Hello and welcome back to Synaptic Tales Season two.
I'm Emma, and I'm here with Mark Lowrie to delve into the
intricate world of canine epilepsy.
Today we are focusing on adjunctive medications and alternative therapies.
Ready?
Mark, we might bring back that snake oil from the first season.
Well, you know what, it depends how long we've got, but we could
definitely get onto that and we can go much further than that if you like.
I mean,
Epilepsy management is a balancing act and when first line treatments don't quite
hit the mark, well, adjunctive medications and therapies can really help us tailor
the approach to the individual patient.
And I think owners are desperate to find that golden bullet, so to speak.
So they'll be all over the internet trying to tell you
what to prescribe to their dog.
Oh yes, for my sins, I am in various Facebook groups and forums as well.
But that's what we really mean by adjunctive therapies, isn't it?
It's those that are given alongside the more traditional treatments.
So I think let's start with those.
Obviously most of us are familiar with the likes of phenobarbital, and we spoke a
lot about it in the first season as well.
But what happens when they're not enough?
And I think, I find clinicians in practice are very good at starting
treatments and taking blood samples.
And if they're like me though, they often panic when you've got your serum
concentration back and the seizures still aren't getting better, what do we do then?
It's really frustrating and yeah, you just want to give a nice quick fix, don't you?
So, a great question.
First, it's important to highlight the concept of appropriate dosing.
So if serum concentrations of the main drug you're giving is sub therapeutic,
but the seizures are well controlled.
Well, there's no need to increase the dose, we're happy.
Yeah.
But if the seizures persist, then adding in a second medication
can often make a big difference.
And when you say sub therapeutic, that can actually be quite tricky, isn't it?
Because the reference ranges from the labs are quite wide,
particularly for phenobarbital.
Yeah.
They can be.
Generally we aim for between 25 to 35 mgs per litre.
As we know, the vast majority of patients are well controlled at these
concentrations, but the lab reference ranges are often much wider than that.
They can go from 15, maybe up to 40.
So if you have a patient say at 15 or 18 mg per litre, although it might be in
the reference range, we still definitely have scope to increase that dose if
the seizures aren't well controlled.
And so once it's in that range, why do we have to keep on monitoring these bloods?
Isn't it just going to stay there?
Well, phenobarbital is effective for about 60 to 80% of epileptic dogs
when used as a monotherapy, but it's got this auto induction effect, which
complicates the long-term effect.
You may remember, I like to liken it to alcohol.
So, if you've never drunk alcohol before and you have a, you enjoy a
nice glass of wine, it gives you like a little woozy feeling at the end.
But then if you have another glass of wine the next night, you might
not quite get that same effect.
So you have to have that little bit more wine to achieve effect.
And so over time you're drinking more and more to maybe achieve that
effect you first had in the first way.
Considering when we are recording, this is giving me echoes of my dry
January and I didn't drink anything.
And then suddenly that first drink again is woo.
I agree.
God, dry January.
I hate dry January.
I did it and I hated it.
But yeah, so exactly that.
So February the first, you enjoyed that drink, but you felt probably
a little bit hungover the next day from that, from very small drink.
I'm not accusing you of being a big drinker, but just that small amount of
alcohol would be enough to tip you over.
But the same thing's true of phenobarbital, so you start off
with say one tablet twice a day.
And then over time the dog will develop a tolerance to it.
So actually we need to increase that dose with time to maintain
the same therapeutic concentration.
So it's why we always say blood monitoring key.
Doing it every six months is a good idea.
Two weeks after any dose change and when there's changes in seizure
frequency because the dog is going to get tolerant and we need to put more
medication in to give that same serum therapeutic concentration long term.
That is interesting then, so when we have a patient that's been on
phenobarbital for a little while, is it the progression of that disease or is
it the tolerance to, to phenobarbital or do we not know necessarily?
I think it absolutely is both.
So I think you are getting a tolerance to medication, but we know epilepsy
is progressive, so I wouldn't want to single one out over the other.
But both those things are happening probably concurrently.
Yeah.
And so moving on to the kind of adjunctive, or therapies, potassium
bromide, I think it's a bit of an old school drug now, but it's really useful.
What do you think about that for adjunctive therapy?
Yeah, you mentioned it to human medics and they sort of think of it
as some kind of witchery or something.
It was in the dark ages, it was considered a medication used to
kind of treat witches and get 'em out of their witch like tendencies.
But you see it pairs really well with phenobarbital because they've
got this kind of synergistic effect.
They work together.
It's also a great option for dogs with the liver conditions that we've mentioned
because it's excreted via the kidneys.
The disadvantages, it does take some months to reach steady state.
So three to four months to be exact.
So if we're going to start it today, don't expect any benefit for a good few months.
And that's where there's a little bit of a drawback and patience is vital.
Yeah, that is quite a long time.
I've seen, of course, that you can do loading doses as well.
So do you recommend those?
Yeah, so a loading dose can be done.
It's 600 mgs per kg divided usually over five days.
But of course it depends on the severity of the seizures you're dealing with.
But look, it speeds things up, but of course it then speeds up
side effects and makes them worse.
So I generally recommend hospitalisation for doing this, due
to the risk of sedation, the ataxia and potentially vomiting as well.
But really keep it for those severe cases because you will see quite
profound side effects that can persist for some weeks or even months.
But I guess those maintenance doses, if you've just got a long term
approach, that's fine then isn't it just a start at the maintenance doses?
And I think if you are preempting that you're going to need it, then
introducing it sooner rather than later is probably the way to go.
Yeah.
And what about imepitoin?
It's another licensed option, although it seems a little bit niched perhaps.
Well, it is.
Phenobarbital and imepitoin are the first two licensed treatments,
so we should make that clear.
They sort of sit at the top of that A-C-V-I-M treatment triangle.
Both are highly effective, but have different applications.
So imepitoin, I mean, it's it's licensed specifically for managing generalised
seizures in idiopathic epilepsy.
In contrast, phenobarbital has a little bit more of a broader range covering
both idiopathic and structural epilepsy.
It's particularly effective for severe conditions like cluster
seizures and status epilepticus, where imepitoin is not the preferred choice.
And actually it would say do avoid in situations such as cluster seizures.
And do we have any kind of studies comparing the two at all?
There was a study about six years ago, I think 2019.
There was a study that provided an excellent comparison
between these two medications.
Highlighting some of the key differences.
For instance, cluster seizures were reported in nearly 70% of dogs that were
treated with imepitoin compared to just under 40% in the Phenobarbital group.
And over a sort of three year period, 90% of dogs on imepitoin experience
cluster seizures compared to only about 35% of those on phenobarb.
Now, imepitoin is sometimes thought to have fewer side effects, but
this study actually showed that adverse effects requiring a change in
medication were actually more common with imepitoin than with phenobarbital.
So I think it's important that when that's raised as an advantage, it may
not always be the case in the particular patient you're prescribing it in.
These findings, combined with the clinical experience we have, often
position phenobarbital a little bit more as the preferred first line
treatment, especially for severe cases.
But imepitoin still might have a place in those cases that maybe
are far less severe and just want to maybe try medication early on.
Okay.
It sounds like careful patient selection then is crucial really for these drugs.
And what about levetiracetam?
It's not obviously licensed for dogs and cats, but it's become
really popular as an add-on.
What are your thoughts on this?
Well, it's brilliant for refractory cases.
I've got no question about that, especially because it's so well tolerated.
It's also really useful in those dogs that have problems with liver disease.
So, if we've got any problem there, let's give levetiracetam because it's renally
excreted and then there's pulse therapy.
So that's where you use the levetiracetam for cluster seizures.
You can go as high as 60 mgs per kg as an initial dose, but then giving
sort of 20 to 30 mgs per kg every eight hours during the cluster.
We call it a cluster buster until the episodes have actually gone.
Yeah, I think that was really useful.
I remember this patient in practice was on phenobarbital like all the time.
Obviously this was a border collie, classic.
But then we'd, when it seizured it had a cluster and it did this every kind of six
to eight weeks or something like that.
And it got to the point where the owners would just call us up and go, oh, can
we get its levy drug again please?
And then we would just prescribe a few days.
And that's acceptable to do, isn't it?
Oh, absolutely.
And that's the perfect time to be using it.
I think that's a great situation where it really helps that patient.
I've read within the literature though that levetiracetam can have
a bit of a honeymoon effect and maybe that's why we pulse dose it.
Do you see that?
Well, I don't really believe it's got a true honeymoon effect.
The idea that it works well for three to six months and then loses its efficacy
isn't really supported by the evidence.
If levetiracetam seems to stop working, it's often more about the
progression of the epilepsy or the underlying disease, rather than the
drug itself becoming less effective.
Similar to the question you asked earlier about phenobarbital.
I think phenobarbital becomes more tolerated, but the epilepsy progresses,
so you have to keep increasing the dose.
The same's true here, because remember we're introducing levetiracetam quite
late on here, and by late on, I just mean after some months of having
used something else previously.
So
the epilepsy's already progressed and so seizures are becoming more problematic.
I suppose what's important is to recognise that a dose adjustment
can often restore seizure control.
So if there is a drop in efficacy, it's worth considering whether the
dose needs to be escalated rather than assuming the medication's failed.
I still think it remains a really useful tool in our management of epilepsy when
you tailor it to the patient's needs.
Yeah.
And so can you have a patient that's on, say, lower doses long
term of levetiracetam and still pulse dose it if you need to.
I kind of want to keep it in my back pocket, I guess for
that emergency cluster episode.
That's fine too.
I tend to be more about having it onboard fully or not at all.
I also get some owners that maybe only give it sort of once or twice a day, and
I actually think that's worse because I think actually what you're doing is the
way the halflife works, you're giving it and there's periods of the day when the
dog will be well covered by levetiracetam and periods when they aren't well covered.
And I tend to find in those periods when they're not well covered, that's when
what we call breakthrough seizures occur.
So actually you can end up making seizures worse in that scenario.
So I always stick to three times daily dosing.
Do we do slightly lower dose?
You could definitely give it a go, but I, it's not something I've done, but I think
there, there could be a reason to do it.
Yeah.
And what about things like the emergency options?
So obviously it's not like a long-term medication, but having things like we
mentioned it in a previous episode, rectal diazepam for instance, at home.
Is that a useful thing for owners to have?
Oh, it's a must have for cluster seizure prone dogs.
I think they have to have this on the shelf ready.
We can give sort of around about half to two mgs per kg at home and you can give
it up to three times in 24 hour period.
So it's a great way to stop the seizure progression while waiting for
the dog to either get to the clinic or for those seizures to pass by.
And for the really refractory cases, we sometimes turn to drugs like
gabapentin, zonisamide, or even felbamate.
Like what are your thoughts on that?
They're worth considering, but they come with caveats.
I don't use them very often, I'll be honest.
And I certainly see plenty of patients that are refractory
to epileptic medication.
The caveats are high cost, limited evidence, it's important to say many of
the studies only include small numbers of dogs in which they show there may
be a benefit and often really quite disappointing results in severe cases.
So they're not magic bullets, but they can sometimes tip the
scales in the right direction.
I think that must be a really important conversation to have
with the owners as well as just to make sure they realise that, you
know, if phenobarbital, potassium
bromide, haven't been the magic bullet, is it likely that this one's going to be?
Perhaps not.
That's right.
Well, we go back to the seven wives, don't we?
But I think, yes, if you're giving an owner a medication in addition to others
that are in place, you're probably doing that because the seizures are frequent.
And I think if the owner's expecting to go home, give that medication
and seizures disappear, then well, you've got a mismatch of expectations
so definitely still remember the client communication is key.
Perfect.
So I think in summary, just kind of wrapping up the medications part
here, getting the most out of those first line options like phenobarbital
and potassium bromide are really key here and kind of only moving on to
those others if we really need to.
So moving on, talking about alternative therapies now.
And I don't mean things that are medications, I mean things that aren't,
and owners often come in asking about these, but some of them can be
quite surprisingly effective, right?
They can, you know what, if you go onto forums and you Google this and
you pretend you're trying to manage to find the cure for your dog.
You'll have some very unusual things that come up.
People present them all the time.
They're huge hot topics at the minute.
Not a week goes past in our clinic where someone might mention
things like MCT oil or CBD oil.
Various things like that that they are using and with variable results,
but certainly some with success.
So you mentioned one there, CBD oil, it comes up a lot in consultations.
What is the evidence behind it?
Well, I suppose the big misnomer we're saying here is, we're not saying let's
smoke cannabis and hope life's good.
That's not what we're doing.
CBD oil is, important to say it's a non psychoactive
compound derived from cannabis.
So really important to say it's different to THC.
So THC is the psychoactive component of cannabis and that causes the high,
that makes cannabis an abused drug.
So we're not looking at that.
So we'll put that to bed straight away.
Definitely.
But CBD oil is sought after for its therapeutic effects
without causing that high.
So medicinal cannabis products are often formulated to maximize the
CBD content while minimising the THC to reduce the psychoactive effects.
I see.
Do we have any kind of studies in dogs looking at CBD products?
Yeah, several studies have examined CBDs, anti-epileptic potential in dogs, it
resulted in a 33% reduction in seizure frequency when compared to a placebo.
But interestingly though, half the dogs in both groups, so that's
the CBD and the placebo group, were classified as responders.
So they both achieve more than a 50% reduction in seizures.
Wow.
That's it.
So, you're giving CBD oil and it's helping, but you're also
giving nothing and it's helping.
There's a second study that found that 6 out of 14 dogs treated
with CBD achieved a more than 50% reduction in seizure frequency, in
the same dogs receiving a placebo.
So clearly CBD in that circumstance seems to have some form of benefit.
It's quite small numbers though, I guess.
They are, and this is important, it comes back to all of them that,
we are looking at small numbers of dogs, not large pools of 200
epileptic dogs, which would be ideal.
But we're just not able to get these numbers in veterinary medicine.
And then there's a third study that looked at dogs with drug
resistant idiopathic epilepsy.
So remember these are dogs that have epilepsy, that have been given the
conventional medication, but still are continuing to have severe seizures.
So the owners of these dogs were given either a placebo, the same as the
previous two studies, and they didn't know which was given to their dog.
They were then monitored for a period of time with seizure frequency
recorded, and then switched to the other medication for the same period of time.
Now in this study, dogs receiving CBD oil alongside standard epileptic drugs
had a 25% reduction in seizure days.
Whereas the placebo group saw a 6% increase.
Total seizure frequency increased in both groups, although the
increase was smaller in the CBD group, like sort of 3% versus 30%.
But the one thing I note from this study is we normally use the definition of
successful treatment being more than a 50% reduction in seizure frequency.
And you'll note that I mentioned reduction in seizure days.
So if we do actually look at the 50% reduction in seizure frequency,
that kind of standard benchmark as a successful outcome, then there was
actually no significant difference between the CBD and placebo groups.
So I feel, when we actually look at these studies in the way we've
looked at all other anti epileptic medications and whether they're
effective or not, then there's not quite such strong evidence for its use.
So there are a few studies out there with perhaps promising results at the moment,
but is there anything on the flip side that we should warn the owners about?
So things like adverse events, for instance, and what about dosing?
It's funny this isn't it because we talk about medications and we're always
talking about adverse effects and things, but I've always noticed with
owners wanting to try these alternative therapies, they don't seem to worry
about
no, it's true
adverse effects.
Side effects were seen in all of these studies, all three of them reported
things like ataxia, so like a drunken walk, lethargy, vomiting, and then
significant increases in some of the liver enzymes like, alkaline phosphatase.
Now when you hear those, that could be a list of side effects from any of the
other conventional medications we use.
Very similar side effects to what we're used to, to our sort of licensed choices.
Now while these early findings are encouraging, I guess
further research is needed to standardise the dosing of CBD oil.
We need to confirm that it is safe and we also need to evaluate its long-term
efficacy as an adjunctive therapy or even as a primary treatment for epilepsy.
At the moment I think the verdict's still out, but when you have a dog with
epilepsy and you're desperate to find a suitable treatment, I certainly think
that CBD oil is worth considering.
And, I can think of many patients where I have used this as an alternative
or as an adjunctive medication.
I think I always worry about the legalities of recommending
or prescribing CBD oil.
Are we allowed to as vets?
In the UK, vets cannot legally prescribe CBD products because,
well, we don't have any veterinary medicinal products containing CBD
that are authorised in the UK.
However, under the Veterinary Medicines Regulations, we can prescribe human
CBD products containing cannabin oil, so the CBD, on the cascade, if
it's deemed clinically necessary.
Okay.
As you say, if they're still refractory, then we can think about adding that in?
Indeed.
So it's not a first line approach here.
Recommending or prescribing CBD you've got to approach it cautiously.
The product would need to come from a reputable source, and I
suppose it's important to ensure that it doesn't contain THC.
So that is a controlled substance under UK law.
And additionally when discussing CBD with clients, it's really important
to manage expectations yet again because you want to highlight the
limited evidence available about its efficacy and the safety in animals.
But ultimately if a client's keen to use CBD for their pet?
Well, we should guide them responsibly.
We should make sure they understand the legalities and
the risks and it's always good.
Well, it's always a good idea to document these conversations
thoroughly in the clinical notes.
Definitely.
That really puts my mind at rest.
Thank you.
What about dietary management?
What about MCT diets?
There's a lot of talk about them at the moment.
Yeah, this is one of my favourites.
So MCT.
So Medium Chain Triglyceride diets.
Studies here, well, they show a 32% reduction in seizure frequency
with medium chain triglycerides.
The diet here that was studied is a specific diet that I
probably should mention.
So it's the Purina Neurocare Diet.
It's a commercial option and it basically allows you to create the same
circumstances they had under the trial.
It isn't a standalone treatment, I should say that again, but it is a great adjunct.
And how does it work?
Well, it's a, the ketogenic diet is something that's long been
used in humans to manage epilepsy and this diet is inspired by the
development of the MCT diet as a more palatable alternative for dogs.
The ketogenic diet traditionally was like high fat diet for people.
You'd kind of see like, a typical English breakfast would be a very good idea of
what you'd have on a ketogenic diet.
But this diet replaces some long chain fatty acids with medium chain
triglycerides, which are far more readily absorbed and form ketones.
And these ketones make the diet ketogenic.
So we like ketones in epilepsy because they reduce excitatory neuronal activity.
So they're effectively calming down all those nerves that are short
circuiting in an epileptic brain.
They improve mitochondrial function, given a more efficient energy source
for neurons, and that improves their stability and resilience under
stress, which basically then means they decrease neuroinflammation.
This is really just trying to help the brain.
There's no doubt that chronic inflammation in the brain is a potential
contributor to seizures and ketones really probably do reduce this through
their anti-inflammatory pathways.
I'm more worried because I think of ketones as like diabetic
dogs and stuff like that.
Should I be worried about using these diets or?
I think as a neurologist, I don't want to get into the ins and outs of
ketones because you're right keto acidosis is clearly a very bad thing,
but I think in these circumstances where you're giving it and giving it
in the kind of doses and the amounts we are, there isn't really a big concern.
Okay.
A dog is able to metabolise these effectively as opposed to in some
of these, well, a diabetic state where there are clearly more
issues with glucose consumption.
Okay.
That's good.
And is the commercial diet the only way to feed these MCT oils?
What about if the owners are, say, reluctant to change
the diet, for instance?
Well, there are different ways to achieve an MCT diet in dogs with epilepsy.
The easiest for me is just to buy a commercial diet.
But you can go and buy a high grade MCT oil, but you really want to ensure
that it contains both caprylic acid, or C8, and capric acid, or C10, as these
are the key medium chain fatty acids that generate ketones efficiently.
Some even look to using coconut oil, but it's not really quite as effective
because it has far less concentrations of these C8 and C10 compounds.
These findings just highlight the potential of what these MCT based
diets might actually do as an adjunctive therapy in epilepsy.
But I should say individual responses vary, but owners are much more receptive
to diets and if you can fix something or at least manage something with a diet,
I think owners are much more willing to give it a go and try it long term.
Yeah, and I think that's really important again, that I think as vets we just
go medications and, but owners want to have these conversations with us
and being open and upfront about, they are possibilities, but also what are
the likely kind of outcomes of these.
Aside from MCTs, the role of diet is really interesting to me.
And I know we've talked in a previous episode about inflammatory bowel
disease and the fly catching behaviour, which was really interesting to me.
But I've also seen some information about the gut brain axis and how patients with
inflammatory bowel diseases or dietary intolerances can have increased seizure
frequencies during flare-ups as well.
So should we be thinking more about a holistic approach when
it comes to epilepsy cases?
I think we should, I really do.
So this is still a very much an emerging area, and I don't think
there's anything too strong there, but there's definitely bits of evidence
pointing towards diet being huge.
And if you can manage your gut, your brain potentially will benefit from that.
There was quite an old study now that I remember that I really
liked, where they looked at only a very small handful of dogs.
And they were dogs with drug resistant epilepsy, so they'd been on
phenobarbital and potassium bromide.
It really effective, well, at appropriate serum concentrations, but
they weren't being that effective.
It was, the dogs were still having frequent seizures.
But in that study, these dogs also had some kind of allergy as well.
And the allergies were either gut allergies or skin allergies.
So they were being managed in this case with a hypoallergenic diet.
Now in half of these dogs, they responded really positively to a hypoallergenic diet
and the seizures reduced significantly and they crossed the threshold for the 50%
reduction in seizure frequency by a mile.
So it showed that there was a real positive benefit here that
was maintained after the study.
So there's clearly stuff going on with diet here, and I always have to say,
it might not be the hypoallergenic diet that was helping them.
There's some other inadvertent component of that diet that helped, but there's
clearly a lot going on with diet, and I know lots is being done right
now, looking into this more to try and come up with further therapies.
Maybe that will be in season three.
Don't talk about season three.
So last season we mentioned vagal nerve stimulation, which
sounded really intriguing, but not exactly mainstream yet.
Is there any updates on that?
Surgically implanted vagal stimulators are really quite effective.
But they're expensive and definitely invasive.
A simpler option is like digital ocular compression, which can sometimes
abort seizures, but it's crude, but it can be effective in the right hands.
You literally mean just putting your fingers on the eyeballs?
That's exactly it.
Now, if you close your eyes and you push your eyeballs.
He's he's doing it right now.
I'm doing it right now.
I'm doing it in both but if you push both eyes, you'll feel, well, you don't feel
anything, but it stimulates the vagus.
And then potentially reduces seizure frequency.
But these are crude techniques, these are going back some years, but I
think it's simpler than going for a surgery to have an implant put in.
Last season our treatments, were you coming home with us going for a walk and
now it's just digital ocular pressure.
Yeah, pushing your eyeballs in.
Simple and effective.
Doesn't cost a thing.
I just want to go back to something you mentioned before.
We were talking about CBD oils and actually that the placebo group
had a really high response as well.
So I think the placebo effect, we can't ignore it, can we?
Absolutely.
So studies show a significant reduction in seizure frequency, even in placebo groups.
It highlights the importance of really trying to control these trials to
validate any treatments efficacy.
There are studies showing the placebo effect is there in canine epilepsy.
It's not really understood why, but it is really interesting
that we see such a thing.
The placebo effect is when we see a psychological or physiological response
to an intervention that doesn't have specific therapeutic activity.
So for example, in a placebo controlled trial, over 50% of dogs
with epilepsy receiving a placebo showed a reduction in seizure
frequency compared to their baseline.
Nearly one third of those dogs were then classified as responders,
meaning they experienced a more than 50% reduction in seizures.
That is actually a shockingly high statistic.
Well, I suppose there are a few reasons why we might see a
placebo effect in canine epilepsy.
You may have heard of the caregiver effect.
So when a caregiver or owner knows their pet's receiving a treatment, they
may perceive improvements or report fewer seizures, even if the frequency
hasn't really changed objectively.
So subjectively, they're feeling there's some form of
improvement, but this is hard.
But it's a hard one to believe as seizures are either present or they're not.
So the use of a rigorous diary to document the seizures, that
should really avoid that pitfall.
Even subtle changes in the dog's environment, routine or the
caregiver's behaviour, during the treatment period could positively
influence seizure frequency.
The fact we see a placebo effect really tells us how important it is to use
rigorous placebo controlled studies to really evaluate the effectiveness
of any anti-epileptic therapy.
And it's a reminder that not all improvements in seizure control
can necessarily be attributed to the treatment itself.
I think that's really hard though, speaking as a pharmaceutical
company, for us to do a placebo controlled trial obviously has
its ethical concerns as well.
Just thought that was an interesting point.
Well, it is.
And it doesn't stop us doing some of these studies because I sometimes feel
this barrier prevents us from learning more because we're saying, well that's
not a placebo controlled study, but it may still give valuable information.
So I think it's something more to be aware of when interpreting results,
but not necessarily a barrier to doing some of these studies.
And I wonder if it has something to do with the owners being
less stressed about their pets, thinking that they're receiving
a treatment that's going to help.
Has there been any studies looking into owner stress and
its impacts upon epilepsy?
Well, you see, that's a fascinating question.
Quite a deep one and one that speaks, I suppose, to that complex relationship
between pets and their owners.
So while dogs themselves obviously aren't really aware of whether they're
receiving an active treatment or a placebo, the owner's perception of
improvement can really play a huge role in how they report their pet's condition.
And that has been well documented in studies on canine epilepsy.
There is evidence suggesting that when owners feel less stressed, perhaps because
they believe a treatment is working, well it can influence how they interpret and
report their dog's seizure behaviour.
And this isn't to say the seizures themselves necessarily change, but
the owners might perceive the dog as doing better, which can impact
how we assess treatment success.
And some research has explored the broader impacts of owner
stress in canine epilepsy.
So a stressed owner may inadvertently contribute to a more stressful
environment for the dog, potentially then influencing seizure frequency or severity.
But the opposite of that would be that when owners feel more in control, say
by starting a new treatment or having a clear management plan, it can have a
positive ripple effect for that patient.
So while the placebo effect is often viewed as a phenomenon
tied to the treatment itself.
It's quite possible that reducing owner stress is part of the equation.
And it's a reminder that as vets supporting the owner, it's really
as important as supporting the patient and helping owners feel
informed, empowered, and reassured.
We can make a real difference.
That's really interesting.
So even in the absence of a drug, it can still yield a
significant response in some cases.
Exactly.
And it emphasises why we need to interpret treatment responses
carefully in clinical practice.
It's not just about the medication, it's also about that broader context of
the dog's care routine and environment.
So we've talked about owner stress and how that can impact on
epilepsy and their dog's epilepsy.
What about the other way round?
So I've been reading that there's some kind of link between epilepsy
and anxiety states in dogs.
And actually if we can calm down these kind of behavioural responses,
can that help the epilepsy?
Yeah, I think that's a really good point.
we're getting more evidence that dogs that have epilepsy have other, well, I
suppose what we call comorbidities, other problems associated with the epilepsy.
And in the past we kind of maybe recognised the dog was a bit more
anxious but didn't appreciate it might be part of the epileptic condition.
So anxiety is definitely one of them.
But all sorts of behavioural changes can be associated with this.
I've known dogs that can be a little bit more aggressive because
of their epilepsy or they might be a little bit more subdued.
I mean it can work both ways.
So if you're dealing with an anxious dog, it might be that relieving
anxiety in some way can help.
Now we've mentioned this on a previous episode.
We are vets so we reached straight for the drugs.
Yep, that was where my mind was going
so you know, we'll open up our cupboard.
We'll see there's plenty of anxiolytic medication out there that can maybe help.
So anxiolytic medication may be appropriate here that we use to try
and help a dog feel calmer and less stressed in certain environments.
So I probably wouldn't use it all the time, but maybe in those situations where
you anticipate a stressful experience coming up, maybe the grandchildren are
coming around for Christmas or whatever it might be, it might help in that situation.
But I think again, by managing epilepsy with medication and
potentially through diet, diet here might well help, it can help anxiety.
I think we're getting to the point where we appreciate a healthy diet
will help you have a healthy brain through a number of mechanisms that
I can't even begin to describe.
But I think all these things would really help.
yeah, and I think, correct me if I'm wrong, but I read that actually
some of these anxiety type states and behavioural comorbidities
are independent of treatment.
So sometimes we think it's because of an adverse effect really
from things like phenobarbital.
But actually they've been seen in treatment naive dogs
as well, isn't that right?
That's absolutely right.
And actually I had a really good example recently where a vet had
started a dog on phenobarbital and the seizures were really loads better.
It was a good improvement.
But actually the dog had started to bite people when it had
never been like that before.
And the question was posed, well, is the phenobarbital doing this?
And actually, I really strongly believed it wasn't the phenobarbital,
it was kind of almost unmasking other aspects of that dog's condition.
So, the dog had a tendency towards that.
And the dog's brain had maybe caused this situation where the threshold
for biting had been lowered.
And so a difficult situation, but one that then can be managed in other ways.
So by managing the anxiety for that dog, we did actually see a good response.
I wouldn't blame anti epileptic medications when we see changes
in behaviour every time.
Certainly it can happen, but I think there's often other causes.
Yeah.
It's really interesting and again, comes back to that holistic approach,
really looking at the whole animal, not just focusing on one part.
So Mark, what is your final advice, I would say, to clinicians managing
these refractory epileptic dogs?
because they can be really quite challenging cases.
Communication.
Well, that's everything.
You've got to set realistic expectations.
So seizure reduction, not elimination, is really the standard
goal we should be heading for.
Managing epilepsy isn't just about the dog, it's about
supporting the family as well.
Okay.
Well said.
I think that's probably all we have time for in this episode.
So thanks again for listening to Synaptic Tails and join us next
time when we turn our eyes to cats.
Until next time.
Goodbye.
Bye, Mark.
Bye for now.