Criteria for choosing among FIV therapies

Checklist: Choosing Among Therapeutic Agents

Click here to open a Glossary of Terms in a separate window.

You have done some reading and made the decision to do something for your FIV+ cat beyond dietary measures and veterinary checkups. What you've discovered, though, is that there are many options for treatment with some promising research behind them, but (1) you obviously can’t give all or even most of them, (2) some might even work at cross-purposes to others, (3) there is no way to be sure which things might work better than which others, and (4) almost everything has some possible downside, large or small, that must be weighed against possible benefits. Here is a ten-point checklist of suggestions to help in winnowing through possibilities. It simplifies admittedly complex and uncertain issues and does not take in all relevant criteria, but should provide an adequate basis for making choices. Choices scoring high by some criteria will score lower by others. That’s somewhat frustrating, but if choices were simple or self-evident, retroviral therapy wouldn’t be the uncertain science that it is. There are no “perfect” therapeutic agents, but some come closer than others and some are more potentially beneficial in some situations than in others. As an addition to research cited or reflected in Bud’s FIV Therapy, a list of pertinent on-line resources (broad, not specific, in focus) to assist in decision-making follows the checklist.

Printing the checklist might be helpful. Keeping written lists and revising them– re-ranking preferences up or down– might also be helpful. Tentative choices may require some research or inquiry beyond whatever commended the treatment to you, but it won’t be time wasted. A reasonable goal would be a final ranking of choices that would allow you to “start small” with one or a few agents in order to discover what you find doable, with an option to expand down the list once you and your cat have acclimated to the treatment process.

1. Because informed guesses are better than uninformed guesses . . . Estimate your cat's current state of FIV-related health and immune competence. Assume that the following are relevant even if you can’t be sure that they are FIV-related: the presence or absence of

■ secondary diseases with a known correlation to FIV: inflammatory problems such as gingivostomatitis and chronic large or small bowel disorders; recurrent or unclearable infections particularly of the upper respiratory tract, eyes, or urinary tract; chronic organ diseases unusual for age bracket, such as diabetes, kidney impairment, pancreatitis, heart disease; ongoing allergic or autoimmune skin disorders.

■ weight loss, ongoing depressive behavior such as inactivity or declining appetite.

■ unusual red or white cell counts and differentials not clearly connected to known diseases or conditions.

■ unexplained fevers or lymphatic swellings.

If your cat’s known history suggests the possibility that it was born with FIV, assume it is less immune competent than you had hoped. If it has probably been infected with FIV for eight years or longer, assume that there has been a decline in immune competence.

2. Because FIV is a chronic inflammatory disease that advances through hyper-immune activity . . . If your estimate is favorable, prefer supplements and pharmaceuticals that are anti-inflammatory in nature and/or tend to quiet chronic immune activation instead of encouraging it. These include pharmaceuticals and supplements that are fat-based (e.g., evening primrose oil, fish oils, phytosterols such as Moducare), are flavonoids (e.g., curcumin, quercetin), have steroidal qualities (e.g., low-dose steroid prednisolone, l-carnitine, licorice) or are said to inhibit T cell self-destruction (or “apoptosis”) (e.g., melatonin, lactoferrin, NAC, Vit C & E).

Co-administration of pharmaceutical (e.g., Immunoregulin, S[taph]P[rotein]A, L[ymphocyte]TC[ell]I[mmunomodulator]) and herbal (e.g., cat’s claw, echinacea, astragalus) immune stimulants might contradict this approach, although there are anecdotal accounts of younger cats without a long history of infection who are alleged to have “cleared” the virus after prolonged administation of stimulative agents.

3. Because inflammatory hyper-immune activity can wear down immune competence. . . An unfavorable estimate may improve the case for some kinds of immune stimulus

■ Prefer agents which have some evidence of specific or narrowly targeted favorable action on immune deficits known to be associated with retroviral infection to those known only as “immune boosters.” (E.g., prefer astragalus to echinacea, LTCI to Immunoregulin).

■ Look more favorably than in the item 2 situation to agents that add T cells by enhancing their production (e.g., mushroom-based supplements, DMG).

Some HIV research at least suggests that short-term stimulus of seemingly beneficial immune substances may compromise long-term prospects. If you have already been using the anti-inflammatory approach and have seen deterioration and poorer quality of life, the case for some kinds of stimulus may be improved. Injectable stimulants usually have more potency than oral and are indicated only for situations where problems are very significant, but some may also carry more risks if used for extended periods.

4. Because FIV is a viral infection of T cells, regardless of its effects at any given time . . . If you remain uncertain in your estimate, combine judiciously chosen anti-inflammatory agents with those that are neither notably stimulative nor suppressive in effect. Preferably agents that are said to enhance cell-mediated/ T cell immunity to those that are said to favor antibody-mediated/ B cell immunity. Agents in this category will usually complement both item 2 and item 3 approaches.

■ Antioxidants (e.g., Vit C, Vit, B12, Vit E, CoQ 10, Alpha Lipoic Acid) Take note of combinations that reinforce one another (e.g., Vit E regenerates Vit C; CoQ10 regenerates Vit E; B12 & folic acid enhance methylating activity of DMG, selenium reinforces Vit E in regeneration of glutathione).

■ Antivirals–pharmaceutical (e.g., injectable interferons, antiretroviral drugs), botanical (e.g., olive leaf, green tea) or nonbotanical (e.g., niacinamide, zinc). Pharmaceutical antivirals are generally more potent than antiviral supplements, are indicated only for situations where problems are very significant, but are more likely to lose some efficacy and/or have side effects with long-term use.

If using agents that favor antibody activity (or the Helper T cell subset that codes for antibody activity, called TH2) (e.g., green tea), try to “balance” with agents favorable to cell-mediated immune activity (or the subset called TH1 that codes for cell-mediated immunity) (e.g., grape seed).

5. Because you should try to “First, do no harm” . . . Give a higher priority to agents with a verifiable record of safety in cats, particularly at dosages beyond trace level, than to those you are unsure of, according to:

■ the longer the time you envision the product being given

■ the more favorable your estimate of the cat’s fiv-related health and immune competence

■ the higher the dosage you envision giving

If a supplement is marketed specifically for pets in pet-sized dosages;(e.g., olive leaf extract, Co Q-10); is milk-, food-, or organ-derived (e.g., colostrum, lactoferrin, ovotransferrin, durolactin, transfer factors, thymus peptides); or is a water-soluble vitamin (e.g., Vit C, any B vitamin), safety can generally be assumed

6. Because not all advice is good advice . . . Prefer agents with demonstrated bona fides as retroviral therapies, favoring:

■ those successful in tests on FIV (e.g., phytosterols/Moducare, Vitamin C & E, NAC, lactoferrin) to those successful in tests on HIV but not tested on FIV (e.g., St. Johnswort, green tea, olive leaf, forsythia). They are similar but different viruses and diseases.

■ those known to be favorable to treatment of HIV (e.g., L-glutamine, olive leaf) to those not shown specifically to be favorable to either FIV or HIV (e.g., L-lysine, echinacea)

■ those which have established usefulness in vivo (the living being) rather than in vitro (the test tube or petrie dish). The first (e.g., some B vitamins, DMG, lactoferrin, curcumin) are much less common than the second (e.g., goldenseal, rosemary extract, grape seed extract), especially where FIV is concerned. In vitro research does not guarantee that the product is readily absorbed, that it will survive metabolic processes with favorable action intact, or that sufficiently high serum levels can be reached at safe or practical dosage levels.

7. Because so much is uncertain about what is best over the long term for retroviral infections . . . Pay attention to known or possible downsides, preferring:

■ things with no known or suspected downsides or only minor ones to those with a known or suspected downside (e.g., olive leaf has no significant downsides, L-carnitine has one possible downside, St. Johnswort has a known downside, i.e., photophobia)

■ things with a possible downside to those with a known downside (e.g., Vitamin A has a possible downside; L-arginine has a known downside, i.e., for cats with suppressed herpes)

■ things with fewer known or possible downsides to those with more (e.g., L-carnitine has one suspected downside, NAC has several suspected downsides)

■ things with upsides that may offset downsides (e.g. lactoferrin is somewhat lymphosuppressive; cat’s claw is somewhat lymphoproliferative; but both lengthen cell-cycle survival of lymphocytes.)

Term-limited or cyclic administration is one way to hedge downsides over the long term.

8. Because it’s so easy to blunder with the best of intentions . . . Check out possible contraindications and interactions related to:

■ preexisting conditions such as reduced renal (e.g., Vit C) and hepatic (e.g., amino acids) clearance, hypertension (e.g., licorice)

■ feline-specific toxicities (e.g., salicylate- or caffeine-containing substances) or dosage-mediated toxicities (e.g., alpha lipoic acid, selenium, zinc)

■ prescription medications (e.g., mineral supplements such as zinc may inhibit some antibiotics); synergies, however, are a plus (e.g., niacinamide improves immune modulating action of doxycycline)

■ multiplier effects (e.g., green tea and licorice have similar impact on potassium levels); synergies, however, are a plus (e.g., curcumin and quercetin)

9. Because a twofer is better than a onefer . . . Prefer agents that favorably impact FIV (or HIV) and disease(s) secondary to FIV that your cat may have. (E.g., prefer lactoferrin to grape seed extract if your cat has oral disease, curcumin to oral interferon if your cat has GI disease, olive leaf to evening primrose oil if your cat has recurring respiratory infection, feline interferon to LTCI if your cat has chronic herpes or calici)

10. Because chronic infections sap the body’s resources . . . Give extra consideration to substances important to normal immune function and found to be in short supply in HIV- or FIV- infected individuals (e.g., most vitamins, selenium, tryptophan, Co Q-10, glutathione, zinc, L-carnitine) or in individuals with secondary diseases commonly associated with retroviral disease (e.g., lactoferrin, lysozyme with stomatitis, B12, folic acid with small bowel inflammation).

___________________________________________________________________________

Some Pertinent On-Line Resources

Antimicrobial Therapy in Veterinary Medicine. S Giguere et al. 4th Ed. 2007.

http://books.google.com/books?id=lxmyfSave4IC

Antiviral Therapy for Human Immunodeficiency Virus Infections. Erik De Clercq. 1995.

http://cmr.asm.org/cgi/reprint/8/2/200

Antiviral therapy in cats: current rationale and recommendations. Sarah Caney. 2005.

http://inpractice.bvapublications.com/cgi/content/abstract/27/9/454

[For full-text, see FIV-HealthScience files or will forward on request.]

CATIE [Canadian AIDS Treatment Information Exchange]: Supplement Sheets.

http://www.catie.ca/supple-e.nsf

Compendium of Pharmacological Actions of Medicinal Plants and Their Constituents. Eric Yarnell. 2004.