How can I stabilise this epileptic ?

RE: How can I stabilise this epileptic ?

Hannah Wynne Richards — Fri, 21 Aug 2015 15:51:08 GMT

If it's only one, it's not too severe, it doesn't leave any neurological deficit and I can't find an underlying cause, I tennd to say "Wait and see - if he gets another we'll have to start treating, but once you start - you stay on." Maybe that's because I was taught that each fit predisposed to more, and that withdrawal of treatment inevitably brought on status epilepticus.

Maybe time for neurology as my next CPD course!

Wynne

RE: How can I stabilise this epileptic ?

Anthony Todd — Fri, 21 Aug 2015 15:37:40 GMT

[quote user="Arlo Guthrie"]given her credentials[/quote]

Hi Arlo, if you get the chance ask her what her approach is, and what medication she suggests in a human who has just one fit with no warning or previous.

I still think, and some of the posts support my view that a months pheno in a reducing regime is the way to go but her view might be helpful.

RE: How can I stabilise this epileptic ?

Arlo Guthrie — Thu, 20 Aug 2015 20:49:32 GMT

[quote user="Anthony Dennison"]

''Epileptogenesis was best described in an animal kindling model (Goddard 1967), where daily, subconvulsive stimulation of defined brain regions resulted in the eventual development of stimulation-induced epileptic seizures, and in some animals, even spontaneous epileptic seizures. These alterations in brain region excitability were permanent and subsequent studies have demonstrated a variety of changes, including selective neuronal loss, axonal reorganisation and altered glutamate channel properties. These findings are used to explain the increase in epileptic seizure frequency and severity, which occurs over time in many human and animal patients.'

Penderis J (2014) Pathophysiology of epileptic seizures In Prac 36: 3-9[/quote]

Well, I raised this with our consultant today, and she said that it was thought in the past that seizures could cause more seizures in humans, but that this had been since been disproved. She was very emphatic about it, and given her credentials I tend to take her word for it!

RE: How can I stabilise this epileptic ?

Clive Ansell — Mon, 17 Aug 2015 10:45:03 GMT

[quote user="Anthony Dennison"]

If a dog had a single fit I wouldn't do anything, not even bloods. I'm most people on here would agree with me. If the animal has more than one every 3 months, or has cluster seizures, then you start investigating.

[/quote]

Agree as general rule, but depends very much on the case and the client.

I had an obese 10 year old Border Collie recently that had only had 2 seizures, both early morning just before her once daily feed. Advised starved blood work and picked up hypoglycaemia and an insulinoma. Had surgery and so far doing well.

Last autumn I saw an 18 month Labrador that had had only 1 seizure. Dog - nad on c/e, owner - neurotic. I advised just obs initially with blood work if further seizures. Owner demanded immediate bloods, which were all wnl. Owner then demanded neurology referral where neuro exam, csf tap and MRI scan were carried out. Nearly £3000 later my initial presumptive diagnosis of idiopathic epilepsy was confirmed, and the dog started on Phenobarbitone. Doing well.

RE: How can I stabilise this epileptic ?

Anthony Dennison — Mon, 17 Aug 2015 09:28:35 GMT

[quote user="Anthony Todd"]Trouble is if you don't treat the first one and the animal has more [er, at 2am...] you are criticised and the dog has had more fits, whereas if you taper over a month or so you sort of cover yourself and the dog.[/quote]

That's were communication skills come to the fore - explain why you don't do anything now, but if there any more fits you spring to action. Most clients accept this. If they're of a nervous disposition, you offer to admit and monitor them for 24 hours.

RE: How can I stabilise this epileptic ?

Anthony Todd — Sun, 16 Aug 2015 17:25:30 GMT

Yes, point taken, although my son had every test under the sun and, I think was on valium for a while, [probably a reaction to vaccination, they thought in the end]

The ECG flatlined at one point which I pointed out to them [much panic from yours truly] they just gave the machine a whack and it was back!

Trouble is if you don't treat the first one and the animal has more [er, at 2am...] you are criticised and the dog has had more fits, whereas if you taper over a month or so you sort of cover yourself and the dog.

Far enough though not to treat on one.

RE: How can I stabilise this epileptic ?

Anthony Dennison — Sun, 16 Aug 2015 09:05:05 GMT

[quote user="Anthony Todd"]

Yes but, conversely, some animals and people only ever have one seizure [including my son].

This is why I used to control the first or latest fit with sufficient pheno then taper it to nil gradually over a month after a month or adjust the dose if fits reoccurred. No blood tests though.....

[/quote]

The dog in this case has been having cluster seizures, hence quoting that In Practice article

RE: How can I stabilise this epileptic ?

Anthony Todd — Sat, 15 Aug 2015 15:25:48 GMT

[quote user="Anthony Todd"]Why is the owner behaving like this? Has anyone bothered to ask?[/quote]

Sorry, I didn't realise so many had tried, but I say again has anyone asked her ?

If she was/is such a ******* why does she come back?

I wonder what her side of the story is?

She may have an aversion to barbiturates for some sort of personal reason; who knows.

Martin, one for Uncle Clive I reckon, [and she'd be all sweetness and light, even if the medicine wasn't state of the art....]

RE: How can I stabilise this epileptic ?

Clive Ansell — Sat, 15 Aug 2015 12:50:18 GMT

[quote user="Hannah Wynne Richards"]

Client's the problem,not the dog!

Wynne

[/quote]

"Right dog, wrong owner syndrome" an ex boss used to say.

RE: How can I stabilise this epileptic ?

Clive Ansell — Sat, 15 Aug 2015 12:49:12 GMT

[quote user="Anthony Todd"]

Why is the owner behaving like this? Has anyone bothered to ask?

I have to say this is may well be because more blood tests, when the dog is just going back onto sufficient pheno may, in the owner's mind, be the reason.

Frankly, I always thought that if I lost a client, or they didn't do what I said then, either I was wrong or I had failed to get enough of the message across.

[/quote]

If I had to use one word, it would be idiot. If 2 words, f****** idiot.

3 veterinary surgeons and 2 experienced RVN's have tried with this one and failed. I would guess that all 5 of us are not wrong or have failed, and the problem is an idiot client.

I don't think excessive blood testing is the reason either. routine bloods including a bile acid stim test were run initially as a step towards a diagnosis. Phenobarb levels and liver enzymes have only been measured once. Further testing has been refused or the client hasn't turned up.

Some you win, some you lose. This one is a lose

RE: How can I stabilise this epileptic ?

Hannah Wynne Richards — Sat, 15 Aug 2015 12:43:34 GMT

Client's the problem,not the dog!

Wynne

RE: How can I stabilise this epileptic ?

Clive Ansell — Sat, 15 Aug 2015 12:39:36 GMT

[quote user="Robin Grimmer"]How long is the locum Clive? If it's a short term one then I would just give them a small amount of Keppra and get them to come back and see the boss or usual vet when they are back. If it's a longer term one then it's more difficult. I agree, phenobarbital would be tbe drug of choice. I'm sure if they increased the dose of phenobarbitone and monitored the blood levels +-KBr then the fits would be better controlled. [/quote]

It's just a 2 week locum, but it is a 2 vet practice where I regularly work 10-12 weeks every year, so want to keep everyone happy. One benefit of being a locum is I can kick it into touch and it can be dealt with by regular staff later (in this case client doesn't like vets, and likes locums even less).

Dog was doing very well on phenobarbitone initially, even at the low end of the therapeutic range. It seemed to go mammaries up when client reduced or stopped drug in favour of dietary management and homeopathy, we think. I think Phenobarbitone would have been successful with some dose alterations +/- KBr.

RE: How can I stabilise this epileptic ?

Anthony Todd — Sat, 15 Aug 2015 11:50:42 GMT

[quote user="Anthony Dennison"]These findings are used to explain the increase in epileptic seizure frequency and severity, which occurs over time in many human and animal patients.'[/quote]

Yes but, conversely, some animals and people only ever have one seizure [including my son].

This is why I used to control the first or latest fit with sufficient pheno then taper it to nil gradually over a month after a month or adjust the dose if fits reoccurred. No blood tests though.....

Many dogs never fitted again. These days, with data mining, it should be easy for this sort of information to be gathered, so it wouldn't all be just anecdotal.

RE: How can I stabilise this epileptic ?

Anthony Dennison — Sat, 15 Aug 2015 11:13:52 GMT

[quote user="Arlo Guthrie"]Really? Is there any evidence that seizure activity causes a reduction in the threshold for future seizure activity? Genuinely interested. Certainly not something we have ever been told or seen any evidence of WRT to our daughter, who at one point was having clusters of 40 in 24 hours. [/quote]

Penderis J (2014) Pathophysiology of epileptic seizures In Prac 36: 3-9

RE: How can I stabilise this epileptic ?

Arlo Guthrie — Sat, 15 Aug 2015 08:51:09 GMT

[quote user="Anthony Todd"]Arlo. does your daughter get her blood level of phenobarb checked every time. If so, do the doctors say why?[/quote]

Not sure what you mean by every time, but blood levels were checked frequently as the dose was increasing, but not for some time now (a few months, i think). You've reminded me to check. I don't remember being warned about possible liver damage (and I think I would remember that), so thanks for pointing that out. I will talk to GP.

[quote user="Thomas Johnson"]That's interesting, my experience has been a little different, my wife has epilepsy, thankfully very well controlled, but when she does have seizures she usually has significant muscle pain for several days afterwards.[/quote]

That's interesting too. My daughter hasn't said the same, but that doesn't necessarily mean anything. I'll ask her next time.

RE: How can I stabilise this epileptic ?

Thomas Johnson — Sat, 15 Aug 2015 08:31:41 GMT

[quote user="Arlo Guthrie"]

My point was just that seizures themselves don't seem to me (based on human experience) to present a welfare issue.

[/quote]

That's interesting, my experience has been a little different, my wife has epilepsy, thankfully very well controlled, but when she does have seizures she usually has significant muscle pain for several days afterwards.

RE: How can I stabilise this epileptic ?

Robin Grimmer — Fri, 14 Aug 2015 20:26:13 GMT

How long is the locum Clive? If it's a short term one then I would just give them a small amount of Keppra and get them to come back and see the boss or usual vet when they are back. If it's a longer term one then it's more difficult. I agree, phenobarbital would be tbe drug of choice. I'm sure if they increased the dose of phenobarbitone and monitored the blood levels +-KBr then the fits would be better controlled.

RE: How can I stabilise this epileptic ?

Anthony Todd — Fri, 14 Aug 2015 18:52:40 GMT

Arlo. does your daughter get her blood level of phenobarb checked every time. If so, do the doctors say why?

Although, in another related thread it was shown that phenobarb, in some cases ,caused serious liver damage others seem to think phenobarb is pretty non-toxic.

I'll bet the owner of the OP's patient is getting *issed off with the repetitive blood tests which she has to pay for, only to be prescribed the same pheno as before.

I'm amazed at this, almost psychopathic, insistence on blood levels particularly when they've been done before and the dose is the same or marginally more and is going to be continued with despite the blood levels found as it's the only thing that stops the fits!

Sometimes, not often, but sometimes, you just have to grit your teeth and do something without an accompanying blood test ,especially when it's not going to change anything at all and, even more especially, when the alternative looks like being euthanasia......

I'd hate to think this dog is going to continue to fit., or be bumped, because some arbitrarily blood value is higher than it should be.

RE: How can I stabilise this epileptic ?

Arlo Guthrie — Fri, 14 Aug 2015 18:15:04 GMT

[quote user="Hannah Wynne Richards"] Is your daughter apprehensive in the pro-dromal phase?[/quote]

Nope.

[quote user="Hannah Wynne Richards"]There's also the increased likelihood of injury during fits[/quote]

I would have thought a reasonably remote chance of injury. I mean, the greatest risk to humans seems to be of hitting your head on the way down, or on (say) a stone floor. If a dog collapses, it's head isn't that far off the ground in the first place!

RE: How can I stabilise this epileptic ?

Anthony Todd — Fri, 14 Aug 2015 18:07:03 GMT

Why is the owner behaving like this? Has anyone bothered to ask?

I have to say this is may well be because more blood tests, when the dog is just going back onto sufficient pheno may, in the owner's mind, be the reason.

Frankly, I always thought that if I lost a client, or they didn't do what I said then, either I was wrong or I had failed to get enough of the message across.

RE: How can I stabilise this epileptic ?

Hannah Wynne Richards — Fri, 14 Aug 2015 18:04:31 GMT

Is your daughter apprehensive in the pro-dromal phase? Many dogs are. There's also the increased likelihood of injury during fits - and under the Animal Welfare Act, it's an offence tofail to protect from injury.

Wynne

RE: How can I stabilise this epileptic ?

Arlo Guthrie — Fri, 14 Aug 2015 17:59:40 GMT

[quote user="Anthony Dennison"]Cluster seizures every couple of days will be really reducing the threshold for any further seizure activity.[/quote]

Really? Is there any evidence that seizure activity causes a reduction in the threshold for future seizure activity? Genuinely interested. Certainly not something we have ever been told or seen any evidence of WRT to our daughter, who at one point was having clusters of 40 in 24 hours.

Nor have we seen any evidence that SE is caused by previous seizures or repeated seizures (although we've been warned that the more seizures a patient has, the greater the statistical likelihood of an incident of SE).

[quote user="Anthony Dennison"]It's also something the client needs to hear - either do it properly or not at all, it's not fair on the dog. [/quote]

I'm not disagreeing with the first part of the sentence. I'm querying the second part. ie the welfare aspect - from the fact that our observation is that partial seizures can cause short term distress, but tonic clonics don't themselves cause any suffering because the patient is, of course, completely unconscious during a tonic clonic seizure.

My point was just that seizures themselves don't seem to me (based on human experience) to present a welfare issue.

RE: How can I stabilise this epileptic ?

Hannah Wynne Richards — Fri, 14 Aug 2015 17:59:05 GMT

Hear hear - and I bet this is the sort of owner who tells the neighbours " I took him to the vet(sic) but he keeps having fits"

Not a word about disobeying instructions

Wynne

RE: How can I stabilise this epileptic ?

Anthony Dennison — Fri, 14 Aug 2015 17:34:21 GMT

[quote user="Arlo Guthrie"]

[quote user="Anthony Dennison"]Phenobarb, at your dose, or the dog needs to be PTS on welfare grounds.[/quote]

Can I ask what welfare grounds?

[/quote]

Cluster seizures every couple of days will be really reducing the threshold for any further seizure activity. If this continues as is, the dog will again go into status epilepticus (SE). I don't understand why the owner is paying for emergency treatment of SE then not continuing with a treatment regime. It's like spending a whole day bailing out a sinking boat, only to not fix the leak in the hull and watch the boat slowly refill again. What's the point?

It's also something the client needs to hear - either do it properly or not at all, it's not fair on the dog.

RE: How can I stabilise this epileptic ?

Arlo Guthrie — Fri, 14 Aug 2015 17:13:42 GMT

[quote user="Anthony Dennison"]Phenobarb, at your dose, or the dog needs to be PTS on welfare grounds.[/quote]

Can I ask what welfare grounds?