Effects of a Single Oral Dose of Imepitoin on Veterinary Visit-Related Stress in Cats: An Open-Label Pilot Study
Round 1
Reviewer 1 Report
Comments and Suggestions for AuthorsFor a cat, a visit to the veterinary clinic is a highly stressful experience that can have a range of consequences, including aggression. The introduction to this paper provides a general overview of the issue and its clinical significance. The topic is presented in an accessible manner, and the reader is provided with basic information to help them understand the subject.
Please specify the purpose of the research more clearly and indicate whether there is a gap in the research.
The information regarding potential confounding factors is insufficient; in particular, it is not specified whether the cats under study had previously been examined by the same veterinarian or whether this was their first visit, which could significantly affect the animals’ stress levels as well as the behavioral and physiological parameters being assessed. The description of the experimental procedures is incomplete—although the type of treatment (e.g., administration of tablets) is indicated, there are no details regarding the method of administration, i.e., how the tablets were administered (by hand or using a tablet dispenser).
The Results section is clear and logically organized but requires further clarification and a more cautious interpretation in light of the study’s methodological limitations. The description of the results should be supplemented with a clear reference to the limitations arising from the open-label design and an emphasis on the potential impact of observer bias on subjective assessments. The results should also be related to possible confounding factors, including an indication of whether the cats’ prior experiences (e.g., a first visit to the veterinarian) may have influenced the outcomes. In addition, the statistical results should be supplemented with effect sizes and confidence intervals.
The Discussion section refers to the obtained results but requires revisions. It is also necessary to expand the discussion to include potential sources of bias, including confounding factors such as the animals’ prior experiences (e.g., a first visit to the veterinarian), which may have influenced the behavioral and physiological outcomes. Furthermore, a more critical comparison of the obtained results with the literature is recommended, as the current comparisons are mainly descriptive in nature. The interpretation of the results should also be more clearly separated from their description, and the clinical significance of the obtained effects should be clarified, taking into account the methodological limitations of the study.
The references are appropriate
Author Response
First of all, we appreciate the time and effort you dedicated to providing feedback on our manuscript and are grateful for your insightful and constructive comments, which we believe have significantly improved our work.
Comment1:Please specify the purpose of the research more clearly and indicate whether there is a gap in the research.
Response1: A section has been added to the Introduction to clearly state the aim of the study and the specific gap it addresses in the literature (page 2, lines 79–87).
Comment 2:The information regarding potential confounding factors is insufficient; in particular, it is not specified whether the cats under study had previously been examined by the same veterinarian or whether this was their first visit, which could significantly affect the animals’ stress levels as well as the behavioral and physiological parameters being assessed. The description of the experimental procedures is incomplete—although the type of treatment (e.g., administration of tablets) is indicated, there are no details regarding the method of administration, i.e., how the tablets were administered (by hand or using a tablet dispenser).
Response 2: Information regarding potential confounding factors has been incorporated into both the Methods and Discussion sections. These additions have substantially strengthened the manuscript. In particular, the Methods section now clarifies that the cats included in the study had not been previously examined by the same veterinarian (page 3, lines 111–112). Furthermore, additional details on the randomization procedure, the method of tablet administration, and the rationale underlying dose selection have been included in the Methods section (page 3, lines 114–124).
Comment 3: The Results section is clear and logically organized but requires further clarification and a more cautious interpretation in light of the study’s methodological limitations. The description of the results should be supplemented with a clear reference to the limitations arising from the open-label design and an emphasis on the potential impact of observer bias on subjective assessments. The results should also be related to possible confounding factors, including an indication of whether the cats’ prior experiences (e.g., a first visit to the veterinarian) may have influenced the outcomes. In addition, the statistical results should be supplemented with effect sizes and confidence intervals.
Response 3: A statement highlighting key methodological limitations has been incorporated into the Results section, particularly within the subsection reporting behavioural outcomes (page 8, lines 264–265), to improve the interpretability of the results. In addition, the potential impact of confounding factors and study limitations on the findings has been discussed in greater depth in the Discussion section (page 9, lines 285–309 and 323–328). We have also added effect sizes and confidence intervals for each result in the text, highlighted in yellow.
Comment 4:The Discussion section refers to the obtained results but requires revisions. It is also necessary to expand the discussion to include potential sources of bias, including confounding factors such as the animals’ prior experiences (e.g., a first visit to the veterinarian), which may have influenced the behavioral and physiological outcomes. Furthermore, a more critical comparison of the obtained results with the literature is recommended, as the current comparisons are mainly descriptive in nature. The interpretation of the results should also be more clearly separated from their description, and the clinical significance of the obtained effects should be clarified, taking into account the methodological limitations of the study.
Response 4: The Discussion section has been revised to adopt a more critical and analytical perspective, moving beyond a purely descriptive approach. Specifically, we have elaborated on possible explanations for the observed findings and addressed the potential influence of confounding variables (page 9, lines 285–309). Moreover, a dedicated section comparing imepitoin with existing therapeutic options has been added (lines 398–435). We have also discussed the effects of imepitoin in other species, such as dogs (page 10, lines 365–368).
In addition to the scientific revisions, we have undertaken thorough English language editing to improve clarity and overall linguistic quality. All revisions have been highlighted in yellow for ease of reference. We believe that these modifications have resulted in a clearer presentation of the study’s limitations, a more cautious and balanced interpretation of the findings, and a more precise positioning of the work within the existing literature. The comparative evaluation of imepitoin in relation to other treatment options has also been further clarified. Overall, we are confident that these revisions have substantially enhanced the rigour and quality of the manuscript, particularly with respect to the Discussion section, and we sincerely thank the Reviewer for their valuable and constructive feedback.
Reviewer 2 Report
Comments and Suggestions for AuthorsThe present study provides a comprehensive and critical evaluation of the efficacy of imepitoin, a compound originally developed for the treatment of epilepsy in humans and characterized by anxiolytic properties without inducing significant sedation, major adverse effects, or clinically relevant elevations in hepatic enzyme activity.
As you presented, imepitoin was generally well tolerated in cats, with no serious adverse events observed under the experimental conditions such as hypersalivation and transient difficulties in food intake.
Your pilot investigation provides evidence that a single oral administration of imepitoin at a dose of 30 mg/kg, administered 90 minutes prior to evaluation, may reduce stress responses in cats during veterinary examination and diagnostic procedures, thereby suggesting its potential utility in feline stress management. Moreover, its application may be further extended to the mitigation and prevention of stress-related behavioral disorders, including stereotypies and aggression in cats or others and maybe different ages of cats, not only in adults.
Author Response
First, we would like to sincerely thank the Reviewer for their constructive comments and valuable suggestions for future research. We agree that further studies investigating the potential of imepitoin for the treatment of stress-related medical and behavioral disorders would be of considerable interest.
Reviewer 3 Report
Comments and Suggestions for AuthorsThe manuscript addresses a clinically relevant and underexplored topic, namely the management of veterinary visit-related stress in cats, and presents interesting preliminary findings regarding the potential role of imepitoin.
The study is generally well structured, and the results are clearly presented. The inclusion of both physiological and behavioural parameters is a strength, providing a multidimensional assessment of stress. However, several points should be addressed to improve the clarity, methodological transparency, and scientific rigor of the manuscript.
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Study design and bias
The open-label design represents a major limitation, particularly for behavioural outcomes such as CSS and CERS, which are inherently subjective. Although the authors appropriately acknowledge this limitation, its potential impact on the results should be more critically discussed. In particular, the lack of blinding and the fact that a single investigator performed both treatment administration and outcome assessment should be explicitly emphasized as a potential source of bias.
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Baseline imbalance
Heart rate was significantly higher in the imepitoin group at baseline. While the authors addressed this statistically, the clinical implications of this imbalance should be discussed more thoroughly, as it may influence the interpretation of treatment effects.
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Sample size and pilot nature
The relatively small sample size (n=32) limits the generalizability of the findings. The manuscript would benefit from a clearer positioning as a pilot or exploratory study throughout, particularly in the Abstract and Discussion.
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Methods – clarity and reproducibility
Some methodological details require further clarification. For example:
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More detail on randomization procedures
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Clarification on handling of missing cortisol data (placebo group n=14)
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Justification for the selected imepitoin dose and timing
These additions would improve reproducibility.
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Interpretation of physiological parameters
Changes in RR and RT were observed irrespective of treatment. The possibility of habituation or environmental adaptation should be more explicitly integrated into the interpretation.
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Clinical applicability
The manuscript appropriately concludes that findings are preliminary. However, the Discussion could further emphasize that the current evidence is not yet sufficient to support clinical recommendation, especially given the study design limitations.
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Language
Minor language editing is recommended to improve clarity and readability.
Overall, this is a valuable pilot study that provides preliminary evidence supporting further investigation. The manuscript is suitable for publication after minor revision.
Author Response
First of all, we appreciate the time and effort you dedicated to providing feedback on our manuscript and are grateful for your insightful and constructive comments, which we believe have significantly improved our work.
- Study design and bias
The open-label design represents a major limitation, particularly for behavioural outcomes such as CSS and CERS, which are inherently subjective. Although the authors appropriately acknowledge this limitation, its potential impact on the results should be more critically discussed. In particular, the lack of blinding and the fact that a single investigator performed both treatment administration and outcome assessment should be explicitly emphasized as a potential source of bias.
Response1: We thank the reviewer for pointing out this issue and for the very constructive suggestions. We have revised the Discussion section to provide a more critical appraisal of the potential effects of the open-label and single-investigator design, particularly on behavioral outcomes (page 11, lines 371–380). We have also expanded the discussion to address other possible confounding factors (page 9, lines 285–309).
- Baseline imbalance
Heart rate was significantly higher in the imepitoin group at baseline. While the authors addressed this statistically, the clinical implications of this imbalance should be discussed more thoroughly, as it may influence the interpretation of treatment effects.
Response 2: We have improved the Discussion section regarding baseline measurements, particularly by addressing the potential for regression to the mean and its impact on the results (page 10, lines 323–328).
- Sample size and pilot nature
The relatively small sample size (n=32) limits the generalizability of the findings. The manuscript would benefit from a clearer positioning as a pilot or exploratory study throughout, particularly in the Abstract and Discussion.
Response 3: We explicitly identified this study as a pilot study and, in light of your suggestion, revised the Abstract, Discussion, and Conclusion sections to better clarify the contribution of this manuscript to the scientific literature (page 1, lines 25–26, 31–33, and 42–45).
- Methods – clarity and reproducibility
Some methodological details require further clarification. For example:
- More detail on randomization procedures
- Clarification on handling of missing cortisol data (placebo group n=14)
- Justification for the selected imepitoin dose and timing
These additions would improve reproducibility.
Response 4: We thank the reviewer for highlighting these important methodological points. We have added more detailed methodological information regarding the study design (page 3, lines 111–112), the randomisation process (lines 114–117), the rationale behind dose selection and timing (lines 119–124), and the management of missing data (page 5, lines 188–190).
- Interpretation of physiological parameters
Changes in RR and RT were observed irrespective of treatment. The possibility of habituation or environmental adaptation should be more explicitly integrated into the interpretation.
Response5: We also discussed the potential habituation effects on RR and RT (page 10, lines 328–333), as well as other possible factors influencing these parameters (page 10, lines 346–352). We believe these additions have strengthened the Discussion regarding physiological parameters.
- Clinical applicability
The manuscript appropriately concludes that findings are preliminary. However, the Discussion could further emphasize that the current evidence is not yet sufficient to support clinical recommendation, especially given the study design limitations.
Response 6: We added a paragraph in the Discussion comparing current treatment options with imepitoin (lines 398–415). We also explicitly stated that the current evidence is insufficient to support clinical recommendations in the Abstract (page 2, lines 47–48), the Discussion (page 12, lines 432–433), and the Conclusion (page 12, lines 444–445).
- Language
Minor language editing is recommended to improve clarity and readability.
Response7: We performed a thorough English language edit to address grammatical issues and improve readability.
We have highlighted all changes in yellow in the manuscript. We believe that these modifications have resulted in a clearer presentation of the study’s methods and limitations, a more cautious and balanced interpretation of the findings, and a more precise positioning of the work within the existing literature.
Reviewer 4 Report
Comments and Suggestions for AuthorsThis is a clinically relevant pilot study addressing stress management in cats during veterinary visits. Despite the limitations of a real-world clinical setting, the study provides useful preliminary evidence on the potential role of imepitoin in reducing visit-related stress in cats.
1. The discussion would benefit from a more comprehensive integration of existing evidence on imepitoin in other species, which would allow a more meaningful comparison with the findings observed in cats.
2. As each measurement reflects an individual animal, the potential impact of individual variability should be further discussed. Factors such as body weight, age, underlying conditions, temperament, and owner-related influences may affect stress responses and should be considered to improve the clinical relevance of the study.
3. A clearer comparison with currently available treatments for feline anxiety (e.g., in terms of efficacy, safety, and clinical applicability) would help better position imepitoin within the existing therapeutic framework.
Author Response
First of all, we appreciate the time and effort you dedicated to providing feedback on our manuscript and are grateful for your insightful and constructive comments, which we believe have significantly improved our work.
- The discussion would benefit from a more comprehensive integration of existing evidence on imepitoin in other species, which would allow a more meaningful comparison with the findings observed in cats.
Response 1: Thank you for highlighting this point. We have expanded the discussion of the effects and available evidence regarding imepitoin in other species in the relevant sections. This includes its effect on cortisol response in dogs (page 10, lines 366–368) and its safety profile (page 11, lines 382–383).
As each measurement reflects an individual animal, the potential impact of individual variability should be further discussed. Factors such as body weight, age, underlying conditions, temperament, and owner-related influences may affect stress responses and should be considered to improve the clinical relevance of the study.
Response 2: We implemented the suggested revision in the first paragraph of the Discussion. This allowed us to more critically discuss the potential effects of confounding factors and to better highlight the multifactorial nature of feline stress (page 9, lines 285–309).
A clearer comparison with currently available treatments for feline anxiety (e.g., in terms of efficacy, safety, and clinical applicability) would help better position imepitoin within the existing therapeutic framework.
Response 3: We added a section in the Discussion comparing available pharmacological options for the same indication in cats and highlighted the need for studies that directly compare these treatments. We believe this section has meaningfully improved the quality of the manuscript (page 11, lines 398–415).
Round 2
Reviewer 1 Report
Comments and Suggestions for AuthorsThe work is significantly better following the revisions and can now be accepted as it stands.
