Dr Emma Hancox: Welcome back to the Synaptic Tails podcast with your
hosts, Emma Hancox, TVM Technical Vet, and Mark Lowrie, RCVS and European
specialist in Veterinary Neurology, and Co-director of Movement Referrals.
Hi Mark.
How are you today?
Dr Mark Lowrie: Yeah, very well, thank you.
Nice to be back again.
Dr Emma Hancox: Yeah, good.
Nice to have you back as well.
Over the last three episodes we've chatted about the importance of owner
communication, what we need to measure, particularly on blood samples, and
how to advise our clients in order to manage our epileptic patients.
If you are a new listener, now is probably a good time to pause this episode and
go back and take a listen to those earlier episodes so that you know what
we are talking about because we will be referencing them as we go through.
This episode really does follow on from the previous.
So if you remember at the end of the last one, we were talking
about how to manage our owners and how to advise appropriately.
And this one is all about being realistic.
So the first thing I wanted to pick up with you actually, Mark, is we mentioned
last time about referral and how, actually it's not inappropriate to refer a case
of course, but it was all about being realistic with these epileptic patients.
But I was just wondering actually afterwards, are there times that you would
definitely want people to refer to you?
Dr Mark Lowrie: Yeah, I’ve said it's never wrong to refer, so if ever you
feel like you should refer a case, there is absolutely nothing wrong in that.
But yeah, the indications to actually refer a case, I think if you've got
a dog that is showing what I like to call hard neurological deficits, that
would be a reason to go for referral.
So we're always thinking.
Yes, we have seizures, but how is the dog outside of that?
Now you can get what I call less hard neurological signs, like behavioural
changes, maybe a dog's a bit more clingy to an owner, that's a common one
Dr Emma Hancox: yeah,
Dr Mark Lowrie: we come across.
Maybe they're not quite as playful as they once were.
They're soft signs which I think can happen in any scenario.
And so I don't worry about them, but the hard neurological signs would be
those attributable to the forebrain.
And I don't like talking about the brain in too much a complicated way 'cause
I don't think I'd understand but I like to think of the brain like a big
black box and you can divide it into forebrain, cerebellum, and brainstem.
When we talk about seizures, we're talking about forebrain problems,
so we can forget about the rest.
Forebrain disease, signs of forebrain disease, the most common
is seizures, but after that you can get signs of central blindness.
So this is dogs where yes, they're blind, but they have
normal pupillary light reflexes.
So it's maybe an ophthalmic problem, you might find PLRs damaged in some way.
So they'll have no menace, but the PLRs are present.
You might find the dogs will start pacing more than normal.
And by pacing, just being restless.
So a nice question I like to ask an owner would be, outside of the seizures,
does your dog settle well at home?
And it's amazing how many owners won't have volunteered the information partly
'cause they may not have realised
Dr Emma Hancox: Yeah,
Dr Mark Lowrie: but they'll say, yeah, actually my dog can't settle at night,
we'll be sat down watching the TV and my dog's just pacing around the living room.
That is a red flag for me.
If they say that, that tells me there's more going on than just
a simple idiopathic epilepsy.
Dr Emma Hancox: I see.
Dr Mark Lowrie: The other one would be circling as well.
So these can be almost around the edge of a room and you'll find they
often go in one direction, it's worth asking an owner about that too.
And the final one to mention, and this is possibly my favourite question
of all, for any seizuring patient and one that should always be asked.
Dr Emma Hancox: I'm excited.
Dr Mark Lowrie: Have I oversold it now?
Dr Emma Hancox: Yeah, maybe
Dr Mark Lowrie: The question I would ask is, does your dog now toilet in the
house when maybe they haven't before?
You need to ask that last bit 'cause some dogs just toilet in the house
Dr Emma Hancox: Yeah.
Dr Mark Lowrie: It's what they do.
But if they've learned to toilet outside as all well-trained dogs should, I’ve
got a puppy at the minute that is yet to do that, so that's hard work.
If they are well-trained and they toilet outside and they've always
been good at that, if they've started to have inappropriate soiling in the
house, that again, is a big red flag.
It shows loss of learned behaviour, and again, that's something owners
are almost embarrassed to admit to.
So unless you program them and ask that question specifically, it might
not be volunteered 'cause all of these things come back to the fact
that the big elephant in the room is the seizures and so often we focus
on the seizures and we don't think about the behaviour outside of that.
So I would be asking all of these sorts of questions sometimes and
dare I say it, this avoids the need for a neurological exam.
So asking about circling, pacing, being blind and loss of toilet training.
They are almost a great substitute for the seizuring patient because if owners
are saying to them there's something wrong or abnormal, I found that they're almost
more sensitive than the neurological exam itself at picking up early disease.
Dr Emma Hancox: I see.
Dr Mark Lowrie: And to go back to your question, so if you get a red flag
in one or more of these, that's an indication you've got hard neurological
signs, therefore you've potentially got a significant problem in the forebrain.
And referral is sensible.
Dr Emma Hancox: That makes sense.
Dr Mark Lowrie: In an owner where they want to do everything, that would
mean an MRI scan is more indicated.
We have talked about epilepsy on a budget, and it's fair to say, owners
with these dogs may be on a budget, but then at least you've still got more
information you can say to those owners, it's looking less likely to be epilepsy.
It's more likely to be one of these other conditions.
So
Dr Emma Hancox: Yes.
Dr Mark Lowrie: you don't have the money for an MRI scan, but let's look
at what these conditions are, what's likely and, I think it's probably worth
bringing up now, if you have all of those signs and they can't afford MRI,
even if they haven't got any of those signs and they can't afford MRI, I always
say time is as good as an MRI scan.
What I mean by that is if you just monitor that dog then you maybe start
your anti-epileptic treatment and do all the other things we've talked about.
But if you just monitor that dog, if there's something sinister
underlying this, you'll become aware of it fairly quickly.
That awareness will come about in how the dog's behaving in between the fits.
So these signs we've discussed might start to present themselves, so then an
owner can go away knowing, let's look out for inappropriate soiling in the house.
Let's look out for pacing.
Let's look out for circling.
And if they see that, that tells you, it's just a bit more
information to tell you, yes, this isn't idiopathic epilepsy any more.
It's something else, so I find that really important.
Dr Emma Hancox: That makes sense.
And I guess there probably is going to be a subset of dogs potentially
that come to you and we've said 97% confident and one of those is if
they're normal interictally, but they might be I guess at that point.
But I suppose we wouldn't expect them to deteriorate as quick, or develop other
signs if they were truly epileptics.
Dr Mark Lowrie: I'm really glad you've mentioned that
because that's absolutely right.
So these dogs, they might deteriorate in terms of seizure
frequency and severity, that's fine.
That happens with idiopathic epilepsy.
We've said it's a progressive disease that's, dare I say
it, it's almost inevitable.
But what we're hoping is their behaviour in between remains the same.
Dr Emma Hancox: Yeah.
Dr Mark Lowrie: and that's what's important.
If it doesn't, then we move away from epilepsy onto considering one of these
more, more significant conditions that cause structural disease and
potentially become life threatening.
Dr Emma Hancox: Yeah, no, that definitely makes sense.
Although, I think some of the signs that you picked up might
be consistent with things like cognitive dysfunction and things, so
I guess they're also non-specific.
We don't truly know the cause, but I guess that would come back to the age,
the signalment and that sort of thing.
Dr Mark Lowrie: It would.
And I think that's a good point too 'cause you’re right.
If you look at the clinical signs first, say a brain tumour
versus cognitive dysfunction, the signs may be very similar.
The difference between the two would be with cognitive dysfunction,
it tends to be a very slowly
Dr Emma Hancox: of course.
Dr Mark Lowrie: progressive condition.
So cognitive dysfunction can cause really bad signs over
time, but really very slowly.
And I'd potentially say over years, over a year, two years, three years.
Whereas a brain tumour, if you've got those sorts of signs over three years,
that's suddenly not a brain tumour.
And brain tumours unfortunately progress quite rapidly, and I'd
say over several months maximum.
So if you are getting these signs developing quite quickly
and rapidly, I'd move away from cognitive dysfunction and more to
brain tumour or something like that.
The other thing is with cognitive dysfunction, you wouldn't really
expect to see seizures unless again, cognitive dysfunction are older dogs,
maybe those older dogs are developing other problems, metabolic problems.
Renal disease, liver disease
Dr Emma Hancox: Yes.
Dr Mark Lowrie: And they cause secondary seizures in that way,
but true cognitive dysfunction without any other co-morbidities
shouldn't cause epileptic seizures.
Dr Emma Hancox: Yeah.
No, that makes absolute sense.
Dr Mark Lowrie: So the other time that you might want to consider
referral would be with those dogs that are really hard to control.
And I think there's a lot to be said for referring those patients to a veterinary
neurology specialist, simply because it gives the owners chance to sit down
with somebody who's familiar with these alternative medications, these difficult
situations where you have what we call a refractory patient that isn't controlled
with the standard medication, and it just gives them an understanding of
why maybe they're in that situation.
Hopefully it will be an opportunity for them to realise it's not you
as a vet, that's the problem.
They're not seeing a bad vet,
Dr Emma Hancox: yeah.
Dr Mark Lowrie: they're seeing a bad dog and so there's a real reassurance
there the owner, that actually everything has been done correctly.
They're just very unfortunate to have a dog that's this badly affected.
They can be hard those, and I think those owners need more time because they're
facing a very difficult situation and those difficult situations, you have to
be frank, you have to say that, sometimes these things can be so bad owners almost
feel a relief sometimes to be told that, that it wasn't, it's not just them being,
being difficult as a client or anything and, maybe they feel the experience of
it's too much for them, it is quite normal having an epileptic dog in the household
that you’re medicating with many drugs each day, that can be a real burden.
And I think owners hearing that, it allows them to feel that burden.
Dr Emma Hancox: Yeah, it's reassuring.
Dr Mark Lowrie: It is reassuring and the burden of this is really helpful for those
owners to just allow them to feel that and hopefully move forward with a plan.
Dr Emma Hancox: Yeah.
Dr Mark Lowrie: And I think sometimes it's good to have a plan where
they go, well, this is our plan.
They're probably on Plan E by this point, but here's Plan E but then E doesn't work.
We've got F and G.
But it's also fair to say, actually after Plan G, I'm afraid that's
it, there's nothing more we can do because there is always an end and I
think owners need to know that there comes a point when we can't do more.
Dr Emma Hancox: Like you say, it's just establishing as well that trust with the
initial referring clinician as well, that actually look, they have done everything
right and this, these are really tricky cases, so it's almost a second opinion
almost at that point, isn't it as well?
It's having the same discussions often, obviously you guys are much
better at bringing in those weird and wonderful drugs that we don't use.
Dr Mark Lowrie: The other thing is they're gonna go away and Google, aren't they?
Dr Emma Hancox: Oh, definitely.
Dr Mark Lowrie: and Google and find out, can we mention Google?
Other search engines are available.
Dr Emma Hancox: Thanks for that
Dr Mark Lowrie: but I think, they can go away and they'll read about
these other things and that they'll always come back with something
that maybe you've never heard about.
Dr Emma Hancox: yes,
Dr Mark Lowrie: I say that because they'll come back to me with
things I’ve never heard about.
But I suppose it just, it's important to be quite clear with them to say, it might
well be that snake oil, I’ve made that up.
Dr Emma Hancox: I was gonna say, is this a new one?
Dr Mark Lowrie: Snake oil may well help the dog with seizures, but
there's no evidence behind it.
And of course, you can't say there's no harm in it 'cause I’ve just made it up.
But,
Dr Emma Hancox: Probably is harm in snake oil
Dr Mark Lowrie: Be cautious with these things and say, yes, you might find one
thing that will help you, or you might read an anecdote where it helped one
individual with their dog, but it doesn't mean it helps every dog and sometimes
these things, epilepsy waxes and wanes.
So you'll have periods when seizures can be really bad in some dogs
other periods when it goes away.
It's inevitable they'll have introduced the snake oil at a period when the
seizures weren't going to return.
So actually they can falsely believe it's working really, really well, but
they're very quick to dismiss two or three months later when the seizures come
back that it must just be getting worse.
And it's like, well, no, no, it's, that was the nature of
the course of the disease.
Dr Emma Hancox: Yeah.
Dr Mark Lowrie: it's easy to attribute benefits to many of these alternative
medications, or indeed some of the medications we use conventionally
to go, oh, it's worked really well.
Maybe not.
Dr Emma Hancox: Yeah.
Dr Mark Lowrie: We never know what was gonna happen if we
hadn't started those drugs.
Dr Emma Hancox: I really want to dig into some of these alternatives if we
can, but maybe just before we do that, when we talk about a refractory patient,
so I feel like this is a conversation we're more getting into is these more
complicated ones, if that's right.
So what, what is meant, and we'll come back to the complimentary stuff,
don't worry everyone, listeners.
But what do we mean by refractory?
What is that?
Dr Mark Lowrie: So refractory epilepsy, some people call it pharmacoresistant
epilepsy to make it sound even more fancy
Dr Emma Hancox: That's very fancy.
So what is pharmacoresistant epilepsy?
Dr Mark Lowrie: Pharmacoresistant epilepsy is when you have a dog that
is on the conventional medication, traditionally we say phenobarbital
with bromide, that's appropriate doses.
So the serum concentrations, they are in the appropriate therapeutic range.
Dr Emma Hancox: I think that's important, in the appropriate range.
Dr Mark Lowrie: because actually, yes, it's true.
If they're not in the appropriate range, they're not being used effectively.
So that dog may not be refractory or pharmacoresistant.
But if they're in that appropriate range and they're still having regular
fits, i e, they're not controlled.
We talk about control of epilepsy being more than a 50%
reduction in seizure frequency.
So if they aren't achieving that on these appropriate doses, that
would be a refractory patient.
Now it's really important and we've touched on it in a previous
podcast to say that 30% of dogs with idiopathic epilepsy can be refractory.
So that's a huge number.
Dr Emma Hancox: That is
Dr Mark Lowrie: Three out of 10, and I dunno if I'm allowed to say
here, you might edit this bit out,
Dr Emma Hancox: I'm nervous.
Now what's he gonna say?
Dr Mark Lowrie: Well, well, so the way I like to liken it and the way that owners
seem to relate to, though you have be careful which owner you pick 'cause, as
you may find, you could cause offence.
Dr Emma Hancox: I'm very nervous now.
Dr Mark Lowrie: well, I think of a dog with epilepsy like being
the man that's had seven wives
Dr Emma Hancox: Okay.
Dr Mark Lowrie: that he's divorced.
Dr Emma Hancox: Okay.
Dr Mark Lowrie: He's not, he's not a bigamist
Dr Emma Hancox: I was gonna say,
Dr Mark Lowrie: you know?
So, um, so in that situation, you've had a man that's married to seven
different women, and for one reason or another, the marriage hasn't
been successful and he is divorced.
So in that scenario, consider that and consider that man and
go, would you blame the wives?
Is it, is it the, the seven women?
Dr Emma Hancox: Being a woman myself, definitely not
Dr Mark Lowrie: but equally, you know, I suppose you could say it could have been
all of their faults on seven different occasions, but actually if we turn it
on its head, it's probably more likely to be there's a problem with the man.
Now, back to the epileptic dog.
We've tried this dog on seven different anti-epileptic medications
and not achieved control.
So I don't go, it's phenobarbitals fault.
Dr Emma Hancox: Yeah.
And
Dr Mark Lowrie: actually when we put bromide in that was a bit rubbish too.
And levetiracetam, I dunno why we even bothered for the money for that one.
It's not the medication's fault.
We know the medication can be very effective in epileptic dogs.
So we sadly have to purely square the blame on the dog's epilepsy.
And so that's the way I see these pharmacoresistant epileptic dogs
that, you’re not gonna suddenly find a medication that's gonna be the golden
bullet and cure all and it doesn't mean you don't add in a third or a fourth
medication, but it would be wrong to bring that owner along on that journey
and say, let's try zonisamide today.
And then for them to go home with this zonisamide, it's quite an
expensive drug, and for them to be quite excited that might be
the thing that stops the seizures.
Because look, taking a step back, it's very clear that won't happen.
Dr Emma Hancox: Yeah.
Dr Mark Lowrie: You might get a small reduction in fits, but if this
is a dog that's fitting, I don't know, say seven times a week, maybe
we'll just get five fits in a week.
Dr Emma Hancox: Yeah.
Yeah.
Dr Mark Lowrie: And that isn't a significant reduction.
And unless the owners are keeping a diary, you'd, accept they may not even
notice that reduction in frequency
Dr Emma Hancox: Yeah.
Dr Mark Lowrie: so this happens a lot and those refractory dogs are
the hardest to manage, but those owners need that conversation.
Dr Emma Hancox: Yeah.
And so are these refractory dogs, are they refractory from day one or do they
develop refractory epilepsy with time or?
Dr Mark Lowrie: Fantastic question, and I think it's fair
to say different things happen.
So there are certain indicators when we see these dogs that might give us a
warning that they could be refractory.
Breed is one of them, generally a border collie with seizures I’ll be a bit more
worried about than say a Jack Russell.
So the border collie has some mutations in some of the ion channels in the brain
that can prevent penetration of certain antiepileptic drugs to stop the drugs
working as effectively in epilepsy.
So that can happen with them.
But then there's other breeds I think, I could pick out German Shepherd
dogs, Weimaraners, there dogs I'm just slightly more nervous around
Dr Emma Hancox: right?
Dr Mark Lowrie: with epilepsy, but that's not meaning that I’ll see a
Weimaraners with seizures, and I’ll just paint a picture of gloom at all.
So that's one thing.
The other thing that is very important to say about epilepsy is, it's one
of the few diseases where the older you are, when you get it, the better.
Dr Emma Hancox: Oh, okay.
Dr Mark Lowrie: So most conditions, as you get older, you would imagine
they're always gonna be worse.
But this is one where actually the young dogs getting epilepsy,
they've got the poorer prognosis because they've got a longer period
Dr Emma Hancox: yeah.
Dr Mark Lowrie: to live with those seizures.
So a longer period for those seizures to progress.
We've said epilepsy's progressive.
So actually if they're two years old, when they are diagnosed, by the age of six,
they've lived with that for four years.
So there's every chance the seizures could be quite difficult
to manage at that point.
So a young dog with epilepsy, unfortunately, has a poorer prognosis.
Again, that doesn't mean I'm gonna do anything too differently,
but that owner needs to be aware
Dr Emma Hancox: yeah.
Dr Mark Lowrie: that's a worry that we're having to go down the route
of medicating at such a young age.
And in that scenario, I'd want to save drugs back as much as I can
Dr Emma Hancox: Yeah.
Dr Mark Lowrie: 'cause if we did throw all the medication onto that dog, because
it's young and he's got bad seizures, you've got nowhere to go in the future.
So if it did go on to phenobarbital and bromide, and some dogs do need to
go on two medications quite quickly, early on in the disease course.
But if you do that, you’re reducing future options, which
may be the right thing to do.
it's a tailored approach.
Dr Emma Hancox: Yeah.
Dr Mark Lowrie: Make sure you do it correctly
Dr Emma Hancox: Because it is gonna progress at some point.
You need something in your armoury.
Absolutely.
Do we know why some dogs are refractory?
Dr Mark Lowrie: We don't, and I think it's fair to say we use
the term idiopathic epilepsy, we don't really know what that is.
Yeah.
So idiopathic epilepsy is the most horrendous umbrella term for probably
a number of different disorders that present with dogs having seizures.
So yes, it's fair to say we probably believe most of them have got genetic
abnormalities that result in epilepsy.
But dare I say it, there are some of the dogs out there that may
have something in their diet that causes the seizures, for example.
So I can think of a study that was done so many years ago now on
a very small subset of dogs.
I want to say it was seven, seven dogs with pharmacoresistant
or refractory epilepsy.
And they also had, as it happened, other sort of allergic type problems.
And what I mean by that is maybe skin allergies, right?
Or gut allergies or both.
Now, these dogs were on appropriate doses of phenobarbital and potassium
bromide, and they just weren't controlled.
They had frequent fits, and from memory it was more than one a week at that point.
But then what they did was they went onto a hypoallergenic diet,
these dogs, that was very strictly followed and in three of the seven
dogs, they actually got a reduction of more than 50% in seizure frequency
Dr Emma Hancox: Oh my goodness.
Dr Mark Lowrie: They didn't mess with the medication.
And then from that, it's fair to say that one of those dogs went
completely seizure free as well.
So pretty good, so that's where you think, actually, if I'm an owner with a
dog on lots of medication, I hear this study of these dogs, actually try diet.
It sounds brilliant.
Dr Emma Hancox: Yeah.
Dr Mark Lowrie: That is the solution.
But of course, there's so many factors in there.
This is quite anecdotal.
It was never published, which tells you immediately there
are failings in the study.
And what I mean by failings is it's not rigorous enough to put through.
And the follow-up wasn't long enough to say, was this sustained?
But that, just that little anecdote tells you that, these are dogs with presumed
idiopathic epilepsy, they could have been having some allergic reaction to something
in the diet and who knows the jury's out.
But that's one example where, whether it was genetic or not,
there was some dietary alteration that helped in those individuals.
So we don't know, but I think there's many things it could be,
the one thing it isn't is toxin.
That's what I'd say.
And I think we've covered that.
But yeah, you can definitely stop blaming the neighbour by this point
Dr Emma Hancox: Yeah.
Dr Mark Lowrie: When the seizures are that recurrent.
Dr Emma Hancox: Yeah.
And I think you've really led us quite nicely, there talking about diet,
onto these like other therapeutic, like non medicinal options really.
So I, I know I just wanna talk about the elephant in the room sometimes because
you are going to get questions about them as first opinion vets and honestly, we
don't have a lot of time to go reading any research behind these things.
So I want to pick up on a couple of things.
Things like diet, does it play a role?
I'm hearing a lot about, there are commercial diets out there now
for a neurological, I will just call neurological diseases, maybe
it's cognitive dysfunction, maybe it's epilepsy, but also then the
role of things like medium chain triglycerides, the M-C-T type oils.
What do you think about those?
Is there any evidence?
Are they worth it?
Dr Mark Lowrie: So there is evidence with these.
I think all of those are very similar in the sense you've got the diets, it's all
based around medium chain triglycerides.
And they're either in the diet or you’re supplementing them with, I
think coconut oil is the one that's frequently mentioned, that sort of idea.
So whether you’re giving it as a supplement or whether you’re giving it
in a diet and as you say, commercially available diets are available, they
are a way of trying to manage seizures.
Now, the evidence that we have there, there are studies that have shown it,
where they have reduced seizure frequency.
But not in every dog and in the dog's where it does reduce seizure frequency,
it isn't necessarily to a level that would be considered to be amazing in
Dr Emma Hancox: right.
Dr Mark Lowrie: owners views.
So I think there's absolutely a place for that.
If owners have used conventional medication, I'd never use it as an
alternative to conventional medication.
But if they've gone down the route of trying the conventional drugs
we've discussed, there's absolutely nothing wrong with trying that in
addition, and it might give some further control, it might not.
It depends on the dog very much how pharmacoresistant
it is and what the cause is.
But there absolutely is a, an area to try.
But as with all the other things we've talked about, the owner must
be aware it might be a complete waste of time for that individual dog.
Yeah, if it works, they'll celebrate, but if it doesn't, it's quite an
expensive process to go through, with diet as well, depending on how
frequent the seizures are, you might need to try it for a long time.
And actually this goes for all the different drugs and therapies we'll
discuss that if you have a dog having one seizure every six weeks, giving a diet
for six, six weeks is not gonna help.
It's, if you get a six week period without seizures, that's expected.
So you really need to do it for much, much longer.
So potentially two or three times longer than that gap.
So that could be 18 weeks.
When you start thinking about 18 weeks, you’re like, oh, that's
a long time to try this diet.
Before you can say it really hasn't worked
Dr Emma Hancox: Yeah.
Dr Mark Lowrie: The waxing and waning nature
Dr Emma Hancox: Yeah.
Dr Mark Lowrie: as we've talked about of epilepsy means there may
be periods when actually it'll feel like the diet's making it worse when
actually, no, it probably isn't.
It's probably just you've had a sort of slight cluster of fits
and then it could really settle down for a much longer period.
So that's a tough one.
And the other thing, just to make it even harder, is owners want to try everything.
Dr Emma Hancox: Yeah.
Dr Mark Lowrie: Now they can do that and throw the baby in
the bath water out with it.
You really, it's the logical way do it, is to do one thing at a time.
So in this scenario where your dog has one seizure every six weeks, if you’re
gonna do it for a, a trial of something for 18 weeks, you’re gonna have to wait
18 weeks until you try the next thing.
And that's a laborious process.
I mean, that that is really tough for any owners to go through.
Needless to say, in the meantime, their dog's fitting.
So it's a tough thing.
But again, with the right communication owners can be aware of that.
They can take it on themselves to try these things.
There's certainly no harm in diet, changing diet, in the majority of dogs.
So it's a fairly safe thing to do.
I’ve said drugs have adverse effects.
I think it's fair to say most diets don't.
There will be individuals that will react to a specific diet, but
it's a fairly safe thing to change.
I always think if I had a dog with epilepsy, I think diet's something I would
explore because I know there are dogs out there that absolutely benefit from it.
But I wouldn't want owners to go away from a consult thinking most dogs benefit from
diet because that's not strictly true.
Dr Emma Hancox: Or that it's an adjunct by the sound of it, to traditional
medication rather than, instead of.
Are you ever in a position that you can reduce any medication with adding these
things in, or is it always just on top of?
Dr Mark Lowrie: There is a whole discussion we could have
there that you bring up about reducing medication in general.
I think with epilepsy, once you've started something and something
works, I never change a winning team.
Dr Emma Hancox: Yes,
Dr Mark Lowrie: it's a, it's not the right thing to do.
I don't feel, however, if you are in the fortunate position where for one
reason or another everything's gone, maybe you've fluked it because to
be fair, it often is like that, that
Dr Emma Hancox: Yeah,
Dr Mark Lowrie: you've just been lucky that the stars have
aligned and things have gone well.
There is the option of reducing medication then to try and see if they can be
managed on diet alone or whatever.
That similarly, if diet works and you get off all the medication, maybe in time you
can reintroduce other foods and find, try and find exactly what it was that helped.
Dr Emma Hancox: Right.
Dr Mark Lowrie: I think it's always a risk, and I think if you are
to reduce medication and take out things, owners need to be aware of
the risk of withdrawal seizures.
If you stop phenobarbital suddenly you’re gonna cause a dog seizures to get a whole
lot worse, and that could be status.
So they, the owners need to know that, and we will reduce phenobarbital
slowly, but I'm scared of doing it.
But you will get some owners that are on board and want to do it because
they really don't want their dog to remain on it on medication for life.
I like them to have been seizure free for a good six to 12 months
before you even consider that.
So it's not a conversation I'd have whilst the dog still has fits.
Dr Emma Hancox: No, that makes sense.
I'm sorry.
I'm gonna talk about CBD oils now 'cause it's a really common question I
used to get asked in practice and was never sure what I should be advising.
It sounds again, a minefield here.
Can you help us?
Dr Mark Lowrie: Yeah.
I think there was a period not that long ago, before we had a
pandemic or something like that
Dr Emma Hancox: Oh yes,
Dr Mark Lowrie: it's a big topic and it was coming up in the news a lot.
So certainly with people with epilepsy, there was a big discussion around
it and the benefits in individuals and all that sort of thing.
Now, yes, I think there's evidence there in people to show there is a benefit to
CBD oil, you've gotta get the right one.
You can't just
Dr Emma Hancox: Okay.
Dr Mark Lowrie: go out and get CBD oil and hope it works.
You've got to do appropriately.
There's not any hard evidence yet that it works in dogs.
That doesn't mean it doesn't work, there's just no evidence there.
Yeah, it means we've not been able to get the studies done and things.
I’ve got no problem with people trying it.
I know of many veterinary neurologists that will consider
using it as another step once other avenues have been exhausted.
So if you've gone through your conventional medication, it is
something people add in now.
It's not cheap, but yeah, there is potentially a role in it.
Again, that might benefit some dogs, but we don't know enough about it yet
and I think studies are ongoing now.
There was a lot of stuff in the press about it, and it's pushed us more
towards looking into what the benefits might be, but I’ve noticed it's not
quite as hot a topic as it once was.
And it, we need to be open to it.
We need to be open.
There might be a benefit.
Dr Emma Hancox: Yeah.
Yeah.
But I guess it's hard for us to recommend anything.
Obviously we can't recommend anything to owners, but just getting them to
be careful where they're sourcing it or what sort of contents it has in it.
So I know there's a worry about the T H C content and things like that in it.
So is there any advice you give to owners or do you litreally just
leave the ball in their court?
Dr Mark Lowrie: Yeah, I think if we are to look into it, there are
certain routes I'd go down through the veterinary avenue, so I would try
and source it through your own vet.
Dr Emma Hancox: Okay.
Dr Mark Lowrie: And if your own vet isn't familiar with where to get
it from, I'd get them to speak to a veterinary neurologist who can
steer them in the right direction.
Dr Emma Hancox: So, we're all coming to you now?
Dr Mark Lowrie: Oh, absolutely.
But I think that's it.
we're happy to give you an idea of where we source it from.
Yeah.
So that's where the owners can then get it from through you, just to make
sure it's the right thing, as you say.
Because if owners are on a budget, they are, and I do it with insurance,
I go on to Compare The Meerkat
Dr Emma Hancox: Yeah,
Dr Mark Lowrie: and I’ll put it in and
Dr Emma Hancox: others are available.
Dr Mark Lowrie: Indeed.
So Go Compare, no, I’ll stop, I’ll stop.
but I’ll, I’ll put the decent, I’ll go for the cheapest insurance option.
But of course by going for the cheapest insurance option, you are basically
insuring there, there are gonna be things that you’re gonna completely
miss out that might be a benefit.
With the cannabis oil if you go for the cheapest option, it's probably not got
in it to what it needs to have in it.
Yeah.
So if you’re gonna do it, do it properly.
Dr Emma Hancox: That makes sense.
And are there any other, I’ve talked about diet and CBD oil,
are there any other weird and wonderful things that you can use?
Dr Mark Lowrie: Yeah.
I suppose the other one that's being looked into a bit, it was Tom Harcourt
Brown at Bristol has been doing studies into this, is the vagal nerve stimulator.
Now, vagal nerve stimulation dates back to ages ago, like before we
even knew what medication was.
When people had seizures, people would stimulate the vagus
nerve by rubbing on the neck.
So the stimulation from the vagal nerve, that, all that tone you’re
getting from that will just dampen the electrical impulses that
firing off in the brain, right?
So that then calms a seizure.
Now what, I mean over many years and lots of work, vagal nerve stimulators
are now able to be surgically placed.
Dr Emma Hancox: Oh wow.
Dr Mark Lowrie: And they can actually be turned on in, in the event a seizure.
And I mentioned Tom at Bristol, he's been placing these in dogs and he's
got early evidence to suggest there may be some benefits again in some dogs.
Now, this sounds great, but of course it comes with a price tag.
Dr Emma Hancox: Of course, I was gonna say that sounds expensive.
Dr Mark Lowrie: yeah.
I think, the tens of thousands isn't a far off figure
Dr Emma Hancox: Oh wow.
So
Dr Mark Lowrie: it's not for everyone, but it is something that may help and
similarly, it's unlikely you’re gonna do that and get a dog that's seizure free.
If that happens, we'll all celebrate.
No one's gonna be disappointed, but don't go into it with that
being the outcome you expect.
Dr Emma Hancox: Brilliant.
Brilliant.
No, that makes sense.
I'm assuming surgical, there's no surgical options.
Dr Mark Lowrie: There's certainly things that are being explored and
who knows, maybe there is a future in that, but that's some way off.
And we always say veterinary medicine is some way behind human medicine and,
and they're doing it in human medicine, so we, we probably will get there.
Dr Emma Hancox: Absolutely.
Thank you once again, Mark, for these really insightful discussions.
Honestly, I think we could be here for hours if we wanted to, talking about all
of these options, but that's unfortunately all we have time for in this episode.
So please tune in next time where myself and Mark will be moving on to the fifth
and unfortunately final instalment of the S.M.A.R.T Approach, which is
Tailor, where we'll be discussing how to create that bespoke approach for
each case and tackling some of the more harder and more ethical questions.
So please join us next time.
Thanks, Mark.
Dr Mark Lowrie: Thank you.
Dr Emma Hancox: Thanks.