An update on treatment of FIP using antiviral drugs in
2024: growing experience but more to learn
Sam Taylor BVetMed(hons) CertSAM DipECVIM-CA MANZCVS FRCVS
Séverine Tasker BSc(hons) BVSc(hons) DSAM PhD DipECVIM-CA FHEA FRCVS
Danièlle Gunn-Moore BSc(hons) BVM&S PhD MANZCVS FHEA FRSB FRCVS
Emi Barker BSc(hons) BVSc(hons) PhD PGCertTLHE DipECVIM-CA MRCVS
Stephanie Sorrell BVetMed(hons) MANZCVS DipECVIM-CA MRCVS
The above specialists run the ‘FIP advice’ email address (fipadvice@[Link]) for vets,
answering queries on the new treatments on a voluntary basis and disseminating
information to veterinary professionals around the world. So far, they have answered
nearly 2000 emails via this free service, hoping this increases access to care for FIP in
cats.
Introduction
In the UK antivirals with high efficacy in the treatment FIP have been legally available since 2021 (initially remdesivir,
and subsequently its active form GS-441524). In that time, we have gained experience in managing the disease and
monitoring treatment, and seen excellent outcomes. Legally available sources of antivirals now exist in many other
countries, although in some parts of the world there remains no quality assured, legal supply. This article
summarises the current advice on treatment of FIP to aid practitioners managing these cases and is based on
current information that may change as more experience and publications become available. It includes information
on the recently available additional antiviral EIDD-1931 (the active form of molnupiravir). Treatment needs to be
tailored to the individual cat based on response, compliance, and client finances. For further information on making
a diagnosis of FIP please see further reading below and the ABCD FIP diagnostic tool flow diagrams here:
[Link]
Treatment protocols (updated February 2024)
Legally available antivirals in the UK and other countries via import now include remdesivir (injectable), GS-441524
(oral suspension and oral tablets), and EIDD-1931 (oral tablets). The following advice is based on published and
unpublished data and experience. Treatment of individual cases remains the responsibility of the attending veterinary
surgeon. The dosages below are based on experience using reputable preparations of known antiviral content.
Extrapolation is not applicable to other oral preparations where the active component and/or its content are not
known or provided by the manufacturer.
Use of oral GS-441524 for the whole treatment course, including at the start
Oral GS-441524 (available as a suspension of 50 mg/ml and tablets of 50 mg tablet or 25 mg (half a 50 mg tablet))
can be used from the start of FIP treatment for the entire (e.g., 12-week/84-days) course. It is important to support
owners in medicating their cats, which can be challenging. Oral GS-441524 suspension or tablets can be given with
a small treat (tablets can be crushed for this) or directly into the cat’s mouth. Further study is needed to review the
effect of food on absorption, but it is recommended to give in a small treat or on an empty stomach, leaving a gap
of an hour or more before feeding a larger meal.
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Fasting cats overnight can increase their hunger to Duration of antiviral treatment is still a
facilitate medicating in the morning, and similarly for an minimum of 84-days
The current recommendation is to treat for 84-days
evening dose. However, starving kittens is never
minimum. Some cats have been successfully treated
recommended as they cannot cope with this. Any with shorter courses, but large case studies have not
withholding of food needs to be tailored to the age of yet been published. If cost constraints necessitate
shorter courses, the dosage used should not be
the cat.
reduced and treatment sustained for as long as
possible.
Injectable remdesivir is reserved for cats that
The transition between remdesivir and oral GS-441524
cannot be medicated orally
can be immediate, i.e., from one treatment to the next.
Injectable remdesivir (10 mg/ml) is effective in the
Dosage recommendations
treatment of FIP but is associated with some side
With experience, and as yet unpublished data on
effects (see below), particularly pain on subcutaneous
therapeutic drug monitoring (TDM), dosage
injection which is seen in 50% of cats. Previous FIP
recommendations have increased from previous FIP
treatment protocols suggested this be used at the start
treatment protocols. However, evidence shows that
of treatment before transitioning to oral GS-441254.
over 85% of cats respond to the previously
However, we now know that FIP cats can be treated
recommended drug dosages, which is still high.
successfully with oral GS-441524 from their first day of
However, based on TDM studies, we now know that
treatment. This avoids pain on injections and reduces
individual cats vary in their absorption of oral
the costs of the treatment (the dose for the weight of
GS-441524, with those absorbing poorly requiring
the cat using GS-441524 is cheaper than remdesivir).
higher dosages to achieve clinical and biochemical
Use of injectable remdesivir should be reserved for the
remission. Ideally, dosage should be adjusted based on
following situations:
TDM, if available (see below), or response to treatment.
Severe neurological signs and inability to swallow or
tolerate oral medication;
Compared to previous FIP treatment protocols,
Extremely dehydrated/unwell cats;
the important changes to dosage
Cats that cannot be orally medicated for other
recommendations are:
reasons.
Dosage of oral GS-441524 given as a divided dose,
In some circumstances, if a cat is hospitalised and has
twice a day (every 12 hours), to optimise serum
a poor appetite, which is affecting the ability to
levels of GS-441524;
medicate it, 48 hours of remdesivir (given intravenously
Higher dosages may overcome issues with poor
not subcutaneously) can result in significant clinical
absorption in some cats and have a better chance
improvements which may facilitate subsequent oral
of crossing the blood brain barrier and the blood
medication with GS-441524. The remainder of the
eye barrier;
treatment course can then be given as an oral
Dosage should be adjusted according to response,
GS-441524.
and TDM if available.
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Table 1
Remdesivir IV or SQ injection
Clinical presentation GS-441524 PO dosage
dosage
6.0 – 7.5 mg/kg q 12 hours
Effusion(s) and without
(i.e., 12 – 15 mg/kg/day given as a 10 mg/kg q 24 hours
ocular or neurological signs
divided dose q 12 hours
No effusion and without
6.0 – 7.5 mg/kg q 12 hours 12 mg/kg q 24 hours
ocular or neurological signs
Ocular signs present
7.5 – 10.0 mg/kg q 12 hours 15 mg/kg q 24 hours
(± effusion)
Neurological signs present
10 mg/kg q 12 hours 20 mg/kg q 24 hours
(± effusion)
PO, per os (orally); IV, intravenous; SQ, subcutaneous; q, every; hours
Cats should be re-examined after 1-2 weeks (sooner if not improving or deteriorating) and dosage
adjusted depending on monitoring at this point (see ‘Monitoring’).
minimum volume required for TDM and AGP
Notes on weighing cats
It is very important to weigh cats weekly during measurements without haematology and biochemistry
treatment, using accurate scales e.g., cat or baby testing. Email Rachael Hammond
scales. Weight gain and/or growth in kittens will occur
with successful treatment necessitating an increase in ([Link]@[Link]) for information on
dose to ensure that the dosage of antiviral submission. Results can allow adjustment of
administered is still appropriate for the type of FIP GS-441524 dosage or frequency of administration.
being treated as in Table 1.
TDM measurement is currently (February 2024) available
Not increasing the dose as the kitten grown appears free of charge.
to be one of the most common causes for a poor
response to treatment, and treatment failure.
What to expect during treatment
In the first 2-5 days you should see an improvement
Therapeutic drug monitoring (TDM) of oral
in demeanour, appetite, resolution of pyrexia, and
GS-441524 during treatment
reduction in abdominal or pleural fluid (if present).
TDM is available currently at Edinburgh University. Cats
NB. More clinical signs attributable to FIP may be
are sampled after 3-5 doses of starting the oral
seen during the initial few days of treatment, i.e.,
GS-441524; ideally, 2-3 ml serum and 0.5 ml EDTA
before the medication has had time to take effect.
should be taken at peak (2-3 hours post-dose) or
This can include the development or recurrence of
trough (9-12 hours post-dose) times after GS-441524
pleural fluid which may require drainage (if the cat is
is given. This can be combined with alpha-1 acid
at home, advise the owner to measure resting
glycoprotein (AGP) measurement. 1.5 ml serum is the
respiratory rate and effort). Neurological or uveitis
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signs may also develop (e.g., owners may notice a Prognosis
change in iris colour). If neurological or ocular changes Response rates are around 85%, with cats that
respond rapidly (e.g., returning to completely normal
are noted, the drug dosage should be reviewed in case
within 30 days) having a better overall response.
an increase is indicated. Some cats fail to respond to antiviral treatment, often
Effusions usually resolve by 2 weeks. If an effusion deteriorating in the first 2 weeks; some cats may be
too sick for the antivirals to work (although consider
is still present at 2 weeks, consider increasing
intravenous remdesivir in sick cats that cannot be
dosage (by 2-3 mg/mg twice daily (every 12 hours) medicated otherwise). Relapse is uncommon (<10%)
if possible) e.g., increasing the dosage to above but tends to occur in the first few weeks after stopping
treatment. Using TDM to inform dosing, and/or higher
that used for cats with effusions only.
dosages, may result in higher response rates. Survival
Serum albumin increases and globulin decreases times are long (although we are all still learning about
(i.e., they normalise) may take several weeks, but this) with late relapses (or reinfections) rarely reported.
Since the drugs have only been available since late
note that globulins can initially increase when a 2021, we don’t yet know if cats that appear to be
large volume effusion is absorbed. In some cases, cured stay that way lifelong, although results so far are
globulins may remain mildly increased even at the very encouraging.
end of the treatment course and this has not been Note on using antiviral treatment trials as an
associated with relapse if all other parameters have aid to diagnosis
normalised. In some situations, it is not possible to achieve a
Lymphopenia and anaemia may take longer to definitive diagnosis of FIP due to cost constraints,
resolve, up to 10 weeks, and a lymphocytosis (and availability of testing, or instability of the patient
eosinophilia) can occur during successful precluding invasive testing. Antiviral treatment trials can
treatment. be considered using an appropriate dosage and
Enlarged lymph nodes typically reduce in size over objective measures to identify improvement e.g., serial
a few weeks but in some cases, they do not return neurological or ocular examinations. Improvements in
to normal size nor normal ultrasonographic demeanour and return of normothermia are expected
echogenicity, even by the end of treatment. within 48 hours, and add weight to the diagnosis. Note
However, this does not seem to signify FIP relapse, that effusions can take longer to resolve (see ‘What to
if all other parameters have returned to normal; expect during treatment’) and improvements in
treatment can be stopped as planned and the haematology and biochemistry abnormalities can also
patient monitored. take weeks. Failure to improve on an adequate dosage
If progress is not as expected, consider reviewing of antivirals (preferably with TDM if available) should
the diagnosis (see below) and/or increasing the prompt investigation for an alternative diagnosis. Most
dosage. cats are notably better by 2-5 days, however, a small
number of cats can take up to 10 days; however, there
have usually been some positive signs before then.
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Monitoring during treatment After 12 weeks the cat should be examined before
Clinical response is most important to monitor; a failure stopping treatment and all assessments should
to improve may necessitate an increase in dosage. ideally be normal. Mild persistent
Monitoring should be adequate to assess response hyperglobulinaemia and mild abdominal
but, particularly when the cat is doing well, repetition of lymphadenomegaly are sometimes reported and
costly tests that are unlikely to alter treatment (e.g., not associated with relapse. If all other parameters
limiting testing to previously abnormal parameters and are normal (including AGP) then treatment can still
basic screen) and multiple, potentially stressful, clinic be stopped.
visits should be limited. Owners should be encouraged Point-of-care ultrasonography (POCUS) to monitor for
to weigh their cat at home (e.g., using inexpensive baby effusion resolution and/or lymph node size is useful if
scales) and keep a diary of appetite and demeanour, available and affordable.
respiratory rate and other parameters as indicated. The
recommendations below will change depending on the Monitoring after treatment
cat’s response to treatment: Once treatment is completed (usually 12 weeks’
After 48 hours an improvement in demeanour and duration), cats should be monitored for relapse by their
normothermia is expected. A verbal report of owners; loss of appetite, weight changes, or other
progress and ease of medicating the cat should be clinical signs. The clinical signs of relapse may differ
obtained around this time. from those at initial diagnosis (e.g., neurological signs in
After 2 weeks weight, demeanour, effusions (in- cats that previously had effusions). Ideally, the cat is
house scanning, abdominal girth measurement) examined ~4 weeks after stopping treatment.
should be reviewed. Additionally, serum Monitoring AGP may provide reassurance if it remains
biochemistry and haematology can be assessed, normal. Any clinical signs should be promptly
adapting to cost constraints as needed (e.g., investigated.
consider whether measurement of total protein,
PCV, and plasma colour assessment, using a spun Supportive care for FIP cats
microhaematocrit tube, could be used as a cost- Cats with FIP may benefit from various types of
effective and rapid initial screen to indicate whether supportive care. No specific supplements have been
additional testing is indicated). Normalisation of studied alongside antivirals, and multiple oral
serum AGP (if elevated before treatment) may be medications may not be optimal due to compliance (as
useful to predict remission; well as additional costs). However, sick and dehydrated
After 6 weeks the cat should be re-examined and cats may require intravenous fluid therapy. The
the above assessments repeated. following interventions can be considered depending on
the case:
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Affected cats may be painful e.g., from pleural and effects and immunosuppression. However, cats with
peritoneal inflammation, distension from masses, uveitis may need topical corticosteroids and cats with
uveitis, and neurological lesions. Treatment with severe neurological signs occasionally require short-
opioids, such as buprenorphine, may be of benefit term systemic corticosteroids (1-5 days) to reduce
and other drugs such as NSAIDs (if hydration status inflammation. Rarely, cats with FIP develop immune-
and renal parameters are normal and the cat is mediated haemolytic anaemia (IMHA) and these often
eating) as part of multimodal analgesia; require systemic corticosteroid treatment for more than
Repeat drainage of pleural effusions may be a few days to help resolve the anaemia alongside the
required during the initial treatment period. antiviral treatment. If an anti-inflammatory agent is
Abdominal effusions are not normally drained, required in cats undergoing FIP treatment, consider
unless they are causing respiratory compromise using an NSAID (if hydration status and renal
due to pressure; parameters are normal and the cat is eating).
Cats with FIP have often lost weight and body
condition so nutrition is a priority. Appetite In the event of a poor response during
stimulants such as mirtazapine (and/or treatment or relapse
capromorelin oral solution) may be useful and some e.g., recurrence or lack of resolution of effusion,
sick cats benefit from feeding tube placement pyrexia, development of new ocular or neurological
short-term, which can facilitate medicating; since signs, or persistent clinical pathology abnormalities:
nasal tubes are poorly tolerated by cats and may Ensure that you are still confident that the cat has
cause depression, cats with profound anorexia that FIP; review the diagnosis, look for additional
cannot be alleviated by the drugs above may pathology, and consider repeat sampling (e.g.,
benefit from an oesophagostomy (O-)tube being external laboratory analysis and culture of any fluid;
placed; cytology or biopsy of lymph nodes ± feline
Drugs such as maropitant may benefit cats feeling coronavirus antigen or RNA detection, but bear-in-
nauseous and encourage eating; mind that finding the virus is more difficult when on
Occasionally, FIP can cause severe (sometimes treatment), AGP;
haemolytic) anaemia and blood transfusion can be Consider TDM if available to check serum
considered alongside antivirals; GS-441524 levels to inform dosing;
Hepatoprotectants e.g., S-adenosyl methionine If relapse occurs during treatment; increase the
(SAME), with or without silybin are not usually dosage of GS-441524 (or remdesivir) by 2-3 mg/kg
required, even in cats with ALT enzyme activity per dose and monitor as above, ensuring treatment
increases; is not stopped before the cat has been normal
Generally, corticosteroids are contraindicated in the clinically and on clinical pathology for at least 2
treatment of FIP with antivirals to avoid adverse weeks. The increased dosage used will depend on
the dosage the cat is on at the time of the relapse,
the nature of the relapse and finances, but can be
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up to that recommended for neurological FIP (see EIDD-1931
dosage table above) or even higher (please seek This drug is another antiviral effective for the treatment
guidance when considering this); of FIP in cats, although knowledge of its usage is much
If relapse occurs after completion of treatment; less than for GS-441524. The recommended dosage is
restart GS-441524 (or remdesivir) course at a 15 mg/kg every 12 hours, and it is available in 60 mg
higher dosage (minimum 2-3 mg/kg per dose tablets for oral use. Potential adverse effects include
higher than used previously) and ideally treat for cytopenia, especially neutropenia, rarely pancytopenia,
another 12 weeks. The increased dosage used reduced appetite/nausea, increased ALT enzyme
will depend on the dosage the cat was on before activity and, potentially, renal compromise. Use of
its relapse and the nature of the relapse, but can EIDD-1931 should be reserved for:
be up to that recommended for neurological FIP Cats failing to respond to treatment with GS-
(see dosage table above); 441524 or remdesivir despite adequate dosage
If the cat is already receiving a high dosage of (ideally assessed with TDM);
GS-441524 and/or TDM serum levels are Cats relapsing after treatment with GS-441524 or
adequate, consider switching to EIDD-1931 (see remdesivir at adequate dosages.
below) and seeking guidance (FIP advice email or
specialists), as adjunct treatments such as
mefloquine, feline interferon or polyprenyl
immunostimulant may be options (see below).
Neutering, parasiticide treatment, and vaccination during or after treatment for FIP
Neutering is ideally performed from a month after treatment is completed if the cat has responded well.
However, if leaving the cat unneutered is causing stress e.g., attempts to escape or distress when queens
are on heat, neutering during therapy may be preferred, ideally when the cat is doing well on treatment with at
least another 4 weeks of treatment remaining. Some measure AGP to confirm it is normal before neutering;
There is no contraindication to routine worming and flea treatment for cats on GS-441524 or remdesivir;
No information is available on response to vaccination of cats receiving treatment for FIP although analysis of
treated cases suggests that cats can be safely vaccinated after or during successful treatment without
causing relapse. Vaccines should be administered as is normally recommended for the cat depending on its
environment and risk (see WSAVA or ABCD Vaccination Guidelines). If urgent vaccination is required whilst
the cat is being treated, due to the risk of infectious disease, vaccines can be given if the cat is well;
If veterinary visits and procedures are necessary, clinic stays should be minimised, and Cat Friendly Clinic
protocols and handling implemented to reduce stress to the cat.
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Treatment with feline interferon (IFN),
polyprenyl immunostimulant, or mefloquine
Combinations of IFN omega, polyprenyl
immunostimulant, and mefloquine have been used
in the period following the end of treatment with
GS-441524 (or remdesivir) in some cats; however,
currently there is no evidence to suggest they are
needed as high response rates of over 85% have
been seen without these adjunct treatments;
Mefloquine has also been used to treat cats with
FIP when cost constraints absolutely prohibit the
use of a full course of, or increased dosage of,
more effective antivirals such as GS-441524.
Studies are needed to evaluate its effectiveness but
it should only be used when absolutely no
alternatives are available as GS-441524 is known to
be very effective.
Further reading
Tasker S, Addie DD, Egberink H, Hofmann-Lehmann R, Hosie MJ, Truyen U, Belák S, Boucraut-Baralon C,
Frymus T, Lloret A, Marsilio F, Pennisi MG, Thiry E, Möstl K, Hartmann K (2023): Feline Infectious Peritonitis:
European Advisory Board on Cat Diseases Guidelines. Viruses 15 (9) 1847.
Taylor SS, Coggins S, Barker EN, Gunn-Moore D, Jeevaratnam K, Norris JM, Hughes D, Stacey E, MacFarlane L,
O'Brien C, Korman R, McLauchlan G, Salord Torres X, Taylor A, Bongers J, Espada Castro L, Foreman M,
McMurrough J, Thomas B, Royaux E, Calvo Saiz I, Bertoldi G, Harlos C, Work M, Prior C, Sorrell S, Malik R,
Tasker S (2023): Retrospective study and outcome of 307 cats with feline infectious peritonitis treated with legally
sourced veterinary compounded preparations of remdesivir and GS-441524 (2020-2022). Journal of Feline
Medicine and Surgery 25 (9) 1098612X231194460.
Thayer V, Gogolski S, Felten S, Hartmann K, Kennedy M, Olah GA (2022): 2022 AAFP/EveryCat Feline Infectious
Peritonitis Diagnosis Guidelines. Journal of Feline Medicine and Surgery 24 (9) 905-933.
Updated February 2024
Thank you to Richard Malik, Alex Kennedy & Sally Coggins for their advice and assistance in producing this
document.
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