1 00:00:00,120 --> 00:00:03,240 Dr Emma Hancox: Welcome back to the Synaptic Tails Podcasts with your 2 00:00:03,240 --> 00:00:08,310 host, Emma Hancox, TVM Technical Vet, and Mark Lowrie, RCVS and European 3 00:00:08,315 --> 00:00:12,000 Specialist in Veterinary Neurology, and Co-director of Movement Referrals. 4 00:00:12,450 --> 00:00:12,960 Hi Mark. 5 00:00:12,960 --> 00:00:13,680 How are you today? 6 00:00:14,250 --> 00:00:15,240 Dr Mark Lowrie: Well, I'm a bit sad today. 7 00:00:15,240 --> 00:00:16,320 Dr Emma Hancox: Why are you sad? 8 00:00:16,350 --> 00:00:17,790 Dr Mark Lowrie: This is the last podcast 9 00:00:17,860 --> 00:00:20,320 Dr Emma Hancox: it's the last in the S.M.A.R.T Series, but hopefully it's 10 00:00:20,320 --> 00:00:22,030 not going to be our last one, so... 11 00:00:22,180 --> 00:00:23,320 Dr Mark Lowrie: That's good to hear. 12 00:00:23,320 --> 00:00:24,820 Dr Emma Hancox: That's if you'll come back? 13 00:00:25,030 --> 00:00:26,500 Dr Mark Lowrie: Oh, well, I’ll happily come back, but it's whether 14 00:00:26,500 --> 00:00:27,860 our listeners will come back to us. 15 00:00:27,940 --> 00:00:28,650 Dr Emma Hancox: That's true. 16 00:00:28,650 --> 00:00:32,995 So hopefully by now all our listeners will know this has been a series of 17 00:00:32,995 --> 00:00:37,135 podcasts dedicated to the S.M.A.R.T Approach to epilepsy, which was TVMs new 18 00:00:37,135 --> 00:00:38,845 guide for first opinion practitioners. 19 00:00:39,415 --> 00:00:42,504 Over the last four episodes, we've chatted through various aspects of 20 00:00:42,504 --> 00:00:44,335 how to manage our epileptic patients. 21 00:00:44,565 --> 00:00:48,625 This episode, as Mark said, is the last in that S.M.A.R.T Approach. 22 00:00:48,625 --> 00:00:53,349 But don't fear if Mark will have us, we are, we hope to come back and 23 00:00:53,349 --> 00:00:55,120 continue our discussions in the future. 24 00:00:55,748 --> 00:00:58,331 If you are new to the podcast and haven't listened to the earlier 25 00:00:58,331 --> 00:01:01,721 episodes, I do encourage you to pause this episode and take a listen now. 26 00:01:02,681 --> 00:01:06,431 So today we'll be discussing the final step, as we said, which is tailor. 27 00:01:06,431 --> 00:01:10,841 So this is all about tailoring your approach to each case and to each owner. 28 00:01:11,261 --> 00:01:13,901 I wonder, Mark, what does tailor mean to you? 29 00:01:14,426 --> 00:01:14,546 Dr Mark Lowrie: Yeah. 30 00:01:14,546 --> 00:01:18,356 Well, I guess we've got through four of these podcasts without, without actually 31 00:01:18,356 --> 00:01:20,616 touching on when to start treatment. 32 00:01:20,951 --> 00:01:22,961 Dr Emma Hancox: That's very true, maybe an oversight on our part. 33 00:01:23,156 --> 00:01:23,696 Dr Mark Lowrie: Not at all. 34 00:01:23,726 --> 00:01:24,326 Not at all. 35 00:01:24,326 --> 00:01:26,366 But I think, you know, it's, it's really important that we, we think about, 36 00:01:26,966 --> 00:01:28,796 when are we gonna start medication? 37 00:01:29,456 --> 00:01:32,426 And I’ve said all the way along that there's no hard and fast rules. 38 00:01:32,426 --> 00:01:35,036 So that's why you never read something that says you must 39 00:01:35,156 --> 00:01:37,046 start medication at this point. 40 00:01:37,586 --> 00:01:42,506 There is guidance out there, but some people say if a dog has two seizures 41 00:01:42,506 --> 00:01:45,596 within a six month period, that would be a reason to start medication. 42 00:01:46,301 --> 00:01:46,991 And that's true. 43 00:01:47,051 --> 00:01:48,311 You know, that would be a reason. 44 00:01:48,821 --> 00:01:50,741 But it doesn't mean you have to, and it doesn't mean you 45 00:01:50,741 --> 00:01:52,151 necessarily need to recommend that. 46 00:01:52,781 --> 00:01:56,261 It's a case of discussing with that owner what they want to do. 47 00:01:56,981 --> 00:01:59,711 And I will have owners that will want to start medication very, very 48 00:01:59,711 --> 00:02:01,511 early on in the course of epilepsy. 49 00:02:02,351 --> 00:02:05,951 But if they understand that starting medication early may mean we've got 50 00:02:06,041 --> 00:02:11,261 less options in the future, and holding off may be better while the epilepsy 51 00:02:11,261 --> 00:02:13,901 isn't too severe, then that's fine too. 52 00:02:14,606 --> 00:02:17,696 Now the big thing to talk about here is kindling. 53 00:02:18,206 --> 00:02:22,466 So there's this word kindling, and all kindling means, it's the idea that one 54 00:02:22,466 --> 00:02:24,476 seizure might lead to another seizure. 55 00:02:24,791 --> 00:02:25,091 Dr Emma Hancox: Right. 56 00:02:25,676 --> 00:02:28,646 Dr Mark Lowrie: So if a dog has a fit, it's more likely to 57 00:02:28,651 --> 00:02:30,356 have another fit in the future. 58 00:02:31,016 --> 00:02:35,216 And the more fits it has, the more fits it's likely to have later on. 59 00:02:35,976 --> 00:02:36,376 Dr Emma Hancox: Makes sense. 60 00:02:37,376 --> 00:02:40,796 Dr Mark Lowrie: So the idea is that if we start medication and can stop 61 00:02:40,801 --> 00:02:45,446 the fits, then it's less likely to progress into a more severe 62 00:02:45,446 --> 00:02:47,156 seizure situation down the line. 63 00:02:47,996 --> 00:02:52,106 So I'm arguing with myself right now because it's, you know, do we start it 64 00:02:52,106 --> 00:02:56,846 early and try and prevent that kindling effect or do we hold off medication and 65 00:02:56,846 --> 00:02:58,616 maybe wait till further down the line? 66 00:02:59,336 --> 00:03:02,186 Clearly there's no right answer, but I think if an owner knows that 67 00:03:02,216 --> 00:03:05,036 and knows that's the situation that we face, that's the dilemma, 68 00:03:05,756 --> 00:03:07,526 and then we can decide what to do. 69 00:03:08,366 --> 00:03:11,456 So each dog, and certainly each owner, really needs a 70 00:03:11,456 --> 00:03:13,586 bespoke approach to epilepsy. 71 00:03:14,516 --> 00:03:18,086 I’ve mentioned it before, but dogs with objection or postictal signs, maybe that's 72 00:03:18,086 --> 00:03:19,856 the reason to start medication earlier. 73 00:03:21,266 --> 00:03:27,146 My approach probably is to say if a dog has one seizure, I don't start 74 00:03:27,151 --> 00:03:30,806 medication 'cause we do know there are dogs out there where they may 75 00:03:30,806 --> 00:03:34,826 only ever have one fit and we don't know why, but it never happens again. 76 00:03:35,096 --> 00:03:37,526 So let's not condemn that dog to a life of medication. 77 00:03:38,156 --> 00:03:41,906 But as soon as we're dealing with two or more fits, then medication is reasonable. 78 00:03:42,281 --> 00:03:46,331 My approach is maybe two fits in a six week period might be me 79 00:03:46,331 --> 00:03:49,571 pushing more towards medication than steering away from it. 80 00:03:49,721 --> 00:03:50,051 Dr Emma Hancox: right. 81 00:03:50,771 --> 00:03:53,591 Dr Mark Lowrie: But as I say, it really, really depends on the 82 00:03:53,591 --> 00:03:55,781 owner and they're the ones who are going to make the decision 83 00:03:56,071 --> 00:03:56,361 Dr Emma Hancox: Yeah, 84 00:03:56,891 --> 00:03:57,791 Dr Mark Lowrie: and decide what to do. 85 00:03:57,791 --> 00:03:59,531 So for me, that's what tailor means. 86 00:03:59,536 --> 00:04:02,891 It's about sitting down and having that conversation and making sure 87 00:04:02,891 --> 00:04:06,671 that owner gets the management that's right for their situation. 88 00:04:07,971 --> 00:04:10,721 Dr Emma Hancox: Is there any situations in which it's definitely 89 00:04:10,721 --> 00:04:12,101 recommended to start treatment? 90 00:04:12,986 --> 00:04:13,826 Dr Mark Lowrie: Yeah, there definitely are. 91 00:04:13,826 --> 00:04:17,606 I mean, I suppose we can list off quite a few, some are obvious, of course. 92 00:04:17,611 --> 00:04:22,206 So a dog with status epilepticus or with severe cluster seizures. 93 00:04:22,436 --> 00:04:25,046 I think there's no doubt there that we'd all be in agreement that 94 00:04:25,046 --> 00:04:26,816 medication is the right thing to do. 95 00:04:28,106 --> 00:04:32,566 One thing I, I pick up on there briefly while I think of it is Status Epilepticus. 96 00:04:32,566 --> 00:04:35,866 We did talk about giving Diazepam in an earlier podcast and how we can use 97 00:04:35,866 --> 00:04:40,456 that to treat epilepsy, but I'd always wanna say, don't ever get confused that 98 00:04:40,456 --> 00:04:44,971 diazepam isn't really treating seizures in a long-term way, it's helping in that 99 00:04:44,971 --> 00:04:47,101 moment, in that emergency situation. 100 00:04:47,101 --> 00:04:51,871 So if you do have a dog in status and you give diazepam and you’re fortunate enough 101 00:04:51,871 --> 00:04:56,421 that things work and, and, these seizures have stopped, definitely, definitely start 102 00:04:56,421 --> 00:04:58,521 a long-term antiepileptic medication. 103 00:04:58,851 --> 00:05:01,371 I have known dogs, well, that's not been done, and inevitably 104 00:05:01,371 --> 00:05:03,231 it has fits at a later date. 105 00:05:03,231 --> 00:05:06,921 So status epilepticus, start medication. 106 00:05:07,896 --> 00:05:12,276 We've also talked about whenever you find an underlying disease, we want to 107 00:05:12,276 --> 00:05:15,786 start medication, you know, so you've got a disease underlying the fits. 108 00:05:16,176 --> 00:05:20,316 It may or may not be treatable, but whichever one it is, we still want 109 00:05:20,316 --> 00:05:23,076 to give medication to try and prevent further seizures because they're always 110 00:05:23,076 --> 00:05:24,486 gonna be damaging in their own way. 111 00:05:24,906 --> 00:05:26,046 So that's another reason. 112 00:05:27,066 --> 00:05:31,896 If you've got severe postictal signs, so aggression or a dog that really takes 113 00:05:31,896 --> 00:05:33,996 a very long time to recover from a fit. 114 00:05:34,536 --> 00:05:36,786 That's another reason to start the medication. 115 00:05:37,506 --> 00:05:40,866 And simply things like multiple seizures in a, in a short period of time. 116 00:05:41,176 --> 00:05:43,756 It may be they only have them every 8 to 12 weeks, but when 117 00:05:43,756 --> 00:05:44,836 they have them, they're bad. 118 00:05:45,136 --> 00:05:48,526 Well, there's another circumstance where we might think about treating, 119 00:05:49,716 --> 00:05:50,006 Dr Emma Hancox: Yeah, 120 00:05:50,116 --> 00:05:55,006 Dr Mark Lowrie: but if you are, if you've been monitoring a dog over some time and 121 00:05:55,006 --> 00:05:58,096 you haven't started medication, but then they are getting a bit more frequent 122 00:05:58,096 --> 00:06:02,536 steadily, again, I'd be moving more towards the treatment than away from it. 123 00:06:02,536 --> 00:06:05,506 So sort of increased frequency of seizures is another time to, 124 00:06:05,506 --> 00:06:06,706 to actually give the medication. 125 00:06:07,156 --> 00:06:09,856 Dr Emma Hancox: Yeah, so like you said, it sounds like there's not 126 00:06:09,856 --> 00:06:13,456 one right or wrong answer to this. 127 00:06:13,736 --> 00:06:18,331 So yes, there's definitely some situations, but I wanted to pick up if I 128 00:06:18,331 --> 00:06:24,931 can, that other cases that maybe warrant a little bit more of a specific approach 129 00:06:24,931 --> 00:06:26,671 or a different approach, put it that way. 130 00:06:26,721 --> 00:06:29,421 One thing I want to pick up on is the clustering dog. 131 00:06:29,511 --> 00:06:34,101 So it's not infrequent, for me anyway I don't know whether I was unlucky 132 00:06:34,551 --> 00:06:40,061 in practice, to have a case where I had started them on phenobarbital, 133 00:06:40,081 --> 00:06:45,031 for instance, and then they won't have seizures for weeks or months, 134 00:06:45,031 --> 00:06:50,131 and then suddenly they will have kind of four or more over usually 135 00:06:50,131 --> 00:06:51,391 a weekend when we're not there. 136 00:06:51,596 --> 00:06:51,816 Dr Mark Lowrie: Yes. 137 00:06:52,096 --> 00:06:52,276 Yeah. 138 00:06:52,541 --> 00:06:54,371 Dr Emma Hancox: So how do you manage those? 139 00:06:54,371 --> 00:06:56,561 Do you put them on a second line or? 140 00:06:57,341 --> 00:06:58,931 I would just be interested in your thoughts. 141 00:06:59,156 --> 00:07:00,596 Dr Mark Lowrie: I suppose it depends what they're on already. 142 00:07:00,596 --> 00:07:03,686 But I mean, I suppose these dogs may be already on phenobarbital and 143 00:07:03,686 --> 00:07:05,216 they may or may not be on bromide. 144 00:07:05,216 --> 00:07:09,896 So, you know, we can think about putting in bromide, but the clusters, 145 00:07:09,901 --> 00:07:13,106 I mean, that's where drugs such as levetiracetam are really helpful. 146 00:07:13,106 --> 00:07:18,971 So levetiracetam is a very rapidly, well, a drug that works very rapidly, it comes, 147 00:07:18,971 --> 00:07:20,861 gets into the body and it works quickly. 148 00:07:20,861 --> 00:07:24,641 So within sort of 24, 48 hours, you've got a really reasonable dose of that drug 149 00:07:24,641 --> 00:07:26,741 in the system trying to prevent seizures. 150 00:07:27,431 --> 00:07:31,091 So in your situation where you've got a dog with a very long period of, 151 00:07:31,201 --> 00:07:34,171 quiescence, if you like, no, no seizures, no fits, and the dog's well, and then 152 00:07:34,171 --> 00:07:38,791 it has say, 48 hour period of lots of seizures, let's say in double figures. 153 00:07:39,661 --> 00:07:43,801 What you can do is after that first fit in the potential cluster, I would 154 00:07:43,801 --> 00:07:49,531 start levetiracetam and I'd give it three times a day during that period 155 00:07:50,041 --> 00:07:53,371 until we know that the likelihood of those seizures has passed by. 156 00:07:53,701 --> 00:07:55,291 So I go quite high with the dose. 157 00:07:55,291 --> 00:07:58,351 I mean, the standard dose for levetiracetam is about 20 158 00:07:58,651 --> 00:08:00,271 mgs per kg three times a day. 159 00:08:00,961 --> 00:08:04,891 But in that circumstance, I'd happily got to 30 mgs per kg three times a day. 160 00:08:05,206 --> 00:08:07,966 Partly because you’re in a situation where the owner really 161 00:08:07,966 --> 00:08:09,586 doesn't want to see the fits. 162 00:08:09,886 --> 00:08:14,936 So they probably will allow, or, or accept, I should say, the, the side 163 00:08:14,936 --> 00:08:17,736 effects that would come with that slightly higher dose of levetiracetam. 164 00:08:17,756 --> 00:08:22,886 So I'd go 30 mgs per kg and I'd do it for double the length of the cluster. 165 00:08:23,006 --> 00:08:26,456 What I mean by that is if we know from historically that this dog will 166 00:08:26,456 --> 00:08:31,481 cluster over a 48 hour period, then I’ll maybe do, do the cluster, the 167 00:08:31,481 --> 00:08:33,401 levetiracetam dose over four days. 168 00:08:33,821 --> 00:08:37,001 Hopefully to be sure we've then got rid of the cluster, they've gone, 169 00:08:37,001 --> 00:08:40,031 and then we, we take the dog off medication and see how things go. 170 00:08:40,841 --> 00:08:43,281 A big advantage of that is people talk about levetiracetam 171 00:08:43,306 --> 00:08:44,801 having the honeymoon effect. 172 00:08:44,831 --> 00:08:46,781 Dr Emma Hancox: Yeah, I’ve heard, I was gonna ask you actually about that. 173 00:08:46,781 --> 00:08:47,741 Do you agree with that? 174 00:08:47,771 --> 00:08:49,691 It's something that gets banded around, isn't it? 175 00:08:49,811 --> 00:08:51,701 Dr Mark Lowrie: I think it's a lot less common than people say. 176 00:08:52,416 --> 00:08:55,266 I think it does happen because it's come from somewhere and we've seen evidence 177 00:08:55,266 --> 00:08:57,066 of it in dogs, but it's not that common. 178 00:08:57,066 --> 00:09:01,806 So I’ve heard people using the honeymoon effect as an excuse not to start 179 00:09:01,806 --> 00:09:04,386 levetiracetam, so I wouldn't do that. 180 00:09:04,476 --> 00:09:07,036 It's absolutely an option out there and it's one of my favourite 181 00:09:07,056 --> 00:09:08,676 medications to use in epilepsy. 182 00:09:08,676 --> 00:09:12,126 So, yes, I'd always use it, but we have to be open to the fact that if 183 00:09:12,126 --> 00:09:16,236 we are giving it three times a day, every day, a tolerance may develop. 184 00:09:16,416 --> 00:09:21,741 So, Pulse dosing with these clusters is a, is a great way of trying to avoid that. 185 00:09:22,191 --> 00:09:25,741 But if you need to give it persistently, then do, because that's what we're 186 00:09:25,741 --> 00:09:26,811 going to have to do for the dog. 187 00:09:26,841 --> 00:09:28,191 So that's my approach there. 188 00:09:28,251 --> 00:09:34,041 Dr Emma Hancox: Yeah, so does, I'm just curious, does tolerance say, I 189 00:09:34,041 --> 00:09:37,372 don't know why it's more described of Levetiracetam, but does it happen to 190 00:09:37,377 --> 00:09:39,651 the other drugs as well, do we think? 191 00:09:39,651 --> 00:09:42,201 Or is it more just epilepsy progression? 192 00:09:42,306 --> 00:09:44,976 Dr Mark Lowrie: Yeah, I mean there's a kind of tolerance, I guess with 193 00:09:44,981 --> 00:09:46,506 phenobarbital because we talked about it. 194 00:09:46,511 --> 00:09:48,036 That idea of auto induction. 195 00:09:48,036 --> 00:09:48,096 Yeah. 196 00:09:48,156 --> 00:09:53,166 Where the, the body gets used to that dose of phenobarbital and we have 197 00:09:53,166 --> 00:09:54,606 to increase the dose accordingly. 198 00:09:56,001 --> 00:09:59,991 So with levetiracetam, it's not got that auto induction, but it just, 199 00:10:00,441 --> 00:10:03,831 even if you go higher with the doses, you just don't get the effect 200 00:10:03,836 --> 00:10:05,031 from it that you would want to get. 201 00:10:05,031 --> 00:10:07,881 So, levetiracetam is a bit unique in that way. 202 00:10:07,911 --> 00:10:09,381 Dr Emma Hancox: Yeah, no, fair enough. 203 00:10:09,951 --> 00:10:14,098 There's potentially, you mentioned actually before, cases where you might 204 00:10:14,098 --> 00:10:18,483 want to introduce two drugs at one time if we don't want to load them. 205 00:10:18,753 --> 00:10:23,253 So this I realise is going a little bit against what we talked about earlier in 206 00:10:23,253 --> 00:10:25,293 following those levels of recommendation. 207 00:10:25,293 --> 00:10:28,383 But again, this is just tailoring that approach, isn't it really? 208 00:10:28,383 --> 00:10:31,623 So if you could just tell our listeners what you were talking 209 00:10:31,623 --> 00:10:32,773 to me about, that would be great? 210 00:10:33,048 --> 00:10:36,018 Dr Mark Lowrie: Yeah, I guess you, you can have a situation where you've got a 211 00:10:36,018 --> 00:10:41,098 dog that's had repeated seizures and is on phenobarbital, and it's used effectively. 212 00:10:41,703 --> 00:10:43,653 We always have to say that, you know, we've got the right, 213 00:10:43,753 --> 00:10:44,593 Dr Emma Hancox: Just check that first. 214 00:10:44,893 --> 00:10:45,913 Dr Mark Lowrie: absolutely always. 215 00:10:46,003 --> 00:10:49,243 Please, please exploit phenobarbital before you move on to a second drug. 216 00:10:49,903 --> 00:10:52,663 But you may have done that and the dog still has frequent seizures. 217 00:10:52,663 --> 00:10:56,023 And for argument's sake, let's say it has three seizures. 218 00:10:56,413 --> 00:10:57,553 No, no. 219 00:10:58,183 --> 00:11:00,283 Let's say it has two seizures per week. 220 00:11:01,243 --> 00:11:05,623 Now the owner still feels that's not acceptable control and that's fine. 221 00:11:05,683 --> 00:11:08,643 You know, they have, they have a right to want to get better control than that. 222 00:11:08,753 --> 00:11:08,993 Dr Emma Hancox: Yeah. 223 00:11:09,513 --> 00:11:10,648 Dr Mark Lowrie: So what do you do there? 224 00:11:10,648 --> 00:11:13,798 I mean, according to the cascade, we should probably add in potassium bromide, 225 00:11:14,878 --> 00:11:18,118 but what we've said already is potassium bromide takes three months to work. 226 00:11:18,148 --> 00:11:21,838 So if we give it at the standard maintenance dose, we're gonna 227 00:11:21,838 --> 00:11:24,748 be waiting three months until it has a, a reasonable effect. 228 00:11:24,898 --> 00:11:26,428 Now, it may work earlier than that. 229 00:11:26,433 --> 00:11:29,128 It may reduce frequency slowly over that three months, but we 230 00:11:29,128 --> 00:11:33,798 are waiting three months for full control with the bromide, or full 231 00:11:33,798 --> 00:11:35,748 effect, I should say, of the bromide. 232 00:11:39,003 --> 00:11:41,253 You could then go, well, let's load the bromide. 233 00:11:41,403 --> 00:11:43,623 Let's, let's give it much more quickly. 234 00:11:43,713 --> 00:11:45,723 Let's load it over two weeks perhaps. 235 00:11:45,723 --> 00:11:48,453 So we, we don't wanna give a massive dose straight away, but 236 00:11:48,453 --> 00:11:49,923 maybe over a two week period. 237 00:11:51,213 --> 00:11:53,763 But the problem there is you’re still gonna get a lot of adverse effects and 238 00:11:53,763 --> 00:11:56,523 that owner may not be happy with that, that you’re right, they're gonna be left 239 00:11:56,523 --> 00:11:59,043 with the dog that's very, very wobbly and falling all over the place and, alright, 240 00:11:59,043 --> 00:12:01,383 maybe the fits are better controlled. 241 00:12:01,473 --> 00:12:04,443 Maybe it's now only seizuring once a week, but it's got quite 242 00:12:04,443 --> 00:12:07,308 a, a poor lifestyle in between. 243 00:12:07,488 --> 00:12:09,168 So its quality of life is diminished. 244 00:12:09,768 --> 00:12:12,948 So what I do there is I wouldn't have a worry with actually starting 245 00:12:12,948 --> 00:12:14,748 the bromide at a maintenance dose. 246 00:12:14,748 --> 00:12:18,948 So say your standard 20, maybe up to 30 mgs per kg once a day. 247 00:12:19,668 --> 00:12:23,968 But because they want a quick fix on the seizures, we can add in levetiracetam 248 00:12:23,988 --> 00:12:27,498 at the same time, at the standard dose of 20 mg per kg three times a day. 249 00:12:28,038 --> 00:12:30,138 And what you’re doing is you’re giving levetiracetam for a short 250 00:12:30,138 --> 00:12:34,023 period of time up until the bromide reach reaches steady state. 251 00:12:34,353 --> 00:12:38,313 So I'd keep it going, the levetiracetam and the Bromide for three months. 252 00:12:38,613 --> 00:12:42,633 I check the blood levels of the bromide at three months, and if you've achieved 253 00:12:42,663 --> 00:12:46,483 the therapeutic concentration with the bromide, I'd then stop the levetiracetam. 254 00:12:47,073 --> 00:12:49,683 We've talked about stopping antiepileptic medications and being 255 00:12:49,683 --> 00:12:53,043 cautious of it, but with levetiracetam it is safe to stop it straight away. 256 00:12:53,043 --> 00:12:54,123 Dr Emma Hancox: Okay, I was gonna ask that actually 257 00:12:54,343 --> 00:12:56,628 Dr Mark Lowrie: Without too much of the risk of withdrawal seizures. 258 00:12:56,628 --> 00:13:00,078 So because there's not that auto induction, it's the auto induction 259 00:13:00,138 --> 00:13:02,508 that means with phenobarbital, we have to be a lot more worried. 260 00:13:02,583 --> 00:13:02,873 Dr Emma Hancox: Yeah. 261 00:13:03,253 --> 00:13:06,513 So in that situation, why don't you just start them on and 262 00:13:06,513 --> 00:13:07,683 keep them on levetiracetam? 263 00:13:08,538 --> 00:13:10,458 Dr Mark Lowrie: And the reason I wouldn't do that is because it's 264 00:13:10,463 --> 00:13:11,928 a nice drug to have down the line. 265 00:13:12,438 --> 00:13:17,958 This dog's still got relatively infrequent fits, and I think, yes, 266 00:13:17,958 --> 00:13:22,128 it's not wrong to do levetiracetam, but it's fair to say it's against the 267 00:13:22,128 --> 00:13:23,793 cascade, that shouldn't be a problem. 268 00:13:23,798 --> 00:13:25,233 You know, you've got a good reason to do it. 269 00:13:25,283 --> 00:13:29,273 But I think levetiracetam is one of those drugs that it's, you know, it's nice 270 00:13:29,273 --> 00:13:31,823 to add later on because you’re gonna get a good beneficial effect from it. 271 00:13:31,823 --> 00:13:33,173 And we know bromide works. 272 00:13:33,503 --> 00:13:37,673 We know it has a good, sustained long-term control, and generally 273 00:13:37,673 --> 00:13:38,753 it has few side effects. 274 00:13:38,753 --> 00:13:40,493 So it's my preferred choice. 275 00:13:41,363 --> 00:13:45,023 It's, the disadvantage being we just have to wait longer, but that's fine. 276 00:13:45,203 --> 00:13:48,443 You know, we've, we've got the option of waiting longer and if you, if you did do 277 00:13:48,443 --> 00:13:51,983 levetiracetam and then the dog seizures worsened, which they inevitably will 278 00:13:51,988 --> 00:13:57,068 do, we haven't got anything to add in to try and help the bromide work so get the 279 00:13:57,068 --> 00:14:00,518 bromide on the scene as soon as you can, is my view there, whilst you've still 280 00:14:00,518 --> 00:14:03,338 got time and other options to, to add in. 281 00:14:03,423 --> 00:14:03,713 Dr Emma Hancox: Yeah. 282 00:14:04,043 --> 00:14:05,243 It's saving stuff for later. 283 00:14:05,528 --> 00:14:06,248 Dr Mark Lowrie: Absolutely. 284 00:14:06,503 --> 00:14:07,913 Dr Emma Hancox: Because then you've not really got anything 285 00:14:07,913 --> 00:14:09,373 that works that quickly. 286 00:14:10,568 --> 00:14:11,318 Dr Mark Lowrie: No, no. 287 00:14:11,318 --> 00:14:13,238 I mean, after that you've got all the other medications like 288 00:14:13,243 --> 00:14:14,768 Gabapentin and Zonisamide. 289 00:14:15,398 --> 00:14:17,828 They might work quickly in terms of they reach steady state 290 00:14:17,828 --> 00:14:19,298 quickly, but they don't work well. 291 00:14:19,658 --> 00:14:20,498 So you’re absolutely right. 292 00:14:20,498 --> 00:14:22,358 There aren't alternatives to add in that would help. 293 00:14:22,493 --> 00:14:22,883 Dr Emma Hancox: Yeah. 294 00:14:23,123 --> 00:14:24,533 Yeah, no, that's fair enough. 295 00:14:25,103 --> 00:14:29,993 The other kind of cases that I wanted to pick up from this as well is 296 00:14:30,203 --> 00:14:34,733 the use of anti-epileptic drugs to control seizures of other causes. 297 00:14:35,303 --> 00:14:42,138 So I, I have to think about seizures as they're just like a symptom or a 298 00:14:42,138 --> 00:14:43,788 clinical sign at the end of the day. 299 00:14:43,788 --> 00:14:46,728 So there may be manifestations from other diseases. 300 00:14:47,028 --> 00:14:49,518 So some of the questions we get through the tech lines, for 301 00:14:49,518 --> 00:14:53,598 instance, I just pick up an example being hepatic encephalopathy. 302 00:14:54,168 --> 00:14:59,958 So there's cases where obviously they're treating as appropriate that 303 00:14:59,988 --> 00:15:05,118 hepatic encephalopathy perhaps, but they obviously want to control any seizures. 304 00:15:06,078 --> 00:15:08,808 Obviously the prognosis for the dog may be poor. 305 00:15:08,808 --> 00:15:09,828 I appreciate that. 306 00:15:09,828 --> 00:15:14,688 But if they are looking to treat those seizures, what's, obviously we 307 00:15:14,688 --> 00:15:19,668 won't wanna be using phenobarbital in that situation, so what sort of 308 00:15:19,728 --> 00:15:21,178 recommendations would you use for that? 309 00:15:22,218 --> 00:15:23,988 Dr Mark Lowrie: Well, I think again, it comes back to whenever 310 00:15:23,988 --> 00:15:27,258 you've got seizures, there's nothing wrong with managing the seizures. 311 00:15:27,258 --> 00:15:28,938 And you’re right, they are a clinical sign. 312 00:15:28,998 --> 00:15:33,618 It's not a disease in itself, so in the scenario where you've got a 313 00:15:33,623 --> 00:15:36,858 dog with severe liver disease and hepatic encephalopathy, it's still 314 00:15:36,858 --> 00:15:38,088 right to treat those seizures. 315 00:15:38,088 --> 00:15:39,648 We wanna be giving something for that. 316 00:15:39,708 --> 00:15:42,588 And it's where you've got to then sort of split the medications a 317 00:15:42,588 --> 00:15:45,438 bit because generally speaking, they're metabolized by the liver 318 00:15:45,438 --> 00:15:46,848 or they're excreted by the kidneys. 319 00:15:46,848 --> 00:15:50,238 So in that scenario, you’re better off going down the ones that are 320 00:15:50,358 --> 00:15:53,358 renally excreted because they're much safer in those patients. 321 00:15:53,793 --> 00:15:54,813 And that leaves very few. 322 00:15:54,873 --> 00:15:57,433 But yes, we've got bromide and we've got levetiracetam. 323 00:15:57,693 --> 00:15:58,128 Dr Emma Hancox: Yeah. 324 00:15:58,593 --> 00:16:01,653 Dr Mark Lowrie: Clearly this is a dog that we want quick benefit from. 325 00:16:01,653 --> 00:16:04,833 So bromide isn't ideal as a choice, and it would mean 326 00:16:04,833 --> 00:16:06,363 levetiracetam is a good one to use. 327 00:16:06,363 --> 00:16:10,383 So any dog with liver shunts, acquired shunts, hepatic encephalopathy, 328 00:16:10,783 --> 00:16:14,233 levetiracetams are a fantastic choice and even those dogs that have surgical 329 00:16:14,233 --> 00:16:17,923 correction of their shunts, now goodness, I'm going off to things that I don't 330 00:16:17,923 --> 00:16:22,063 talk about much, but, but even in that scenario, when they have breakthrough, 331 00:16:22,213 --> 00:16:25,633 breakthrough seizures, you know, adding levetiracetam at that stage is 332 00:16:25,633 --> 00:16:27,373 a, is a very sensible option to do. 333 00:16:27,653 --> 00:16:31,433 And maybe if you fix the problem, fix the liver's problem, if it is a fixable cause, 334 00:16:31,433 --> 00:16:32,903 you can stop them again in the future. 335 00:16:32,903 --> 00:16:34,573 But it's just to get them through that time. 336 00:16:34,613 --> 00:16:34,883 Dr Emma Hancox: Yeah 337 00:16:35,333 --> 00:16:39,473 Dr Mark Lowrie: and then you've got dogs that maybe have, well, can I mention cats? 338 00:16:39,683 --> 00:16:41,033 Dr Emma Hancox: Of course you can mention cats. 339 00:16:41,038 --> 00:16:43,743 We haven't hardly talked about them at all, so please mention cats. 340 00:16:44,108 --> 00:16:47,088 Dr Mark Lowrie: Well, cats sort of thinking, hypertension because 341 00:16:47,108 --> 00:16:50,708 I think people forget high blood pressure is enough to cause seizures. 342 00:16:50,948 --> 00:16:52,658 And I say cats because it's more common in them. 343 00:16:52,658 --> 00:16:56,078 It doesn't mean it does happen in dogs too, but it's just more commonly a 344 00:16:56,078 --> 00:16:57,818 present, a presenting sign in cats. 345 00:16:57,818 --> 00:17:01,808 So you can do a full epileptic workup on a cat and use many of the 346 00:17:01,808 --> 00:17:03,248 rules I’ve, I’ve explained for dogs. 347 00:17:03,248 --> 00:17:04,608 I mean it, the same things apply. 348 00:17:05,298 --> 00:17:09,413 But high blood pressure can cause what we call a hypertensive encephalopathy, 349 00:17:09,563 --> 00:17:10,973 and that can then cause seizures. 350 00:17:10,973 --> 00:17:14,753 So in those circumstances, again, it's very reasonable to treat the seizures. 351 00:17:14,993 --> 00:17:17,003 Now, you might want to sort out the blood pressure. 352 00:17:17,873 --> 00:17:20,333 And it would take a medic to take you through that rather than myself. 353 00:17:20,528 --> 00:17:21,998 Dr Emma Hancox: I was gonna say, I thought you were going off 354 00:17:21,998 --> 00:17:23,408 onto your medicine again then. 355 00:17:24,113 --> 00:17:26,183 Dr Mark Lowrie: Well, so, so you know, you definitely want to get the 356 00:17:26,183 --> 00:17:28,853 blood pressure down through whatever means, but giving an anti-epileptic 357 00:17:28,853 --> 00:17:30,413 medication there is very appropriate. 358 00:17:30,418 --> 00:17:33,473 And yeah, you can use levetiracetam, but then phenobarbital comes back 359 00:17:33,473 --> 00:17:36,143 into the picture because hopefully there's no liver disease and 360 00:17:36,148 --> 00:17:37,553 it's a reasonable drug to choose. 361 00:17:37,718 --> 00:17:38,108 Dr Emma Hancox: Yeah. 362 00:17:38,548 --> 00:17:41,348 So you can use levetiracetam in cats, obviously off license, 363 00:17:41,348 --> 00:17:42,948 but they tolerate it well? 364 00:17:43,298 --> 00:17:43,688 Dr Mark Lowrie: They do. 365 00:17:43,688 --> 00:17:44,888 And, and cats in general. 366 00:17:44,888 --> 00:17:47,408 I mean like, yes, we have to sort of, there isn't really 367 00:17:47,408 --> 00:17:48,758 a great cascade for cats. 368 00:17:48,758 --> 00:17:51,578 Well, well there isn't, there aren't many licensed choices I should say. 369 00:17:51,583 --> 00:17:54,218 So we have to go down the cascade and look at what we do in dogs. 370 00:17:55,028 --> 00:17:58,458 So for cats really phenobarbital is, is a great drug to use. 371 00:17:58,458 --> 00:18:00,248 It's a first line approach, works well. 372 00:18:00,648 --> 00:18:03,708 We completely avoid bromide in cats, so yeah, we wouldn't be 373 00:18:03,708 --> 00:18:06,438 giving bromide in cats because they get the allergic pneumonitis. 374 00:18:07,023 --> 00:18:09,133 And then, levetiracetam is great. 375 00:18:09,193 --> 00:18:09,703 You know, it works. 376 00:18:09,703 --> 00:18:13,663 And dare I say it, the problem with levetiracetam in cats, we do, we are 377 00:18:13,663 --> 00:18:15,493 meant to give it three times a day. 378 00:18:16,093 --> 00:18:18,853 Now, I would never do this approach that I'm about to say in dogs, 379 00:18:18,853 --> 00:18:21,633 but in cats you can maybe get away with giving it twice a day. 380 00:18:21,633 --> 00:18:25,153 It does seem to work in, in many of those, of those patients, 381 00:18:25,543 --> 00:18:27,073 dogs always three times a day. 382 00:18:27,253 --> 00:18:31,483 I’ve known twice a day dosing in dogs to make seizures worse, but cats, 383 00:18:31,483 --> 00:18:32,743 we seem be able to get away with it. 384 00:18:33,123 --> 00:18:34,603 Dr Emma Hancox: Interesting that makes seizures worse. 385 00:18:34,603 --> 00:18:34,663 Yeah. 386 00:18:35,083 --> 00:18:37,183 Dr Mark Lowrie: And it seems to be that it's there and it's helping, but then 387 00:18:37,183 --> 00:18:40,903 as, as the dose drops away before that second dose, there's just this period when 388 00:18:40,903 --> 00:18:42,433 seizures can actually come back through. 389 00:18:42,433 --> 00:18:46,283 So I have seen breakthrough seizures from dogs given twice daily levetiracetam, 390 00:18:46,963 --> 00:18:48,253 rather than three times daily. 391 00:18:48,553 --> 00:18:51,043 And people might be thinking, well, you know, is it all right to start twice 392 00:18:51,043 --> 00:18:52,903 daily and up to three times daily? 393 00:18:52,903 --> 00:18:55,863 But I wouldn't, I'd, I'd always go three times a day with levetiracetam. 394 00:18:56,263 --> 00:18:59,773 Dr Emma Hancox: Yeah, and you've just given me another idea actually. 395 00:19:00,013 --> 00:19:05,473 So there's some places that talk about using phenobarbital three times a day. 396 00:19:06,343 --> 00:19:07,363 What do you think about that? 397 00:19:07,363 --> 00:19:09,643 I feel like I’ve just opened a can of worms you didn't wanna answer. 398 00:19:10,378 --> 00:19:12,478 Dr Mark Lowrie: No, I, well, so... 399 00:19:12,478 --> 00:19:14,023 Dr Emma Hancox: The look that he gave me, by the way, everyone. 400 00:19:15,718 --> 00:19:18,788 Dr Mark Lowrie: Well, So, so we start phenobarbital twice a day. 401 00:19:19,448 --> 00:19:25,148 The idea is you take a peak and a trough serum concentration, and I mentioned much 402 00:19:25,148 --> 00:19:28,448 earlier on in this series that you don't have to do that, just be consistent. 403 00:19:28,478 --> 00:19:31,853 But if you’re thinking this dogs really poorly controlled, is 404 00:19:31,858 --> 00:19:34,973 there scope to go to three times a day dosing with phenobarbital? 405 00:19:35,303 --> 00:19:39,153 I do a peak and a trough level, and then you can go to, find a, 406 00:19:39,153 --> 00:19:42,433 a, a special formula if you like, that's, it's on many websites. 407 00:19:42,443 --> 00:19:46,163 You can look up what the, what the half-life is for phenobarbital in that 408 00:19:46,163 --> 00:19:48,233 particular dog using the the equation 409 00:19:48,233 --> 00:19:48,293 Dr Emma Hancox: wow. 410 00:19:49,143 --> 00:19:50,783 Dr Mark Lowrie: and it will tell you whether it is actually appropriate 411 00:19:50,783 --> 00:19:52,013 to go to three times a day. 412 00:19:52,013 --> 00:19:55,493 So dividing three times rather than twice a day with medication. 413 00:19:55,853 --> 00:19:56,783 And that can work. 414 00:19:56,963 --> 00:19:58,283 Dr Emma Hancox: That does sound complicated though. 415 00:19:58,433 --> 00:19:59,423 Dr Mark Lowrie: And I don't want to go into it 416 00:19:59,483 --> 00:19:59,753 Dr Emma Hancox: Yeah. 417 00:19:59,753 --> 00:19:59,993 No, we 418 00:20:00,083 --> 00:20:01,463 Dr Mark Lowrie: because, 'cause it will bore people. 419 00:20:02,348 --> 00:20:02,888 Dr Emma Hancox: That's fine. 420 00:20:03,218 --> 00:20:06,638 I'm getting very off piste and probably very off license for phenobarbital now, 421 00:20:06,638 --> 00:20:12,018 but I'm wondering, just litreally come to my head, if you have a clustering dog, 422 00:20:12,888 --> 00:20:17,718 can you give, that's on Phenobarbital twice a day, can you like add in 423 00:20:17,718 --> 00:20:21,168 another phenobarbital in the middle of the day at times they cluster? 424 00:20:21,783 --> 00:20:25,053 Dr Mark Lowrie: So I'd, I'd only do that when we've done the serum concentration. 425 00:20:25,053 --> 00:20:28,533 So the, the, the, the possibility, yes, possibly you might be able to do it, 426 00:20:28,533 --> 00:20:31,949 but the, the, the serum concentrations peak and trough will help with that. 427 00:20:32,639 --> 00:20:35,579 I suppose I'm, it's made me think of the situation where you've 428 00:20:35,579 --> 00:20:38,379 got a dog in status that comes in that's already on phenobarbital. 429 00:20:39,179 --> 00:20:42,629 I’ve given you great tips in, in the previous episodes about how to, I say 430 00:20:42,629 --> 00:20:43,799 they're great, maybe they're not great. 431 00:20:43,859 --> 00:20:44,819 Maybe they weren't helpful. 432 00:20:44,989 --> 00:20:45,969 Dr Emma Hancox: Blowing his own whistle there. 433 00:20:47,169 --> 00:20:49,394 Dr Mark Lowrie: So I’ve given tips on, on how we give the 434 00:20:49,394 --> 00:20:51,404 phenobarbital in that situation. 435 00:20:51,404 --> 00:20:55,484 But if, if it's a dog already on phenobarbital, then you’re a bit stuck. 436 00:20:55,544 --> 00:20:59,804 So what I do is I still give that initial loading dose of four mgs 437 00:20:59,809 --> 00:21:02,774 per kg of Phenobarbital IV, but then you’re gonna have to look to another 438 00:21:02,774 --> 00:21:07,244 medication to give, and that could be levetiracetam, maybe you can get away 439 00:21:07,244 --> 00:21:10,424 with giving it orally if the dog's just kind of coming round from the fits. 440 00:21:10,424 --> 00:21:13,874 But if it's actively seizuring, you'd have to go for intravenous 441 00:21:13,874 --> 00:21:16,004 levetiracetam which is really expensive 442 00:21:16,294 --> 00:21:16,674 Dr Emma Hancox: right 443 00:21:17,424 --> 00:21:19,559 Dr Mark Lowrie: or you can load bromide. 444 00:21:20,369 --> 00:21:24,089 And what you can do there is you work out your loading dose using everything I’ve 445 00:21:24,089 --> 00:21:28,139 described in the previous episodes, so 600 mgs per kg in total divided over however 446 00:21:28,139 --> 00:21:32,459 many days, you get the tablets and you might not be able to give them orally, but 447 00:21:32,464 --> 00:21:33,899 what you can actually do is crush them up. 448 00:21:34,679 --> 00:21:36,869 You mix them with water and actually give them rectally. 449 00:21:37,019 --> 00:21:39,109 So you give them through a urinary catheter. 450 00:21:39,134 --> 00:21:39,554 Dr Emma Hancox: Oh wow. 451 00:21:39,584 --> 00:21:39,764 Okay. 452 00:21:39,864 --> 00:21:42,484 Dr Mark Lowrie: Put it up the bum and then you, you can inject it. 453 00:21:42,484 --> 00:21:46,384 So it's a way of getting a loading dose of bromide into the dog that's otherwise 454 00:21:46,384 --> 00:21:47,974 fitting and can't take oral medication. 455 00:21:47,974 --> 00:21:50,634 So that can also work, but it's very messy. 456 00:21:50,804 --> 00:21:51,074 Dr Emma Hancox: Yeah. 457 00:21:51,474 --> 00:21:53,794 What is with neurologists and putting everything up the bum? 458 00:21:53,974 --> 00:21:55,414 Dr Mark Lowrie: I didn't think we'd put anything else up the bum. 459 00:21:55,474 --> 00:21:55,954 Oh, we do. 460 00:21:56,254 --> 00:21:57,184 Let's not talk about that. 461 00:21:57,244 --> 00:21:58,684 Dr Emma Hancox: You do rectal diazepam and everything. 462 00:21:59,324 --> 00:22:01,744 Dr Mark Lowrie: Have you, have you ever seen the insert on rectal diazepam? 463 00:22:02,284 --> 00:22:02,824 Dr Emma Hancox: Yes, I have. 464 00:22:03,154 --> 00:22:05,014 Dr Mark Lowrie: Yeah, let's just leave that there, shall we? 465 00:22:05,014 --> 00:22:06,844 Dr Emma Hancox: We'll just leave everyone with that image. 466 00:22:07,214 --> 00:22:13,844 We mentioned it in a previous podcast that I don't want people with epileptic dogs to 467 00:22:13,844 --> 00:22:20,579 think that this is a life sentence, like this is quite, we've, maybe we were trying 468 00:22:20,579 --> 00:22:24,124 to make it simple with some of these podcasts, you can do this and that and you 469 00:22:24,124 --> 00:22:27,424 can follow these guidelines, but I felt like we've undone that on this podcast. 470 00:22:27,424 --> 00:22:30,094 We've just gone, yeah, you can use all these different combinations and 471 00:22:30,094 --> 00:22:33,994 things, but this can feel obviously quite overwhelming for us, but 472 00:22:34,204 --> 00:22:37,804 obviously quite overwhelming for the owners as well at the end of the day. 473 00:22:37,859 --> 00:22:41,519 Just wanted to go back to them really, because it's obviously tailoring the 474 00:22:41,519 --> 00:22:45,374 approach yes, for that patient, but if we remember, also for that owner. 475 00:22:45,374 --> 00:22:48,104 So don't know whether you had any words on that one? 476 00:22:48,854 --> 00:22:52,964 Dr Mark Lowrie: Yeah, I mean, I guess we need to remind ourselves that 477 00:22:53,309 --> 00:22:55,229 epileptic dogs are still normal patients. 478 00:22:55,229 --> 00:22:59,129 There's no pain associated with the condition, dogs that suffer a 479 00:22:59,129 --> 00:23:01,439 seizure will recover most of the time. 480 00:23:01,469 --> 00:23:04,019 It's very rare to have sudden death from seizures. 481 00:23:04,019 --> 00:23:07,959 It's not impossible, but it's very rare, so they should recover and 482 00:23:07,959 --> 00:23:10,899 they may be a bit disorientated or confused, but they're otherwise okay. 483 00:23:11,499 --> 00:23:12,849 So that's important. 484 00:23:12,949 --> 00:23:18,259 I think when you get an owner come in with a dog with these seizures, 485 00:23:18,754 --> 00:23:21,004 It really depends on how bad the seizures are, but you'll often get 486 00:23:21,004 --> 00:23:22,204 an owner come in at their wits end. 487 00:23:22,399 --> 00:23:22,789 Dr Emma Hancox: Yeah. 488 00:23:23,674 --> 00:23:26,194 Dr Mark Lowrie: And I’ve always said that you need to give 489 00:23:26,194 --> 00:23:27,784 owners all of the options. 490 00:23:28,624 --> 00:23:31,804 Now, this is a bit miserable to bring this up, but I think it is important 491 00:23:31,804 --> 00:23:34,054 that one of those options is euthanasia. 492 00:23:35,349 --> 00:23:38,584 It's wrong not to discuss euthanasia with the owners because you will get 493 00:23:38,584 --> 00:23:43,264 some owners that when you enter that discussion, they actually, they almost 494 00:23:43,264 --> 00:23:47,854 breathe a sigh of relief to go, oh, that's an option I hadn't realised. 495 00:23:48,184 --> 00:23:48,574 Dr Emma Hancox: Yeah. 496 00:23:49,039 --> 00:23:52,729 Dr Mark Lowrie: Because they may see it as a, a cruel thing to do for their dog. 497 00:23:52,819 --> 00:23:56,989 You know, why am I, am I doing it for, for me, putting my dog to sleep? 498 00:23:56,989 --> 00:23:58,209 Because I don't want to see it any more? 499 00:23:59,689 --> 00:24:03,349 But if, if it's really impacting on your quality of life too, it's 500 00:24:03,349 --> 00:24:07,759 not wrong to consider euthanasia if it's that frequent and that bad. 501 00:24:08,359 --> 00:24:12,319 So I’ve known of owners I’ve met where their dog will have several fits a day 502 00:24:12,319 --> 00:24:16,219 and they're still going, going with it for their pet to try and give them the 503 00:24:16,219 --> 00:24:17,959 best quality of life, life possible. 504 00:24:18,094 --> 00:24:18,514 Dr Emma Hancox: Yeah. 505 00:24:19,039 --> 00:24:20,839 Dr Mark Lowrie: But I remember one individual in particular, and when I 506 00:24:20,839 --> 00:24:24,529 mentioned to her, you know, euthanasia is an option, she broke down in 507 00:24:24,529 --> 00:24:26,389 tears and I thought I'd upset her. 508 00:24:26,449 --> 00:24:28,879 But no, she was really, really relieved to hear it. 509 00:24:29,389 --> 00:24:33,079 And so there are owners out there that have that feeling that they 510 00:24:33,084 --> 00:24:36,889 just want someone to say it is an option, and it's always an option. 511 00:24:37,489 --> 00:24:42,109 It becomes more a consideration as things worsen, of course, but if, if you speak 512 00:24:42,109 --> 00:24:45,769 about that, and even at the very first consult, now this, this is, and I think, 513 00:24:45,769 --> 00:24:48,589 but right at the first consult mentioning that euthanasia is something you'll 514 00:24:48,589 --> 00:24:50,059 likely to have to consider in the future. 515 00:24:50,059 --> 00:24:52,459 If it gets bad, it prepares them. 516 00:24:52,639 --> 00:24:55,189 So when that day comes, it's not a huge shock. 517 00:24:55,889 --> 00:24:58,829 Now hopefully that's years away and, and really, hopefully it's something 518 00:24:58,829 --> 00:25:02,459 that may never even need to consider, but we have to be upfront about 519 00:25:02,489 --> 00:25:06,119 this and it's the thing that's not always talked about with epilepsy. 520 00:25:06,404 --> 00:25:09,944 We don't mention euthanasia enough, and I think, yes, don't mention 521 00:25:09,944 --> 00:25:13,394 it every time they come in, that's not the right way to go, but it 522 00:25:13,394 --> 00:25:15,044 needs putting in at the right time. 523 00:25:15,374 --> 00:25:18,374 So the owners know that if you've mentioned it, they won't feel bad 524 00:25:18,374 --> 00:25:20,474 bringing it up at the time when they feel it's right for them. 525 00:25:20,774 --> 00:25:24,434 Dr Emma Hancox: That's absolutely what I was gonna pick up on is that I think 526 00:25:24,439 --> 00:25:28,214 owners don't want to mention it a lot of the time or talk about it because 527 00:25:28,214 --> 00:25:33,519 they feel guilty for bringing it up and feel like they're the ones making 528 00:25:33,519 --> 00:25:38,049 the ultimate decision when it actually, it should be all of this, right? 529 00:25:38,139 --> 00:25:40,209 We're, this is everything that we're saying. 530 00:25:40,209 --> 00:25:42,609 It should be a team approach between us all. 531 00:25:43,179 --> 00:25:46,029 So we just need to have those open discussions and allow them 532 00:25:46,034 --> 00:25:47,889 to voice how they're feeling. 533 00:25:48,134 --> 00:25:48,309 Dr Mark Lowrie: Yeah. 534 00:25:48,309 --> 00:25:51,339 And make sure that they don't feel like they're being cruel or selfish 535 00:25:51,369 --> 00:25:51,599 Dr Emma Hancox: Yeah. 536 00:25:51,619 --> 00:25:51,689 Yeah. 537 00:25:51,789 --> 00:25:54,339 Dr Mark Lowrie: Because they're not, they're not, you know, 538 00:25:54,339 --> 00:25:55,420 they need to understand that. 539 00:25:55,749 --> 00:25:56,319 Dr Emma Hancox: Absolutely. 540 00:25:56,559 --> 00:25:57,039 Absolutely. 541 00:25:57,339 --> 00:26:01,389 Although on the flip side of that, hopefully, sometimes I had clients 542 00:26:01,394 --> 00:26:03,969 come in the very first time with a seizure and they go, that's it. 543 00:26:04,314 --> 00:26:05,004 That's it. 544 00:26:05,404 --> 00:26:09,004 it's the day I am having my dog put to sleep and I'm, no, it's not. 545 00:26:09,004 --> 00:26:10,684 No, we can try something first. 546 00:26:10,954 --> 00:26:13,204 So it's just the flip side of that as well. 547 00:26:13,254 --> 00:26:15,924 Dr Mark Lowrie: It's true, especially with something like status, because 548 00:26:15,924 --> 00:26:18,684 actually if you mention euthanasia in the first consult with status, 549 00:26:18,684 --> 00:26:21,564 then that will be elected for, and of course that's not the right thing. 550 00:26:21,654 --> 00:26:21,714 Yeah. 551 00:26:22,059 --> 00:26:26,259 So it's important to know when to bring it up and whether it's correct to bring 552 00:26:26,259 --> 00:26:29,619 it up immediately, but it is a discussion that needs to be had at some point. 553 00:26:29,679 --> 00:26:29,739 Yeah. 554 00:26:30,009 --> 00:26:30,789 But you’re absolutely right. 555 00:26:30,789 --> 00:26:33,069 It's, that's, that's, it's like the art of veterinary medicine, 556 00:26:33,069 --> 00:26:33,749 we always say, isn't it? 557 00:26:33,749 --> 00:26:34,344 Dr Emma Hancox: It really is. 558 00:26:34,779 --> 00:26:36,189 Dr Mark Lowrie: It's not clear cut. 559 00:26:36,219 --> 00:26:39,669 We're scientists and we have to try and negotiate the right thing with 560 00:26:39,669 --> 00:26:41,299 these people and it's very difficult. 561 00:26:41,494 --> 00:26:41,764 Dr Emma Hancox: Yeah. 562 00:26:42,184 --> 00:26:44,404 And all of us get into this to treat the animals and we're here 563 00:26:44,404 --> 00:26:46,834 treating the owners and counselling the owners at the end of the day. 564 00:26:47,224 --> 00:26:48,004 Dr Mark Lowrie: Yes, yes. 565 00:26:48,064 --> 00:26:50,344 And then drinking at the end of the day ourselves, because 566 00:26:50,404 --> 00:26:51,334 that's the way to cope with it. 567 00:26:51,784 --> 00:26:54,064 Dr Emma Hancox: Okay, let's try and end on a more positive note. 568 00:26:54,064 --> 00:26:57,124 I feel like it went really deep there in quite ethical questions, wasn't it? 569 00:26:57,174 --> 00:27:02,874 I just want to finish off, is there, if you could say or give one piece of 570 00:27:02,874 --> 00:27:09,264 advice or words of wisdom to us GP vets in clinical practice, what would it be? 571 00:27:10,194 --> 00:27:11,574 Dr Mark Lowrie: Yeah, that's a really tough one. 572 00:27:11,694 --> 00:27:16,644 So throughout these podcasts, I'd like to think you were carrying around 573 00:27:16,644 --> 00:27:18,564 sort of certain patients in your head. 574 00:27:18,894 --> 00:27:22,844 There are probably, certain dogs, cats, guinea pigs that might 575 00:27:22,844 --> 00:27:24,164 come in with, with epilepsy. 576 00:27:24,164 --> 00:27:28,284 And, and you, you really, you, you almost dread seeing those owners because 577 00:27:28,284 --> 00:27:32,034 you’re kind of like, well, I, I feel I’ve done so much, what more can I do? 578 00:27:33,204 --> 00:27:36,384 So I think the main message I'd want to give across is in those 579 00:27:36,384 --> 00:27:39,414 situations with those cases that are dogs that are very difficult to 580 00:27:39,414 --> 00:27:41,844 manage, I'd really wanna reassure you that you’re doing nothing wrong. 581 00:27:43,314 --> 00:27:45,534 There may be some tips you've picked up here that might help in 582 00:27:45,534 --> 00:27:46,554 the management, and that's great. 583 00:27:46,554 --> 00:27:48,564 And I, I hope that's the case, that there's a bit more 584 00:27:48,564 --> 00:27:49,594 you can do there to help. 585 00:27:50,134 --> 00:27:52,704 But you've not done anything wrong, it's not you failing as a vet, 586 00:27:52,854 --> 00:27:55,314 it's because you’re dealing with a very difficult condition that we 587 00:27:55,314 --> 00:27:57,114 would all struggle to cope with. 588 00:27:57,144 --> 00:28:00,864 So don't be afraid when you have those cases that are going badly, 589 00:28:01,074 --> 00:28:02,874 it's not you, it's the dog. 590 00:28:03,054 --> 00:28:04,764 And that's, that's how I'd sort of summarise it. 591 00:28:05,409 --> 00:28:07,119 Dr Emma Hancox: That's really reassuring actually to hear. 592 00:28:08,049 --> 00:28:09,299 Help quell all of us. 593 00:28:10,409 --> 00:28:11,139 Thank you Mark. 594 00:28:11,489 --> 00:28:13,479 This series has been really brilliant. 595 00:28:13,659 --> 00:28:17,394 I’ve learned so much and it really has just helped to discuss some of 596 00:28:17,399 --> 00:28:21,624 these things that often are forgotten aspects of epilepsy management. 597 00:28:22,164 --> 00:28:24,114 Note, I'm saying management now, not treatment. 598 00:28:24,114 --> 00:28:25,044 So you've taught me something. 599 00:28:25,504 --> 00:28:29,464 I do definitely hold my hands up and say that sometimes I used to get stuck 600 00:28:29,464 --> 00:28:32,374 in the numbers, and I think I said this in the very first episode actually, 601 00:28:32,854 --> 00:28:37,654 that whether that be looking at serum concentrations, the biochemistry, those 602 00:28:37,714 --> 00:28:42,424 liver enzymes, the seizure numbers, and I just forget to just take that step 603 00:28:42,424 --> 00:28:43,674 back and look at that bigger picture. 604 00:28:43,894 --> 00:28:47,074 So that's probably the most important part I was missing though. 605 00:28:47,154 --> 00:28:49,674 I really could sit here all day discussing the nuances of 606 00:28:49,764 --> 00:28:51,234 epilepsy management with you. 607 00:28:51,234 --> 00:28:55,584 But just a reminder to our listeners, this was the fifth and final part of 608 00:28:55,584 --> 00:28:57,384 our series on the S.M.A.R.T Approach. 609 00:28:57,414 --> 00:29:00,294 So if you haven't already, please do check out the previous 610 00:29:00,299 --> 00:29:01,854 episodes for more information. 611 00:29:02,574 --> 00:29:05,604 We would also be really grateful if you could tell us what you think of 612 00:29:05,604 --> 00:29:09,844 these, if they've taken off and people do enjoy these, we would be more than 613 00:29:09,844 --> 00:29:13,474 happy to get back together and to keep having these podcasts and discussions 614 00:29:13,474 --> 00:29:14,584 if that's what you would like. 615 00:29:15,064 --> 00:29:20,254 Equally, if you want to email us at TVM or if you want to get in contact with Mark, 616 00:29:20,254 --> 00:29:21,784 I'm sure he would be happy with that. 617 00:29:22,094 --> 00:29:25,779 He's based at Movement Referrals and if there's any areas of epilepsy you 618 00:29:25,779 --> 00:29:29,229 would like us to do some podcasts on that maybe we haven't covered, then 619 00:29:29,349 --> 00:29:33,384 equally, please do feel free to give us some information, give us some ideas, 620 00:29:33,714 --> 00:29:36,114 so hopefully we'll see you again soon. 621 00:29:36,144 --> 00:29:37,704 Thanks again so much, Mark. 622 00:29:37,704 --> 00:29:37,884 Thank you. 623 00:29:37,974 --> 00:29:38,334 Dr Mark Lowrie: Thank you. 624 00:29:38,334 --> 00:29:38,994 It's been a pleasure. 625 00:29:39,234 --> 00:29:39,894 Dr Emma Hancox: Perfect. 626 00:29:39,954 --> 00:29:41,364 Thanks so much guys. 627 00:29:41,544 --> 00:29:42,174 Bye. 628 00:29:42,294 --> 00:29:42,784 Dr Mark Lowrie: Bye bye.