Cluster seizure treatment?

Re: Cluster seizure treatment?

Martin Atkinson — Mon, 06 Feb 2012 18:08:16 GMT

[quote user="Justine D"]

I will try the KBr to start with. And I will be moving out of the city in 2 months, so fingers crossed!

[/quote]

I would be in broad consensus with most of the other recommendations in this thread but don't underestimate environmental effects. I had a dog several years ago that had a seizure every Monday until a bank holiday then it had it on a Tuesday. What was different? The dustbin men normally came on a Monday and the dog got really wound up about them but after a bank holiday they came on the Tuesday. This case was controlled just by keeping the dog in the back of the house until the bin men had been and gone. So maybe moving out of the city may help.

Re: Cluster seizure treatment?

J Monz — Mon, 06 Feb 2012 15:35:57 GMT

[quote user="robloxley"]

[quote user="Bob Russell"]if the Pb levels are lower end of normal and the dog is not showing significant side effects what is wrong with just stepping up the PB dose?[/quote]

From my reading, the dose of Pb was doubled after the reported lowish blood level

[/quote]

Yes this is correct. Started on 50mg bid then upped to 75 (only stayed on this for short period) and then upped again to 100mg bid.

I took all of your advice on board and went in to speak with vet re next step.

He upped the dose to 150mg bid and starting on KBr (seemed slightly hesitant to do this?). He also gave me Gordius (not sure what the trade name for it is in Ireland or UK) but it is gabapentin. He was looking to see if was available in rectal form - and suggested giving it at onset of first seizure to prevent subsequent fits. But they are so close together this wouldn't work on time. Then suggested I give the maximum 4 x 10mg rectal diazepam with the first and this may potentially halt the last 2. Get bloods done in 1 months to get levels of KBr and PB.

For any endocrinologists out there, this is just a side note we noticed when studying for Internal Medicine. The link between oestrogen, testosterone and epilepsy. He is castrated but since I had him as a pup almost 90% of dogs in the park cannot get enough of him! Both male and female, entire and not, manically follow him around the park. He is like the pied piper of dogs. Any link? I am often asked "Is she in heat?". No no, he's not :D

Thanks!

Re: Cluster seizure treatment?

Mark Lowrie — Mon, 06 Feb 2012 14:09:42 GMT

[quote user="robloxley"]

[quote user="Bob Russell"]if the Pb levels are lower end of normal and the dog is not showing significant side effects what is wrong with just stepping up the PB dose?[/quote]

From my reading, the dose of Pb was doubled after the reported lowish blood level

[/quote]

That's right Rob! I would agree that checking PB is worthwhile to ensure it is within a therapeutic range and would definitely increase it if it is subtherapeutic. However Bob, I also agree that if you can get away with using one drug that is ABSOLUTELY the right thing to do.

Re: Cluster seizure treatment?

Rob Loxley — Mon, 06 Feb 2012 13:37:43 GMT

[quote user="Bob Russell"]if the Pb levels are lower end of normal and the dog is not showing significant side effects what is wrong with just stepping up the PB dose?[/quote]

From my reading, the dose of Pb was doubled after the reported lowish blood level

Re: Cluster seizure treatment?

Bob Russell — Mon, 06 Feb 2012 13:28:21 GMT

I am coming in a bit late to this and I am happy to bow down to the neurologists out there but if the Pb levels are lower end of normal and the dog is not showing significant side effects what is wrong with just stepping up the PB dose? We had a stubborn case (collie) with a very neurotic owner (as they are allowed to be) and all it took was a small increase in PB to calm things down. I had stepped the dose up a little fast and the dog behaved very oddly and panicked the owner!

Two drugs, two drugs to monitor. I try to keep it simple and give the medication time to work. Sometimes it takes time and patience to get these stabilised . An occasional seizure may be better than very heavy medication IMO!

Introduce KBr if things are really not settling! The only case I felt needed Keppra went to another practice for a second opinion and was euthanased , very frustrating!!

Re: Cluster seizure treatment?

Mark Lowrie — Mon, 06 Feb 2012 08:38:41 GMT

In that case I would probably not rush into using Keppra and just start KBr. Although it takes 3 months to reach steady state it should reduce the frequency of these small clusters quite quickly. Successful management is considered to be reducing the frequency and severity of seizures by at least 50%. With this in mind I would hope you can ensure the dog only has 2 seizures every 2 weeks (or 4 seizures every 4 weeks). Though there is a good chance of achieving even better control than this. It is never possible to predict how effective therapy will be as every dog has a different sensitivity to it. The reason for holding off on Keppra is (1) the cost and (2) over time dogs tend to develop a tolerance to it so I always like to keep it in my back pocket in case of problems with seizures in the future.

Re: Cluster seizure treatment?

J Monz — Sun, 05 Feb 2012 20:57:26 GMT

[quote user="Mark Lowrie"]

I suspect that PB will be within a good therapeutic range and I would be cautious with increasing above this as likely to cause adverse effects. Even if it doesn't, in the long-term it will, more than likely impact on the liver.

I wouldn't worry about metabolic problems during the seizures - it is unlikely to occur though you suggest these clusters are severe and going on for hours and hours. How many seizures are you seeing over what space of time? However, getting rid of clusters completely is unlikely. Getting rid of seizures completely is even less likely.

[/quote]

Oh sorry no, they don't go on for hours. They occur usually over a half and hour period. There are always 4 seizures. Each lasts roughly 1 minute (used to be 2- 3 minutes) and there is approximately 3-5 minutes in between each one. They are now occurring every 10 days exactly.

Re: Cluster seizure treatment?

Mark Lowrie — Sun, 05 Feb 2012 19:59:41 GMT

[quote user="Justine D"]

Fantastic Mark.

What would you consider to be a good management of clusters? Occurring how often, with what seizure length and an inter-ictal period of what?

Also side effects of these severe seizures are hypoglyc/calcemia, metabolic acidosis etc...is there any way I can counteract some of these during the period of clusters....he gets so little time to recover after each one, that he is just flat to the board, I was giving bowl of water with honey and small bit of milk. Only thing I could think of in my hour of need!

[/quote]

Re: Cluster seizure treatment?

Neil Wheadon — Sun, 05 Feb 2012 19:41:57 GMT

Vet Times have an archive and I'll often use this

There are a number of good articles on ideopathic epilepsy online, the latest is

http://www.vetsonline.com/Publication/pdf/vt/2011/VT41028028.pdf

This was part 2.

You have to register with your E mail address and a password, but the clinical resource is very good (Google Vet Times)

Hope your? dog settles

Neil

Re: Cluster seizure treatment?

J Monz — Sun, 05 Feb 2012 17:52:03 GMT

Fantastic Mark.

What would you consider to be a good management of clusters? Occurring how often, with what seizure length and an inter-ictal period of what?

Re: Cluster seizure treatment?

J Monz — Sun, 05 Feb 2012 17:46:04 GMT

Ok he is currently on 100mg bid - haven't tested the bloods since it was 50mg bid and 17ug.

Should I get the bloods checked, (and as long as below 45ug) continue to increase PB? All whist adding KBr and perhaps the pulse-method of Keppra?

Re: Cluster seizure treatment?

Michael Woodhouse — Sun, 05 Feb 2012 17:25:00 GMT

I feel a little out of my depth looking at some of the contributors qualifications, but with a PB level so low I would go to 100mg bid and add in KBR. Check the PB level after a couple of weeks to make sure we are not too high, but even if you had to back the PB dose off to somewhere in the middle the higher dose would give you some extra cover whilst KBR levels increase.

Re: Cluster seizure treatment?

Mark Lowrie — Sun, 05 Feb 2012 16:51:57 GMT

If the bloods were taken after a 12 hour fast and if PB levels were checked since these nasty clusters started I would add in KBr. But the fact it takes up to 3 months to work means Keppra is a good drug to add in waiting for KBr to reach steady state. You have 2 options here: 1) start Keppra at 20 mg/of q8h and stop it when KBr levels are good. This is likely to be quite expensive. Or... 2) give Keppra in pulse-dose manner. So give 20 mg/kg q8h after a seizure and discontinue when the dog has been seizure free for 48 hours. It can then be re-started at the next cluster. MRI probably unnecessary given long history and fact dog sounds normal inter-ictally. CSF is not really worthwhile ad a stand alone test in dogs with seizures. Hope this helps, but I would second a move to the country, they're much nicer than cities anyway.

Re: Cluster seizure treatment?

J Monz — Sun, 05 Feb 2012 16:48:28 GMT

Hi Andy,

So if he is on phenobarb, and I was adding KBr - you are suggesting to add Kepra aswell to compensate for the time it takes to get the right levels?

Justine

Re: Cluster seizure treatment?

J Monz — Sun, 05 Feb 2012 16:44:42 GMT

Thanks guys, that is a step forward in the right direction.

Yes his bloods were taken and all parameters were normal, and the CSF was done merely for my piece of mind.

I will try the KBr to start with. And I will be moving out of the city in 2 months, so fingers crossed!

Thanks!

Justine

Re: Cluster seizure treatment?

Lorna McHardy — Sun, 05 Feb 2012 15:32:35 GMT

Well, I certainly wouldn't bother with homeopathy for a start! And if your bloods were normal, I wouldn't worry about an insulinoma, either.

If I've got a presumptive diagnosis of idiopathic epilepsy (and in a dog of that age with no other symptoms and normal bloods - I don't even usually run a CSF in these circumstances and don't think an MRI would be indicated either), I'll usually use a combination of phenobarb and KBr initially, and this does achieve control in the majority of cases. The two drugs complement each other in their mode of action so you're more likely to get results from a combination than from one alone. So the first thing I'd do is add KBr.

However, cluster seizures are not a good sign; and unfortunately, there is a reasonable proportion of epileptic dogs (20-30%) that do not respond to this treatment. The available alternatives aren't that promising at present, as I understand it - not enough data, and what there is, doubtful. Levetiracetam looks good in theory; Holger Volk quotes a dose range of 10-20mg/kg q8h in dogs and cats, a half life of 3-4 hours in the dog, and few side effects.

Regarding the therapeutic range of phenobarbitone, that's a bit of an arbitrary one anyway... 17ug/ml is low, but still within quoted values, for instance. It's an indication rather than a certain thing, and whilst I would run those tests just to get an idea of what levels are needed in that particular individual, my main indicator of therapeutic levels is cessation of seizures.

Finally, if it is true that he has fewer, or even no seizures when not in the city, and if this happens consistently, one obvious though possibly unpalatable solution might be to re-home him out of the city. The triggers for seizures are many, and occasionally weird!

Re: Cluster seizure treatment?

Andrew Kent — Sun, 05 Feb 2012 14:56:07 GMT

One other thought - you don't mention any blood test results - metabolic causes of seizures, for example liver disease do occur so I suggest a CBC, biochem and bile acid stimulation if they haven't been done.

Re: Cluster seizure treatment?

Andrew Kent — Sun, 05 Feb 2012 14:54:26 GMT

Hi Justine, MRI can be useful in these cases to exclude structural causes of seizures but finances mean they are not always possible. In terms of management in dogs who are poorly controlled on phenobarbitone alone (but with adequate blood levels) then the addition of KBr would be an appropriate choice. This dates a few months to reach steady state so you can either load rapidly (but you will get side effects) or use an additional medication during this period. Levetiracetam (keppra) would be my first choice for this but it is an expensive medication to use especially if needed long term. I would check pheno blood levels and increase if sub-therapeutic, then add KBr +/- short term Keppra if levels ok. Hope that helps, Andy