By Dr Daisy A. May MRCVS BVSc (Veterinary Surgeon)
Ten years ago, Apoquel was licensed for the treatment of atopic (allergic) dermatitis in dogs. And – as an estimate – 9.5 years ago the internet decided that Apoquel was the devil’s work. In fact, as an experiment, prior to writing this article I decided I’d do a little googling myself, specifically the term: ‘is there an alternative to Apoquel for dogs?’
Three of the top five results fell immediately into the irrational scaremongering category, and rather bluntly stated that Apoquel would give my dog cancer. Two results encouraged the reader to consider CBD instead of Apoquel, and one rather optimistically stated that substituting Apoquel for Yucca would do the trick.
But here’s the interesting part: 100% of the top five search results for the term ‘is there an alternative to Apoquel for dogs?’ were written by pet owners or generic freelance writers, with zero veterinary or medical education. Zero were written by veterinary doctors or scientists.
I can’t be the only one who thinks that might just be a problem.
Now, I’m not suggesting that these articles are entirely useless (although, to be fair, they are bordering on it), nor that they were written with anything but good intentions. But the fact is that all of these articles have been written by individuals who do not have a medical education and therefore are presumably in turn obtaining their own source information by googling things.
This can quickly turn into a game of Chinese whispers in which misinformation is spread and the truth of the matter is lost. Which sucks, because it means dog owners who genuinely desire factual, scientifically proven and helpful information regarding apoquel are less likely to find this, and more likely to find pro-Yucca hearsay.
Think this isn’t your problem? Trust me, it is (if you’re a dog owner, at least). Because it means your ability to make an informed decision based on credible information is being undermined by websites peddling bullshit (there, I said it).
So: if you want unbiased, rational and scientific information regarding Apoquel and your dog, stick around. Like practically every vet, I don’t work on commission.
Let’s go.
What is Apoquel?
Apoquel is a medication licensed for the treatment of atopic (allergic) dermatitis in dogs. It contains the active ingredient oclacitinib, which is a Janus Kinase (JAK) inhibitor.
Janus Kinase (JAK) is one of the body’s many signaling systems. Put simply, it allows cells to communicate with each other. JAK signaling is especially important in canine allergies, so blocking the JAK signaling system effectively prevents allergy symptoms, in particular the sensation of itch.
Apoquel works differently than antihistamines, steroids, cytopoint injections and atopica (ciclosporin). This means that Apoquel might be able to control your dog’s allergy symptoms even if these other methods have failed. The reverse is also true: if you don’t have success with Apoquel, then it’s still likely one of these other options will work for your pet.
Does Apoquel Work?
Apoquel has been proven to be as effective, if not more so, than steroids [5], and (for comparison) steroids provide incredibly powerful itch relief. But – as any vet worthy of their scrubs will tell you – apoquel is vastly safer as a long-term allergy management option than a daily whack of prednisolone.
Proving itself again a worthy front runner for allergy management, Apoquel kicks in much faster and produces fewer side effects than Atopica (ciclosporin). Anti-itch effects can be seen within 24 hours of taking Apoquel [3], but are relatively short lived, lasting 12-24 hours.
Most dogs get by very happily on a once-daily Apoquel dose (following an initial two week loading period of twice-daily dosing), however in rare cases twice-daily dosing may need to be considered as a long term option. Whilst Apoquel isn’t licensed for ongoing twice daily use, there are certainly cases where your vet might deem it to be the best and safest option for your dog.
Preliminary research has shown that long term twice-daily administration is tolerated very well in most dogs [9]; running bloods every 2-3 months to check in on white blood cell counts can make things even safer.
Anyway, I digress. To answer the question, in most cases yes, Apoquel works.
What are the Side Effects of Apoquel?
Contrary to what the internet at large might have you believe, vomiting and diarrhea are actually considered to be rare side effects of Apoquel. In fact, one large-scale study found that dogs given a placebo (basically a sugar pill) experienced an equal amount of vomiting and diarrhea as dogs taking Apoquel, suggesting that this side effect may in reality be little more than a coincidence [3].
The development of warts or other benign skin lumps, and a possibly increased likelihood of developing superficial skin infections are also listed amongst Apoquel’s possible side effects. Although (and more on this later), we should keep in mind that association doesn’t always equal causation.
Dogs with allergies are – by default – prone to developing skin infections (as allergies are in part a skin barrier issue), so frankly, I’d take Apoquel-as-a-cause with a pinch of salt. The same goes for the fungal skin infections, pododermatitis, and ear infections that are sometimes blamed on Apoquel usage. Dogs with allergies are super prone to all of these conditions.
It makes very little sense to me, to assume Apoquel is the cause.
Owners of dogs taking Apoquel have also uncommonly reported lethargy; increased (or in some cases reduced) appetite; increased thirst; and aggressive behaviour. To the best of my knowledge, science has yet to prove any link between Apoquel and aggression or thirst, so really it’s a case of needing more research to establish whether or not these things are true side effects, or just a coincidence.
Is Apoquel Safe?
No medication is 100% safe for 100% of the individuals that take it. Fact.
However – Apoquel is relatively safe, when compared to the other options we have available for canine allergy management.
Personally, I’d rate the safety of our options as follows:
- Allergen Specific Immunotherapy (ASIT)
- Cytopoint injections
- Apoquel
- Antihistamines
- Atopica (ciclosporin)
- Steroids (such as prednisolone)
As you can see, I’ve ranked Apoquel in third place out of six options. So: not completely safe, but it could certainly be worse.
Of course, there’s still very much an elephant in the room at this point to be addressed, and that’s the c word. No, I’m not talking about proponents of raw diets and Yucca extract (although I certainly could be). I’m talking about cancer.
Let me explain the basis for this myth (for indeed, it is a myth), and – importantly – why Apoquel will not give your dog cancer.
Thing number one: association is different from causation.
Put simply, just because some dogs taking Apoquel have tumors, doesn’t necessarily mean Apoquel caused the tumors. Cancer is common in dogs. In fact, it’s been estimated based on large scale data collection that around one in fifty dogs has cancer at any given moment in time[1]. And more than twice this (around 2.5 in fifty) dogs will suffer from a benign or malignant cancer at some point in their life [10].
Oh, and this data doesn’t take into account the large number of dogs who’s cancer goes entirely undiagnosed, due (for example) to not receiving veterinary treatment, or (SUPER common) due to the dog being put to sleep without a diagnosis actually being obtained. So it’s likely that the true percentage of cancer-affected dogs is actually rather higher still.
So: key point. Cancer? Common. Allergies? Very common.
Example time. In one long-term study, mast cell tumors (MCTs) were found to be the most common cancer affected dogs both taking and not taking Apoquel [9]. The interesting part?
The affected number of dogs was pretty much equal, between the two groups.
Association doesn’t always mean causation.
Thing number two: science says no.
Much like the computer in Little Britain, when it comes to the question of whether or not Apoquel will give your dog cancer, science says no.
In fact, the key message we can draw from the data we have, is that the incidence of cancerous tumors, and the age of death in patients receiving Apoquel is no higher than the corresponding figures for dogs not taking Apoquel [9].
So, whilst that XL bully breeder you chatted to on Reddit might be of the opinion that giving your dog Apoquel is akin to feeding him or her formaldehyde or encouraging him/her to chain smoke, actual science says otherwise.
Who would you rather believe? A keyboard warrior, or a bunch of brainiacs with PhDs?
Thing number three: the “but”.
There is a “but”, and (by the way) it’s not a secret. Vets aren’t trying to hide it from you, and nor are the makers of Apoquel. It’s right there on the datasheet, in fact. In relatively big letters:
“Do not use apoquel [in dogs with] evidence of progressive malignant neoplasia as the active substance has not been evaluated in these cases.’
What that means in simple terms is that Apoquel shouldn’t be given to dogs with known or suspected malignant cancers, as we don’t yet know how Apoquel will affect these cancers. There’s certainly the potential for Apoquel to possibly make some types of tumor grow faster (not currently a proven fact, but certainly possible). For this exact reason if I prescribe Apoquel for your dog, I’ll ask you to please keep an eye out for any signs that might indicate a cancer.
On the flip side though, it’s also worth pointing out that the tumor-fighting properties of Apoquel have also been receiving attention lately [9]; so, who knows. In the future Apoquel might even find a new niche as a chemotherapy agent. Time will tell.
Is there an Alternative to Apoquel for Dogs?
Yes. In fact, there are plenty, although not every allergy treatment will work for every dog, and many pets require a combination approach.
For example, Dog A’s allergies might be manageable with omega supplements and lifestyle changes, whereas Dog B’s allergies might require an omega supplement, lifestyle changes, and one or two allergy medications to control their symptoms.
Let’s look at some alternatives you can try out.
Alternatives to Apoquel for Dogs
Omega Supplementation
In terms of skin health, two omega fatty acids are really important: omega 3 (found abundantly in salmon oil) and omega 6 (flaxseed oil is a great source). These fatty acids help reduce inflammation, in turn reducing itch.
Appropriate omega 3 and 6 supplementation will also improve the overall robustness and health of the skin barrier [8], meaning allergens contacting the skin are less likely to penetrate through the outer epidermis of the skin and encounter immune system cells, sparking an allergic response.
Salmon oil is also a rich source of vitamin E, supplementation of which has been shown to provide itch relief in it’s own right [7].
Omega fatty acid supplements are widely available without a prescription. In particular I tend to recommend YouMOVE’s ‘Skin & Coat Care Itching’ oil, or Zesty Paws Wild Alaskan Salmon Oil (for my readers on the other side of the pond). When used daily, you’ll absolutely notice a difference.
Lifestyle Changes
This means stuff like:
- Washing your dog’s feet after walks
- Avoiding contact with known allergens
- Bathing your dog once weekly with a non-irritating shampoo containing colloidal oatmeal*
- Switching to a hypoallergenic diet (please not a raw diet)
- Controlling yeast and bacterial growth through the sensible and judicious use of things like CLX wipes or Pyo Pads
- Cleaning your dog’s ears regularly using an appropriate and safe antimicrobial liquid ear cleanser
P.S…Want to get your hands on the exact same ear cleaners I prescribe my patients, but for half the price it costs at the vets?
Otodine or Epiotic are ideal for routine cleaning. Malacetic is the better choice if your pet suffers with particularly wet, waxy ears.
You’re welcome :))
* A quick work on colloidal oatmeal. This stuff rocks. It’s moisturising, anti-inflammatory, anti-oxidant and even has some natural anti-histamine effects. Oh, and it can also modulate (fiddle around with and make better) the immune system; specifically, it can calm down an overreacting immune system which is freaking out about a harmless allergen [4]. Honestly, I never thought I’d be so passionate about oatmeal (I fucking hate porridge), but I really do love this stuff in shampoos.
I particularly love this colloidal oatmeal and honey shampoo from Burt’s Bees, which is pH balanced, tearless and completely suitable for sensitive or allergic skin.
Hypoallergenic Diets
If your dog’s symptoms (itchy skin +/- tummy upset) are down to food allergies, you can banish the demons for good simply by making sure he or she has absolutely no further opportunity to consume the foods that are causing their allergic reaction.
The best sure-fire way to achieve this is to feed your dog a strict (and I really do mean strict) hypoallergenic, or better yet anallergenic diet. And be patient with it, please: it’s going to take 8-12 weeks of no-allergen nutrition to see the full effects of the change.
I fully appreciate what a massive pain in the ass a diet change is, but I promise you it’s cheaper and easier than living with untreated food allergies. Trust me on that one.
As somebody who at least tries to give a shit about the environment, I‘m frankly really into feeding dogs insect protein (not least because insect protein based diets are completely hypoallergenic). You might think that’s a weird tangent at first, but actually it isn’t; shockingly, 20% of the World’s meat and fish is consumed by our pets, generating 106 million tonnes of carbon dioxide every year and providing a driving force behind deforestation.
You can help the planet and your pet’s allergies by choosing bugs, so long as you’re mature enough to wrap your head around the initial “gross” factor (and by the way, dogs really seem to love bug based food).
Cytopoint Injections
Interestingly, Google hates Cytopoint almost as much as Apoquel, and will merrily inform you without missing a beat that cytopoint will make your dog drop dead.
As a veterinarian, I am happy to report that I have in fact never seen a dog experience any serious side effects from Cytopoint injections, and nor have any of the (many) vets that I know and chat to on a weekly basis. Least of all “deadness”.
Like apoquel, Cytopoint injections are expensive, but they are a very convenient option (given monthly by a quick and simple injection under the skin), and more often than not, Cytopoint is pretty darn effective.
Atopica (ciclosporin)
Atopica was very much the go-to allergy treatment when I was at vet school. Thankfully, these days – largely because we have Apoquel and Cytopoint – Atopica tends to get left on the shelf.
I say “thankfully, given Atopica’s slow onset of action, notoriously expensive price tag, and it’s significant potential to cause a cornucopia of very interesting side effects such becoming extremely hairy (like a werewolf) or developing comically large gums (yes, gums)…or the sudden and extremely concerning absence of every white blood cell in your body (a true ‘oh shit’ situation, if ever there was one).
I still prescribe Atopica occasionally where other methods of allergy relief have failed, but it shouldn’t really be taken lightly, especially when the full moon is approaching.
Topical Steroids
Topical steroids – that is, those applied to the surface of the skin, ears or eyes rather than taken by mouth – are preferable to oral steroids in terms of having less potential for the adverse effects for which oral steroids are famous.
Cortavance spray and recicort ear drops, as well as Maxidex eye drops, are some common examples in this category.
If your dog’s allergy symptoms are localised (for example, itchy ears or eyes) topical steroids might be a great choice, rather than Apoquel, and are certainly worth bringing up with your vet.
Oral Steroids
For long term use, oral steroids should really be a very last resort, reserved for cases where other options have been tried and failed, or (because we live in the real world) where money is an issue.
Steroids suppress the immune system in an entirely non judgemental way: unlike Apoquel and Cytopoint, they aren’t selective. They will absolutely also affect your dog’s liver parameters over time, as well as causing thinned skin, hair loss, weight gain, muscle weakness and iatrogenic (medication-caused) Cushing’s disease.
Not ideal.
FAQs
Is Apoquel a Steroid?
Nope. Apoquel is not a steroid. It’s a Janus Kinase inhibitor.
Sorry you asked?
I’ll explain.
Janus Kinase (JAK) is one of the body’s many signaling systems. Put simply, it allows cells to communicate with each other. JAK signaling is especially important in canine allergies, so blocking the JAK signaling system effectively prevents allergy symptoms, in particular the sensation of itch.
Apoquel works very differently from steroids. You can think of apoquel as being more targeted, mostly blocking itch-specific signaling, whereas steroids suppress all types of inflammation (itch and otherwise) more equally. Both drugs have the potential to dampen down the immune system, although – being more targeted – apoquel is certainly considered safer, and appears to be less likely to cause significant immunosuppression.
You (and your dog) need an immune system for important daily functions like staying alive. Without a healthy immune system, your pet will be vulnerable to infections, and to developing cancers. If I was a dog, trust me: I’d much rather be relying on apoquel than on steroids to keep me itch free.
Is there a Cheaper Alternative to Apoquel?
Yes, but there’s a catch.
Steroids are cheaper but less safe.
Antihistamines are cheaper and still very safe, but the trade off here is that – to be honest – they are rarely effective enough to control a dog’s allergies on their own.
Lifestyle changes can be the cheapest option of all, but they may or may not be enough for your dog, depending on the severity of his or her allergies.
My advice? Maybe start with lifestyle changes and antihistamines, but consider Apoquel as a “step two” if that doesn’t work (or steroids if you’re cost concerned and willing to accept that your dog’s overall lifespan will likely be shortened).
Sorry if that’s hard pill to swallow, but I’d rather be honest with you so that you can make the most informed decision possible.
Can I Use Benadryl Instead of Apoquel?
Benadryl (trade name) contains the antihistamine drug diphenhydramine.
When dogs take Benadryl by mouth, the diphenhydramine quickly reaches a blood level that would be effective in humans [2]. However, the effectiveness of Benadryl as an allergy medication for dogs has not been proven, with studies (like at least one ex boyfriend) providing rather mixed signals.
Whilst at least one study has shown that oral diphenhydramine may be as effective as a short-term steroid injection when it comes to treating a single, one-off allergic reaction (for example, to a bee sting)[6], other studies have shown zero positive effect [2].
It’s also important to note that the toxic dose of diphenhydramine appears to vary quite significantly between individual dogs [11], and so a dose that is safe for one dog, might cause unpleasant side effects or even full-blown poisoning in another individual. So, if you do decide to give Benadryl to your dog, it’s vital that you speak to your vet first to get the all clear (based on your pet’s specific medical history), and to obtain a safe dose.
And, in case you didn’t know: it’s actually illegal to give your dog human medications unless this is done on the direct advice of a licensed veterinarian. Whilst this law seems to be rarely upheld, it’s worth being aware of. Please don’t be afraid to tell your vet, if you are giving your pet a human medication, though: we aren’t the police and frankly, we don’t care. We just want to be able to advise you on what’s best for your pet, and for that to work you need to be honest with us.
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References
- Baioni, E., Sanziani, E., Vincenti, M.C., Leschiera, M., Bozzetta, E., Pezzolato, M., Desiato, R., Bertolini, S., Maurelle, C. and Giuseppe, R. (2017) ‘Estimating canine cancer incidence: findings from a population-based tumour registry in northwestern Italy’, BMC Veterinary Research. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5490209/#:~:text=The%20incidence%20rate%20was%20804,in%20Yorkshire%20terrier%20and%20Boxer. (Accessed 15 August 2023).
- Banovic, F., Denley, T., Blubaugh, A., Scheibe, I., Lemo, N. and Papich, M.G. (2020) ‘Effect of diphenhydramine and cetirizine on immediate and late-phase cutaneous allergic reactions in healthy dogs: a randomized, double-blinded crossover study’, Veterinary Dermatology. Available at: https://onlinelibrary.wiley.com/doi/full/10.1111/vde.12840 (Accessed 3 August 2023).
- Cosgrove, S.B., Wren, J.A., Cleaver, D.M., Martin, D.D., Walsh, K.F., Harfst, J.A., Follis, S.L., King, V.L., Boucher, J.F. and Stegemann, M.R. (2013) ‘Efficacy and safety of oclacitinib for the control of pruritus and associated skin lesions in dogs with canine allergic dermatitis’, Veterinary Dermatology, 24(5). Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4282347/ (Accessed 3 August 2023).
- DVM360 (2023) Comparing treatments for restoring the skin barrier in atopic dogs. Available at: https://www.dvm360.com/view/comparing-treatments-for-restoring-the-skin-barrier-in-atopic-dogs (Accessed 2 July 2023).
- Gadeyne, C., Little, P., King, V.L., Edwards, N., Davis, K. and Stegemann, M.R. (2014) ‘Efficacy of oclacitinib (Apoquel®) compared with prednisolone for the control of pruritus and clinical signs associated with allergic dermatitis in client-owned dogs in Australia’, Veterinary Dermatology, 25(6). Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4282467/ (Accessed 15 August 2023).
- Helgeson, M.E., Pigott, A.M. and Kierski, K.R. (2021) ‘Retrospective review of diphenhydramine versus diphenhydramine plus glucocorticoid for treatment of uncomplicated allergic reaction in dogs’, Journal of Veterinary Emergency and Critical Care. Available at: https://onlinelibrary.wiley.com/doi/abs/10.1111/vec.13054 (Accessed 3 August 2023).
- Kapun, A.P., Salobir, J., Levert, A., Kalcher, G.T., Svete, A.N. and Kotnik, T. (2014) ‘Vitamin E supplementation in canine atopic dermatitis: improvement of clinical signs and effects on oxidative stress markers’, Veterinary Record, 175(22). Available at: https://pubmed.ncbi.nlm.nih.gov/25205675/ (Accessed 2 July 2023).
- Kaur, H., Singla, A., Singh, S., Shilwant, S. and Kaur, R. (2020) ‘Role of Omega-3 Fatty Acids in Canine Health: A Review’, International Journal of Current Microbiology and Applied Sciences, 9(3). Available at: https://www.ijcmas.com/9-3-2020/Haneet%20Kaur,%20et%20al.pdf (Accessed 2 July 2023).
- Marsella, R., Doerr, K., Gonzales, A. and Rosenkrantz, W. (2023) ‘Oclacitinib 10 years later: lessons learned and directions for the future’, Journal of the American Veterinary Medical Association, 261. Available at: https://avmajournals.avma.org/view/journals/javma/261/S1/javma.22.12.0570.xml (Accessed 15 August 2023).
- Schwartz, S.M., Urfer, S.R., White, M., Megquier, K., Shrager, S. and Ruple, A. (2022) ‘Lifetime prevalence of malignant and benign tumours in companion dogs: Cross-sectional analysis of Dog Aging Project baseline survey’, Veterinary and Comparative Oncology, 20(4), pp. 797-804. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10089278/ (Accessed 15 August 2023).
- Worth, A.C., Wismer, T.A. and Dorman, D.C. (2016) ‘Diphenhydramine exposure in dogs: 621 cases (2008–2013)’, Journal of the American Veterinary Medical Association, 249(1). Available at: https://avmajournals.avma.org/view/journals/javma/249/1/javma.249.1.77.xml (Accessed 3 August 2023).
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