Epilepsy treatment advice

RE: Epilepsy treatment advice

Anthony Dennison — Thu, 11 Aug 2016 12:47:48 GMT

[quote user="Bob Russell"]Not sure who to believe when it comes to tolerance developing to LEV. Some neurologists seem convinced it does happen others not so much.[/quote]

Maybe I've just been unlucky then, or I've used it in refractory cases where it wouldn't have done much anyway.

RE: Epilepsy treatment advice

Bob Russell — Thu, 11 Aug 2016 10:31:23 GMT

Not sure who to believe when it comes to tolerance developing to LEV. Some neurologists seem convinced it does happen others not so much.

The human studies I have read just suggest more investigation is needed!

The collie is on it long-term and has been much improved for the last 18 months.

RE: Epilepsy treatment advice

Karen Eggleton — Thu, 11 Aug 2016 10:21:17 GMT

Apologies, too busy to do a detailed review of this dog's history here but just to say he is 15kg, he was started on the low dose of phenobarb & titrated up based on regular and consistently taken blood results. He was one of these dogs that metabolised phenobarb super efficiently ( a blood reading of always 60 springs to mind) then suddenly that stopped & blood levels & liver enzymes shot up dramatically with associated unacceptable clinical signs. AHT reviewed all the history & we have been in regular touch with veterinary advisors.

RE: Epilepsy treatment advice

Anthony Dennison — Thu, 11 Aug 2016 10:06:10 GMT

I'd agree with what has been said so far about the phenobarb dose and other potential anti-epileptic drugs.

I'm not as massive a fan of long-term levetiracetam because I've seen too many cases where the effects wear off within a few months, sometimes sooner. I have heard of it being used as pulse therapy - basically for 3 days when the dog has a seizure, then stop. Dose wise for this, I think it is a much higher dose (20-30mg/kg).

The fact this dog is having refractory seizures despite being on high doses of phenobarb is probably a bad sign - if cases don't respond to the primary AED it's unlikely adding more in will settle things.

RE: Epilepsy treatment advice

Bob Russell — Thu, 11 Aug 2016 10:04:45 GMT

One star for quoting data sheet starting doses? Clearly we don't know the size and full history of this patient but starting doses are 2-5mg/kg per day.

Our overweight labs and labradoodles (40Kg +) are on 60-75mg bd but one 24Kg problem collie is on 72.5mg bd plus keppra and KBR.

Not sure how heavy this dog is but the recommendation stated that the dose of phenobarb be reduced to 90mg bd then dropped further suggests an even higher dose. If the patient requires these doses to reduce seizure activity then it is no surprise that side effects are dramatic!

The devil is in the detail and I am not suggesting anything has been done wrong. It does seem to be a massive phenobarb dose though.

RE: Epilepsy treatment advice

Thomas Johnson — Wed, 10 Aug 2016 18:30:05 GMT

[quote user="nobbygonzo"]History - ‘The dog is on Phenobarbitone 8.5mg/kg/12h. Phenobarbitone serum level measured at trough is 38,74mg/l.[/quote]

That seems like a very high dose of phenobarb to me, and from memory the top of the recommended therapeutic range is 40mg/L, and I would suspect that with a trough level of 38.74mg/L the peak value is over 40. Did the dog start on that high a dose of phenobarb or did you gradually increase the dose to get to that level? I wonder if you would get good seizure control with a lower dose of phenobarb now that you have levetiracetam and potassium bromide being given as well.

RE: Epilepsy treatment advice

Bob Russell — Wed, 10 Aug 2016 18:12:30 GMT

I would be looking at a dose of phonobarb of 2mg/kg to start with. Not sure how big this dog is but 90mg bd seems very high. A standard cocker (15Kg) would be on 30mg once or twice daily.

It does take time for them to settle!

8.5mg/kg bd does seem very high but as I was advised long ago by one of the labs 'the right dose is the one that settles the seizures'! I tend to look to the numbers for dangerous levels!

KBR can take a very long time to take effect.

RE: Epilepsy treatment advice

Karen Eggleton — Wed, 10 Aug 2016 17:57:09 GMT

Sorry for tardy response. The dog was suffering unacceptable side effects with Epiphen-awful ataxia, markedly elevated liver enzymes. Also pancreatitis (aggravated by KBR)?

We sent all the history to AHT via Vetoquinol & this was their response:

History - ‘The dog is on Phenobarbitone 8.5mg/kg/12h. Phenobarbitone serum level measured at trough is 38,74mg/l.

I would strongly recommend:

- Performing a BAST;

- Performing clotting profile.

- Performing ultrasound of the liver and FNA if required.

- Increase Potassium bromide to 1 and 1/2 of 325mg tablets orally every 12 hours

- Start Levetiracetam 20mg/kg/8h orally indefinitely

- Decrease PB oral dosage immediately as follow:

o 90mg BID for 5 days

o 60mg BID for 2 weeks

o 45mg BID for 2 weeks

o 30mg BID for 2 weeks

o 15mg BID for 2 weeks

o 15mg SID for 2 weeks

o STOP treatment

This plan is flexible. The dog can be taken off PB more quickly if needed. The “5 days and 2 weeks” timing are indicative and they can be shortened if required.

I am just concerned in decreasing it too rapidly because of rebound seizure activity which might not respond to treatment.’

RE: Epilepsy treatment advice

Bob Russell — Wed, 10 Aug 2016 14:04:50 GMT

The side effects of phenobaritone can be a pain for the owner but I have never had to take a patient off it. I would also be interested to know what the side effects were.

Most of the time referral is to help confirm it is idiopathic epilepsy (by eliminating other causes more comprehensively). Generally the options remain phenobarb, KBr and levetiracetam.

I tend not to blood test patients that regularly if they are settled and doing well. Generic Keppra is quite affordable and does work well.

Perhaps you also need to manage owner expectations. Some authorities will accept one seizure a month as being acceptable. I use this as a maximum acceptable interval although none of my cases are this bad!

RE: Epilepsy treatment advice

Rob Loxley — Wed, 10 Aug 2016 13:54:47 GMT

Are you sure it's idiopathic epilepsy rather than something more?
What were the side effects of pheno, is there room to reintroduce this at a lower dose. If an option is increasing the bromide then it's a risk/benefit decision to make.
Other antiepileptic medications include gabapentin

http://bmcvetres.biomedcentral.com/articles/10.1186/s12917-015-0464-z

Sometimes epilepsy is just poorly responsive...

http://bmcvetres.biomedcentral.com/articles/10.1186/s12917-015-0465-y

RE: Epilepsy treatment advice

Robin Grimmer — Wed, 10 Aug 2016 11:18:27 GMT

[quote user="Anthony Todd"]

[quote user="Robin Grimmer"]Did you check blood levels? [/quote]

This has been discussed before. IMHO blood levels are only relevant to prove that an animal is not getting the prescribed dose.

If a dog is still fitting the dose is not high enough. If it is too sleepy at another anti epileptic but I agree with the previous post totally [except the bloods].

[/quote]

We've been through all this before. The reason for checking blood phenobarb levels is twofold. Firstly in a dog that is still fitting that the blood levels are adequate, not so much to check the dog is getting the prescribed dose, but that all animals metabolise drugs differently.

Secondly, with an animal on long term medication, particularly if a high dose is needed to control seizures, that it is not likely to cause liver damage.

RE: Epilepsy treatment advice

Anthony Todd — Wed, 10 Aug 2016 10:39:01 GMT

[quote user="Robin Grimmer"]Did you check blood levels? [/quote]

This has been discussed before. IMHO blood levels are only relevant to prove that an animal is not getting the prescribed dose.

If a dog is still fitting the dose is not high enough. If it is too sleepy add another anti epileptic but I agree with the previous post totally [except the bloods].

RE: Epilepsy treatment advice

Robin Grimmer — Wed, 10 Aug 2016 10:25:59 GMT

And what was the dose of phenobarb? Did you check blood levels? Phenobarb will cause side effects (sedation, ataxia, pupd, etc) initially, but most will wear off and so long as you warn the client what to expect there's not normally a problem and not a reason to stop.

RE: Epilepsy treatment advice

Anthony Todd — Wed, 10 Aug 2016 08:33:26 GMT

What were the "side effects" of phenobarb?

RE: Epilepsy treatment advice

Emily Rainbow — Wed, 10 Aug 2016 07:42:52 GMT

Who do you normally refer your neuro patients too? I'd give them a ring and pick their brains. Most are happy to have a chat over the phone.