Dr Emma Hancox: Welcome back to the Synaptic Tails Podcasts with your
host, Emma Hancox, TVM Technical Vet, and Mark Lowrie, RCVS and European
Specialist in Veterinary Neurology, and Co-director of Movement Referrals.
Hi Mark.
How are you today?
Dr Mark Lowrie: Well, I'm a bit sad today.
Dr Emma Hancox: Why are you sad?
Dr Mark Lowrie: This is the last podcast
Dr Emma Hancox: it's the last in the S.M.A.R.T Series, but hopefully it's
not going to be our last one, so...
Dr Mark Lowrie: That's good to hear.
Dr Emma Hancox: That's if you'll come back?
Dr Mark Lowrie: Oh, well, I’ll happily come back, but it's whether
our listeners will come back to us.
Dr Emma Hancox: That's true.
So hopefully by now all our listeners will know this has been a series of
podcasts dedicated to the S.M.A.R.T Approach to epilepsy, which was TVMs new
guide for first opinion practitioners.
Over the last four episodes, we've chatted through various aspects of
how to manage our epileptic patients.
This episode, as Mark said, is the last in that S.M.A.R.T Approach.
But don't fear if Mark will have us, we are, we hope to come back and
continue our discussions in the future.
If you are new to the podcast and haven't listened to the earlier
episodes, I do encourage you to pause this episode and take a listen now.
So today we'll be discussing the final step, as we said, which is tailor.
So this is all about tailoring your approach to each case and to each owner.
I wonder, Mark, what does tailor mean to you?
Dr Mark Lowrie: Yeah.
Well, I guess we've got through four of these podcasts without, without actually
touching on when to start treatment.
Dr Emma Hancox: That's very true, maybe an oversight on our part.
Dr Mark Lowrie: Not at all.
Not at all.
But I think, you know, it's, it's really important that we, we think about,
when are we gonna start medication?
And I’ve said all the way along that there's no hard and fast rules.
So that's why you never read something that says you must
start medication at this point.
There is guidance out there, but some people say if a dog has two seizures
within a six month period, that would be a reason to start medication.
And that's true.
You know, that would be a reason.
But it doesn't mean you have to, and it doesn't mean you
necessarily need to recommend that.
It's a case of discussing with that owner what they want to do.
And I will have owners that will want to start medication very, very
early on in the course of epilepsy.
But if they understand that starting medication early may mean we've got
less options in the future, and holding off may be better while the epilepsy
isn't too severe, then that's fine too.
Now the big thing to talk about here is kindling.
So there's this word kindling, and all kindling means, it's the idea that one
seizure might lead to another seizure.
Dr Emma Hancox: Right.
Dr Mark Lowrie: So if a dog has a fit, it's more likely to
have another fit in the future.
And the more fits it has, the more fits it's likely to have later on.
Dr Emma Hancox: Makes sense.
Dr Mark Lowrie: So the idea is that if we start medication and can stop
the fits, then it's less likely to progress into a more severe
seizure situation down the line.
So I'm arguing with myself right now because it's, you know, do we start it
early and try and prevent that kindling effect or do we hold off medication and
maybe wait till further down the line?
Clearly there's no right answer, but I think if an owner knows that
and knows that's the situation that we face, that's the dilemma,
and then we can decide what to do.
So each dog, and certainly each owner, really needs a
bespoke approach to epilepsy.
I’ve mentioned it before, but dogs with objection or postictal signs, maybe that's
the reason to start medication earlier.
My approach probably is to say if a dog has one seizure, I don't start
medication 'cause we do know there are dogs out there where they may
only ever have one fit and we don't know why, but it never happens again.
So let's not condemn that dog to a life of medication.
But as soon as we're dealing with two or more fits, then medication is reasonable.
My approach is maybe two fits in a six week period might be me
pushing more towards medication than steering away from it.
Dr Emma Hancox: right.
Dr Mark Lowrie: But as I say, it really, really depends on the
owner and they're the ones who are going to make the decision
Dr Emma Hancox: Yeah,
Dr Mark Lowrie: and decide what to do.
So for me, that's what tailor means.
It's about sitting down and having that conversation and making sure
that owner gets the management that's right for their situation.
Dr Emma Hancox: Is there any situations in which it's definitely
recommended to start treatment?
Dr Mark Lowrie: Yeah, there definitely are.
I mean, I suppose we can list off quite a few, some are obvious, of course.
So a dog with status epilepticus or with severe cluster seizures.
I think there's no doubt there that we'd all be in agreement that
medication is the right thing to do.
One thing I, I pick up on there briefly while I think of it is Status Epilepticus.
We did talk about giving Diazepam in an earlier podcast and how we can use
that to treat epilepsy, but I'd always wanna say, don't ever get confused that
diazepam isn't really treating seizures in a long-term way, it's helping in that
moment, in that emergency situation.
So if you do have a dog in status and you give diazepam and you’re fortunate enough
that things work and, and, these seizures have stopped, definitely, definitely start
a long-term antiepileptic medication.
I have known dogs, well, that's not been done, and inevitably
it has fits at a later date.
So status epilepticus, start medication.
We've also talked about whenever you find an underlying disease, we want to
start medication, you know, so you've got a disease underlying the fits.
It may or may not be treatable, but whichever one it is, we still want
to give medication to try and prevent further seizures because they're always
gonna be damaging in their own way.
So that's another reason.
If you've got severe postictal signs, so aggression or a dog that really takes
a very long time to recover from a fit.
That's another reason to start the medication.
And simply things like multiple seizures in a, in a short period of time.
It may be they only have them every 8 to 12 weeks, but when
they have them, they're bad.
Well, there's another circumstance where we might think about treating,
Dr Emma Hancox: Yeah,
Dr Mark Lowrie: but if you are, if you've been monitoring a dog over some time and
you haven't started medication, but then they are getting a bit more frequent
steadily, again, I'd be moving more towards the treatment than away from it.
So sort of increased frequency of seizures is another time to,
to actually give the medication.
Dr Emma Hancox: Yeah, so like you said, it sounds like there's not
one right or wrong answer to this.
So yes, there's definitely some situations, but I wanted to pick up if I
can, that other cases that maybe warrant a little bit more of a specific approach
or a different approach, put it that way.
One thing I want to pick up on is the clustering dog.
So it's not infrequent, for me anyway I don't know whether I was unlucky
in practice, to have a case where I had started them on phenobarbital,
for instance, and then they won't have seizures for weeks or months,
and then suddenly they will have kind of four or more over usually
a weekend when we're not there.
Dr Mark Lowrie: Yes.
Yeah.
Dr Emma Hancox: So how do you manage those?
Do you put them on a second line or?
I would just be interested in your thoughts.
Dr Mark Lowrie: I suppose it depends what they're on already.
But I mean, I suppose these dogs may be already on phenobarbital and
they may or may not be on bromide.
So, you know, we can think about putting in bromide, but the clusters,
I mean, that's where drugs such as levetiracetam are really helpful.
So levetiracetam is a very rapidly, well, a drug that works very rapidly, it comes,
gets into the body and it works quickly.
So within sort of 24, 48 hours, you've got a really reasonable dose of that drug
in the system trying to prevent seizures.
So in your situation where you've got a dog with a very long period of,
quiescence, if you like, no, no seizures, no fits, and the dog's well, and then
it has say, 48 hour period of lots of seizures, let's say in double figures.
What you can do is after that first fit in the potential cluster, I would
start levetiracetam and I'd give it three times a day during that period
until we know that the likelihood of those seizures has passed by.
So I go quite high with the dose.
I mean, the standard dose for levetiracetam is about 20
mgs per kg three times a day.
But in that circumstance, I'd happily got to 30 mgs per kg three times a day.
Partly because you’re in a situation where the owner really
doesn't want to see the fits.
So they probably will allow, or, or accept, I should say, the, the side
effects that would come with that slightly higher dose of levetiracetam.
So I'd go 30 mgs per kg and I'd do it for double the length of the cluster.
What I mean by that is if we know from historically that this dog will
cluster over a 48 hour period, then I’ll maybe do, do the cluster, the
levetiracetam dose over four days.
Hopefully to be sure we've then got rid of the cluster, they've gone,
and then we, we take the dog off medication and see how things go.
A big advantage of that is people talk about levetiracetam
having the honeymoon effect.
Dr Emma Hancox: Yeah, I’ve heard, I was gonna ask you actually about that.
Do you agree with that?
It's something that gets banded around, isn't it?
Dr Mark Lowrie: I think it's a lot less common than people say.
I think it does happen because it's come from somewhere and we've seen evidence
of it in dogs, but it's not that common.
So I’ve heard people using the honeymoon effect as an excuse not to start
levetiracetam, so I wouldn't do that.
It's absolutely an option out there and it's one of my favourite
medications to use in epilepsy.
So, yes, I'd always use it, but we have to be open to the fact that if
we are giving it three times a day, every day, a tolerance may develop.
So, Pulse dosing with these clusters is a, is a great way of trying to avoid that.
But if you need to give it persistently, then do, because that's what we're
going to have to do for the dog.
So that's my approach there.
Dr Emma Hancox: Yeah, so does, I'm just curious, does tolerance say, I
don't know why it's more described of Levetiracetam, but does it happen to
the other drugs as well, do we think?
Or is it more just epilepsy progression?
Dr Mark Lowrie: Yeah, I mean there's a kind of tolerance, I guess with
phenobarbital because we talked about it.
That idea of auto induction.
Yeah.
Where the, the body gets used to that dose of phenobarbital and we have
to increase the dose accordingly.
So with levetiracetam, it's not got that auto induction, but it just,
even if you go higher with the doses, you just don't get the effect
from it that you would want to get.
So, levetiracetam is a bit unique in that way.
Dr Emma Hancox: Yeah, no, fair enough.
There's potentially, you mentioned actually before, cases where you might
want to introduce two drugs at one time if we don't want to load them.
So this I realise is going a little bit against what we talked about earlier in
following those levels of recommendation.
But again, this is just tailoring that approach, isn't it really?
So if you could just tell our listeners what you were talking
to me about, that would be great?
Dr Mark Lowrie: Yeah, I guess you, you can have a situation where you've got a
dog that's had repeated seizures and is on phenobarbital, and it's used effectively.
We always have to say that, you know, we've got the right,
Dr Emma Hancox: Just check that first.
Dr Mark Lowrie: absolutely always.
Please, please exploit phenobarbital before you move on to a second drug.
But you may have done that and the dog still has frequent seizures.
And for argument's sake, let's say it has three seizures.
No, no.
Let's say it has two seizures per week.
Now the owner still feels that's not acceptable control and that's fine.
You know, they have, they have a right to want to get better control than that.
Dr Emma Hancox: Yeah.
Dr Mark Lowrie: So what do you do there?
I mean, according to the cascade, we should probably add in potassium bromide,
but what we've said already is potassium bromide takes three months to work.
So if we give it at the standard maintenance dose, we're gonna
be waiting three months until it has a, a reasonable effect.
Now, it may work earlier than that.
It may reduce frequency slowly over that three months, but we
are waiting three months for full control with the bromide, or full
effect, I should say, of the bromide.
You could then go, well, let's load the bromide.
Let's, let's give it much more quickly.
Let's load it over two weeks perhaps.
So we, we don't wanna give a massive dose straight away, but
maybe over a two week period.
But the problem there is you’re still gonna get a lot of adverse effects and
that owner may not be happy with that, that you’re right, they're gonna be left
with the dog that's very, very wobbly and falling all over the place and, alright,
maybe the fits are better controlled.
Maybe it's now only seizuring once a week, but it's got quite
a, a poor lifestyle in between.
So its quality of life is diminished.
So what I do there is I wouldn't have a worry with actually starting
the bromide at a maintenance dose.
So say your standard 20, maybe up to 30 mgs per kg once a day.
But because they want a quick fix on the seizures, we can add in levetiracetam
at the same time, at the standard dose of 20 mg per kg three times a day.
And what you’re doing is you’re giving levetiracetam for a short
period of time up until the bromide reach reaches steady state.
So I'd keep it going, the levetiracetam and the Bromide for three months.
I check the blood levels of the bromide at three months, and if you've achieved
the therapeutic concentration with the bromide, I'd then stop the levetiracetam.
We've talked about stopping antiepileptic medications and being
cautious of it, but with levetiracetam it is safe to stop it straight away.
Dr Emma Hancox: Okay, I was gonna ask that actually
Dr Mark Lowrie: Without too much of the risk of withdrawal seizures.
So because there's not that auto induction, it's the auto induction
that means with phenobarbital, we have to be a lot more worried.
Dr Emma Hancox: Yeah.
So in that situation, why don't you just start them on and
keep them on levetiracetam?
Dr Mark Lowrie: And the reason I wouldn't do that is because it's
a nice drug to have down the line.
This dog's still got relatively infrequent fits, and I think, yes,
it's not wrong to do levetiracetam, but it's fair to say it's against the
cascade, that shouldn't be a problem.
You know, you've got a good reason to do it.
But I think levetiracetam is one of those drugs that it's, you know, it's nice
to add later on because you’re gonna get a good beneficial effect from it.
And we know bromide works.
We know it has a good, sustained long-term control, and generally
it has few side effects.
So it's my preferred choice.
It's, the disadvantage being we just have to wait longer, but that's fine.
You know, we've, we've got the option of waiting longer and if you, if you did do
levetiracetam and then the dog seizures worsened, which they inevitably will
do, we haven't got anything to add in to try and help the bromide work so get the
bromide on the scene as soon as you can, is my view there, whilst you've still
got time and other options to, to add in.
Dr Emma Hancox: Yeah.
It's saving stuff for later.
Dr Mark Lowrie: Absolutely.
Dr Emma Hancox: Because then you've not really got anything
that works that quickly.
Dr Mark Lowrie: No, no.
I mean, after that you've got all the other medications like
Gabapentin and Zonisamide.
They might work quickly in terms of they reach steady state
quickly, but they don't work well.
So you’re absolutely right.
There aren't alternatives to add in that would help.
Dr Emma Hancox: Yeah.
Yeah, no, that's fair enough.
The other kind of cases that I wanted to pick up from this as well is
the use of anti-epileptic drugs to control seizures of other causes.
So I, I have to think about seizures as they're just like a symptom or a
clinical sign at the end of the day.
So there may be manifestations from other diseases.
So some of the questions we get through the tech lines, for
instance, I just pick up an example being hepatic encephalopathy.
So there's cases where obviously they're treating as appropriate that
hepatic encephalopathy perhaps, but they obviously want to control any seizures.
Obviously the prognosis for the dog may be poor.
I appreciate that.
But if they are looking to treat those seizures, what's, obviously we
won't wanna be using phenobarbital in that situation, so what sort of
recommendations would you use for that?
Dr Mark Lowrie: Well, I think again, it comes back to whenever
you've got seizures, there's nothing wrong with managing the seizures.
And you’re right, they are a clinical sign.
It's not a disease in itself, so in the scenario where you've got a
dog with severe liver disease and hepatic encephalopathy, it's still
right to treat those seizures.
We wanna be giving something for that.
And it's where you've got to then sort of split the medications a
bit because generally speaking, they're metabolized by the liver
or they're excreted by the kidneys.
So in that scenario, you’re better off going down the ones that are
renally excreted because they're much safer in those patients.
And that leaves very few.
But yes, we've got bromide and we've got levetiracetam.
Dr Emma Hancox: Yeah.
Dr Mark Lowrie: Clearly this is a dog that we want quick benefit from.
So bromide isn't ideal as a choice, and it would mean
levetiracetam is a good one to use.
So any dog with liver shunts, acquired shunts, hepatic encephalopathy,
levetiracetams are a fantastic choice and even those dogs that have surgical
correction of their shunts, now goodness, I'm going off to things that I don't
talk about much, but, but even in that scenario, when they have breakthrough,
breakthrough seizures, you know, adding levetiracetam at that stage is
a, is a very sensible option to do.
And maybe if you fix the problem, fix the liver's problem, if it is a fixable cause,
you can stop them again in the future.
But it's just to get them through that time.
Dr Emma Hancox: Yeah
Dr Mark Lowrie: and then you've got dogs that maybe have, well, can I mention cats?
Dr Emma Hancox: Of course you can mention cats.
We haven't hardly talked about them at all, so please mention cats.
Dr Mark Lowrie: Well, cats sort of thinking, hypertension because
I think people forget high blood pressure is enough to cause seizures.
And I say cats because it's more common in them.
It doesn't mean it does happen in dogs too, but it's just more commonly a
present, a presenting sign in cats.
So you can do a full epileptic workup on a cat and use many of the
rules I’ve, I’ve explained for dogs.
I mean it, the same things apply.
But high blood pressure can cause what we call a hypertensive encephalopathy,
and that can then cause seizures.
So in those circumstances, again, it's very reasonable to treat the seizures.
Now, you might want to sort out the blood pressure.
And it would take a medic to take you through that rather than myself.
Dr Emma Hancox: I was gonna say, I thought you were going off
onto your medicine again then.
Dr Mark Lowrie: Well, so, so you know, you definitely want to get the
blood pressure down through whatever means, but giving an anti-epileptic
medication there is very appropriate.
And yeah, you can use levetiracetam, but then phenobarbital comes back
into the picture because hopefully there's no liver disease and
it's a reasonable drug to choose.
Dr Emma Hancox: Yeah.
So you can use levetiracetam in cats, obviously off license,
but they tolerate it well?
Dr Mark Lowrie: They do.
And, and cats in general.
I mean like, yes, we have to sort of, there isn't really
a great cascade for cats.
Well, well there isn't, there aren't many licensed choices I should say.
So we have to go down the cascade and look at what we do in dogs.
So for cats really phenobarbital is, is a great drug to use.
It's a first line approach, works well.
We completely avoid bromide in cats, so yeah, we wouldn't be
giving bromide in cats because they get the allergic pneumonitis.
And then, levetiracetam is great.
You know, it works.
And dare I say it, the problem with levetiracetam in cats, we do, we are
meant to give it three times a day.
Now, I would never do this approach that I'm about to say in dogs,
but in cats you can maybe get away with giving it twice a day.
It does seem to work in, in many of those, of those patients,
dogs always three times a day.
I’ve known twice a day dosing in dogs to make seizures worse, but cats,
we seem be able to get away with it.
Dr Emma Hancox: Interesting that makes seizures worse.
Yeah.
Dr Mark Lowrie: And it seems to be that it's there and it's helping, but then
as, as the dose drops away before that second dose, there's just this period when
seizures can actually come back through.
So I have seen breakthrough seizures from dogs given twice daily levetiracetam,
rather than three times daily.
And people might be thinking, well, you know, is it all right to start twice
daily and up to three times daily?
But I wouldn't, I'd, I'd always go three times a day with levetiracetam.
Dr Emma Hancox: Yeah, and you've just given me another idea actually.
So there's some places that talk about using phenobarbital three times a day.
What do you think about that?
I feel like I’ve just opened a can of worms you didn't wanna answer.
Dr Mark Lowrie: No, I, well, so...
Dr Emma Hancox: The look that he gave me, by the way, everyone.
Dr Mark Lowrie: Well, So, so we start phenobarbital twice a day.
The idea is you take a peak and a trough serum concentration, and I mentioned much
earlier on in this series that you don't have to do that, just be consistent.
But if you’re thinking this dogs really poorly controlled, is
there scope to go to three times a day dosing with phenobarbital?
I do a peak and a trough level, and then you can go to, find a,
a, a special formula if you like, that's, it's on many websites.
You can look up what the, what the half-life is for phenobarbital in that
particular dog using the the equation
Dr Emma Hancox: wow.
Dr Mark Lowrie: and it will tell you whether it is actually appropriate
to go to three times a day.
So dividing three times rather than twice a day with medication.
And that can work.
Dr Emma Hancox: That does sound complicated though.
Dr Mark Lowrie: And I don't want to go into it
Dr Emma Hancox: Yeah.
No, we
Dr Mark Lowrie: because, 'cause it will bore people.
Dr Emma Hancox: That's fine.
I'm getting very off piste and probably very off license for phenobarbital now,
but I'm wondering, just litreally come to my head, if you have a clustering dog,
can you give, that's on Phenobarbital twice a day, can you like add in
another phenobarbital in the middle of the day at times they cluster?
Dr Mark Lowrie: So I'd, I'd only do that when we've done the serum concentration.
So the, the, the, the possibility, yes, possibly you might be able to do it,
but the, the, the serum concentrations peak and trough will help with that.
I suppose I'm, it's made me think of the situation where you've
got a dog in status that comes in that's already on phenobarbital.
I’ve given you great tips in, in the previous episodes about how to, I say
they're great, maybe they're not great.
Maybe they weren't helpful.
Dr Emma Hancox: Blowing his own whistle there.
Dr Mark Lowrie: So I’ve given tips on, on how we give the
phenobarbital in that situation.
But if, if it's a dog already on phenobarbital, then you’re a bit stuck.
So what I do is I still give that initial loading dose of four mgs
per kg of Phenobarbital IV, but then you’re gonna have to look to another
medication to give, and that could be levetiracetam, maybe you can get away
with giving it orally if the dog's just kind of coming round from the fits.
But if it's actively seizuring, you'd have to go for intravenous
levetiracetam which is really expensive
Dr Emma Hancox: right
Dr Mark Lowrie: or you can load bromide.
And what you can do there is you work out your loading dose using everything I’ve
described in the previous episodes, so 600 mgs per kg in total divided over however
many days, you get the tablets and you might not be able to give them orally, but
what you can actually do is crush them up.
You mix them with water and actually give them rectally.
So you give them through a urinary catheter.
Dr Emma Hancox: Oh wow.
Okay.
Dr Mark Lowrie: Put it up the bum and then you, you can inject it.
So it's a way of getting a loading dose of bromide into the dog that's otherwise
fitting and can't take oral medication.
So that can also work, but it's very messy.
Dr Emma Hancox: Yeah.
What is with neurologists and putting everything up the bum?
Dr Mark Lowrie: I didn't think we'd put anything else up the bum.
Oh, we do.
Let's not talk about that.
Dr Emma Hancox: You do rectal diazepam and everything.
Dr Mark Lowrie: Have you, have you ever seen the insert on rectal diazepam?
Dr Emma Hancox: Yes, I have.
Dr Mark Lowrie: Yeah, let's just leave that there, shall we?
Dr Emma Hancox: We'll just leave everyone with that image.
We mentioned it in a previous podcast that I don't want people with epileptic dogs to
think that this is a life sentence, like this is quite, we've, maybe we were trying
to make it simple with some of these podcasts, you can do this and that and you
can follow these guidelines, but I felt like we've undone that on this podcast.
We've just gone, yeah, you can use all these different combinations and
things, but this can feel obviously quite overwhelming for us, but
obviously quite overwhelming for the owners as well at the end of the day.
Just wanted to go back to them really, because it's obviously tailoring the
approach yes, for that patient, but if we remember, also for that owner.
So don't know whether you had any words on that one?
Dr Mark Lowrie: Yeah, I mean, I guess we need to remind ourselves that
epileptic dogs are still normal patients.
There's no pain associated with the condition, dogs that suffer a
seizure will recover most of the time.
It's very rare to have sudden death from seizures.
It's not impossible, but it's very rare, so they should recover and
they may be a bit disorientated or confused, but they're otherwise okay.
So that's important.
I think when you get an owner come in with a dog with these seizures,
It really depends on how bad the seizures are, but you'll often get
an owner come in at their wits end.
Dr Emma Hancox: Yeah.
Dr Mark Lowrie: And I’ve always said that you need to give
owners all of the options.
Now, this is a bit miserable to bring this up, but I think it is important
that one of those options is euthanasia.
It's wrong not to discuss euthanasia with the owners because you will get
some owners that when you enter that discussion, they actually, they almost
breathe a sigh of relief to go, oh, that's an option I hadn't realised.
Dr Emma Hancox: Yeah.
Dr Mark Lowrie: Because they may see it as a, a cruel thing to do for their dog.
You know, why am I, am I doing it for, for me, putting my dog to sleep?
Because I don't want to see it any more?
But if, if it's really impacting on your quality of life too, it's
not wrong to consider euthanasia if it's that frequent and that bad.
So I’ve known of owners I’ve met where their dog will have several fits a day
and they're still going, going with it for their pet to try and give them the
best quality of life, life possible.
Dr Emma Hancox: Yeah.
Dr Mark Lowrie: But I remember one individual in particular, and when I
mentioned to her, you know, euthanasia is an option, she broke down in
tears and I thought I'd upset her.
But no, she was really, really relieved to hear it.
And so there are owners out there that have that feeling that they
just want someone to say it is an option, and it's always an option.
It becomes more a consideration as things worsen, of course, but if, if you speak
about that, and even at the very first consult, now this, this is, and I think,
but right at the first consult mentioning that euthanasia is something you'll
likely to have to consider in the future.
If it gets bad, it prepares them.
So when that day comes, it's not a huge shock.
Now hopefully that's years away and, and really, hopefully it's something
that may never even need to consider, but we have to be upfront about
this and it's the thing that's not always talked about with epilepsy.
We don't mention euthanasia enough, and I think, yes, don't mention
it every time they come in, that's not the right way to go, but it
needs putting in at the right time.
So the owners know that if you've mentioned it, they won't feel bad
bringing it up at the time when they feel it's right for them.
Dr Emma Hancox: That's absolutely what I was gonna pick up on is that I think
owners don't want to mention it a lot of the time or talk about it because
they feel guilty for bringing it up and feel like they're the ones making
the ultimate decision when it actually, it should be all of this, right?
We're, this is everything that we're saying.
It should be a team approach between us all.
So we just need to have those open discussions and allow them
to voice how they're feeling.
Dr Mark Lowrie: Yeah.
And make sure that they don't feel like they're being cruel or selfish
Dr Emma Hancox: Yeah.
Yeah.
Dr Mark Lowrie: Because they're not, they're not, you know,
they need to understand that.
Dr Emma Hancox: Absolutely.
Absolutely.
Although on the flip side of that, hopefully, sometimes I had clients
come in the very first time with a seizure and they go, that's it.
That's it.
it's the day I am having my dog put to sleep and I'm, no, it's not.
No, we can try something first.
So it's just the flip side of that as well.
Dr Mark Lowrie: It's true, especially with something like status, because
actually if you mention euthanasia in the first consult with status,
then that will be elected for, and of course that's not the right thing.
Yeah.
So it's important to know when to bring it up and whether it's correct to bring
it up immediately, but it is a discussion that needs to be had at some point.
Yeah.
But you’re absolutely right.
It's, that's, that's, it's like the art of veterinary medicine,
we always say, isn't it?
Dr Emma Hancox: It really is.
Dr Mark Lowrie: It's not clear cut.
We're scientists and we have to try and negotiate the right thing with
these people and it's very difficult.
Dr Emma Hancox: Yeah.
And all of us get into this to treat the animals and we're here
treating the owners and counselling the owners at the end of the day.
Dr Mark Lowrie: Yes, yes.
And then drinking at the end of the day ourselves, because
that's the way to cope with it.
Dr Emma Hancox: Okay, let's try and end on a more positive note.
I feel like it went really deep there in quite ethical questions, wasn't it?
I just want to finish off, is there, if you could say or give one piece of
advice or words of wisdom to us GP vets in clinical practice, what would it be?
Dr Mark Lowrie: Yeah, that's a really tough one.
So throughout these podcasts, I'd like to think you were carrying around
sort of certain patients in your head.
There are probably, certain dogs, cats, guinea pigs that might
come in with, with epilepsy.
And, and you, you really, you, you almost dread seeing those owners because
you’re kind of like, well, I, I feel I’ve done so much, what more can I do?
So I think the main message I'd want to give across is in those
situations with those cases that are dogs that are very difficult to
manage, I'd really wanna reassure you that you’re doing nothing wrong.
There may be some tips you've picked up here that might help in
the management, and that's great.
And I, I hope that's the case, that there's a bit more
you can do there to help.
But you've not done anything wrong, it's not you failing as a vet,
it's because you’re dealing with a very difficult condition that we
would all struggle to cope with.
So don't be afraid when you have those cases that are going badly,
it's not you, it's the dog.
And that's, that's how I'd sort of summarise it.
Dr Emma Hancox: That's really reassuring actually to hear.
Help quell all of us.
Thank you Mark.
This series has been really brilliant.
I’ve learned so much and it really has just helped to discuss some of
these things that often are forgotten aspects of epilepsy management.
Note, I'm saying management now, not treatment.
So you've taught me something.
I do definitely hold my hands up and say that sometimes I used to get stuck
in the numbers, and I think I said this in the very first episode actually,
that whether that be looking at serum concentrations, the biochemistry, those
liver enzymes, the seizure numbers, and I just forget to just take that step
back and look at that bigger picture.
So that's probably the most important part I was missing though.
I really could sit here all day discussing the nuances of
epilepsy management with you.
But just a reminder to our listeners, this was the fifth and final part of
our series on the S.M.A.R.T Approach.
So if you haven't already, please do check out the previous
episodes for more information.
We would also be really grateful if you could tell us what you think of
these, if they've taken off and people do enjoy these, we would be more than
happy to get back together and to keep having these podcasts and discussions
if that's what you would like.
Equally, if you want to email us at TVM or if you want to get in contact with Mark,
I'm sure he would be happy with that.
He's based at Movement Referrals and if there's any areas of epilepsy you
would like us to do some podcasts on that maybe we haven't covered, then
equally, please do feel free to give us some information, give us some ideas,
so hopefully we'll see you again soon.
Thanks again so much, Mark.
Thank you.
Dr Mark Lowrie: Thank you.
It's been a pleasure.
Dr Emma Hancox: Perfect.
Thanks so much guys.
Bye.
Dr Mark Lowrie: Bye bye.