, the initial cost may range from $1.50-$10 per day. Significant rebate programs are often available when purchases are made through veterinarians (as much as 50% off ) but not through online pharmacies. The cost often goes down over time if the dose is able to be reduced.

Apoquel comes in three sizes: 3.6, 5.4, and 16 mg tablets. Dogs less than 90 pounds need only take 0.5 or 1.0 tablet per day, long term. Big dogs will require 1.5 or 2.0 tablets per day. A novel feature of Apoquel is that all three tablets are priced the same. There isn’t much information on the retail pricing of Apoquel available, but it is likely to be around $1.50-$2.00 per tablet in most veterinary hospitals that have it in stock.

Dosing of Atopica and Apoquel

Atopica comes as capsules, which are fairly large in the 100 mg size. Pet owners often find the larger size difficult to administer. The initial dose is 5 mg per kg body weight. In most cases, it is given once daily for the first month. If your dog responds well, the dose can often be reduced to every 48 hours or even twice weekly. It is then given long-term, or at least during the seasons that your dog itches from allergies.

Apoquel comes as scored tablets, which are fairly small and easy to administer. There is a narrow dose range of 0.4-0.6 mg per kg of body weight. Your veterinarian will sometimes need to use half of two different sizes to get the proper dose. For up to 14 days, Apoquel is administered twice daily. In cases of chronic itch in dogs, it is given once daily, long term. Apoquel has a short half-life, meaning that it doesn’t persist for long in the blood stream. Missing even one dose may result in a return of the itching behavior. Establishing a daily routine or setting an iPhone reminder is important. A good reason to check out the Itchology app on Facebook!

Speed of Atopica and Apoquel in reducing itch

Atopica does not usually achieve its maximum effect on itching until after daily dosing for four weeks.Apoquel vs Atopica

Apoquel reduces itching quickly, often within one day. There is a major reduction in itching within 7 days in most dogs. In a head-to-head study, Apoquel reduced the itch level more than Atopica during the first 14 days. There is often a slight increase in itch level when Apoquel dosing is switched from twice daily to once daily, usually at 14 days of therapy.

Side effects of Atopica and Apoquel

Both Atopica and Apoquel affect the immune system. An allergy is, after all, an overactive immune system. Atopica is considered immunosuppressive, effecting T-cells. Apoquel is considered immunomodulatory, blocking transmission of the itch sensation, among other activities. Both medications have the potential to increase the risk of dogs getting infections. In reality, this is uncommon at recommended doses. Dogs with allergies often get skin infections (pyoderma), whether they are taking one of these medications or not.

Atopica is associated with vomiting and diarrhea more often than Apoquel. In a review study compiling results of 672 dogs treated with Atopica, vomiting occurred in 25% and diarrhea or soft stools in 15% of dogs. Usually, veterinarians and pet owners can overcome this, with a slight modification of dosing.

Apoquel is uncommonly associated with vomiting or soft stools (1-2% of dogs). In most studies, these occur with a similar frequency in placebo-treated dogs and those treated with Apoquel. Because Apoquel is still relatively new, it is prudent to monitor our patients rather closely. I recommend an examination, complete blood panel and urinalysis at 0, 3, and 6 months, then every 6 months while taking Apoquel, for now.

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Experience with Apoquel® (oclacitinib) for the treatment of 117 allergic dogs. Part 1: control of itch.

Jon Plant, DVM, DACVD

We started hearing about a new drug to control the itch of allergic dermatitis and canine atopic dermatitis in dogs over 1 year of age at the Vancouver World Congress of Veterinary Dermatology. The research showed some amazing findings. Like most veterinary dermatologists, I was eager to try it in my practice. I started prescribing (oclacitinib) Apoquel® for itchy dogs at SkinVet Clinic in November 2013. As of August 2014, I had treated over 100 dogs with Apoquel.

Dogs with skin allergies can have skin lesions and odor, but the thing that is most troublesome to pet parents (and the dogs!) is the itch that can make them miserable. At SkinVet Clinic, we ask pet owners to grade their dog’s itch level at each examination using a validated visual analog scale (0 – 10). While this is the best method that we have had to grade itch in practice, it gives an incomplete picture of itch severity over time. Soon, pet owners and veterinarians will be able to easily record and view a more complete itch diary using the Itchology app for iPhones (see www.itchology.com for more info and to sign up to get notified when it is released).

This graph shows the owner-reported itch level of dogs before Apoquel blogtreatment and after 1, 3 and 6 months. Both per-protocol data (dogs returned for recommended follow-up examinations at 1, 3, and 6 months) and intent-to-treat (ITT) data (previous value carried forward when dogs did not return for examinations or medication was discontinued) are shown.

  • 117 dogs started taking Apoquel at least 40 days ago (day 0 median = 6.0). Month 1 itch level scores were available for 104 of these (median = 2.5). The ITT data yielded similar results taking into account carried-forward values for the 13 dogs that did not return (median = 2.7).
  • 108 dogs started taking Apooquel at least 3 months ago (day 0 median = 6.0). Month 3 itch level scores were available for 85 of these (median = 2.0). The ITT value was slightly higher (median = 2.5).
  • 91 dogs started taking Apoquel at least 6 months ago (day 0 median of these 91 dogs = 5.7). Month 6 itch level scores were available for 59 of these (median = 2.3). The ITT value was similar (median = 2.5).
  • The percentage of dogs that achieved a level of itch considered “normal” by dog owners (0.0-1.9) was 36.8% at 1 month, 39.8% at 3 months, and 40.7% at 6 months (based on ITT values). Many others were in the “very mild” itch category.

These findings are remarkable, considering that most of the dogs began taking Apoquel during cooler, winter months and follow-up examinations more often occurred during warmer months, when many dogs with allergies would be flaring up. Further, as this was not a rigorous clinical trial, the day 0 itch level was often recorded while the dogs were still taking other medications – from prednisone to Atopica®. (These were discontinued for three days prior to the owner initiating Apoquel, in most cases.) Therefore, it is likely that the day 0 itch level reported here was slightly lower than it would have been with a medication wash-out period.

All in all, Apoquel has performed as expected in my hands. Check back to read my next post concerning Apoquel side effects. And, don’t forget to visit www.itchology.com to sign up for Itchology, a must-have app to help your vet help your itchy pet!