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Welcome to the Synaptic Tails podcast, where neurology meets practical tips in veterinary care. Hosted by Dr Emma Hancox, a Technical Vet Advisor at TVM UK, a Dômes Pharma Brand, alongside Dr Mark Lowrie of Movement Referrals.
In each episode, we delve into managing neurology cases in first-opinion practice, sharing insights, tips, and tricks we've gained through our experiences.
But that's not all! Over the upcoming episodes, we'll introduce you to TVM's S.M.A.R.T. Approach To Epilepsy. What does S.M.A.R.T. stand for? Speak, Measure, Advise, Realistic, and Tailor. We'll explore how this innovative approach can be applied to real-life cases, providing practical solutions to enhance patient care.
About TVM UK:
TVM UK is more than an animal health company; we're dedicated to the well-being of pets and the support of vets and pet owners. Specialising in crucial areas such as poisoning, ophthalmology and neurology, we strive to improve the quality of life for pets in your care.
Join us on the Synaptic Tails podcast as we unravel the complexities of neurology, share stories, and empower you with knowledge. Together, let's enhance the health and happiness of our canine companions.
🌐 Learn more about TVM UK: https://www.tvm-uk.com/
If you're passionate about veterinary care, subscribe now for expert insights and engaging
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To contact TVM UK email help@tvm-uk.com
🌐 Learn more about Movement Referrals: https://www.movementvets.co.uk
Movement Referrals is an independent, specialist veterinary hospital based in the north-west of
England. Our aim is to provide high quality but efficient Specialist referral services. We concentrate
on orthopaedics and neurology, two of the most common reasons for referrals. We are able to offer
common referral procedures, such as TPLO, patellar luxation, and spinal surgery, at reasonable
prices. One of our fundamental philosophies is “getting it right first time”. We not only provide more
choice at better value but we aim to objectively demonstrate our value through measuring and
publishing our outcomes.
Dr Emma Hancox: Welcome back to the
Synaptic Tails podcast with your
hosts, Emma Hancox, TVM Tech Advisor,
and Mark Lowrie, RCVS and European
specialist in Veterinary Neurology,
and Co-director of Movement Referrals.
Mark, how are you today?
Hi!
Dr Mark Lowrie: Hi, Emma.
Yeah, no.
Nice to be back again.
Ready to talk about more about epilepsy?
Yeah, can't wait.
Dr Emma Hancox: Oh, good.
Just as a reminder to our listeners,
this is the third episode of the
S.M.A.R.T Approach to Epilepsy.
So if you’re a new listener and you
haven't listened to those first two
episodes, please do pause this and
head back to episode number one.
If you’re a regular listener,
and hopefully we've got a few
of you by now, you'll hopefully
remember that we introduced a
S.M.A.R.T Approach to epilepsy.
That's TVMs new guide for
first opinion practitioners.
Over the last two episodes, we've
chatted about the importance of owner
communication and what we need to measure
in order to manage our epileptic patients.
And it goes without saying that
once we've established those
measurements, it's obviously time to
advise the owner on what we found.
In this episode, I'm really gonna hand
over to Mark, to be honest, because he's
going to hopefully talk us through his
key three areas to epilepsy treatment.
So over to you, Mark.
Dr Mark Lowrie: Yeah.
Thanks Emma.
Well, I should start again by
saying that word treatment.
I think that's a bad word.
It should be banned because
treatment to me implies a cure.
And I think if you are wanting
to cure a dog's seizures, you
should give up right away.
You know, I think it, it, we
may get lucky, it might happen.
I'm not gonna say it never happens,
but it shouldn't be our expectation.
So both the owners and ourselves
should be ready that curing seizures
completely is very unlikely to happen.
But when we look at seizure management, I
suppose you can break it up into three key
areas and we can focus on each in turn.
So I sort of wanna look at management
of the seizures themselves, management
of the potential underlying cause.
And then the last one is
management of the owner.
it sounds a bit...
Dr Emma Hancox: Managing the owners?
Dr Mark Lowrie: Yeah, exactly.
Managing the owner.
It sounds a bit wrong, but, but actually,
the owners do need to know what's
happening and there's a really big
discussion around what you do to help them
through it so they know what to expect.
And hopefully in turn, then
really trust your word and know
that we're doing the right thing.
So, we'll start with
management of the seizures.
We're looking at various
conventional medications.
And as with any medication, we have
to look to the cascade and think
what are the drugs out there that
we can use to manage seizures?
There's this ACVIM pyramid of hierarchy
that describes all the recommended
antiepileptic treatments based on
their effectiveness, their efficacy
and how they work, and also the quality
of evidence out there that helps
you to know which one we should use.
The best choices then are at the top
of the pyramid, and then as you go
to the bottom of the pyramid, there's
the ones that maybe haven't quite got
that established efficacy and are kind
of alternative choices to add into
the top of the pyramid medications.
Dr Emma Hancox: It sounds like a really
useful tool because we all want to be
like evidence-based when it comes to our
medication options and trawling through
the litreature ourselves is really hard.
Dr Mark Lowrie: Yeah.
So it's a useful little tool.
Now when we go to this pyramid, before
we start these medications, I think the
other thing that an owner needs to be
aware of, and this is again a figure
that I think is quite a scary negative
figure, is that up to 30% of dogs with
idiopathic epilepsy may never achieve
adequate control of their seizures
with these conventional medications.
So that's pretty disappointing and if you
just put it down to like, you know, of,
if you think of three, three owners coming
in to see you with, with epileptic dogs,
one of those three is gonna be really
quite disappointed, whatever you do.
And so it's not, it's not
you that's the problem.
You know, it's the dog's
epilepsy that's a problem.
So never be worried about that.
Now, looking at this, this pyramid at the
top there, the, the, the main medication
for me and the one that's licensed
for use in epilepsy is phenobarbital.
So I, I feel that's kind of a first line.
I should bring in a imepitoin here
because that's also a medication that we
can consider as first line medication.
My feeling with it is it's, it's
very useful early on in epilepsy.
Dr Emma Hancox: Right.
Dr Mark Lowrie: So if you've got dogs that
aren't having frequent fits and the owners
aren't too concerned yet, then I think
a imepitoin is a very reasonable choice.
But as soon as the owners are approaching
you with a concern, then I would go to
phenobarbital and, and skip the step
where we, we try imepitoin but then
after that, that's when we can start
to add in medications as we go along.
And the thing about medicating dogs with
seizures, it's, there's an approach.
Well, if we think about analgesia,
analgesia in the veterinary world
is about using lots of different
medications at lowish doses to
achieve nice control of pain.
Dr Emma Hancox: Like a
multimodal type approach.
Dr Mark Lowrie: Absolutely.
And that's, that's a fairly standard thing
that we're all very familiar with as vets.
Now with epilepsy, it's quite different
because what you want to do with
epilepsy is you want to exploit each
medication to its fullest potential first
before adding in another medication.
And so with phenobarbital, we'll
do everything we've talked about
in the previous podcast where we
get it up to the right dose, check
the serum concentration is good.
And when we're at that level, if seizures
are still not controlled, what I'm doing
is I'm adding in another medication.
Dr Emma Hancox: Yeah.
Dr Mark Lowrie: I very rarely stop a
medication and the indications to stop
an antiepileptic medication are only
if you've got adverse effects from it.
So I’ll be adding in a second, potentially
a third who, who knows a fourth medication
to these dogs to get them under control.
Now, the other factor, of course,
is when we're giving all of these
medications, we wanna make sure the
dog remains as normal as possible.
And we've talked about that.
I mean, I think of it like a
scale where on the one hand
you've got the side effects of
the medication that you’re giving.
On the other hand, you've got
control of the seizures and you
really wanna balance that scale.
And that scale's gonna be
different with every dog you see.
So you’re gonna have the dogs that
maybe have very, very frequent fits.
And so the owners will tolerate
more side effects in order
to control those seizures.
You may have the dogs that seizure
infrequently, but because the postictal
signs are really objectionable,
Dr Emma Hancox: Yeah.
Dr Mark Lowrie: Say an aggressive dog
following a seizure, just one seizure
every six weeks may be too much for
that owner because they're like the,
the aggression they're seeing from their
pet is really difficult to cope with.
We've mentioned children and the family
and things like that make it more of a
concern, so actually they may tolerate
more adverse effects from the medication
to try and really reduce seizures in that
dog than say, a dog that's seizure-ing
once every six weeks but is otherwise
completely happy and doing well.
So that's my approach to managing
the seizures and thinking about what
we use and when we need to use it.
Dr Emma Hancox: That's a really
interesting point on the side effects
and balancing any adverse side
effects 'cause these can change.
But if we, obviously we don't want to,
but they can sometimes affect the dog's
demeanour, behaviour sometimes as well.
For our patients, that we only see
them when they come into us and we
don't know what they're doing at home.
It definitely is a balance between
that kind of quality of life and that
seizure control at the end of the day.
Dr Mark Lowrie: And I think it's
hard because you'll get owners that
come in and they'll tell you that
the phenobarbital has changed how
their dog is behaving and the dog can
look normal to you in the consult.
In the past we might have blamed
phenobarbital a little bit
for that, but I think actually
it's the wiring of the brain.
There's a neurodiversity in idiopathic
epilepsy that maybe we've not understood
and the other thing with medication is
if medication is causing these changes, I
often like to make an owner really stick
with a medication for a period of time.
So you start phenobarbital.
The first couple of weeks, you could
get some side effects, but very
often dogs will become tolerant to
them and they'll, they'll disappear.
So that covers the
management of the seizures.
We then need to look at the
underlying cause and, again, there's
so much we can talk about here.
Now, we have talked about
monitoring the liver.
And the reason I bring that up here
is we've got to also think about what
blood tests and what things we're gonna
be doing at the very beginning, that,
that allow us to make sure we're, we're
dealing with the right type of epilepsy.
So epilepsy litreally means recurrent
seizures, that's all it means.
So it means a dog is
having repeated seizures.
So epilepsy can happen for
so many different reasons.
When we've been talking, I’ve probably
kind of usually been defaulting to
referring to idiopathic epilepsy.
There isn't a single test that's gonna
make you know you have got idiopathic
epilepsy I think we have to be
realistic and we have to say, well,
how can we be sure that what we're
dealing with is idiopathic epilepsy?
Now the first thing is, is those blood
tests, it's so straightforward to do
very basic blood tests at the beginning,
and I would do exactly the same blood
tests here as I always do for monitoring
dogs that are on phenobarbital.
You wanna do something more for the owner
than just counsel them on the seizures.
Let's talk about blood testing the dog
because it's the right thing to do.
Get the dog through, do the
bloods, and then send them home
hopefully with a selection of blood
tests that show normal results.
Now, what I find there is
we haven't fasted the dog,
Dr Emma Hancox: Yeah
Dr Mark Lowrie: So it's not been through
a 12 hour fast, and that is really,
really important because I’ve seen
a lot of dogs in the past where the
blood tests were done by the vet and
all the right blood tests were done.
So they've done their glucose, they've
looked at the urea, the albumin, they've
done all of those, those parameters
that we talked about earlier, to rule
out problems with liver function.
But what they haven't done is
they haven't starved the dog.
We need to look at a fasted glucose.
If the dog has eaten recently, even
if it's a dog with hypoglycaemia as
a cause for the seizures, it might
appear normal on a glucometer, and
the glucometer is really cheap.
The test for that is, is, is peanuts
in comparison to everything else we do.
The owners need to know that actually
you’re gonna want get that dog back
in on another day, and get them
back in when they've been starved
to repeat some of those parameters.
The glucose is the key one, and
I say that if the glucose is less
than three and a half millimoles per
litre, just keep an eye on that dog.
Maybe check it again.
If it's well below three
and a half, then be worried.
But if it's sort of three to three
and a half, which is slightly higher
than the textbooks say, I'd probably
be checking that again every couple
of weeks, because it could be that dog
has hyperglycemia causing seizures.
Insulinoma is the most common reason
for that amongst many other conditions.
But that's the common reason for it.
So, we talk about idiopathic
epilepsy being in dogs between the
ages of six months and six years.
I’ve seen young, young pups
with idiopathic epilepsy
that are only a month or two.
I’ve seen elderly dogs that are 10, 11,
12 years old, develop idiopathic epilepsy.
But what we're saying is when
they're in that age range,
that's the most common diagnosis.
Dr Emma Hancox: Yeah, that makes sense.
Dr Mark Lowrie: If I get a dog over
six that's having seizures, I'd really,
really, really want to look at the
glucose because that's what's gonna
help me know, you know, could it be
hypoglycaemic and hence an in insulinoma.
And then that's a whole
different management strategy.
You know, we don't want to give that
dog phenobarbital 'cause we're just
masking the fact that it's hypoglycaemic.
To give some tips on that, I mean,
'cause I am worried, I, I worry
there's a lot of dog, hypoglycaemic
dogs, out there that we miss.
And so the other tip on that,
which, which can come up when
we're talking about seizures.
We, we always talk about seizures,
but we also wanna think about
behaviour outside of seizures.
We focus so much on the seizure
themselves that we want to kind of find
out how the dog is in between the fits.
So if you have a hypoglycaemic dog
with fits, you are gonna find, rather
than being a typical epileptic dog
where they have seizures when they're
relaxed, you might find they are
having seizures more when they're
active or associated with exercise.
Dr Emma Hancox: Makes sense.
Dr Mark Lowrie: It may even be associated
with meal times or even just before meal
times, they're getting a bit hungry,
their body's not coping 'cause the insulin
levels are potentially quite high and
these dogs are then going into a seizure.
Dr Emma Hancox: Yeah,
Dr Mark Lowrie: And the other one
is, a dog with hypoglycaemia will
be abnormal in between seizures.
Indeed a dog with anything
other than idiopathic epilepsy
will be abnormal in some way.
You may find the dog has
occasional collapsing or stumbling.
They can also almost look like a dog with
cataplexy, these dogs have momentary
loss of muscle tone and sort of have
little brief collapses or, or, or falls.
Now they may not completely collapse.
They might might just
be very, very subtle.
But if you’re seeing that in between
the fits as well as your typical
generalized tonic-clonic seizures,
that should just be a warning sign.
There's something else going
on other than epilepsy.
And that leads me on to say with
idiopathic epilepsy, if you've done
all the blood tests and they all
come back normal and you have a dog
aged between six months and six years
when they've had their first seizure.
And if you ask the owner the question, is
your dog otherwise normal in between fits.
Then what I'd say is if they answer yes
to that question and everything else is
normal, we can actually say that that dog
is 97% likely to have idiopathic epilepsy.
The reason I mention that is
we haven't mentioned the three
scary letters of MRI yet.
Dr Emma Hancox: We've been actively
avoiding that conversation for now.
Dr Mark Lowrie: We have
and, and I feel a bit bad.
I'm only bringing it up now because,
and, and please don't turn off
because I’ve said MRI, many of
these patients don't need an MRI.
I think if you've got a dog between six
months and six years, that's otherwise
normal, you don't need to go spending
lots of money on an MRI scan to just check
the brain is normal because all the clues
are indicating the brain is likely to be
normal and you've just got an epileptic
patient to manage with medication.
MRIs can be really expensive, so owners
don't want to do it and you'll still
be in the same position at the end of
that as you were at the beginning, that
you now just more strongly suspected
idiopathic epilepsy than before.
And if you've sat that owner down and
said, well, I'm already 97% confident,
the reason for the MRI is to just get
that 3% lack of confidence, if you
like, and, and quash it completely.
And I don't think that's necessary.
Dr Emma Hancox: you’re saying this
as a referral clinician as well
Dr Mark Lowrie: I am.
I am.
Who has
Dr Emma Hancox: access to his MRI
Dr Mark Lowrie: Absolutely and actually
it's so frequent, we'll get owners that
come in who have been referred for an
MRI scan, and actually after this sort
of discussion, the owners choose, well,
actually let's not go for the MRI scan.
Let's just continue with
managing appropriately.
And so that's where, you know,
discussion's really important around that.
Dr Emma Hancox: yeah, that's actually
really useful for kind of first opinion
practitioners to hear as well, because
that 97%, we all have those cases
where they've come in with their first
seizure, you've had a chat to the owner,
you've taken some bloods, and then
you get them back and they're normal.
And it's now what?
Do you refer them or don't you refer them?
And I’ve never knew in practice how
confident I could be in that diagnosis.
So it does help to put a
fairly high number at 97%
Dr Mark Lowrie: I think it's huge.
I’ll say, well, yes, we can do if, if
you’re one of those people that just wants
to know, then the MRI scan is for you.
Dr Emma Hancox: Absolutely.
I think as much as, maybe we're maybe
going into our next, oh, we're leaving
some spoilers again for the realistic
part of the S.M.A.R.T Approach, isn't it?
It's that I'm never
gonna with withhold them.
If they want to go for referral,
I'm never gonna stop it.
It's just making sure that we are
realistic and we're advising them right
about what is the likely outcomes from
this, and we're not gonna find a miracle.
Dr Mark Lowrie: It's, it's
never wrong to refer these dogs.
Never wrong.
And I think owners always get a lot from
it because we're fortunate enough in the
referral setting to have a lot more time
to sit down and speak to these owners
because, I mean, we do, we charge more
in terms of, they have a much longer
consult, so we charge more for that
consult than in a first opinion setting.
And there's nothing wrong with actually
saying, well, look, you do need to
come in for a longer consult to get
all of this and charge more for it.
That's fine and actually that, that could
be a big solution for many, many of the
listeners that actually doing a double
consult or three times consult and charge
more for it to deliver this information.
Dr Emma Hancox: These are often
emergencies when they come in.
So they're often stacked in a already full
consult list in first opinion practice.
You talk to them as much as you can,
reassure them, take some bloods.
Maybe actually schedule in a follow-up
consult, even if you can double book
it out, for instance, so you know,
you've got time, like I’ve got these
bloods, this is what this means.
And then you can, they've
had time to digest it for at
least a day or so, a few days.
This is obviously if you’re sending
bloods away or whether you’re
doing them in house, of course, but
scheduling that second appointment,
if you can, making it slightly longer,
then at least you've got that time
booked out to have a chat with them.
Dr Mark Lowrie: I think that's good.
And, and you know, the other thing that
actually leads on nicely too, when we're
talking about managing seizures, is you
do that, but don't be afraid right from
day one to start antiepileptic medication.
So we've talked all about
the different causes.
Let's ignore what the cause is.
You know, it's a dog with seizures.
There's nothing wrong with starting
phenobarbital for that dog.
It gives the owners something to go
away with so they feel more reassured.
They may not, may not have had all
that information yet about what it's
gonna do and stuff like that, but at
least they've got something that's
managing the immediate problem.
Maybe you’re waiting to refer it.
Maybe, maybe the owners really want
an MRI scan, but start phenobarbital,
you know, it's not gonna affect
the results of blood testing or
anything like that down the line.
Not significantly.
So I’ve got absolutely no problem with
starting medication straight away.
Dr Emma Hancox: That's interesting.
It comes back to again, another
previous conversation we're more
than happy to start other medications
at that first consult so why is it
different for antiepileptic drugs?
Dr Mark Lowrie: Well, this is
where it is like analgesia.
You know, we talked in the last one
about how, you know, we don't treat
epilepsy like we'd manage pain with a
multimodal approach, but in this case we
can, you start it straight away, there's
nothing that should stop you doing that,
unless there's a glaring liver problem.
But then you start a different
antiepileptic medication.
You know, I mean, if, if there
really is a clear indication this
dog has raging liver disease, then
start something like levetiracetam.
It's off license.
It's, you know, it's metabolized by the
or it's, it's, excreted by the kidney.
So a very appropriate
choice in those cases.
Dr Emma Hancox: Yeah, I guess you are
more likely to start antiepileptic drug
if they've come in after a severe seizure
or a particularly long one or status
obviously, you’re going to want to start
something straight away and you might not
have those blood results straight away.
Dr Mark Lowrie: That's right.
And, and actually status, we, we need to
talk about the status a bit because that
is, that's a really distressing situation.
And it's not unusual for a dog for
its first seizure to be status.
And then you can imagine how much more
distressing that is for the owners.
Not only are they seeing a seizure,
but the seizure's not stopping.
What I would say about status epilepticus
though is just 'cause you’re seeing
a severe seizure doesn't mean you've
got a severe underlying cause.
So I will see dogs that have
idiopathic epilepsy whose
first presentation is status.
So if we can manage the status
epilepticus, then this dog could
still have a really good outcome.
You know, status epilepticus
doesn't mean brain tumour.
know an owner would be very
worried that they come and go,
well, it must be a brain tumour.
It's like, well, no, not necessarily.
And that's just quite unusual
for a brain tumour to present a
status as the first presentation.
Never say never.
Dr Emma Hancox: Yeah,
you've said it now...
tomorrow...
Dr Mark Lowrie: Exactly.
A busy, busy day then.
The other thing here I suppose is,
and with status, the other thing
about status and and indeed with,
with seizures in general is owners
always like to blame toxicities.
So when they come in with a dog
that's seizuring, they'll often
think it's a neighbour that's that's
poisoned their dog or it, it's
been drinking from the local canal.
Dr Emma Hancox: Oh, yeah,
Dr Mark Lowrie: Something to do with rats?
Dr Emma Hancox: This is like
seizure bingo for me right now.
Yes.
What the owners think it is.
Dr Mark Lowrie: Exactly.
So, so, you know, so that, that
malicious neighbour or that, you
know, that terrible canal water.
Yeah.
All right.
You, you can't sit there at the time
of the consult and say definitely
not that 'cause who knows, you know,
these things could, could happen
unlikely, but they could happen.
What I would say about them
is, is when it's recurrent
seizures, you can rule them out.
So yes, if it's having status
today and it's really bad, fine.
If it's having few seizures every
week for the next few weeks, that's
a very dedicated toxicity criminal
out there that really is getting to
your dog very frequently to cause it.
As soon as we remove that
toxin, the seizure should stop.
And yeah, I mean, I suppose with
toxicities, if there is a toxicity,
often you have other clues.
I mean, maybe the owner did actually
see when they know there's a toxin
that's been ingested and things, and I
suppose it's a good opportunity to say
TVM have an antitoxin range, don't they?
Dr Emma Hancox: We do so yeah,
thanks for the plug there, Mark.
But it is something that we actually
discuss in both of our kind of
neurology type lunch and learns, but
also our antitox lunch and learns.
And there is definitely like a crossover
that if, and this is what we would say, if
you've never seen that patient before with
seizures and they suddenly come in with
status epilepticus, you would want to rule
in or out toxins and maybe have a think
about is there a toxicological cause,
it was often preceded by other things.
And I think that's, something that if they
do come in status that, still want that
history because it may have been preceded
by tremors, muscle like shivers and
things like that, that the owner hasn't
thought about necessarily at the time.
That is to say then if they come in with
tremors, there could be a likelihood
it's gonna progress so, yeah, that's
probably my little spiel on toxins.
Dr Mark Lowrie: No.
And, and, and with status, with the
management of that, I mean, it's
a good time to bring up the facts.
It's another one where
you need a team effort.
Status is a pretty intimidating
presentation for a vet to deal
with, let alone the owners.
So, don't be afraid with status to, I
mean 'cause 'cause when you present with
it, it's again, this whole situation
of a panic and you’re haven't tried
to function in a panicking scenario.
So of course the advice is not
to panic, but you will, you will.
It's inevitable, 'cause you, you, it's
hopefully something you, don't come
across too frequently, but my view
with it is, yes, there's the diazepam.
We can give that IV or rectally
depending on, on the access.
But you want to get like, hopefully the
people around you, other vets, other
nurse in the practice to help place an IV.
Things like taking the dog's
temperature, get bloods for managing,
all of this, this is stuff that can
all be going on and you just need to
delegate, delegate what you need to do.
But what it says in textbooks,
it says give diazepam.
I think, you know, it says anywhere
between half to two mgs per kg IV.
And then wait 5 to 10 minutes for the
seizure to stop, now 5 to 10 minutes...
Dr Emma Hancox: That's a long time.
Dr Mark Lowrie: And if it's
status, and it's not gonna stop.
It probably won't stop.
So what the textbook then
says, is it textbooks nowadays?
It's probably like the app
Dr Emma Hancox: Google now or something.
Dr Mark Lowrie: but it says give a
second dose of injectable diazepam at a
similar dose and wait 5 to 10 minutes.
So if you, if you’re following this
strictly, 20 minutes might have passed.
Well, the dog is still fitting.
I don't like doing that.
And I’ll be honest, my experience
is diazepam isn't quite the drug
there that will stop everything.
And that's not, you may get lucky, but
it isn't so what you want to be doing is
you want to be loading some medication.
Now, if the dog's never had
phenobarbital in its life, we can give
IV phenobarbital at a loading dose.
This is when doses get
very boring on a podcast,
Dr Emma Hancox: But people love
doses 'cause it's something
Dr Mark Lowrie: If people are driving
now, I'm gonna have to ask them to
pull over onto the hard shoulder,
grab a pen, but no, the, the, the
loading dose is, I mean, we give 20
to 24 mgs per kg as a loading dose.
Dr Emma Hancox: That sounds massive.
Dr Mark Lowrie: It is and that's
why we don't give it all at once
Dr Emma Hancox: Okay.
Dr Mark Lowrie: So we want to divide that
up and so we do it into like bite-sized
chunks of four mgs per kg at a time.
So you give a four mgs per kg
dose of Phenobarbital IV, you’re
meant to wait 5 to 10 minutes.
So loads of time has passed
now and dogs still fitting.
What I do is I give it, if the dog is
still fitting, when I finish giving
it, I’ll slowly give another dose.
I’ll keep going until either
the seizure has stopped, which
is hopefully what happens.
Or until I’ve reached that 24 mg
per kg total, it’s very possible
the dog could still be fitting then.
Now, I would say at that point you
just wanna do what you are good at.
And I think what vets do really,
really well is anaesthesia.
You’re doing it daily.
It’s something that happens in the
practice all of the time, and I think
that’s when you’re in your, kind of,
in your zone where you function best.
There’s nothing wrong with
anaesthetising that dog then because
with generalized tonic-clonic seizures
in status anaesthesia will fix it
only temporarily, but it will fix it.
It gives you thinking time.
Dr Emma Hancox: Yeah,
Dr Mark Lowrie: And this is where I
go right back to the beginning when
that dog first presents, because if
you know all of this great, you can
keep it in your head and you can
do it in the steps I’ve described.
But if a dog presents in status, actually
one of the easiest things to do right
from the beginning is anaesthetise the
dog, because then it's stopped fitting.
It allows you to find notes, look in
books, look up doses, and get everyone
on board to get that dog managed.
And there's nothing wrong with doing that.
And then hopefully you'll be giving
that dog the best care without
everyone panicking around you.
Dr Emma Hancox: That's really good advice.
Dr Mark Lowrie: So I quite like that
with status, but it, it's just meant
I’ve gone completely off piste again.
Dr Emma Hancox: We've gone into really
good information, I feel like I would
never have thought to go straight to
anaesthesia, but you are right, it's
gonna stop that seizure activity.
It's gonna buy us some time.
I just wonder how do you then stop?
Do you give your phenobarbital
or diazepam or whatever first?
Dr Mark Lowrie: So I think in that
scenario, so if you've now got a
dog intubated and anaesthetised.
And the seizures stopped.
What I'd do is I'd, if the dog hasn't been
on phenobarbital before, I'd give it the
the first loading dose of phenobarbital
IV, and then I'd start to recover the dog.
But what I'd do is I'd keep it in
sternal because there's this propofol
paddling thing that people talk about.
And so if you've got a dog that's
just been given propofol and then you
recovering it, it might start to paddle.
You won't know is that propofol?
Is it the seizure?
And if you keep them in sternal,
then if it is sort of paddling in
sternal, that probably is more the
seizure as opposed to the propofol.
Dr Emma Hancox: Yeah, that makes sense.
Dr Mark Lowrie: And then if
you’re seeing that, it tells you,
well, let's give another four
mgs per kg as you are recovering.
But actually you might find
you need to induce it back in
and wait a little bit longer.
Dr Emma Hancox: Yeah.
Dr Mark Lowrie: And so I'd keep recovering
the dog intermittently, hoping it will
come around fully without fitting.
But if it does, you give another loading
dose, hopefully that will fix it.
Dr Emma Hancox: Perfect.
No, that makes sense.
Thank you.
Yeah.
I feel like we have gone
a little bit off piste.
We were talking about management
of the seizures, management of
the underlying cause and because
then we went on to toxicities
and status and things like that.
I think we are a little bit off course,
but I think your last thing you wanted
to talk about, correct me if I'm
wrong, is management of the owner.
Dr Mark Lowrie: Yeah,
Dr Emma Hancox: We've kind
of touched on it, but if you
wanted to say any more there
Dr Mark Lowrie: We do well, well,
when we're going on about this.
Every owner has different circumstances,
so the reason why you never get any vet
say, this is when to start medication
or this is what you do with epilepsy.
It's because there is no right answer
and it depends on so many things.
One owner will want a very
different strategy to another owner.
So you do need to kind of sit down with
the owners, find out their concerns.
That may sound silly because
you'll say, well, of course it's
the seizures, but it isn't always.
It could be the postictal
phase is their concern.
So what you'd have to say is, well,
there's no way we, because I’ll
have owners that approach me and
say, we don't mind the fits at all.
They're fine, they're infrequent,
they're not a problem.
But it's how my dog is in that
postictal phase, and the aggression
is the common one that comes up.
But we can't give medication to
stop postictal phases without,
we have to stop the fit.
So it comes back to the same thing.
But the owner would need to understand
that and they might even ask for something
to administer during the fit that
will make the postictal stage go away.
And it's like, no, that the, the
horse has already bolted then.
Yeah.
You know, the fit started.
We know what's to come.
So you have to talk through strategies
to try and reduce the risk with an
aggressive dog in that temporary postictal
period but by doing that, speaking
to owner and actually listening to the
owner, might seem really obvious, but
it just engages the owner much more
with you, and it allows a much more
collaborative environment in which
you can actually get on top of the
dog's epilepsy one way or another.
And that doesn't mean you'll necessarily
be successful in your own, so you might
think, well actually, you know, the
seizures still don't feel well controlled,
but the owner can feel better managed and
that's what's important, that they know
that you are doing everything you can.
You might not be the super vet that you
need to be to fix it, but none of us are.
No one, no one has those skills.
You know, we're not God, we're just trying
to get things managed as best we can.
So by doing that, hopefully it allows
an owner to understand that we are doing
our best, it may not be the cure that
they want, but it's the best we can
do and hopefully everyone is on board.
Dr Emma Hancox: Great.
Thanks, Mark.
That's a really useful summary, I think
splitting it down into those three stages.
So management of seizures, management
of that underlying cause, and then not
forgetting to manage the owners and
their expectations is really useful.
And I think sometimes we can forget as
first, first opinion, clinicians as well.
And that for us, as much as it's uncommon,
it's not as uncommon for our owners and
for them it's completely new information.
So no, that was really useful.
But unfortunately, I think that's all
we've got time for really on this podcast.
So just a plug, please tune in next time
where we'll be discussing and moving onto
the fourth instalment of the S.M.A.R.T
Approach, which is to be realistic.
It is maybe as you've picked up, we
are always talking about the owners
and being realistic with them, but just
a little cliffhanger, hopefully we're
gonna talk about some of the other,
perhaps non medicinal therapeutic
options, where they might fit, how
to be realistic with those as well.
So do tune in for that next episode.
Thanks again, Mark.
Dr Mark Lowrie: Thanks, Emma.
Bye-bye.
Dr Emma Hancox: See you soon.
Bye.