Decision making in Status epilepticus

Re: Decision making in Status epilepticus

Anthony Todd — Thu, 22 May 2014 10:19:58 GMT

[quote user="Mark Hedberg"]Think about it this way - if PB causes mild sedation or slow learning, it's still probably better than multiple cluster seizures. [/quote]

+1, after all the "dose rate" doesn't allow for individual variation and there is a tolerance that builds up anyway.

Just look at the variation with alcohol.

Anything's got to be better than a fit.

Trouble is, these days, the practice is to compare the dose with "the dose rate" via measurement of the dose not the response to the dose.

Re: Decision making in Status epilepticus

Arlo Guthrie — Thu, 22 May 2014 09:50:48 GMT

[quote user="Francisco Gomez"]Fantastic, I really hope you get there![/quote]

[quote user="Mark Hedberg"]Fingers crossed here too.[/quote]

Thank you both, very much.

Very disappointingly, she had another seizure at school yesterday. But given she had only been on the higher dose since Friday night (and PB has a three day half-life), I'm hoping perhaps blood levels haven't peaked yet.

[quote user="Mark Hedberg"]Think about it this way - if PB causes mild sedation or slow learning, it's still probably better than multiple cluster seizures. [/quote]

My thoughts zigactly.

Re: Decision making in Status epilepticus

Mark Hedberg — Wed, 21 May 2014 09:18:03 GMT

[quote user="Arlo Guthrie"][quote user="Matt Hilary"]

Congratulations!

[/quote]

And of course whether such a high dose of PB is actually going to cause new learning difficulties. There are lots of unknowns!

[/quote]

Fingers crossed here too. Don't worry just now about the learning difficulties; you've got enough on your shoulders to just worry about one bridge at a time. (I know, easy for me to say that.) Think about it this way - if PB causes mild sedation or slow learning, it's still probably better than multiple cluster seizures.

And give your daughter a hug. We're all rooting for her! (and you, of course!)

Re: Decision making in Status epilepticus

Francisco Gomez — Tue, 20 May 2014 21:51:11 GMT

Fantastic, I really hope you get there!

Re: Decision making in Status epilepticus

Arlo Guthrie — Tue, 20 May 2014 19:43:59 GMT

[quote user="Matt Hilary"]

Congratulations!

[/quote]

Well, I think it's still premature to talk of congratulations, because no doubt it will all go tits up tomorrow, but I sincerely appreciate the sentiment, thanks Matt.

I suppose if we have three weeks seizure-free, I'm going to think we've cracked it. Six weeks and I'll be sure. 8 and I'll be completely certain. Then on, it's a question of whether the learning difficulties are a consequence of her brain being effectively non-operational for four years, or the underlying disease. And of course whether such a high dose of PB is actually going to cause new learning difficulties. There are lots of unknowns!

Re: Decision making in Status epilepticus

Matt Hilary — Tue, 20 May 2014 17:13:31 GMT

[quote user="Arlo Guthrie"]

Well, I don't want to tempt fate too much, but after a very long discussion, we upped the phenobarbitone dose again on Friday, because although it seemed to have stopped clusters, our daughter had started having one a day instead. She had a really brief episode on Saturday morning. None since.

She has gone for longer without a seizure in the past, but this just seems too coincidental. I've got fingers, arms, legs and eyes crossed at the moment. Almost more exciting than seizure control itself is the continued remarkable improvement in speech, gait, engagement and cognition. It really is a joy to see. Just praying (not something I'm usually given to), that it is not a false dawn.

[/quote]

Congratulations!

Re: Decision making in Status epilepticus

Arlo Guthrie — Tue, 20 May 2014 11:13:03 GMT

Re: Decision making in Status epilepticus

Mark Hedberg — Tue, 06 May 2014 16:17:52 GMT

[quote user="Arlo Guthrie"] Our doc has been very non committal about what the maximum dose might be

[/quote]

Quite possibly this is because there's not really an ironclad rule on this one. Seizure control, (as I'm certain you can testify to!) can be a frustrating and challenging issue when you're trying to get them managed and the underlying medical condition isn't cooperating.

Re: Decision making in Status epilepticus

Anthony Dennison — Tue, 06 May 2014 15:16:42 GMT

[quote user="Arlo Guthrie"]Also very interesting. Our doc has been very non committal about what the maximum dose might be (so we have little sense of how far down the road we are with PB). [/quote]

i don't know whether it's transferable to human medicine, but I have been told at CPD that in epileptic dogs you can increase the dose past the dose range in the formulary if the phenobarb levels in the blood are still low. Toxicity levels are what to monitor when it comes to dosing, rather than mg/kg etc.

Re: Decision making in Status epilepticus

Anthony Todd — Fri, 02 May 2014 22:30:22 GMT

[quote user="Francisco Gomez"]If you talking about phenobarbital, yes some animals need increase dose because they build tolerance so it becomes less effective with time. I simply up the dose, there are some side effects re increase liver enzymes but I never had to stop phenobarbital because a liver issue, instead if I find the drug dose scarily high I tend to combine with another product to try reduce the potential side effects of both but keeping the efficacy up...

[/quote]

+1 but I think these days of tests dictating treatment rather than results the dose will tend to be too light.

The other thing, of course, is that it may be that the condition is getting worse rather than the dose is too low. I think epilepsy is a condition where the real important thing is to control seizures rather than say "ooeehh, the dose is too high 'cos the blood levels are greater than x".

So it's the lowest dose that controls seizures for me as no seizures, and a bit spaced out, is better than the reverse.

Re: Decision making in Status epilepticus

Francisco Gomez — Fri, 02 May 2014 21:08:18 GMT

If you talking about phenobarbital, yes some animals need increase dose because they build tolerance so it becomes less effective with time. I simply up the dose, there are some side effects re increase liver enzymes but I never had to stop phenobarbital because a liver issue, instead if I find the drug dose scarily high I tend to combine with another product to try reduce the potential side effects of both but keeping the efficacy up...

Re: Decision making in Status epilepticus

Arlo Guthrie — Fri, 02 May 2014 18:58:24 GMT

[quote user="Anthony Todd"]

[quote user="Arlo Guthrie"] except when on the loading dose.[/quote]

Sounds like what we used to do, though our "loading dose" was the dose that stopped the fits initially, then we gradually reduced it to the minimum dose that still stopped the fits. So dogs were on a high "dopey" dose to start with and reducing after say a month ['cos, as I said, they became tolerant to that "high" dose after a while]

[/quote]

Also very interesting. Our doc has been very non committal about what the maximum dose might be (so we have little sense of how far down the road we are with PB). Sounds like we're just doing the reverse of what you're doing. That gives me even more hope that if we can get to a daily dose similar to our initial loading dose, we might, just might achieve control (ie initial loading dose was 240mg. Then we started at 60mg daily plus loading 180mg, now we are at 150mg daily, loading 90mg. Given 240mg achieved 80-90% control, and the half life is something like 3 days, I'd hope we might get 100% control if we can get her a bit nearer to 240mg daily.)

Would be interested to know if, when you say dogs build a tolerance, whether you mean both in terms of drowsyness and efficacy. i.e. Do you see it becoming less effective with time?

Re: Decision making in Status epilepticus

Anthony Todd — Fri, 02 May 2014 17:44:44 GMT

[quote user="Arlo Guthrie"] except when on the loading dose.[/quote]

Re: Decision making in Status epilepticus

Arlo Guthrie — Fri, 02 May 2014 17:28:09 GMT

[quote user="Bob Russell"]Amazing how all the so called wonder drugs available to treat human epilepsy can be outsmarted by a 'sleeping tablet' discovered over a century ago![/quote]

My thoughts exactly. The reason why our doc was reluctant to prescribe it earlier is that there are apparently some studies showing it can cause a drop in IQ. But I look back and think of the days when we were watching my daughter becoming increasingly catatonic over the course of a day and watching her losing the ability to speak in between clusters and just cannot understand why it was not discussed as an option. Everything is easier in hindsight I suppose.

[quote user="Anthony Todd"]Arlo, my experience with phenobarb orally in dogs is that they gradually become "tolerant" and the depressive sleepy ,dopey, effect wears off with time[/quote]

Yup, that's the same as we've been told to expect with our daughter, though no signs of being over dopey yet - except when on the loading dose.

[quote user="Bob Russell"]Clearly your recent experience suggests the doctors need to remember some epilepsy treatment history! Phenobarbitone may not be perfect in all patients but it provides a lot of pets and owners a good quality of life!

Hopefully your daughter will go from strength to strength as the seizures are controlled. [/quote]

Thank you. Very much. I'm keeping my fingers crossed. We've still got a way to go (daughter had one a moment ago, actually). What it is doing at the moment is stopping the clusters as soon as we recognise that it is actually a cluster starting, and not just an isolated one (i.e. we load after seizure no 2). That's life-changing in itself. Instead of 24 hours intensive nursing every week or two (worrying about how to get drugs into her, or whether we should get her to hospital), now she's just a bit spaced out for the day. In between, improvements are more subtle, but definitely speaking much better. I'm just wondering now whether the recent assertiveness / stroppiness we've seen is drug-related, or just a consequence of her brain functioning better. I'm hoping the latter.

Re: Decision making in Status epilepticus

Anthony Todd — Fri, 02 May 2014 16:49:56 GMT

[quote user="Martin Atkinson"]Not sure if that was tongue in cheek Anthony but I have found sub-lethal pentobarbital to be the most effective method of controlling SE and close cluster seizures when other methods have failed. [/quote]

+1, God knows why it was discontinued?! Never failed with me, but then I was used to pentobarb GAs.....

No Martin, totally serious. I can't get my head around a barbiturate taking 30 minutes I/V to work when all the other barbiturates work in seconds...

I assume we're talking about the time taken for the overt [not EEG!] signs of fitting to stop??

I also can't understand the dire safety warnings over pentobarb. Given slowly to effect it was safe as houses on induction and maintenance but had a very prolonged recovery time and was contraindicated in greyhounds, I remember, something to do with fat absorption I think.

Arlo, my experience with phenobarb orally in dogs is that they gradually become "tolerant" and the depressive sleepy ,dopey, effect wears off with time so my regime was to guess a dose and increase or decrease it gradually to get to the minimum preventative dose and increase or decrease over time if nd or when the fits start again. You may find that the negative effects wear off after a while, I hope. Dogs did put on weight though.....

Re: Decision making in Status epilepticus

Bob Russell — Fri, 02 May 2014 15:02:09 GMT

[quote user="Arlo Guthrie"]

[quote user="Anthony Dennison"](Including for your daughter Arlo)?[/quote]

Nope - hadn't even heard of it!

[/quote]

Amazing how all the so called wonder drugs available to treat human epilepsy can be outsmarted by a 'sleeping tablet' discovered over a century ago! I have grumbled for years that the veterinary profession has to struggle with old drugs whereas the human medics have a wide choice! Many of the drugs you mention have been tried in veterinary medicine, are in vogue for a bit then found wanting.

Clearly your recent experience suggests the doctors need to remember some epilepsy treatment history! Phenobarbitone may not be perfect in all patients but it provides a lot of pets and owners a good quality of life!

Hopefully your daughter will go from strength to strength as the seizures are controlled.

Re: Decision making in Status epilepticus

Thomas Johnson — Fri, 02 May 2014 12:04:18 GMT

[quote user="Martin Atkinson"]

[quote user="Thomas Johnson"]I'm not sure I would be happy using the stuff designed for euthanasia though as it's not sterile.[/quote]This is mooted as a potential issue but its hardly going to be hooching with bugs is it in reality?! As I've said it is a desperate last measure when there is little else left to try, I'm not sayng I've had hundreds of cases to document just a handful over the years but non have woken up with an infection!!

[/quote]

If I'd run out of other options then I probably would try it, and I would open a new bottle to reduce the risk of problems.

Re: Decision making in Status epilepticus

Arlo Guthrie — Fri, 02 May 2014 10:50:05 GMT

[quote user="Anthony Dennison"](Including for your daughter Arlo)?[/quote]

Nope - hadn't even heard of it!

Re: Decision making in Status epilepticus

Anthony Dennison — Fri, 02 May 2014 10:41:10 GMT

[quote user="Arlo Guthrie"] (whilst in France, because everything goes up the bum in France)[/quote]

LOL.

I was reading through some CPD notes on epilepsy yesterday to help someone who had problems with a fitting dog, and there was a section on the use of Pregabalin. Has anyone had experience of using this (Including for your daughter Arlo)?

Re: Decision making in Status epilepticus

Martin Atkinson — Fri, 02 May 2014 10:31:30 GMT

Re: Decision making in Status epilepticus

Thomas Johnson — Fri, 02 May 2014 10:06:10 GMT

[quote user="Anthony Todd"]

[quote user="Thomas Johnson"]Yes, up to half an hour to have effect if given i/v.[/quote]

Would you say pentobarb works in 30 seconds, just to make sure we are on the same page?

[/quote]

Yes, I can remember using Sagatal a number of years ago, I'm not sure I would be happy using the stuff designed for euthanasia though as it's not sterile. And as Mark explained in one of his posts it mainly works by masking the seizure not stopping it.

Re: Decision making in Status epilepticus

Martin Atkinson — Fri, 02 May 2014 09:55:20 GMT

[quote user="Anthony Todd"]

[quote user="Thomas Johnson"]Yes, up to half an hour to have effect if given i/v.[/quote]

Would you say pentobarb works in 30 seconds, just to make sure we are on the same page?

[/quote]Not sure if that was tongue in cheek Anthony but I have found sub-lethal pentobarbital to be the most effective method of controlling SE and close cluster seizures when other methods have failed. I've found propofol to be pretty useless and continuing administration in a non-hospital situation tedious and often impractical. Phenobarb doesn't last long enough although I've usually found it works quicker than 30 mins. Most cases I've treated with pentobarb sleep peacefully for hours and when they recover are far less likely to seizure again in the short term. Maybe sailing a bit close to the wind so you need the owners fully on board and aware of the risk but the first time it was done in desperation with little other choice available. If they continue to seizure on recovering from a pentobarb. induced coma then the prognosis is pretty poor.

Re: Decision making in Status epilepticus

Arlo Guthrie — Fri, 02 May 2014 09:29:59 GMT

[quote user="David Mills"]Interestingly, ketamine is the new vogue drug in human medicine for the treatment of SE[/quote]

I didn't know that. Good to know.

Not sure whether this is of interest or completely irrelevant, but our daughter had seizure clusters which it was hard to know whether you would define as SE (though we suspected subclinical seizure activity in between tonic-clonic seizures every 30 minutes or so). We used valium rectally (whilst in France, because everything goes up the bum in France), then midazolam orally (back in the UK).

Always found it very effective in the short term, but would only work for a few hours (when clusters would last 24-48hrs).

Only about 5 months ago, when we really were in a state of some desperation (and having tried lamotrigine, valproic acid, clonazepam, levetiracetam, carbamazepine and topiramate, not to mention a ketogenic diet), the doc said to give phenobarbitone a go.

What a revelation. Takes 30 minutes to work, then 80-90% control, usually lasting for the duration of the cluster. So effective that we've put her on a daily dose, loading at the start of a cluster.

We're increasing the daily dose hoping we'll reach a point where clusters are prevented before it makes her too sleepy. But for the moment at least, it is paradoxically improving her cognitive ability (speaking noticeably more clearly with a wider vocabulary).

I have no way of proving it, but it seems to me as if she has had subclinical SE going on for 4 years, and the PB is, if not achieving complete control at the current dose, certainly damping down unwanted subclinical seizure activity and allowing her to operate on a slightly higher plane.

Re: Decision making in Status epilepticus

David Mills — Thu, 01 May 2014 23:49:16 GMT

[quote user="Virginia Campbell"]I like using a bit of propofol[/quote]

It is funny how different vets are, because personally, I hate propofol in SE.

I find diazepam or derivatives work best when there is partial seizing going on or post-ictal, though it does seem to reduce the severity of the seizure activity, so normally I'd use both phono and diazepam at the start.

Interestingly, ketamine is the new vogue drug in human medicine for the treatment of SE - yet to use it in a dog but might be something to consider.

Re: Decision making in Status epilepticus

Virginia Campbell — Thu, 01 May 2014 22:10:17 GMT

I turned up to work a bit early yesterday so was the lucky person to deal with the cluster seizuring lab that arrived a few minutes earlier. Our fab nurse managed to get an IV in then we gave midazolam IV first (drawn up to give IM in case couldn't get IV in) - did pretty much nothing so gave it 3ml propofol, then 200mg pheno, and carried on like this slowly giving more pheno, interspersed with 2-3ml boluses of propofol any time the paddling and dog in general looked more seizurey than the gentle propofol "swimming", and after half an hour it was flat enough to carry into a nice padded quiet bed out the back. We kept it fairly flat all day and night (needed a bit more pheno) - I aimed for a level of sleepiness where it could just about swallow Pexion safely. Let it come round this morning (now on Pexion bid in addition to the 60mg Epiphen it's already on), home this afternoon with owner under orders to give it an extra Epiphen tab tonight if it looks anything other than sleepy. If it fits he's going to give it the diazepam rectubes and call my mobile (one of the few cases I have given my number to - the dog is not insured and I don't want him landing up at Vets Now).

I like using a bit of propofol - gives you thinking time and the nerve to let the pheno have half an hour to work rather than just piling loads in cos the owner is standing there and it appears not to be working and you're desparate to "make it stop", then end up with a dog that's scarily flat half an hour later.