1 00:00:01,260 --> 00:00:04,050 Dr Emma Hancox: Welcome back to the Synaptic Tails podcast with your 2 00:00:04,050 --> 00:00:09,240 hosts, Emma Hancox, TVM Technical Vet, and Mark Lowrie, RCVS and European 3 00:00:09,240 --> 00:00:12,870 specialist in Veterinary Neurology, and Co-director of Movement Referrals. 4 00:00:13,230 --> 00:00:13,710 Hi Mark. 5 00:00:13,710 --> 00:00:14,430 How are you today? 6 00:00:14,520 --> 00:00:15,570 Dr Mark Lowrie: Yeah, very well, thank you. 7 00:00:15,630 --> 00:00:16,650 Nice to be back again. 8 00:00:16,650 --> 00:00:17,430 Dr Emma Hancox: Yeah, good. 9 00:00:17,460 --> 00:00:18,900 Nice to have you back as well. 10 00:00:19,830 --> 00:00:23,100 Over the last three episodes we've chatted about the importance of owner 11 00:00:23,100 --> 00:00:27,000 communication, what we need to measure, particularly on blood samples, and 12 00:00:27,000 --> 00:00:30,330 how to advise our clients in order to manage our epileptic patients. 13 00:00:31,290 --> 00:00:35,550 If you are a new listener, now is probably a good time to pause this episode and 14 00:00:35,550 --> 00:00:38,670 go back and take a listen to those earlier episodes so that you know what 15 00:00:38,670 --> 00:00:42,000 we are talking about because we will be referencing them as we go through. 16 00:00:43,140 --> 00:00:45,630 This episode really does follow on from the previous. 17 00:00:45,630 --> 00:00:48,510 So if you remember at the end of the last one, we were talking 18 00:00:48,510 --> 00:00:52,080 about how to manage our owners and how to advise appropriately. 19 00:00:52,530 --> 00:00:54,930 And this one is all about being realistic. 20 00:00:55,260 --> 00:00:59,160 So the first thing I wanted to pick up with you actually, Mark, is we mentioned 21 00:00:59,160 --> 00:01:06,000 last time about referral and how, actually it's not inappropriate to refer a case 22 00:01:06,000 --> 00:01:09,840 of course, but it was all about being realistic with these epileptic patients. 23 00:01:09,840 --> 00:01:14,370 But I was just wondering actually afterwards, are there times that you would 24 00:01:14,430 --> 00:01:16,860 definitely want people to refer to you? 25 00:01:16,910 --> 00:01:19,720 Dr Mark Lowrie: Yeah, I’ve said it's never wrong to refer, so if ever you 26 00:01:19,720 --> 00:01:22,809 feel like you should refer a case, there is absolutely nothing wrong in that. 27 00:01:23,589 --> 00:01:27,120 But yeah, the indications to actually refer a case, I think if you've got 28 00:01:27,125 --> 00:01:33,090 a dog that is showing what I like to call hard neurological deficits, that 29 00:01:33,090 --> 00:01:35,190 would be a reason to go for referral. 30 00:01:36,180 --> 00:01:37,500 So we're always thinking. 31 00:01:37,920 --> 00:01:41,039 Yes, we have seizures, but how is the dog outside of that? 32 00:01:41,039 --> 00:01:45,670 Now you can get what I call less hard neurological signs, like behavioural 33 00:01:45,690 --> 00:01:49,595 changes, maybe a dog's a bit more clingy to an owner, that's a common one 34 00:01:49,625 --> 00:01:49,725 Dr Emma Hancox: yeah, 35 00:01:49,725 --> 00:01:50,364 Dr Mark Lowrie: we come across. 36 00:01:50,994 --> 00:01:53,500 Maybe they're not quite as playful as they once were. 37 00:01:53,820 --> 00:01:57,100 They're soft signs which I think can happen in any scenario. 38 00:01:57,460 --> 00:02:00,940 And so I don't worry about them, but the hard neurological signs would be 39 00:02:00,945 --> 00:02:03,120 those attributable to the forebrain. 40 00:02:03,400 --> 00:02:07,210 And I don't like talking about the brain in too much a complicated way 'cause 41 00:02:07,270 --> 00:02:10,240 I don't think I'd understand but I like to think of the brain like a big 42 00:02:10,240 --> 00:02:14,380 black box and you can divide it into forebrain, cerebellum, and brainstem. 43 00:02:14,800 --> 00:02:17,210 When we talk about seizures, we're talking about forebrain problems, 44 00:02:17,230 --> 00:02:18,610 so we can forget about the rest. 45 00:02:19,350 --> 00:02:22,485 Forebrain disease, signs of forebrain disease, the most common 46 00:02:22,575 --> 00:02:27,345 is seizures, but after that you can get signs of central blindness. 47 00:02:28,155 --> 00:02:31,800 So this is dogs where yes, they're blind, but they have 48 00:02:31,900 --> 00:02:33,610 normal pupillary light reflexes. 49 00:02:33,640 --> 00:02:38,200 So it's maybe an ophthalmic problem, you might find PLRs damaged in some way. 50 00:02:38,800 --> 00:02:41,530 So they'll have no menace, but the PLRs are present. 51 00:02:42,100 --> 00:02:44,950 You might find the dogs will start pacing more than normal. 52 00:02:44,950 --> 00:02:46,935 And by pacing, just being restless. 53 00:02:47,295 --> 00:02:52,135 So a nice question I like to ask an owner would be, outside of the seizures, 54 00:02:52,135 --> 00:02:54,485 does your dog settle well at home? 55 00:02:55,105 --> 00:02:58,600 And it's amazing how many owners won't have volunteered the information partly 56 00:02:58,600 --> 00:02:59,830 'cause they may not have realised 57 00:02:59,830 --> 00:02:59,890 Dr Emma Hancox: Yeah, 58 00:02:59,890 --> 00:03:02,530 Dr Mark Lowrie: but they'll say, yeah, actually my dog can't settle at night, 59 00:03:02,560 --> 00:03:05,620 we'll be sat down watching the TV and my dog's just pacing around the living room. 60 00:03:06,220 --> 00:03:07,480 That is a red flag for me. 61 00:03:07,660 --> 00:03:10,240 If they say that, that tells me there's more going on than just 62 00:03:10,240 --> 00:03:12,130 a simple idiopathic epilepsy. 63 00:03:12,385 --> 00:03:12,775 Dr Emma Hancox: I see. 64 00:03:13,710 --> 00:03:16,270 Dr Mark Lowrie: The other one would be circling as well. 65 00:03:16,910 --> 00:03:19,879 So these can be almost around the edge of a room and you'll find they 66 00:03:19,879 --> 00:03:23,359 often go in one direction, it's worth asking an owner about that too. 67 00:03:24,499 --> 00:03:27,889 And the final one to mention, and this is possibly my favourite question 68 00:03:27,889 --> 00:03:30,619 of all, for any seizuring patient and one that should always be asked. 69 00:03:30,709 --> 00:03:31,169 Dr Emma Hancox: I'm excited. 70 00:03:31,679 --> 00:03:32,649 Dr Mark Lowrie: Have I oversold it now? 71 00:03:32,649 --> 00:03:33,199 Dr Emma Hancox: Yeah, maybe 72 00:03:34,399 --> 00:03:37,429 Dr Mark Lowrie: The question I would ask is, does your dog now toilet in the 73 00:03:37,429 --> 00:03:39,289 house when maybe they haven't before? 74 00:03:39,769 --> 00:03:42,549 You need to ask that last bit 'cause some dogs just toilet in the house 75 00:03:42,549 --> 00:03:42,889 Dr Emma Hancox: Yeah. 76 00:03:43,129 --> 00:03:43,819 Dr Mark Lowrie: It's what they do. 77 00:03:43,819 --> 00:03:47,839 But if they've learned to toilet outside as all well-trained dogs should, I’ve 78 00:03:47,839 --> 00:03:50,329 got a puppy at the minute that is yet to do that, so that's hard work. 79 00:03:51,254 --> 00:03:54,294 If they are well-trained and they toilet outside and they've always 80 00:03:54,294 --> 00:03:57,954 been good at that, if they've started to have inappropriate soiling in the 81 00:03:57,954 --> 00:03:59,934 house, that again, is a big red flag. 82 00:04:00,234 --> 00:04:03,444 It shows loss of learned behaviour, and again, that's something owners 83 00:04:03,444 --> 00:04:04,824 are almost embarrassed to admit to. 84 00:04:05,304 --> 00:04:08,814 So unless you program them and ask that question specifically, it might 85 00:04:08,814 --> 00:04:11,904 not be volunteered 'cause all of these things come back to the fact 86 00:04:11,904 --> 00:04:15,789 that the big elephant in the room is the seizures and so often we focus 87 00:04:15,789 --> 00:04:18,549 on the seizures and we don't think about the behaviour outside of that. 88 00:04:18,579 --> 00:04:23,739 So I would be asking all of these sorts of questions sometimes and 89 00:04:23,739 --> 00:04:27,429 dare I say it, this avoids the need for a neurological exam. 90 00:04:27,530 --> 00:04:33,185 So asking about circling, pacing, being blind and loss of toilet training. 91 00:04:33,545 --> 00:04:37,055 They are almost a great substitute for the seizuring patient because if owners 92 00:04:37,055 --> 00:04:41,135 are saying to them there's something wrong or abnormal, I found that they're almost 93 00:04:41,135 --> 00:04:44,150 more sensitive than the neurological exam itself at picking up early disease. 94 00:04:44,150 --> 00:04:44,700 Dr Emma Hancox: I see. 95 00:04:45,080 --> 00:04:47,855 Dr Mark Lowrie: And to go back to your question, so if you get a red flag 96 00:04:47,855 --> 00:04:51,855 in one or more of these, that's an indication you've got hard neurological 97 00:04:51,855 --> 00:04:55,755 signs, therefore you've potentially got a significant problem in the forebrain. 98 00:04:56,354 --> 00:04:57,484 And referral is sensible. 99 00:04:57,979 --> 00:04:58,679 Dr Emma Hancox: That makes sense. 100 00:04:59,414 --> 00:05:01,724 Dr Mark Lowrie: In an owner where they want to do everything, that would 101 00:05:01,724 --> 00:05:03,494 mean an MRI scan is more indicated. 102 00:05:04,634 --> 00:05:08,364 We have talked about epilepsy on a budget, and it's fair to say, owners 103 00:05:08,364 --> 00:05:11,574 with these dogs may be on a budget, but then at least you've still got more 104 00:05:11,574 --> 00:05:15,234 information you can say to those owners, it's looking less likely to be epilepsy. 105 00:05:15,775 --> 00:05:17,544 It's more likely to be one of these other conditions. 106 00:05:17,544 --> 00:05:17,874 So 107 00:05:18,535 --> 00:05:18,755 Dr Emma Hancox: Yes. 108 00:05:18,804 --> 00:05:20,784 Dr Mark Lowrie: you don't have the money for an MRI scan, but let's look 109 00:05:20,784 --> 00:05:26,069 at what these conditions are, what's likely and, I think it's probably worth 110 00:05:26,069 --> 00:05:31,150 bringing up now, if you have all of those signs and they can't afford MRI, 111 00:05:32,159 --> 00:05:35,369 even if they haven't got any of those signs and they can't afford MRI, I always 112 00:05:35,369 --> 00:05:37,679 say time is as good as an MRI scan. 113 00:05:38,399 --> 00:05:43,019 What I mean by that is if you just monitor that dog then you maybe start 114 00:05:43,049 --> 00:05:45,599 your anti-epileptic treatment and do all the other things we've talked about. 115 00:05:45,599 --> 00:05:49,049 But if you just monitor that dog, if there's something sinister 116 00:05:49,049 --> 00:05:51,299 underlying this, you'll become aware of it fairly quickly. 117 00:05:51,795 --> 00:05:56,065 That awareness will come about in how the dog's behaving in between the fits. 118 00:05:56,104 --> 00:05:59,895 So these signs we've discussed might start to present themselves, so then an 119 00:05:59,895 --> 00:06:02,884 owner can go away knowing, let's look out for inappropriate soiling in the house. 120 00:06:03,274 --> 00:06:04,504 Let's look out for pacing. 121 00:06:04,594 --> 00:06:05,734 Let's look out for circling. 122 00:06:06,184 --> 00:06:09,004 And if they see that, that tells you, it's just a bit more 123 00:06:09,364 --> 00:06:12,394 information to tell you, yes, this isn't idiopathic epilepsy any more. 124 00:06:12,814 --> 00:06:16,125 It's something else, so I find that really important. 125 00:06:16,305 --> 00:06:17,025 Dr Emma Hancox: That makes sense. 126 00:06:17,295 --> 00:06:21,664 And I guess there probably is going to be a subset of dogs potentially 127 00:06:21,669 --> 00:06:25,755 that come to you and we've said 97% confident and one of those is if 128 00:06:25,755 --> 00:06:29,025 they're normal interictally, but they might be I guess at that point. 129 00:06:29,235 --> 00:06:36,225 But I suppose we wouldn't expect them to deteriorate as quick, or develop other 130 00:06:36,285 --> 00:06:38,865 signs if they were truly epileptics. 131 00:06:39,135 --> 00:06:40,545 Dr Mark Lowrie: I'm really glad you've mentioned that 132 00:06:40,575 --> 00:06:42,165 because that's absolutely right. 133 00:06:42,165 --> 00:06:45,795 So these dogs, they might deteriorate in terms of seizure 134 00:06:45,795 --> 00:06:48,925 frequency and severity, that's fine. 135 00:06:48,975 --> 00:06:51,145 That happens with idiopathic epilepsy. 136 00:06:51,165 --> 00:06:54,555 We've said it's a progressive disease that's, dare I say 137 00:06:54,555 --> 00:06:55,785 it, it's almost inevitable. 138 00:06:56,265 --> 00:07:00,525 But what we're hoping is their behaviour in between remains the same. 139 00:07:00,735 --> 00:07:01,125 Dr Emma Hancox: Yeah. 140 00:07:01,215 --> 00:07:02,415 Dr Mark Lowrie: and that's what's important. 141 00:07:02,415 --> 00:07:06,465 If it doesn't, then we move away from epilepsy onto considering one of these 142 00:07:06,615 --> 00:07:10,305 more, more significant conditions that cause structural disease and 143 00:07:10,545 --> 00:07:12,075 potentially become life threatening. 144 00:07:12,435 --> 00:07:14,175 Dr Emma Hancox: Yeah, no, that definitely makes sense. 145 00:07:14,565 --> 00:07:18,945 Although, I think some of the signs that you picked up might 146 00:07:18,945 --> 00:07:22,965 be consistent with things like cognitive dysfunction and things, so 147 00:07:23,265 --> 00:07:25,005 I guess they're also non-specific. 148 00:07:25,010 --> 00:07:28,425 We don't truly know the cause, but I guess that would come back to the age, 149 00:07:28,430 --> 00:07:30,015 the signalment and that sort of thing. 150 00:07:30,150 --> 00:07:30,510 Dr Mark Lowrie: It would. 151 00:07:30,510 --> 00:07:32,280 And I think that's a good point too 'cause you’re right. 152 00:07:32,280 --> 00:07:35,080 If you look at the clinical signs first, say a brain tumour 153 00:07:35,100 --> 00:07:38,730 versus cognitive dysfunction, the signs may be very similar. 154 00:07:39,195 --> 00:07:42,104 The difference between the two would be with cognitive dysfunction, 155 00:07:42,104 --> 00:07:43,665 it tends to be a very slowly 156 00:07:43,975 --> 00:07:44,475 Dr Emma Hancox: of course. 157 00:07:44,475 --> 00:07:45,595 Dr Mark Lowrie: progressive condition. 158 00:07:45,614 --> 00:07:50,295 So cognitive dysfunction can cause really bad signs over 159 00:07:50,295 --> 00:07:52,125 time, but really very slowly. 160 00:07:52,545 --> 00:07:56,835 And I'd potentially say over years, over a year, two years, three years. 161 00:07:57,285 --> 00:08:00,375 Whereas a brain tumour, if you've got those sorts of signs over three years, 162 00:08:01,155 --> 00:08:02,345 that's suddenly not a brain tumour. 163 00:08:02,445 --> 00:08:05,475 And brain tumours unfortunately progress quite rapidly, and I'd 164 00:08:05,480 --> 00:08:07,455 say over several months maximum. 165 00:08:08,385 --> 00:08:10,575 So if you are getting these signs developing quite quickly 166 00:08:10,575 --> 00:08:15,255 and rapidly, I'd move away from cognitive dysfunction and more to 167 00:08:15,555 --> 00:08:17,115 brain tumour or something like that. 168 00:08:18,045 --> 00:08:20,995 The other thing is with cognitive dysfunction, you wouldn't really 169 00:08:20,995 --> 00:08:25,555 expect to see seizures unless again, cognitive dysfunction are older dogs, 170 00:08:25,555 --> 00:08:28,585 maybe those older dogs are developing other problems, metabolic problems. 171 00:08:29,230 --> 00:08:30,740 Renal disease, liver disease 172 00:08:30,740 --> 00:08:31,130 Dr Emma Hancox: Yes. 173 00:08:31,340 --> 00:08:33,400 Dr Mark Lowrie: And they cause secondary seizures in that way, 174 00:08:33,400 --> 00:08:37,090 but true cognitive dysfunction without any other co-morbidities 175 00:08:37,330 --> 00:08:39,000 shouldn't cause epileptic seizures. 176 00:08:39,000 --> 00:08:39,250 Dr Emma Hancox: Yeah. 177 00:08:39,630 --> 00:08:40,840 No, that makes absolute sense. 178 00:08:41,690 --> 00:08:43,540 Dr Mark Lowrie: So the other time that you might want to consider 179 00:08:43,540 --> 00:08:47,950 referral would be with those dogs that are really hard to control. 180 00:08:48,430 --> 00:08:52,650 And I think there's a lot to be said for referring those patients to a veterinary 181 00:08:52,740 --> 00:08:55,920 neurology specialist, simply because it gives the owners chance to sit down 182 00:08:55,920 --> 00:09:00,270 with somebody who's familiar with these alternative medications, these difficult 183 00:09:00,270 --> 00:09:04,440 situations where you have what we call a refractory patient that isn't controlled 184 00:09:04,440 --> 00:09:08,030 with the standard medication, and it just gives them an understanding of 185 00:09:08,030 --> 00:09:09,800 why maybe they're in that situation. 186 00:09:10,340 --> 00:09:13,280 Hopefully it will be an opportunity for them to realise it's not you 187 00:09:13,280 --> 00:09:14,270 as a vet, that's the problem. 188 00:09:14,330 --> 00:09:15,585 They're not seeing a bad vet, 189 00:09:15,625 --> 00:09:15,825 Dr Emma Hancox: yeah. 190 00:09:15,825 --> 00:09:21,150 Dr Mark Lowrie: they're seeing a bad dog and so there's a real reassurance 191 00:09:21,150 --> 00:09:23,330 there the owner, that actually everything has been done correctly. 192 00:09:23,330 --> 00:09:26,120 They're just very unfortunate to have a dog that's this badly affected. 193 00:09:26,540 --> 00:09:30,370 They can be hard those, and I think those owners need more time because they're 194 00:09:30,370 --> 00:09:34,600 facing a very difficult situation and those difficult situations, you have to 195 00:09:34,600 --> 00:09:38,830 be frank, you have to say that, sometimes these things can be so bad owners almost 196 00:09:38,835 --> 00:09:43,570 feel a relief sometimes to be told that, that it wasn't, it's not just them being, 197 00:09:43,750 --> 00:09:46,960 being difficult as a client or anything and, maybe they feel the experience of 198 00:09:46,960 --> 00:09:50,715 it's too much for them, it is quite normal having an epileptic dog in the household 199 00:09:50,715 --> 00:09:55,005 that you’re medicating with many drugs each day, that can be a real burden. 200 00:09:55,335 --> 00:09:59,595 And I think owners hearing that, it allows them to feel that burden. 201 00:09:59,775 --> 00:10:01,455 Dr Emma Hancox: Yeah, it's reassuring. 202 00:10:01,770 --> 00:10:05,550 Dr Mark Lowrie: It is reassuring and the burden of this is really helpful for those 203 00:10:05,550 --> 00:10:11,050 owners to just allow them to feel that and hopefully move forward with a plan. 204 00:10:11,455 --> 00:10:11,815 Dr Emma Hancox: Yeah. 205 00:10:11,950 --> 00:10:14,020 Dr Mark Lowrie: And I think sometimes it's good to have a plan where 206 00:10:14,020 --> 00:10:15,790 they go, well, this is our plan. 207 00:10:15,820 --> 00:10:19,630 They're probably on Plan E by this point, but here's Plan E but then E doesn't work. 208 00:10:19,630 --> 00:10:20,830 We've got F and G. 209 00:10:21,190 --> 00:10:24,450 But it's also fair to say, actually after Plan G, I'm afraid that's 210 00:10:24,450 --> 00:10:27,125 it, there's nothing more we can do because there is always an end and I 211 00:10:27,130 --> 00:10:29,785 think owners need to know that there comes a point when we can't do more. 212 00:10:29,895 --> 00:10:32,885 Dr Emma Hancox: Like you say, it's just establishing as well that trust with the 213 00:10:32,885 --> 00:10:36,305 initial referring clinician as well, that actually look, they have done everything 214 00:10:36,305 --> 00:10:41,825 right and this, these are really tricky cases, so it's almost a second opinion 215 00:10:41,825 --> 00:10:43,385 almost at that point, isn't it as well? 216 00:10:43,805 --> 00:10:47,375 It's having the same discussions often, obviously you guys are much 217 00:10:47,380 --> 00:10:50,375 better at bringing in those weird and wonderful drugs that we don't use. 218 00:10:50,640 --> 00:10:52,600 Dr Mark Lowrie: The other thing is they're gonna go away and Google, aren't they? 219 00:10:52,800 --> 00:10:53,450 Dr Emma Hancox: Oh, definitely. 220 00:10:53,465 --> 00:10:55,480 Dr Mark Lowrie: and Google and find out, can we mention Google? 221 00:10:55,480 --> 00:10:56,980 Other search engines are available. 222 00:10:57,880 --> 00:10:58,360 Dr Emma Hancox: Thanks for that 223 00:10:59,050 --> 00:11:00,670 Dr Mark Lowrie: but I think, they can go away and they'll read about 224 00:11:00,675 --> 00:11:02,890 these other things and that they'll always come back with something 225 00:11:02,890 --> 00:11:04,120 that maybe you've never heard about. 226 00:11:04,270 --> 00:11:04,490 Dr Emma Hancox: yes, 227 00:11:04,700 --> 00:11:06,310 Dr Mark Lowrie: I say that because they'll come back to me with 228 00:11:06,310 --> 00:11:07,450 things I’ve never heard about. 229 00:11:07,450 --> 00:11:10,800 But I suppose it just, it's important to be quite clear with them to say, it might 230 00:11:10,800 --> 00:11:13,250 well be that snake oil, I’ve made that up. 231 00:11:13,960 --> 00:11:15,040 Dr Emma Hancox: I was gonna say, is this a new one? 232 00:11:16,160 --> 00:11:19,190 Dr Mark Lowrie: Snake oil may well help the dog with seizures, but 233 00:11:19,190 --> 00:11:20,510 there's no evidence behind it. 234 00:11:20,570 --> 00:11:23,370 And of course, you can't say there's no harm in it 'cause I’ve just made it up. 235 00:11:23,430 --> 00:11:23,640 But, 236 00:11:23,690 --> 00:11:24,830 Dr Emma Hancox: Probably is harm in snake oil 237 00:11:24,860 --> 00:11:27,505 Dr Mark Lowrie: Be cautious with these things and say, yes, you might find one 238 00:11:27,505 --> 00:11:29,995 thing that will help you, or you might read an anecdote where it helped one 239 00:11:29,995 --> 00:11:34,575 individual with their dog, but it doesn't mean it helps every dog and sometimes 240 00:11:34,595 --> 00:11:37,355 these things, epilepsy waxes and wanes. 241 00:11:38,135 --> 00:11:40,735 So you'll have periods when seizures can be really bad in some dogs 242 00:11:40,895 --> 00:11:42,065 other periods when it goes away. 243 00:11:42,440 --> 00:11:46,610 It's inevitable they'll have introduced the snake oil at a period when the 244 00:11:46,610 --> 00:11:48,290 seizures weren't going to return. 245 00:11:48,620 --> 00:11:51,980 So actually they can falsely believe it's working really, really well, but 246 00:11:51,980 --> 00:11:54,770 they're very quick to dismiss two or three months later when the seizures come 247 00:11:54,770 --> 00:11:56,690 back that it must just be getting worse. 248 00:11:56,690 --> 00:11:58,910 And it's like, well, no, no, it's, that was the nature of 249 00:11:58,915 --> 00:11:59,770 the course of the disease. 250 00:11:59,770 --> 00:11:59,990 Dr Emma Hancox: Yeah. 251 00:12:00,510 --> 00:12:03,950 Dr Mark Lowrie: it's easy to attribute benefits to many of these alternative 252 00:12:03,950 --> 00:12:06,890 medications, or indeed some of the medications we use conventionally 253 00:12:06,905 --> 00:12:08,445 to go, oh, it's worked really well. 254 00:12:08,975 --> 00:12:09,385 Maybe not. 255 00:12:09,745 --> 00:12:09,975 Dr Emma Hancox: Yeah. 256 00:12:10,165 --> 00:12:11,630 Dr Mark Lowrie: We never know what was gonna happen if we 257 00:12:11,630 --> 00:12:13,010 hadn't started those drugs. 258 00:12:13,305 --> 00:12:16,705 Dr Emma Hancox: I really want to dig into some of these alternatives if we 259 00:12:16,705 --> 00:12:23,545 can, but maybe just before we do that, when we talk about a refractory patient, 260 00:12:23,545 --> 00:12:27,295 so I feel like this is a conversation we're more getting into is these more 261 00:12:27,295 --> 00:12:29,095 complicated ones, if that's right. 262 00:12:29,100 --> 00:12:33,505 So what, what is meant, and we'll come back to the complimentary stuff, 263 00:12:33,595 --> 00:12:34,705 don't worry everyone, listeners. 264 00:12:34,975 --> 00:12:37,320 But what do we mean by refractory? 265 00:12:37,350 --> 00:12:37,860 What is that? 266 00:12:38,325 --> 00:12:41,875 Dr Mark Lowrie: So refractory epilepsy, some people call it pharmacoresistant 267 00:12:41,900 --> 00:12:43,530 epilepsy to make it sound even more fancy 268 00:12:43,630 --> 00:12:44,565 Dr Emma Hancox: That's very fancy. 269 00:12:44,615 --> 00:12:46,855 So what is pharmacoresistant epilepsy? 270 00:12:47,005 --> 00:12:50,255 Dr Mark Lowrie: Pharmacoresistant epilepsy is when you have a dog that 271 00:12:50,405 --> 00:12:53,555 is on the conventional medication, traditionally we say phenobarbital 272 00:12:53,585 --> 00:12:56,015 with bromide, that's appropriate doses. 273 00:12:56,255 --> 00:13:00,180 So the serum concentrations, they are in the appropriate therapeutic range. 274 00:13:00,450 --> 00:13:02,970 Dr Emma Hancox: I think that's important, in the appropriate range. 275 00:13:03,105 --> 00:13:04,635 Dr Mark Lowrie: because actually, yes, it's true. 276 00:13:04,635 --> 00:13:07,095 If they're not in the appropriate range, they're not being used effectively. 277 00:13:07,095 --> 00:13:09,895 So that dog may not be refractory or pharmacoresistant. 278 00:13:10,005 --> 00:13:13,365 But if they're in that appropriate range and they're still having regular 279 00:13:13,365 --> 00:13:15,135 fits, i e, they're not controlled. 280 00:13:15,345 --> 00:13:18,675 We talk about control of epilepsy being more than a 50% 281 00:13:18,675 --> 00:13:20,445 reduction in seizure frequency. 282 00:13:20,445 --> 00:13:24,945 So if they aren't achieving that on these appropriate doses, that 283 00:13:24,945 --> 00:13:26,655 would be a refractory patient. 284 00:13:27,495 --> 00:13:29,985 Now it's really important and we've touched on it in a previous 285 00:13:29,985 --> 00:13:35,205 podcast to say that 30% of dogs with idiopathic epilepsy can be refractory. 286 00:13:35,535 --> 00:13:36,585 So that's a huge number. 287 00:13:36,615 --> 00:13:36,795 Dr Emma Hancox: That is 288 00:13:37,095 --> 00:13:40,215 Dr Mark Lowrie: Three out of 10, and I dunno if I'm allowed to say 289 00:13:40,330 --> 00:13:42,255 here, you might edit this bit out, 290 00:13:42,375 --> 00:13:42,715 Dr Emma Hancox: I'm nervous. 291 00:13:42,815 --> 00:13:44,555 Now what's he gonna say? 292 00:13:44,705 --> 00:13:47,415 Dr Mark Lowrie: Well, well, so the way I like to liken it and the way that owners 293 00:13:47,415 --> 00:13:50,145 seem to relate to, though you have be careful which owner you pick 'cause, as 294 00:13:50,145 --> 00:13:51,715 you may find, you could cause offence. 295 00:13:52,615 --> 00:13:53,895 Dr Emma Hancox: I'm very nervous now. 296 00:13:54,175 --> 00:13:57,025 Dr Mark Lowrie: well, I think of a dog with epilepsy like being 297 00:13:57,055 --> 00:13:58,945 the man that's had seven wives 298 00:13:59,455 --> 00:13:59,745 Dr Emma Hancox: Okay. 299 00:14:00,025 --> 00:14:01,060 Dr Mark Lowrie: that he's divorced. 300 00:14:01,060 --> 00:14:01,220 Dr Emma Hancox: Okay. 301 00:14:01,220 --> 00:14:02,400 Dr Mark Lowrie: He's not, he's not a bigamist 302 00:14:02,870 --> 00:14:03,525 Dr Emma Hancox: I was gonna say, 303 00:14:03,835 --> 00:14:04,045 Dr Mark Lowrie: you know? 304 00:14:04,045 --> 00:14:07,745 So, um, so in that situation, you've had a man that's married to seven 305 00:14:07,745 --> 00:14:10,055 different women, and for one reason or another, the marriage hasn't 306 00:14:10,060 --> 00:14:11,705 been successful and he is divorced. 307 00:14:12,155 --> 00:14:15,755 So in that scenario, consider that and consider that man and 308 00:14:15,755 --> 00:14:18,005 go, would you blame the wives? 309 00:14:18,095 --> 00:14:19,715 Is it, is it the, the seven women? 310 00:14:19,715 --> 00:14:21,305 Dr Emma Hancox: Being a woman myself, definitely not 311 00:14:22,305 --> 00:14:25,610 Dr Mark Lowrie: but equally, you know, I suppose you could say it could have been 312 00:14:25,910 --> 00:14:29,420 all of their faults on seven different occasions, but actually if we turn it 313 00:14:29,420 --> 00:14:32,690 on its head, it's probably more likely to be there's a problem with the man. 314 00:14:33,650 --> 00:14:35,990 Now, back to the epileptic dog. 315 00:14:36,620 --> 00:14:40,850 We've tried this dog on seven different anti-epileptic medications 316 00:14:40,880 --> 00:14:42,140 and not achieved control. 317 00:14:42,650 --> 00:14:45,265 So I don't go, it's phenobarbitals fault. 318 00:14:45,445 --> 00:14:45,625 Dr Emma Hancox: Yeah. 319 00:14:45,685 --> 00:14:45,805 And 320 00:14:45,805 --> 00:14:47,985 Dr Mark Lowrie: actually when we put bromide in that was a bit rubbish too. 321 00:14:48,645 --> 00:14:51,465 And levetiracetam, I dunno why we even bothered for the money for that one. 322 00:14:52,065 --> 00:14:53,535 It's not the medication's fault. 323 00:14:53,595 --> 00:14:56,595 We know the medication can be very effective in epileptic dogs. 324 00:14:56,595 --> 00:15:00,405 So we sadly have to purely square the blame on the dog's epilepsy. 325 00:15:01,335 --> 00:15:04,630 And so that's the way I see these pharmacoresistant epileptic dogs 326 00:15:04,630 --> 00:15:08,575 that, you’re not gonna suddenly find a medication that's gonna be the golden 327 00:15:08,575 --> 00:15:12,565 bullet and cure all and it doesn't mean you don't add in a third or a fourth 328 00:15:12,565 --> 00:15:15,835 medication, but it would be wrong to bring that owner along on that journey 329 00:15:15,865 --> 00:15:18,905 and say, let's try zonisamide today. 330 00:15:19,115 --> 00:15:21,785 And then for them to go home with this zonisamide, it's quite an 331 00:15:21,785 --> 00:15:25,325 expensive drug, and for them to be quite excited that might be 332 00:15:25,325 --> 00:15:26,734 the thing that stops the seizures. 333 00:15:26,765 --> 00:15:30,635 Because look, taking a step back, it's very clear that won't happen. 334 00:15:30,665 --> 00:15:30,875 Dr Emma Hancox: Yeah. 335 00:15:31,265 --> 00:15:33,965 Dr Mark Lowrie: You might get a small reduction in fits, but if this 336 00:15:33,965 --> 00:15:38,825 is a dog that's fitting, I don't know, say seven times a week, maybe 337 00:15:38,825 --> 00:15:40,545 we'll just get five fits in a week. 338 00:15:40,545 --> 00:15:40,605 Dr Emma Hancox: Yeah. 339 00:15:40,810 --> 00:15:40,955 Yeah. 340 00:15:40,955 --> 00:15:42,605 Dr Mark Lowrie: And that isn't a significant reduction. 341 00:15:42,605 --> 00:15:45,865 And unless the owners are keeping a diary, you'd, accept they may not even 342 00:15:45,865 --> 00:15:47,985 notice that reduction in frequency 343 00:15:48,085 --> 00:15:48,145 Dr Emma Hancox: Yeah. 344 00:15:48,505 --> 00:15:52,945 Dr Mark Lowrie: so this happens a lot and those refractory dogs are 345 00:15:52,945 --> 00:15:56,485 the hardest to manage, but those owners need that conversation. 346 00:15:56,590 --> 00:15:57,040 Dr Emma Hancox: Yeah. 347 00:15:57,460 --> 00:16:02,560 And so are these refractory dogs, are they refractory from day one or do they 348 00:16:02,560 --> 00:16:06,620 develop refractory epilepsy with time or? 349 00:16:06,730 --> 00:16:09,190 Dr Mark Lowrie: Fantastic question, and I think it's fair 350 00:16:09,190 --> 00:16:10,839 to say different things happen. 351 00:16:11,560 --> 00:16:16,780 So there are certain indicators when we see these dogs that might give us a 352 00:16:16,780 --> 00:16:18,760 warning that they could be refractory. 353 00:16:20,655 --> 00:16:23,894 Breed is one of them, generally a border collie with seizures I’ll be a bit more 354 00:16:23,894 --> 00:16:25,784 worried about than say a Jack Russell. 355 00:16:25,904 --> 00:16:29,620 So the border collie has some mutations in some of the ion channels in the brain 356 00:16:29,680 --> 00:16:34,480 that can prevent penetration of certain antiepileptic drugs to stop the drugs 357 00:16:34,480 --> 00:16:36,670 working as effectively in epilepsy. 358 00:16:37,120 --> 00:16:38,290 So that can happen with them. 359 00:16:38,290 --> 00:16:40,995 But then there's other breeds I think, I could pick out German Shepherd 360 00:16:40,995 --> 00:16:44,005 dogs, Weimaraners, there dogs I'm just slightly more nervous around 361 00:16:44,085 --> 00:16:44,345 Dr Emma Hancox: right? 362 00:16:44,435 --> 00:16:47,295 Dr Mark Lowrie: with epilepsy, but that's not meaning that I’ll see a 363 00:16:47,295 --> 00:16:50,865 Weimaraners with seizures, and I’ll just paint a picture of gloom at all. 364 00:16:51,375 --> 00:16:52,305 So that's one thing. 365 00:16:53,205 --> 00:16:57,360 The other thing that is very important to say about epilepsy is, it's one 366 00:16:57,360 --> 00:17:00,930 of the few diseases where the older you are, when you get it, the better. 367 00:17:01,575 --> 00:17:02,235 Dr Emma Hancox: Oh, okay. 368 00:17:02,460 --> 00:17:05,200 Dr Mark Lowrie: So most conditions, as you get older, you would imagine 369 00:17:05,200 --> 00:17:06,220 they're always gonna be worse. 370 00:17:06,520 --> 00:17:09,280 But this is one where actually the young dogs getting epilepsy, 371 00:17:10,000 --> 00:17:12,870 they've got the poorer prognosis because they've got a longer period 372 00:17:13,130 --> 00:17:13,530 Dr Emma Hancox: yeah. 373 00:17:13,780 --> 00:17:14,980 Dr Mark Lowrie: to live with those seizures. 374 00:17:15,560 --> 00:17:17,590 So a longer period for those seizures to progress. 375 00:17:17,590 --> 00:17:19,120 We've said epilepsy's progressive. 376 00:17:19,540 --> 00:17:24,670 So actually if they're two years old, when they are diagnosed, by the age of six, 377 00:17:24,675 --> 00:17:25,810 they've lived with that for four years. 378 00:17:25,810 --> 00:17:28,600 So there's every chance the seizures could be quite difficult 379 00:17:28,600 --> 00:17:29,830 to manage at that point. 380 00:17:29,830 --> 00:17:33,700 So a young dog with epilepsy, unfortunately, has a poorer prognosis. 381 00:17:34,480 --> 00:17:37,240 Again, that doesn't mean I'm gonna do anything too differently, 382 00:17:37,860 --> 00:17:39,100 but that owner needs to be aware 383 00:17:39,135 --> 00:17:39,425 Dr Emma Hancox: yeah. 384 00:17:39,800 --> 00:17:42,020 Dr Mark Lowrie: that's a worry that we're having to go down the route 385 00:17:42,020 --> 00:17:43,850 of medicating at such a young age. 386 00:17:44,570 --> 00:17:48,560 And in that scenario, I'd want to save drugs back as much as I can 387 00:17:48,710 --> 00:17:48,970 Dr Emma Hancox: Yeah. 388 00:17:49,340 --> 00:17:51,980 Dr Mark Lowrie: 'cause if we did throw all the medication onto that dog, because 389 00:17:51,980 --> 00:17:56,690 it's young and he's got bad seizures, you've got nowhere to go in the future. 390 00:17:56,690 --> 00:18:00,890 So if it did go on to phenobarbital and bromide, and some dogs do need to 391 00:18:00,890 --> 00:18:04,220 go on two medications quite quickly, early on in the disease course. 392 00:18:04,220 --> 00:18:07,640 But if you do that, you’re reducing future options, which 393 00:18:08,330 --> 00:18:09,440 may be the right thing to do. 394 00:18:09,440 --> 00:18:10,670 it's a tailored approach. 395 00:18:10,715 --> 00:18:10,975 Dr Emma Hancox: Yeah. 396 00:18:11,485 --> 00:18:12,505 Dr Mark Lowrie: Make sure you do it correctly 397 00:18:12,595 --> 00:18:14,285 Dr Emma Hancox: Because it is gonna progress at some point. 398 00:18:14,315 --> 00:18:15,665 You need something in your armoury. 399 00:18:15,845 --> 00:18:16,355 Absolutely. 400 00:18:17,115 --> 00:18:19,905 Do we know why some dogs are refractory? 401 00:18:20,485 --> 00:18:22,645 Dr Mark Lowrie: We don't, and I think it's fair to say we use 402 00:18:22,645 --> 00:18:26,365 the term idiopathic epilepsy, we don't really know what that is. 403 00:18:26,370 --> 00:18:26,425 Yeah. 404 00:18:26,995 --> 00:18:31,465 So idiopathic epilepsy is the most horrendous umbrella term for probably 405 00:18:31,465 --> 00:18:35,725 a number of different disorders that present with dogs having seizures. 406 00:18:35,725 --> 00:18:40,045 So yes, it's fair to say we probably believe most of them have got genetic 407 00:18:40,750 --> 00:18:42,850 abnormalities that result in epilepsy. 408 00:18:43,930 --> 00:18:47,470 But dare I say it, there are some of the dogs out there that may 409 00:18:47,470 --> 00:18:51,520 have something in their diet that causes the seizures, for example. 410 00:18:51,910 --> 00:18:55,845 So I can think of a study that was done so many years ago now on 411 00:18:55,845 --> 00:18:57,225 a very small subset of dogs. 412 00:18:57,225 --> 00:19:00,865 I want to say it was seven, seven dogs with pharmacoresistant 413 00:19:00,885 --> 00:19:02,175 or refractory epilepsy. 414 00:19:03,105 --> 00:19:08,895 And they also had, as it happened, other sort of allergic type problems. 415 00:19:08,895 --> 00:19:11,235 And what I mean by that is maybe skin allergies, right? 416 00:19:11,595 --> 00:19:13,155 Or gut allergies or both. 417 00:19:14,115 --> 00:19:17,445 Now, these dogs were on appropriate doses of phenobarbital and potassium 418 00:19:17,445 --> 00:19:19,545 bromide, and they just weren't controlled. 419 00:19:19,550 --> 00:19:23,026 They had frequent fits, and from memory it was more than one a week at that point. 420 00:19:24,645 --> 00:19:27,105 But then what they did was they went onto a hypoallergenic diet, 421 00:19:27,105 --> 00:19:31,890 these dogs, that was very strictly followed and in three of the seven 422 00:19:31,890 --> 00:19:36,150 dogs, they actually got a reduction of more than 50% in seizure frequency 423 00:19:36,195 --> 00:19:36,885 Dr Emma Hancox: Oh my goodness. 424 00:19:37,705 --> 00:19:39,105 Dr Mark Lowrie: They didn't mess with the medication. 425 00:19:40,500 --> 00:19:43,860 And then from that, it's fair to say that one of those dogs went 426 00:19:43,860 --> 00:19:45,520 completely seizure free as well. 427 00:19:45,540 --> 00:19:49,565 So pretty good, so that's where you think, actually, if I'm an owner with a 428 00:19:49,565 --> 00:19:52,894 dog on lots of medication, I hear this study of these dogs, actually try diet. 429 00:19:52,894 --> 00:19:53,654 It sounds brilliant. 430 00:19:53,784 --> 00:19:53,924 Dr Emma Hancox: Yeah. 431 00:19:53,924 --> 00:19:54,834 Dr Mark Lowrie: That is the solution. 432 00:19:55,669 --> 00:19:57,705 But of course, there's so many factors in there. 433 00:19:57,725 --> 00:19:59,495 This is quite anecdotal. 434 00:19:59,735 --> 00:20:01,805 It was never published, which tells you immediately there 435 00:20:01,805 --> 00:20:03,095 are failings in the study. 436 00:20:03,125 --> 00:20:06,635 And what I mean by failings is it's not rigorous enough to put through. 437 00:20:06,695 --> 00:20:09,365 And the follow-up wasn't long enough to say, was this sustained? 438 00:20:09,935 --> 00:20:13,325 But that, just that little anecdote tells you that, these are dogs with presumed 439 00:20:13,325 --> 00:20:17,345 idiopathic epilepsy, they could have been having some allergic reaction to something 440 00:20:17,345 --> 00:20:19,725 in the diet and who knows the jury's out. 441 00:20:19,814 --> 00:20:23,280 But that's one example where, whether it was genetic or not, 442 00:20:23,280 --> 00:20:26,850 there was some dietary alteration that helped in those individuals. 443 00:20:26,949 --> 00:20:30,189 So we don't know, but I think there's many things it could be, 444 00:20:30,399 --> 00:20:31,749 the one thing it isn't is toxin. 445 00:20:32,169 --> 00:20:32,949 That's what I'd say. 446 00:20:32,949 --> 00:20:33,934 And I think we've covered that. 447 00:20:33,934 --> 00:20:36,744 But yeah, you can definitely stop blaming the neighbour by this point 448 00:20:36,744 --> 00:20:36,804 Dr Emma Hancox: Yeah. 449 00:20:36,804 --> 00:20:38,544 Dr Mark Lowrie: When the seizures are that recurrent. 450 00:20:38,774 --> 00:20:39,064 Dr Emma Hancox: Yeah. 451 00:20:39,524 --> 00:20:43,274 And I think you've really led us quite nicely, there talking about diet, 452 00:20:43,274 --> 00:20:49,574 onto these like other therapeutic, like non medicinal options really. 453 00:20:49,579 --> 00:20:53,384 So I, I know I just wanna talk about the elephant in the room sometimes because 454 00:20:54,344 --> 00:20:59,774 you are going to get questions about them as first opinion vets and honestly, we 455 00:20:59,834 --> 00:21:03,464 don't have a lot of time to go reading any research behind these things. 456 00:21:03,854 --> 00:21:06,464 So I want to pick up on a couple of things. 457 00:21:07,034 --> 00:21:09,284 Things like diet, does it play a role? 458 00:21:09,284 --> 00:21:12,859 I'm hearing a lot about, there are commercial diets out there now 459 00:21:12,859 --> 00:21:17,959 for a neurological, I will just call neurological diseases, maybe 460 00:21:17,959 --> 00:21:21,379 it's cognitive dysfunction, maybe it's epilepsy, but also then the 461 00:21:21,379 --> 00:21:25,519 role of things like medium chain triglycerides, the M-C-T type oils. 462 00:21:25,519 --> 00:21:26,869 What do you think about those? 463 00:21:26,869 --> 00:21:28,249 Is there any evidence? 464 00:21:28,249 --> 00:21:29,029 Are they worth it? 465 00:21:29,824 --> 00:21:31,564 Dr Mark Lowrie: So there is evidence with these. 466 00:21:31,614 --> 00:21:34,254 I think all of those are very similar in the sense you've got the diets, it's all 467 00:21:34,254 --> 00:21:37,194 based around medium chain triglycerides. 468 00:21:37,244 --> 00:21:39,944 And they're either in the diet or you’re supplementing them with, I 469 00:21:39,944 --> 00:21:43,154 think coconut oil is the one that's frequently mentioned, that sort of idea. 470 00:21:43,154 --> 00:21:45,674 So whether you’re giving it as a supplement or whether you’re giving it 471 00:21:45,674 --> 00:21:49,514 in a diet and as you say, commercially available diets are available, they 472 00:21:49,514 --> 00:21:51,804 are a way of trying to manage seizures. 473 00:21:52,104 --> 00:21:55,134 Now, the evidence that we have there, there are studies that have shown it, 474 00:21:55,134 --> 00:21:57,384 where they have reduced seizure frequency. 475 00:21:58,214 --> 00:22:02,384 But not in every dog and in the dog's where it does reduce seizure frequency, 476 00:22:02,384 --> 00:22:06,134 it isn't necessarily to a level that would be considered to be amazing in 477 00:22:06,254 --> 00:22:06,374 Dr Emma Hancox: right. 478 00:22:07,334 --> 00:22:08,114 Dr Mark Lowrie: owners views. 479 00:22:08,114 --> 00:22:11,024 So I think there's absolutely a place for that. 480 00:22:11,204 --> 00:22:14,354 If owners have used conventional medication, I'd never use it as an 481 00:22:14,359 --> 00:22:16,154 alternative to conventional medication. 482 00:22:16,154 --> 00:22:18,524 But if they've gone down the route of trying the conventional drugs 483 00:22:18,524 --> 00:22:21,644 we've discussed, there's absolutely nothing wrong with trying that in 484 00:22:21,644 --> 00:22:25,814 addition, and it might give some further control, it might not. 485 00:22:26,309 --> 00:22:29,119 It depends on the dog very much how pharmacoresistant 486 00:22:29,119 --> 00:22:30,299 it is and what the cause is. 487 00:22:30,719 --> 00:22:33,179 But there absolutely is a, an area to try. 488 00:22:33,719 --> 00:22:36,539 But as with all the other things we've talked about, the owner must 489 00:22:36,544 --> 00:22:40,289 be aware it might be a complete waste of time for that individual dog. 490 00:22:40,294 --> 00:22:43,019 Yeah, if it works, they'll celebrate, but if it doesn't, it's quite an 491 00:22:43,019 --> 00:22:48,529 expensive process to go through, with diet as well, depending on how 492 00:22:48,529 --> 00:22:51,299 frequent the seizures are, you might need to try it for a long time. 493 00:22:51,479 --> 00:22:55,069 And actually this goes for all the different drugs and therapies we'll 494 00:22:55,069 --> 00:23:00,239 discuss that if you have a dog having one seizure every six weeks, giving a diet 495 00:23:00,239 --> 00:23:02,159 for six, six weeks is not gonna help. 496 00:23:02,209 --> 00:23:05,104 It's, if you get a six week period without seizures, that's expected. 497 00:23:05,524 --> 00:23:07,234 So you really need to do it for much, much longer. 498 00:23:07,234 --> 00:23:09,784 So potentially two or three times longer than that gap. 499 00:23:09,784 --> 00:23:11,344 So that could be 18 weeks. 500 00:23:11,874 --> 00:23:13,924 When you start thinking about 18 weeks, you’re like, oh, that's 501 00:23:13,924 --> 00:23:15,604 a long time to try this diet. 502 00:23:15,604 --> 00:23:17,354 Before you can say it really hasn't worked 503 00:23:17,354 --> 00:23:17,704 Dr Emma Hancox: Yeah. 504 00:23:18,354 --> 00:23:19,679 Dr Mark Lowrie: The waxing and waning nature 505 00:23:19,729 --> 00:23:19,929 Dr Emma Hancox: Yeah. 506 00:23:19,929 --> 00:23:21,709 Dr Mark Lowrie: as we've talked about of epilepsy means there may 507 00:23:21,709 --> 00:23:25,219 be periods when actually it'll feel like the diet's making it worse when 508 00:23:25,219 --> 00:23:26,389 actually, no, it probably isn't. 509 00:23:26,389 --> 00:23:28,939 It's probably just you've had a sort of slight cluster of fits 510 00:23:29,179 --> 00:23:31,669 and then it could really settle down for a much longer period. 511 00:23:31,674 --> 00:23:34,039 So that's a tough one. 512 00:23:34,429 --> 00:23:39,049 And the other thing, just to make it even harder, is owners want to try everything. 513 00:23:39,244 --> 00:23:39,534 Dr Emma Hancox: Yeah. 514 00:23:39,679 --> 00:23:41,299 Dr Mark Lowrie: Now they can do that and throw the baby in 515 00:23:41,299 --> 00:23:42,559 the bath water out with it. 516 00:23:42,639 --> 00:23:46,779 You really, it's the logical way do it, is to do one thing at a time. 517 00:23:47,199 --> 00:23:50,709 So in this scenario where your dog has one seizure every six weeks, if you’re 518 00:23:50,709 --> 00:23:54,664 gonna do it for a, a trial of something for 18 weeks, you’re gonna have to wait 519 00:23:54,664 --> 00:23:56,524 18 weeks until you try the next thing. 520 00:23:57,304 --> 00:23:58,804 And that's a laborious process. 521 00:23:59,044 --> 00:24:02,494 I mean, that that is really tough for any owners to go through. 522 00:24:02,844 --> 00:24:04,774 Needless to say, in the meantime, their dog's fitting. 523 00:24:04,894 --> 00:24:07,414 So it's a tough thing. 524 00:24:07,534 --> 00:24:10,324 But again, with the right communication owners can be aware of that. 525 00:24:10,654 --> 00:24:12,754 They can take it on themselves to try these things. 526 00:24:13,099 --> 00:24:16,909 There's certainly no harm in diet, changing diet, in the majority of dogs. 527 00:24:16,909 --> 00:24:18,259 So it's a fairly safe thing to do. 528 00:24:18,769 --> 00:24:20,569 I’ve said drugs have adverse effects. 529 00:24:20,569 --> 00:24:22,189 I think it's fair to say most diets don't. 530 00:24:22,249 --> 00:24:24,829 There will be individuals that will react to a specific diet, but 531 00:24:24,829 --> 00:24:26,719 it's a fairly safe thing to change. 532 00:24:27,889 --> 00:24:30,449 I always think if I had a dog with epilepsy, I think diet's something I would 533 00:24:30,449 --> 00:24:34,519 explore because I know there are dogs out there that absolutely benefit from it. 534 00:24:34,639 --> 00:24:37,999 But I wouldn't want owners to go away from a consult thinking most dogs benefit from 535 00:24:38,419 --> 00:24:39,669 diet because that's not strictly true. 536 00:24:39,939 --> 00:24:44,179 Dr Emma Hancox: Or that it's an adjunct by the sound of it, to traditional 537 00:24:44,179 --> 00:24:46,399 medication rather than, instead of. 538 00:24:46,879 --> 00:24:51,409 Are you ever in a position that you can reduce any medication with adding these 539 00:24:51,409 --> 00:24:53,419 things in, or is it always just on top of? 540 00:24:53,519 --> 00:24:55,079 Dr Mark Lowrie: There is a whole discussion we could have 541 00:24:55,079 --> 00:24:57,929 there that you bring up about reducing medication in general. 542 00:24:57,929 --> 00:25:01,439 I think with epilepsy, once you've started something and something 543 00:25:01,439 --> 00:25:03,489 works, I never change a winning team. 544 00:25:03,649 --> 00:25:03,869 Dr Emma Hancox: Yes, 545 00:25:03,879 --> 00:25:06,339 Dr Mark Lowrie: it's a, it's not the right thing to do. 546 00:25:06,339 --> 00:25:11,724 I don't feel, however, if you are in the fortunate position where for one 547 00:25:11,724 --> 00:25:14,924 reason or another everything's gone, maybe you've fluked it because to 548 00:25:14,924 --> 00:25:16,334 be fair, it often is like that, that 549 00:25:16,334 --> 00:25:16,394 Dr Emma Hancox: Yeah, 550 00:25:16,409 --> 00:25:17,789 Dr Mark Lowrie: you've just been lucky that the stars have 551 00:25:17,789 --> 00:25:18,869 aligned and things have gone well. 552 00:25:19,559 --> 00:25:23,009 There is the option of reducing medication then to try and see if they can be 553 00:25:23,009 --> 00:25:24,749 managed on diet alone or whatever. 554 00:25:25,189 --> 00:25:30,694 That similarly, if diet works and you get off all the medication, maybe in time you 555 00:25:30,694 --> 00:25:34,154 can reintroduce other foods and find, try and find exactly what it was that helped. 556 00:25:34,154 --> 00:25:34,524 Dr Emma Hancox: Right. 557 00:25:35,114 --> 00:25:37,139 Dr Mark Lowrie: I think it's always a risk, and I think if you are 558 00:25:37,139 --> 00:25:40,769 to reduce medication and take out things, owners need to be aware of 559 00:25:40,769 --> 00:25:42,359 the risk of withdrawal seizures. 560 00:25:42,409 --> 00:25:46,399 If you stop phenobarbital suddenly you’re gonna cause a dog seizures to get a whole 561 00:25:46,399 --> 00:25:47,989 lot worse, and that could be status. 562 00:25:48,889 --> 00:25:51,949 So they, the owners need to know that, and we will reduce phenobarbital 563 00:25:51,954 --> 00:25:54,409 slowly, but I'm scared of doing it. 564 00:25:54,609 --> 00:25:57,099 But you will get some owners that are on board and want to do it because 565 00:25:57,099 --> 00:26:00,214 they really don't want their dog to remain on it on medication for life. 566 00:26:00,784 --> 00:26:03,394 I like them to have been seizure free for a good six to 12 months 567 00:26:03,394 --> 00:26:04,624 before you even consider that. 568 00:26:04,804 --> 00:26:08,044 So it's not a conversation I'd have whilst the dog still has fits. 569 00:26:08,449 --> 00:26:09,259 Dr Emma Hancox: No, that makes sense. 570 00:26:09,829 --> 00:26:10,189 I'm sorry. 571 00:26:10,189 --> 00:26:15,709 I'm gonna talk about CBD oils now 'cause it's a really common question I 572 00:26:15,709 --> 00:26:20,149 used to get asked in practice and was never sure what I should be advising. 573 00:26:20,179 --> 00:26:22,219 It sounds again, a minefield here. 574 00:26:22,579 --> 00:26:23,239 Can you help us? 575 00:26:24,334 --> 00:26:24,664 Dr Mark Lowrie: Yeah. 576 00:26:24,714 --> 00:26:27,954 I think there was a period not that long ago, before we had a 577 00:26:27,954 --> 00:26:29,214 pandemic or something like that 578 00:26:29,269 --> 00:26:30,689 Dr Emma Hancox: Oh yes, 579 00:26:30,689 --> 00:26:33,354 Dr Mark Lowrie: it's a big topic and it was coming up in the news a lot. 580 00:26:33,354 --> 00:26:36,544 So certainly with people with epilepsy, there was a big discussion around 581 00:26:36,544 --> 00:26:40,354 it and the benefits in individuals and all that sort of thing. 582 00:26:40,534 --> 00:26:46,084 Now, yes, I think there's evidence there in people to show there is a benefit to 583 00:26:46,134 --> 00:26:48,559 CBD oil, you've gotta get the right one. 584 00:26:48,619 --> 00:26:49,099 You can't just 585 00:26:49,099 --> 00:26:49,189 Dr Emma Hancox: Okay. 586 00:26:49,189 --> 00:26:51,109 Dr Mark Lowrie: go out and get CBD oil and hope it works. 587 00:26:51,109 --> 00:26:52,429 You've got to do appropriately. 588 00:26:53,269 --> 00:26:56,319 There's not any hard evidence yet that it works in dogs. 589 00:26:56,969 --> 00:26:59,599 That doesn't mean it doesn't work, there's just no evidence there. 590 00:26:59,599 --> 00:27:02,469 Yeah, it means we've not been able to get the studies done and things. 591 00:27:03,129 --> 00:27:04,839 I’ve got no problem with people trying it. 592 00:27:04,929 --> 00:27:07,569 I know of many veterinary neurologists that will consider 593 00:27:07,569 --> 00:27:11,769 using it as another step once other avenues have been exhausted. 594 00:27:11,774 --> 00:27:14,379 So if you've gone through your conventional medication, it is 595 00:27:14,379 --> 00:27:15,489 something people add in now. 596 00:27:15,819 --> 00:27:19,539 It's not cheap, but yeah, there is potentially a role in it. 597 00:27:19,539 --> 00:27:24,734 Again, that might benefit some dogs, but we don't know enough about it yet 598 00:27:24,734 --> 00:27:26,119 and I think studies are ongoing now. 599 00:27:26,119 --> 00:27:28,699 There was a lot of stuff in the press about it, and it's pushed us more 600 00:27:28,699 --> 00:27:32,634 towards looking into what the benefits might be, but I’ve noticed it's not 601 00:27:32,634 --> 00:27:34,344 quite as hot a topic as it once was. 602 00:27:34,344 --> 00:27:36,294 And it, we need to be open to it. 603 00:27:36,354 --> 00:27:36,984 We need to be open. 604 00:27:36,984 --> 00:27:37,854 There might be a benefit. 605 00:27:37,854 --> 00:27:38,154 Dr Emma Hancox: Yeah. 606 00:27:38,784 --> 00:27:39,054 Yeah. 607 00:27:39,084 --> 00:27:42,664 But I guess it's hard for us to recommend anything. 608 00:27:42,669 --> 00:27:46,624 Obviously we can't recommend anything to owners, but just getting them to 609 00:27:46,624 --> 00:27:51,934 be careful where they're sourcing it or what sort of contents it has in it. 610 00:27:51,934 --> 00:27:55,984 So I know there's a worry about the T H C content and things like that in it. 611 00:27:55,984 --> 00:27:59,974 So is there any advice you give to owners or do you litreally just 612 00:27:59,979 --> 00:28:01,054 leave the ball in their court? 613 00:28:01,534 --> 00:28:03,304 Dr Mark Lowrie: Yeah, I think if we are to look into it, there are 614 00:28:03,304 --> 00:28:06,034 certain routes I'd go down through the veterinary avenue, so I would try 615 00:28:06,034 --> 00:28:07,404 and source it through your own vet. 616 00:28:07,554 --> 00:28:07,754 Dr Emma Hancox: Okay. 617 00:28:07,754 --> 00:28:09,914 Dr Mark Lowrie: And if your own vet isn't familiar with where to get 618 00:28:09,914 --> 00:28:12,254 it from, I'd get them to speak to a veterinary neurologist who can 619 00:28:12,254 --> 00:28:13,544 steer them in the right direction. 620 00:28:13,674 --> 00:28:14,774 Dr Emma Hancox: So, we're all coming to you now? 621 00:28:15,014 --> 00:28:15,664 Dr Mark Lowrie: Oh, absolutely. 622 00:28:15,664 --> 00:28:16,294 But I think that's it. 623 00:28:16,324 --> 00:28:18,394 we're happy to give you an idea of where we source it from. 624 00:28:18,394 --> 00:28:18,454 Yeah. 625 00:28:18,664 --> 00:28:21,484 So that's where the owners can then get it from through you, just to make 626 00:28:21,484 --> 00:28:22,864 sure it's the right thing, as you say. 627 00:28:22,869 --> 00:28:27,604 Because if owners are on a budget, they are, and I do it with insurance, 628 00:28:27,634 --> 00:28:28,644 I go on to Compare The Meerkat 629 00:28:28,644 --> 00:28:28,934 Dr Emma Hancox: Yeah, 630 00:28:29,914 --> 00:28:31,024 Dr Mark Lowrie: and I’ll put it in and 631 00:28:31,024 --> 00:28:31,814 Dr Emma Hancox: others are available. 632 00:28:32,149 --> 00:28:32,809 Dr Mark Lowrie: Indeed. 633 00:28:32,989 --> 00:28:34,759 So Go Compare, no, I’ll stop, I’ll stop. 634 00:28:35,659 --> 00:28:38,889 but I’ll, I’ll put the decent, I’ll go for the cheapest insurance option. 635 00:28:38,894 --> 00:28:42,039 But of course by going for the cheapest insurance option, you are basically 636 00:28:42,039 --> 00:28:44,079 insuring there, there are gonna be things that you’re gonna completely 637 00:28:44,079 --> 00:28:45,399 miss out that might be a benefit. 638 00:28:45,919 --> 00:28:49,514 With the cannabis oil if you go for the cheapest option, it's probably not got 639 00:28:49,634 --> 00:28:50,954 in it to what it needs to have in it. 640 00:28:50,954 --> 00:28:51,014 Yeah. 641 00:28:51,044 --> 00:28:53,624 So if you’re gonna do it, do it properly. 642 00:28:53,894 --> 00:28:54,494 Dr Emma Hancox: That makes sense. 643 00:28:55,184 --> 00:28:58,994 And are there any other, I’ve talked about diet and CBD oil, 644 00:28:59,094 --> 00:29:03,354 are there any other weird and wonderful things that you can use? 645 00:29:03,489 --> 00:29:03,699 Dr Mark Lowrie: Yeah. 646 00:29:03,699 --> 00:29:06,829 I suppose the other one that's being looked into a bit, it was Tom Harcourt 647 00:29:06,849 --> 00:29:10,899 Brown at Bristol has been doing studies into this, is the vagal nerve stimulator. 648 00:29:11,590 --> 00:29:15,579 Now, vagal nerve stimulation dates back to ages ago, like before we 649 00:29:15,579 --> 00:29:17,879 even knew what medication was. 650 00:29:17,879 --> 00:29:20,894 When people had seizures, people would stimulate the vagus 651 00:29:20,894 --> 00:29:22,094 nerve by rubbing on the neck. 652 00:29:22,164 --> 00:29:24,469 So the stimulation from the vagal nerve, that, all that tone you’re 653 00:29:24,469 --> 00:29:27,479 getting from that will just dampen the electrical impulses that 654 00:29:27,479 --> 00:29:28,379 firing off in the brain, right? 655 00:29:28,469 --> 00:29:30,989 So that then calms a seizure. 656 00:29:31,139 --> 00:29:35,469 Now what, I mean over many years and lots of work, vagal nerve stimulators 657 00:29:35,469 --> 00:29:37,149 are now able to be surgically placed. 658 00:29:37,554 --> 00:29:37,914 Dr Emma Hancox: Oh wow. 659 00:29:38,034 --> 00:29:41,724 Dr Mark Lowrie: And they can actually be turned on in, in the event a seizure. 660 00:29:42,234 --> 00:29:45,274 And I mentioned Tom at Bristol, he's been placing these in dogs and he's 661 00:29:45,274 --> 00:29:49,174 got early evidence to suggest there may be some benefits again in some dogs. 662 00:29:49,564 --> 00:29:52,484 Now, this sounds great, but of course it comes with a price tag. 663 00:29:52,594 --> 00:29:55,474 Dr Emma Hancox: Of course, I was gonna say that sounds expensive. 664 00:29:55,529 --> 00:29:55,834 Dr Mark Lowrie: yeah. 665 00:29:56,174 --> 00:29:58,344 I think, the tens of thousands isn't a far off figure 666 00:29:58,464 --> 00:29:58,974 Dr Emma Hancox: Oh wow. 667 00:29:59,889 --> 00:30:00,069 So 668 00:30:00,069 --> 00:30:02,709 Dr Mark Lowrie: it's not for everyone, but it is something that may help and 669 00:30:02,709 --> 00:30:05,819 similarly, it's unlikely you’re gonna do that and get a dog that's seizure free. 670 00:30:05,824 --> 00:30:07,199 If that happens, we'll all celebrate. 671 00:30:07,204 --> 00:30:10,139 No one's gonna be disappointed, but don't go into it with that 672 00:30:10,139 --> 00:30:11,609 being the outcome you expect. 673 00:30:12,244 --> 00:30:12,444 Dr Emma Hancox: Brilliant. 674 00:30:12,804 --> 00:30:13,004 Brilliant. 675 00:30:13,154 --> 00:30:14,054 No, that makes sense. 676 00:30:15,704 --> 00:30:18,554 I'm assuming surgical, there's no surgical options. 677 00:30:19,014 --> 00:30:21,744 Dr Mark Lowrie: There's certainly things that are being explored and 678 00:30:21,744 --> 00:30:25,134 who knows, maybe there is a future in that, but that's some way off. 679 00:30:25,134 --> 00:30:28,525 And we always say veterinary medicine is some way behind human medicine and, 680 00:30:28,530 --> 00:30:31,559 and they're doing it in human medicine, so we, we probably will get there. 681 00:30:31,729 --> 00:30:32,329 Dr Emma Hancox: Absolutely. 682 00:30:32,879 --> 00:30:35,909 Thank you once again, Mark, for these really insightful discussions. 683 00:30:35,969 --> 00:30:39,179 Honestly, I think we could be here for hours if we wanted to, talking about all 684 00:30:39,184 --> 00:30:43,259 of these options, but that's unfortunately all we have time for in this episode. 685 00:30:43,559 --> 00:30:47,459 So please tune in next time where myself and Mark will be moving on to the fifth 686 00:30:47,459 --> 00:30:50,699 and unfortunately final instalment of the S.M.A.R.T Approach, which is 687 00:30:50,699 --> 00:30:54,719 Tailor, where we'll be discussing how to create that bespoke approach for 688 00:30:54,719 --> 00:30:58,139 each case and tackling some of the more harder and more ethical questions. 689 00:30:58,139 --> 00:30:59,639 So please join us next time. 690 00:31:00,089 --> 00:31:00,809 Thanks, Mark. 691 00:31:00,814 --> 00:31:01,179 Dr Mark Lowrie: Thank you. 692 00:31:01,399 --> 00:31:01,819 Dr Emma Hancox: Thanks.