1 00:00:00,049 --> 00:00:02,809 Dr Emma Hancox: Welcome back to the Synaptic Tails podcast with your 2 00:00:02,809 --> 00:00:08,329 hosts, Emma Hancox, TVM Tech Advisor, and Mark Lowrie, RCVS and European 3 00:00:08,335 --> 00:00:12,140 specialist in Veterinary Neurology, and Co-director of Movement Referrals. 4 00:00:12,469 --> 00:00:13,550 Mark, how are you today? 5 00:00:13,555 --> 00:00:13,730 Hi! 6 00:00:14,090 --> 00:00:14,570 Dr Mark Lowrie: Hi, Emma. 7 00:00:14,570 --> 00:00:14,960 Yeah, no. 8 00:00:14,960 --> 00:00:15,980 Nice to be back again. 9 00:00:16,009 --> 00:00:17,720 Ready to talk about more about epilepsy? 10 00:00:17,720 --> 00:00:19,160 Yeah, can't wait. 11 00:00:19,249 --> 00:00:19,999 Dr Emma Hancox: Oh, good. 12 00:00:20,439 --> 00:00:23,859 Just as a reminder to our listeners, this is the third episode of the 13 00:00:23,859 --> 00:00:25,329 S.M.A.R.T Approach to Epilepsy. 14 00:00:25,569 --> 00:00:28,239 So if you’re a new listener and you haven't listened to those first two 15 00:00:28,239 --> 00:00:31,839 episodes, please do pause this and head back to episode number one. 16 00:00:32,589 --> 00:00:34,809 If you’re a regular listener, and hopefully we've got a few 17 00:00:34,809 --> 00:00:37,924 of you by now, you'll hopefully remember that we introduced a 18 00:00:37,924 --> 00:00:39,294 S.M.A.R.T Approach to epilepsy. 19 00:00:39,294 --> 00:00:42,324 That's TVMs new guide for first opinion practitioners. 20 00:00:42,864 --> 00:00:45,894 Over the last two episodes, we've chatted about the importance of owner 21 00:00:45,899 --> 00:00:50,124 communication and what we need to measure in order to manage our epileptic patients. 22 00:00:50,785 --> 00:00:52,974 And it goes without saying that once we've established those 23 00:00:52,974 --> 00:00:56,154 measurements, it's obviously time to advise the owner on what we found. 24 00:00:56,785 --> 00:01:00,994 In this episode, I'm really gonna hand over to Mark, to be honest, because he's 25 00:01:00,994 --> 00:01:04,675 going to hopefully talk us through his key three areas to epilepsy treatment. 26 00:01:04,705 --> 00:01:05,934 So over to you, Mark. 27 00:01:06,450 --> 00:01:06,649 Dr Mark Lowrie: Yeah. 28 00:01:06,649 --> 00:01:07,210 Thanks Emma. 29 00:01:07,210 --> 00:01:10,929 Well, I should start again by saying that word treatment. 30 00:01:11,485 --> 00:01:12,684 I think that's a bad word. 31 00:01:12,744 --> 00:01:16,315 It should be banned because treatment to me implies a cure. 32 00:01:16,374 --> 00:01:19,945 And I think if you are wanting to cure a dog's seizures, you 33 00:01:19,945 --> 00:01:20,845 should give up right away. 34 00:01:21,175 --> 00:01:23,785 You know, I think it, it, we may get lucky, it might happen. 35 00:01:23,815 --> 00:01:27,354 I'm not gonna say it never happens, but it shouldn't be our expectation. 36 00:01:27,354 --> 00:01:31,344 So both the owners and ourselves should be ready that curing seizures 37 00:01:31,344 --> 00:01:33,804 completely is very unlikely to happen. 38 00:01:34,975 --> 00:01:39,039 But when we look at seizure management, I suppose you can break it up into three key 39 00:01:39,039 --> 00:01:41,470 areas and we can focus on each in turn. 40 00:01:41,830 --> 00:01:46,679 So I sort of wanna look at management of the seizures themselves, management 41 00:01:46,679 --> 00:01:48,820 of the potential underlying cause. 42 00:01:49,360 --> 00:01:51,309 And then the last one is management of the owner. 43 00:01:51,700 --> 00:01:52,390 it sounds a bit... 44 00:01:53,155 --> 00:01:53,845 Dr Emma Hancox: Managing the owners? 45 00:01:54,070 --> 00:01:54,580 Dr Mark Lowrie: Yeah, exactly. 46 00:01:54,580 --> 00:01:55,240 Managing the owner. 47 00:01:55,245 --> 00:01:58,460 It sounds a bit wrong, but, but actually, the owners do need to know what's 48 00:01:58,460 --> 00:02:01,340 happening and there's a really big discussion around what you do to help them 49 00:02:01,340 --> 00:02:02,750 through it so they know what to expect. 50 00:02:02,750 --> 00:02:05,960 And hopefully in turn, then really trust your word and know 51 00:02:05,960 --> 00:02:06,950 that we're doing the right thing. 52 00:02:08,269 --> 00:02:10,620 So, we'll start with management of the seizures. 53 00:02:10,869 --> 00:02:13,420 We're looking at various conventional medications. 54 00:02:13,450 --> 00:02:17,320 And as with any medication, we have to look to the cascade and think 55 00:02:17,325 --> 00:02:20,410 what are the drugs out there that we can use to manage seizures? 56 00:02:20,570 --> 00:02:25,680 There's this ACVIM pyramid of hierarchy that describes all the recommended 57 00:02:25,710 --> 00:02:29,330 antiepileptic treatments based on their effectiveness, their efficacy 58 00:02:29,330 --> 00:02:33,795 and how they work, and also the quality of evidence out there that helps 59 00:02:33,795 --> 00:02:36,375 you to know which one we should use. 60 00:02:36,375 --> 00:02:38,865 The best choices then are at the top of the pyramid, and then as you go 61 00:02:38,865 --> 00:02:41,235 to the bottom of the pyramid, there's the ones that maybe haven't quite got 62 00:02:41,235 --> 00:02:45,115 that established efficacy and are kind of alternative choices to add into 63 00:02:45,115 --> 00:02:47,425 the top of the pyramid medications. 64 00:02:48,415 --> 00:02:51,835 Dr Emma Hancox: It sounds like a really useful tool because we all want to be 65 00:02:51,835 --> 00:02:55,930 like evidence-based when it comes to our medication options and trawling through 66 00:02:55,955 --> 00:02:58,235 the litreature ourselves is really hard. 67 00:02:58,425 --> 00:02:58,575 Dr Mark Lowrie: Yeah. 68 00:02:58,575 --> 00:02:59,805 So it's a useful little tool. 69 00:02:59,885 --> 00:03:04,625 Now when we go to this pyramid, before we start these medications, I think the 70 00:03:04,625 --> 00:03:07,385 other thing that an owner needs to be aware of, and this is again a figure 71 00:03:07,390 --> 00:03:14,285 that I think is quite a scary negative figure, is that up to 30% of dogs with 72 00:03:14,295 --> 00:03:18,075 idiopathic epilepsy may never achieve adequate control of their seizures 73 00:03:18,225 --> 00:03:19,845 with these conventional medications. 74 00:03:19,875 --> 00:03:24,465 So that's pretty disappointing and if you just put it down to like, you know, of, 75 00:03:24,525 --> 00:03:28,125 if you think of three, three owners coming in to see you with, with epileptic dogs, 76 00:03:28,365 --> 00:03:31,395 one of those three is gonna be really quite disappointed, whatever you do. 77 00:03:31,995 --> 00:03:34,395 And so it's not, it's not you that's the problem. 78 00:03:34,725 --> 00:03:37,035 You know, it's the dog's epilepsy that's a problem. 79 00:03:37,035 --> 00:03:38,295 So never be worried about that. 80 00:03:38,805 --> 00:03:43,855 Now, looking at this, this pyramid at the top there, the, the, the main medication 81 00:03:43,855 --> 00:03:47,295 for me and the one that's licensed for use in epilepsy is phenobarbital. 82 00:03:47,295 --> 00:03:49,095 So I, I feel that's kind of a first line. 83 00:03:49,485 --> 00:03:52,765 I should bring in a imepitoin here because that's also a medication that we 84 00:03:52,765 --> 00:03:55,345 can consider as first line medication. 85 00:03:55,685 --> 00:03:58,895 My feeling with it is it's, it's very useful early on in epilepsy. 86 00:03:59,045 --> 00:03:59,345 Dr Emma Hancox: Right. 87 00:03:59,915 --> 00:04:03,125 Dr Mark Lowrie: So if you've got dogs that aren't having frequent fits and the owners 88 00:04:03,130 --> 00:04:06,665 aren't too concerned yet, then I think a imepitoin is a very reasonable choice. 89 00:04:07,145 --> 00:04:10,795 But as soon as the owners are approaching you with a concern, then I would go to 90 00:04:10,795 --> 00:04:16,045 phenobarbital and, and skip the step where we, we try imepitoin but then 91 00:04:16,045 --> 00:04:19,765 after that, that's when we can start to add in medications as we go along. 92 00:04:20,125 --> 00:04:23,755 And the thing about medicating dogs with seizures, it's, there's an approach. 93 00:04:23,755 --> 00:04:27,045 Well, if we think about analgesia, analgesia in the veterinary world 94 00:04:27,045 --> 00:04:31,425 is about using lots of different medications at lowish doses to 95 00:04:31,425 --> 00:04:32,835 achieve nice control of pain. 96 00:04:33,000 --> 00:04:34,890 Dr Emma Hancox: Like a multimodal type approach. 97 00:04:35,115 --> 00:04:35,895 Dr Mark Lowrie: Absolutely. 98 00:04:35,955 --> 00:04:39,885 And that's, that's a fairly standard thing that we're all very familiar with as vets. 99 00:04:40,755 --> 00:04:43,215 Now with epilepsy, it's quite different because what you want to do with 100 00:04:43,215 --> 00:04:47,810 epilepsy is you want to exploit each medication to its fullest potential first 101 00:04:47,930 --> 00:04:49,910 before adding in another medication. 102 00:04:50,870 --> 00:04:53,150 And so with phenobarbital, we'll do everything we've talked about 103 00:04:53,150 --> 00:04:57,590 in the previous podcast where we get it up to the right dose, check 104 00:04:57,590 --> 00:04:58,990 the serum concentration is good. 105 00:04:58,990 --> 00:05:02,810 And when we're at that level, if seizures are still not controlled, what I'm doing 106 00:05:02,810 --> 00:05:05,060 is I'm adding in another medication. 107 00:05:05,115 --> 00:05:05,405 Dr Emma Hancox: Yeah. 108 00:05:05,870 --> 00:05:09,080 Dr Mark Lowrie: I very rarely stop a medication and the indications to stop 109 00:05:09,080 --> 00:05:11,930 an antiepileptic medication are only if you've got adverse effects from it. 110 00:05:11,960 --> 00:05:17,670 So I’ll be adding in a second, potentially a third who, who knows a fourth medication 111 00:05:17,730 --> 00:05:19,760 to these dogs to get them under control. 112 00:05:20,690 --> 00:05:24,270 Now, the other factor, of course, is when we're giving all of these 113 00:05:24,270 --> 00:05:27,270 medications, we wanna make sure the dog remains as normal as possible. 114 00:05:28,080 --> 00:05:28,770 And we've talked about that. 115 00:05:28,770 --> 00:05:31,020 I mean, I think of it like a scale where on the one hand 116 00:05:31,020 --> 00:05:33,420 you've got the side effects of the medication that you’re giving. 117 00:05:34,260 --> 00:05:36,660 On the other hand, you've got control of the seizures and you 118 00:05:36,660 --> 00:05:38,190 really wanna balance that scale. 119 00:05:38,580 --> 00:05:41,320 And that scale's gonna be different with every dog you see. 120 00:05:41,620 --> 00:05:45,950 So you’re gonna have the dogs that maybe have very, very frequent fits. 121 00:05:45,980 --> 00:05:48,290 And so the owners will tolerate more side effects in order 122 00:05:48,290 --> 00:05:50,320 to control those seizures. 123 00:05:50,980 --> 00:05:56,200 You may have the dogs that seizure infrequently, but because the postictal 124 00:05:56,200 --> 00:05:58,420 signs are really objectionable, 125 00:05:58,540 --> 00:05:59,050 Dr Emma Hancox: Yeah. 126 00:05:59,230 --> 00:06:02,980 Dr Mark Lowrie: Say an aggressive dog following a seizure, just one seizure 127 00:06:02,985 --> 00:06:06,070 every six weeks may be too much for that owner because they're like the, 128 00:06:06,250 --> 00:06:09,280 the aggression they're seeing from their pet is really difficult to cope with. 129 00:06:09,610 --> 00:06:12,520 We've mentioned children and the family and things like that make it more of a 130 00:06:12,525 --> 00:06:16,940 concern, so actually they may tolerate more adverse effects from the medication 131 00:06:16,960 --> 00:06:20,800 to try and really reduce seizures in that dog than say, a dog that's seizure-ing 132 00:06:20,800 --> 00:06:24,790 once every six weeks but is otherwise completely happy and doing well. 133 00:06:25,765 --> 00:06:30,505 So that's my approach to managing the seizures and thinking about what 134 00:06:30,505 --> 00:06:32,096 we use and when we need to use it. 135 00:06:33,370 --> 00:06:36,880 Dr Emma Hancox: That's a really interesting point on the side effects 136 00:06:36,880 --> 00:06:40,820 and balancing any adverse side effects 'cause these can change. 137 00:06:41,690 --> 00:06:45,815 But if we, obviously we don't want to, but they can sometimes affect the dog's 138 00:06:45,845 --> 00:06:48,485 demeanour, behaviour sometimes as well. 139 00:06:48,885 --> 00:06:52,515 For our patients, that we only see them when they come into us and we 140 00:06:52,515 --> 00:06:55,005 don't know what they're doing at home. 141 00:06:55,315 --> 00:06:59,665 It definitely is a balance between that kind of quality of life and that 142 00:06:59,665 --> 00:07:01,345 seizure control at the end of the day. 143 00:07:01,750 --> 00:07:03,220 Dr Mark Lowrie: And I think it's hard because you'll get owners that 144 00:07:03,220 --> 00:07:06,010 come in and they'll tell you that the phenobarbital has changed how 145 00:07:06,010 --> 00:07:09,730 their dog is behaving and the dog can look normal to you in the consult. 146 00:07:09,780 --> 00:07:12,510 In the past we might have blamed phenobarbital a little bit 147 00:07:12,510 --> 00:07:14,700 for that, but I think actually it's the wiring of the brain. 148 00:07:14,820 --> 00:07:19,020 There's a neurodiversity in idiopathic epilepsy that maybe we've not understood 149 00:07:19,530 --> 00:07:23,910 and the other thing with medication is if medication is causing these changes, I 150 00:07:23,910 --> 00:07:28,050 often like to make an owner really stick with a medication for a period of time. 151 00:07:28,260 --> 00:07:29,730 So you start phenobarbital. 152 00:07:30,660 --> 00:07:34,350 The first couple of weeks, you could get some side effects, but very 153 00:07:34,350 --> 00:07:37,110 often dogs will become tolerant to them and they'll, they'll disappear. 154 00:07:37,660 --> 00:07:39,670 So that covers the management of the seizures. 155 00:07:39,670 --> 00:07:42,790 We then need to look at the underlying cause and, again, there's 156 00:07:42,790 --> 00:07:44,020 so much we can talk about here. 157 00:07:44,020 --> 00:07:47,060 Now, we have talked about monitoring the liver. 158 00:07:47,870 --> 00:07:51,230 And the reason I bring that up here is we've got to also think about what 159 00:07:51,230 --> 00:07:55,190 blood tests and what things we're gonna be doing at the very beginning, that, 160 00:07:55,850 --> 00:07:59,750 that allow us to make sure we're, we're dealing with the right type of epilepsy. 161 00:07:59,750 --> 00:08:04,460 So epilepsy litreally means recurrent seizures, that's all it means. 162 00:08:04,460 --> 00:08:06,590 So it means a dog is having repeated seizures. 163 00:08:06,620 --> 00:08:09,770 So epilepsy can happen for so many different reasons. 164 00:08:10,835 --> 00:08:14,795 When we've been talking, I’ve probably kind of usually been defaulting to 165 00:08:14,795 --> 00:08:17,105 referring to idiopathic epilepsy. 166 00:08:18,095 --> 00:08:22,595 There isn't a single test that's gonna make you know you have got idiopathic 167 00:08:22,595 --> 00:08:25,818 epilepsy I think we have to be realistic and we have to say, well, 168 00:08:25,818 --> 00:08:29,388 how can we be sure that what we're dealing with is idiopathic epilepsy? 169 00:08:30,348 --> 00:08:35,658 Now the first thing is, is those blood tests, it's so straightforward to do 170 00:08:35,658 --> 00:08:39,048 very basic blood tests at the beginning, and I would do exactly the same blood 171 00:08:39,048 --> 00:08:43,428 tests here as I always do for monitoring dogs that are on phenobarbital. 172 00:08:43,493 --> 00:08:47,718 You wanna do something more for the owner than just counsel them on the seizures. 173 00:08:47,773 --> 00:08:50,293 Let's talk about blood testing the dog because it's the right thing to do. 174 00:08:50,503 --> 00:08:52,903 Get the dog through, do the bloods, and then send them home 175 00:08:52,963 --> 00:08:56,083 hopefully with a selection of blood tests that show normal results. 176 00:08:57,103 --> 00:08:59,563 Now, what I find there is we haven't fasted the dog, 177 00:09:00,148 --> 00:09:00,568 Dr Emma Hancox: Yeah 178 00:09:00,613 --> 00:09:03,763 Dr Mark Lowrie: So it's not been through a 12 hour fast, and that is really, 179 00:09:03,763 --> 00:09:06,974 really important because I’ve seen a lot of dogs in the past where the 180 00:09:07,063 --> 00:09:10,003 blood tests were done by the vet and all the right blood tests were done. 181 00:09:10,123 --> 00:09:13,483 So they've done their glucose, they've looked at the urea, the albumin, they've 182 00:09:13,488 --> 00:09:17,353 done all of those, those parameters that we talked about earlier, to rule 183 00:09:17,353 --> 00:09:18,583 out problems with liver function. 184 00:09:19,033 --> 00:09:21,013 But what they haven't done is they haven't starved the dog. 185 00:09:21,093 --> 00:09:23,133 We need to look at a fasted glucose. 186 00:09:23,403 --> 00:09:28,413 If the dog has eaten recently, even if it's a dog with hypoglycaemia as 187 00:09:28,418 --> 00:09:32,823 a cause for the seizures, it might appear normal on a glucometer, and 188 00:09:32,823 --> 00:09:34,173 the glucometer is really cheap. 189 00:09:34,263 --> 00:09:37,563 The test for that is, is, is peanuts in comparison to everything else we do. 190 00:09:38,338 --> 00:09:41,308 The owners need to know that actually you’re gonna want get that dog back 191 00:09:41,308 --> 00:09:43,948 in on another day, and get them back in when they've been starved 192 00:09:43,948 --> 00:09:45,648 to repeat some of those parameters. 193 00:09:46,128 --> 00:09:50,058 The glucose is the key one, and I say that if the glucose is less 194 00:09:50,058 --> 00:09:54,393 than three and a half millimoles per litre, just keep an eye on that dog. 195 00:09:54,603 --> 00:09:55,743 Maybe check it again. 196 00:09:55,923 --> 00:09:58,323 If it's well below three and a half, then be worried. 197 00:09:58,593 --> 00:10:00,873 But if it's sort of three to three and a half, which is slightly higher 198 00:10:00,873 --> 00:10:04,023 than the textbooks say, I'd probably be checking that again every couple 199 00:10:04,028 --> 00:10:08,043 of weeks, because it could be that dog has hyperglycemia causing seizures. 200 00:10:08,093 --> 00:10:11,423 Insulinoma is the most common reason for that amongst many other conditions. 201 00:10:11,423 --> 00:10:13,103 But that's the common reason for it. 202 00:10:13,103 --> 00:10:17,573 So, we talk about idiopathic epilepsy being in dogs between the 203 00:10:17,573 --> 00:10:19,463 ages of six months and six years. 204 00:10:19,973 --> 00:10:22,553 I’ve seen young, young pups with idiopathic epilepsy 205 00:10:22,553 --> 00:10:23,573 that are only a month or two. 206 00:10:24,143 --> 00:10:28,343 I’ve seen elderly dogs that are 10, 11, 12 years old, develop idiopathic epilepsy. 207 00:10:28,763 --> 00:10:30,653 But what we're saying is when they're in that age range, 208 00:10:30,653 --> 00:10:32,403 that's the most common diagnosis. 209 00:10:32,433 --> 00:10:33,243 Dr Emma Hancox: Yeah, that makes sense. 210 00:10:33,893 --> 00:10:37,373 Dr Mark Lowrie: If I get a dog over six that's having seizures, I'd really, 211 00:10:37,378 --> 00:10:40,508 really, really want to look at the glucose because that's what's gonna 212 00:10:40,508 --> 00:10:43,868 help me know, you know, could it be hypoglycaemic and hence an in insulinoma. 213 00:10:44,018 --> 00:10:45,918 And then that's a whole different management strategy. 214 00:10:46,138 --> 00:10:48,578 You know, we don't want to give that dog phenobarbital 'cause we're just 215 00:10:48,578 --> 00:10:50,948 masking the fact that it's hypoglycaemic. 216 00:10:51,938 --> 00:10:55,028 To give some tips on that, I mean, 'cause I am worried, I, I worry 217 00:10:55,028 --> 00:10:57,428 there's a lot of dog, hypoglycaemic dogs, out there that we miss. 218 00:10:57,728 --> 00:10:59,948 And so the other tip on that, which, which can come up when 219 00:10:59,948 --> 00:11:01,358 we're talking about seizures. 220 00:11:02,018 --> 00:11:04,808 We, we always talk about seizures, but we also wanna think about 221 00:11:04,808 --> 00:11:05,918 behaviour outside of seizures. 222 00:11:06,383 --> 00:11:10,433 We focus so much on the seizure themselves that we want to kind of find 223 00:11:10,433 --> 00:11:12,653 out how the dog is in between the fits. 224 00:11:13,103 --> 00:11:16,883 So if you have a hypoglycaemic dog with fits, you are gonna find, rather 225 00:11:16,883 --> 00:11:20,153 than being a typical epileptic dog where they have seizures when they're 226 00:11:20,153 --> 00:11:23,303 relaxed, you might find they are having seizures more when they're 227 00:11:23,303 --> 00:11:25,943 active or associated with exercise. 228 00:11:25,963 --> 00:11:26,243 Dr Emma Hancox: Makes sense. 229 00:11:26,963 --> 00:11:30,473 Dr Mark Lowrie: It may even be associated with meal times or even just before meal 230 00:11:30,473 --> 00:11:33,613 times, they're getting a bit hungry, their body's not coping 'cause the insulin 231 00:11:33,613 --> 00:11:37,183 levels are potentially quite high and these dogs are then going into a seizure. 232 00:11:37,378 --> 00:11:37,798 Dr Emma Hancox: Yeah, 233 00:11:38,023 --> 00:11:41,003 Dr Mark Lowrie: And the other one is, a dog with hypoglycaemia will 234 00:11:41,008 --> 00:11:43,313 be abnormal in between seizures. 235 00:11:43,313 --> 00:11:45,653 Indeed a dog with anything other than idiopathic epilepsy 236 00:11:45,653 --> 00:11:47,063 will be abnormal in some way. 237 00:11:47,463 --> 00:11:50,403 You may find the dog has occasional collapsing or stumbling. 238 00:11:51,288 --> 00:11:55,258 They can also almost look like a dog with cataplexy, these dogs have momentary 239 00:11:55,263 --> 00:11:59,638 loss of muscle tone and sort of have little brief collapses or, or, or falls. 240 00:11:59,638 --> 00:12:00,928 Now they may not completely collapse. 241 00:12:00,928 --> 00:12:02,398 They might might just be very, very subtle. 242 00:12:02,698 --> 00:12:05,428 But if you’re seeing that in between the fits as well as your typical 243 00:12:05,428 --> 00:12:08,788 generalized tonic-clonic seizures, that should just be a warning sign. 244 00:12:08,788 --> 00:12:11,518 There's something else going on other than epilepsy. 245 00:12:12,838 --> 00:12:16,948 And that leads me on to say with idiopathic epilepsy, if you've done 246 00:12:16,948 --> 00:12:21,208 all the blood tests and they all come back normal and you have a dog 247 00:12:21,298 --> 00:12:24,598 aged between six months and six years when they've had their first seizure. 248 00:12:25,528 --> 00:12:30,718 And if you ask the owner the question, is your dog otherwise normal in between fits. 249 00:12:31,078 --> 00:12:34,498 Then what I'd say is if they answer yes to that question and everything else is 250 00:12:34,498 --> 00:12:40,468 normal, we can actually say that that dog is 97% likely to have idiopathic epilepsy. 251 00:12:41,488 --> 00:12:44,908 The reason I mention that is we haven't mentioned the three 252 00:12:45,028 --> 00:12:47,388 scary letters of MRI yet. 253 00:12:48,583 --> 00:12:51,093 Dr Emma Hancox: We've been actively avoiding that conversation for now. 254 00:12:51,123 --> 00:12:52,558 Dr Mark Lowrie: We have and, and I feel a bit bad. 255 00:12:52,558 --> 00:12:55,288 I'm only bringing it up now because, and, and please don't turn off 256 00:12:55,288 --> 00:12:58,268 because I’ve said MRI, many of these patients don't need an MRI. 257 00:12:58,288 --> 00:13:01,948 I think if you've got a dog between six months and six years, that's otherwise 258 00:13:01,948 --> 00:13:07,288 normal, you don't need to go spending lots of money on an MRI scan to just check 259 00:13:07,288 --> 00:13:10,858 the brain is normal because all the clues are indicating the brain is likely to be 260 00:13:10,858 --> 00:13:14,158 normal and you've just got an epileptic patient to manage with medication. 261 00:13:15,478 --> 00:13:19,098 MRIs can be really expensive, so owners don't want to do it and you'll still 262 00:13:19,103 --> 00:13:21,618 be in the same position at the end of that as you were at the beginning, that 263 00:13:21,618 --> 00:13:25,338 you now just more strongly suspected idiopathic epilepsy than before. 264 00:13:25,998 --> 00:13:29,688 And if you've sat that owner down and said, well, I'm already 97% confident, 265 00:13:30,078 --> 00:13:34,608 the reason for the MRI is to just get that 3% lack of confidence, if you 266 00:13:34,608 --> 00:13:36,408 like, and, and quash it completely. 267 00:13:36,918 --> 00:13:38,298 And I don't think that's necessary. 268 00:13:39,283 --> 00:13:42,253 Dr Emma Hancox: you’re saying this as a referral clinician as well 269 00:13:42,373 --> 00:13:42,853 Dr Mark Lowrie: I am. 270 00:13:42,853 --> 00:13:43,063 I am. 271 00:13:43,063 --> 00:13:43,243 Who has 272 00:13:43,243 --> 00:13:44,483 Dr Emma Hancox: access to his MRI 273 00:13:44,483 --> 00:13:46,963 Dr Mark Lowrie: Absolutely and actually it's so frequent, we'll get owners that 274 00:13:46,963 --> 00:13:51,313 come in who have been referred for an MRI scan, and actually after this sort 275 00:13:51,318 --> 00:13:54,703 of discussion, the owners choose, well, actually let's not go for the MRI scan. 276 00:13:55,063 --> 00:13:57,943 Let's just continue with managing appropriately. 277 00:13:58,663 --> 00:14:01,873 And so that's where, you know, discussion's really important around that. 278 00:14:02,623 --> 00:14:05,653 Dr Emma Hancox: yeah, that's actually really useful for kind of first opinion 279 00:14:05,893 --> 00:14:11,198 practitioners to hear as well, because that 97%, we all have those cases 280 00:14:11,198 --> 00:14:15,918 where they've come in with their first seizure, you've had a chat to the owner, 281 00:14:15,918 --> 00:14:19,188 you've taken some bloods, and then you get them back and they're normal. 282 00:14:19,193 --> 00:14:20,078 And it's now what? 283 00:14:20,648 --> 00:14:22,538 Do you refer them or don't you refer them? 284 00:14:22,628 --> 00:14:28,788 And I’ve never knew in practice how confident I could be in that diagnosis. 285 00:14:28,788 --> 00:14:32,568 So it does help to put a fairly high number at 97% 286 00:14:32,733 --> 00:14:33,753 Dr Mark Lowrie: I think it's huge. 287 00:14:33,823 --> 00:14:36,403 I’ll say, well, yes, we can do if, if you’re one of those people that just wants 288 00:14:36,403 --> 00:14:38,383 to know, then the MRI scan is for you. 289 00:14:38,603 --> 00:14:38,843 Dr Emma Hancox: Absolutely. 290 00:14:38,963 --> 00:14:44,343 I think as much as, maybe we're maybe going into our next, oh, we're leaving 291 00:14:44,343 --> 00:14:48,313 some spoilers again for the realistic part of the S.M.A.R.T Approach, isn't it? 292 00:14:48,313 --> 00:14:52,273 It's that I'm never gonna with withhold them. 293 00:14:52,513 --> 00:14:54,733 If they want to go for referral, I'm never gonna stop it. 294 00:14:54,738 --> 00:14:57,943 It's just making sure that we are realistic and we're advising them right 295 00:14:57,948 --> 00:15:02,923 about what is the likely outcomes from this, and we're not gonna find a miracle. 296 00:15:03,268 --> 00:15:05,098 Dr Mark Lowrie: It's, it's never wrong to refer these dogs. 297 00:15:05,128 --> 00:15:05,698 Never wrong. 298 00:15:05,728 --> 00:15:09,748 And I think owners always get a lot from it because we're fortunate enough in the 299 00:15:09,748 --> 00:15:12,928 referral setting to have a lot more time to sit down and speak to these owners 300 00:15:13,018 --> 00:15:16,798 because, I mean, we do, we charge more in terms of, they have a much longer 301 00:15:16,798 --> 00:15:20,358 consult, so we charge more for that consult than in a first opinion setting. 302 00:15:20,748 --> 00:15:23,088 And there's nothing wrong with actually saying, well, look, you do need to 303 00:15:23,088 --> 00:15:25,848 come in for a longer consult to get all of this and charge more for it. 304 00:15:25,898 --> 00:15:30,048 That's fine and actually that, that could be a big solution for many, many of the 305 00:15:30,048 --> 00:15:33,638 listeners that actually doing a double consult or three times consult and charge 306 00:15:33,638 --> 00:15:35,648 more for it to deliver this information. 307 00:15:35,933 --> 00:15:38,003 Dr Emma Hancox: These are often emergencies when they come in. 308 00:15:38,003 --> 00:15:41,723 So they're often stacked in a already full consult list in first opinion practice. 309 00:15:42,173 --> 00:15:45,533 You talk to them as much as you can, reassure them, take some bloods. 310 00:15:45,878 --> 00:15:50,708 Maybe actually schedule in a follow-up consult, even if you can double book 311 00:15:50,708 --> 00:15:54,098 it out, for instance, so you know, you've got time, like I’ve got these 312 00:15:54,103 --> 00:15:55,958 bloods, this is what this means. 313 00:15:56,048 --> 00:15:59,168 And then you can, they've had time to digest it for at 314 00:15:59,168 --> 00:16:01,143 least a day or so, a few days. 315 00:16:01,353 --> 00:16:03,693 This is obviously if you’re sending bloods away or whether you’re 316 00:16:03,698 --> 00:16:07,143 doing them in house, of course, but scheduling that second appointment, 317 00:16:07,143 --> 00:16:10,633 if you can, making it slightly longer, then at least you've got that time 318 00:16:10,638 --> 00:16:11,863 booked out to have a chat with them. 319 00:16:12,413 --> 00:16:13,153 Dr Mark Lowrie: I think that's good. 320 00:16:13,213 --> 00:16:15,913 And, and you know, the other thing that actually leads on nicely too, when we're 321 00:16:15,913 --> 00:16:20,308 talking about managing seizures, is you do that, but don't be afraid right from 322 00:16:20,308 --> 00:16:23,128 day one to start antiepileptic medication. 323 00:16:23,128 --> 00:16:25,348 So we've talked all about the different causes. 324 00:16:25,618 --> 00:16:26,878 Let's ignore what the cause is. 325 00:16:26,878 --> 00:16:28,168 You know, it's a dog with seizures. 326 00:16:28,468 --> 00:16:31,588 There's nothing wrong with starting phenobarbital for that dog. 327 00:16:31,948 --> 00:16:34,708 It gives the owners something to go away with so they feel more reassured. 328 00:16:35,038 --> 00:16:37,108 They may not, may not have had all that information yet about what it's 329 00:16:37,108 --> 00:16:39,988 gonna do and stuff like that, but at least they've got something that's 330 00:16:39,988 --> 00:16:41,488 managing the immediate problem. 331 00:16:41,968 --> 00:16:43,438 Maybe you’re waiting to refer it. 332 00:16:43,468 --> 00:16:46,648 Maybe, maybe the owners really want an MRI scan, but start phenobarbital, 333 00:16:46,678 --> 00:16:49,738 you know, it's not gonna affect the results of blood testing or 334 00:16:49,738 --> 00:16:50,998 anything like that down the line. 335 00:16:51,028 --> 00:16:52,138 Not significantly. 336 00:16:52,558 --> 00:16:56,738 So I’ve got absolutely no problem with starting medication straight away. 337 00:16:57,708 --> 00:16:58,328 Dr Emma Hancox: That's interesting. 338 00:16:58,628 --> 00:17:01,958 It comes back to again, another previous conversation we're more 339 00:17:01,958 --> 00:17:06,443 than happy to start other medications at that first consult so why is it 340 00:17:06,443 --> 00:17:08,153 different for antiepileptic drugs? 341 00:17:08,828 --> 00:17:10,448 Dr Mark Lowrie: Well, this is where it is like analgesia. 342 00:17:10,598 --> 00:17:13,178 You know, we talked in the last one about how, you know, we don't treat 343 00:17:13,178 --> 00:17:18,098 epilepsy like we'd manage pain with a multimodal approach, but in this case we 344 00:17:18,098 --> 00:17:21,548 can, you start it straight away, there's nothing that should stop you doing that, 345 00:17:21,878 --> 00:17:23,288 unless there's a glaring liver problem. 346 00:17:23,293 --> 00:17:25,388 But then you start a different antiepileptic medication. 347 00:17:25,508 --> 00:17:27,698 You know, I mean, if, if there really is a clear indication this 348 00:17:27,698 --> 00:17:31,578 dog has raging liver disease, then start something like levetiracetam. 349 00:17:31,598 --> 00:17:32,468 It's off license. 350 00:17:32,843 --> 00:17:36,343 It's, you know, it's metabolized by the or it's, it's, excreted by the kidney. 351 00:17:36,343 --> 00:17:38,533 So a very appropriate choice in those cases. 352 00:17:38,768 --> 00:17:42,298 Dr Emma Hancox: Yeah, I guess you are more likely to start antiepileptic drug 353 00:17:42,298 --> 00:17:47,198 if they've come in after a severe seizure or a particularly long one or status 354 00:17:47,198 --> 00:17:49,898 obviously, you’re going to want to start something straight away and you might not 355 00:17:49,898 --> 00:17:51,938 have those blood results straight away. 356 00:17:52,223 --> 00:17:52,703 Dr Mark Lowrie: That's right. 357 00:17:52,708 --> 00:17:56,003 And, and actually status, we, we need to talk about the status a bit because that 358 00:17:56,003 --> 00:17:58,973 is, that's a really distressing situation. 359 00:17:59,558 --> 00:18:04,148 And it's not unusual for a dog for its first seizure to be status. 360 00:18:04,178 --> 00:18:07,778 And then you can imagine how much more distressing that is for the owners. 361 00:18:07,778 --> 00:18:10,298 Not only are they seeing a seizure, but the seizure's not stopping. 362 00:18:10,958 --> 00:18:15,428 What I would say about status epilepticus though is just 'cause you’re seeing 363 00:18:15,518 --> 00:18:19,298 a severe seizure doesn't mean you've got a severe underlying cause. 364 00:18:19,718 --> 00:18:24,188 So I will see dogs that have idiopathic epilepsy whose 365 00:18:24,188 --> 00:18:25,688 first presentation is status. 366 00:18:26,228 --> 00:18:29,168 So if we can manage the status epilepticus, then this dog could 367 00:18:29,168 --> 00:18:30,218 still have a really good outcome. 368 00:18:30,548 --> 00:18:32,818 You know, status epilepticus doesn't mean brain tumour. 369 00:18:33,458 --> 00:18:36,428 know an owner would be very worried that they come and go, 370 00:18:36,428 --> 00:18:37,488 well, it must be a brain tumour. 371 00:18:37,488 --> 00:18:39,218 It's like, well, no, not necessarily. 372 00:18:39,488 --> 00:18:42,548 And that's just quite unusual for a brain tumour to present a 373 00:18:42,548 --> 00:18:44,378 status as the first presentation. 374 00:18:44,378 --> 00:18:45,188 Never say never. 375 00:18:45,338 --> 00:18:46,598 Dr Emma Hancox: Yeah, you've said it now... 376 00:18:46,603 --> 00:18:47,053 tomorrow... 377 00:18:47,683 --> 00:18:48,043 Dr Mark Lowrie: Exactly. 378 00:18:48,043 --> 00:18:49,183 A busy, busy day then. 379 00:18:49,663 --> 00:18:52,763 The other thing here I suppose is, and with status, the other thing 380 00:18:52,763 --> 00:18:57,143 about status and and indeed with, with seizures in general is owners 381 00:18:57,143 --> 00:18:59,243 always like to blame toxicities. 382 00:18:59,933 --> 00:19:03,083 So when they come in with a dog that's seizuring, they'll often 383 00:19:03,083 --> 00:19:08,303 think it's a neighbour that's that's poisoned their dog or it, it's 384 00:19:08,303 --> 00:19:10,163 been drinking from the local canal. 385 00:19:10,193 --> 00:19:10,523 Dr Emma Hancox: Oh, yeah, 386 00:19:10,573 --> 00:19:11,743 Dr Mark Lowrie: Something to do with rats? 387 00:19:11,803 --> 00:19:13,603 Dr Emma Hancox: This is like seizure bingo for me right now. 388 00:19:14,483 --> 00:19:14,703 Yes. 389 00:19:15,073 --> 00:19:16,573 What the owners think it is. 390 00:19:16,843 --> 00:19:17,143 Dr Mark Lowrie: Exactly. 391 00:19:17,263 --> 00:19:20,203 So, so, you know, so that, that malicious neighbour or that, you 392 00:19:20,203 --> 00:19:21,763 know, that terrible canal water. 393 00:19:22,453 --> 00:19:22,603 Yeah. 394 00:19:22,603 --> 00:19:23,023 All right. 395 00:19:23,023 --> 00:19:25,993 You, you can't sit there at the time of the consult and say definitely 396 00:19:25,993 --> 00:19:28,813 not that 'cause who knows, you know, these things could, could happen 397 00:19:28,873 --> 00:19:29,923 unlikely, but they could happen. 398 00:19:30,823 --> 00:19:33,253 What I would say about them is, is when it's recurrent 399 00:19:33,253 --> 00:19:34,903 seizures, you can rule them out. 400 00:19:35,023 --> 00:19:39,073 So yes, if it's having status today and it's really bad, fine. 401 00:19:40,553 --> 00:19:45,253 If it's having few seizures every week for the next few weeks, that's 402 00:19:45,253 --> 00:19:50,278 a very dedicated toxicity criminal out there that really is getting to 403 00:19:50,278 --> 00:19:51,958 your dog very frequently to cause it. 404 00:19:52,168 --> 00:19:54,988 As soon as we remove that toxin, the seizure should stop. 405 00:19:55,378 --> 00:20:00,548 And yeah, I mean, I suppose with toxicities, if there is a toxicity, 406 00:20:00,548 --> 00:20:01,958 often you have other clues. 407 00:20:01,988 --> 00:20:04,868 I mean, maybe the owner did actually see when they know there's a toxin 408 00:20:04,873 --> 00:20:08,578 that's been ingested and things, and I suppose it's a good opportunity to say 409 00:20:09,228 --> 00:20:11,578 TVM have an antitoxin range, don't they? 410 00:20:11,578 --> 00:20:14,098 Dr Emma Hancox: We do so yeah, thanks for the plug there, Mark. 411 00:20:14,998 --> 00:20:19,588 But it is something that we actually discuss in both of our kind of 412 00:20:19,588 --> 00:20:23,308 neurology type lunch and learns, but also our antitox lunch and learns. 413 00:20:23,308 --> 00:20:29,193 And there is definitely like a crossover that if, and this is what we would say, if 414 00:20:29,198 --> 00:20:34,443 you've never seen that patient before with seizures and they suddenly come in with 415 00:20:34,448 --> 00:20:40,173 status epilepticus, you would want to rule in or out toxins and maybe have a think 416 00:20:40,173 --> 00:20:45,013 about is there a toxicological cause, it was often preceded by other things. 417 00:20:45,013 --> 00:20:50,868 And I think that's, something that if they do come in status that, still want that 418 00:20:50,868 --> 00:20:57,948 history because it may have been preceded by tremors, muscle like shivers and 419 00:20:57,953 --> 00:21:03,318 things like that, that the owner hasn't thought about necessarily at the time. 420 00:21:03,678 --> 00:21:08,578 That is to say then if they come in with tremors, there could be a likelihood 421 00:21:08,598 --> 00:21:13,683 it's gonna progress so, yeah, that's probably my little spiel on toxins. 422 00:21:13,998 --> 00:21:14,478 Dr Mark Lowrie: No. 423 00:21:14,483 --> 00:21:17,598 And, and, and with status, with the management of that, I mean, it's 424 00:21:17,603 --> 00:21:19,368 a good time to bring up the facts. 425 00:21:19,368 --> 00:21:21,018 It's another one where you need a team effort. 426 00:21:21,318 --> 00:21:25,218 Status is a pretty intimidating presentation for a vet to deal 427 00:21:25,218 --> 00:21:26,328 with, let alone the owners. 428 00:21:26,848 --> 00:21:31,933 So, don't be afraid with status to, I mean 'cause 'cause when you present with 429 00:21:31,933 --> 00:21:34,693 it, it's again, this whole situation of a panic and you’re haven't tried 430 00:21:34,693 --> 00:21:36,493 to function in a panicking scenario. 431 00:21:36,493 --> 00:21:40,363 So of course the advice is not to panic, but you will, you will. 432 00:21:40,363 --> 00:21:42,793 It's inevitable, 'cause you, you, it's hopefully something you, don't come 433 00:21:42,793 --> 00:21:47,303 across too frequently, but my view with it is, yes, there's the diazepam. 434 00:21:47,443 --> 00:21:50,713 We can give that IV or rectally depending on, on the access. 435 00:21:50,773 --> 00:21:53,193 But you want to get like, hopefully the people around you, other vets, other 436 00:21:53,193 --> 00:21:54,673 nurse in the practice to help place an IV. 437 00:21:55,693 --> 00:21:58,603 Things like taking the dog's temperature, get bloods for managing, 438 00:21:58,603 --> 00:22:01,003 all of this, this is stuff that can all be going on and you just need to 439 00:22:01,003 --> 00:22:03,553 delegate, delegate what you need to do. 440 00:22:04,513 --> 00:22:07,903 But what it says in textbooks, it says give diazepam. 441 00:22:08,503 --> 00:22:11,503 I think, you know, it says anywhere between half to two mgs per kg IV. 442 00:22:12,493 --> 00:22:17,293 And then wait 5 to 10 minutes for the seizure to stop, now 5 to 10 minutes... 443 00:22:17,503 --> 00:22:18,433 Dr Emma Hancox: That's a long time. 444 00:22:18,913 --> 00:22:21,043 Dr Mark Lowrie: And if it's status, and it's not gonna stop. 445 00:22:21,538 --> 00:22:22,528 It probably won't stop. 446 00:22:22,918 --> 00:22:26,428 So what the textbook then says, is it textbooks nowadays? 447 00:22:26,428 --> 00:22:27,788 It's probably like the app 448 00:22:27,793 --> 00:22:28,673 Dr Emma Hancox: Google now or something. 449 00:22:29,588 --> 00:22:33,568 Dr Mark Lowrie: but it says give a second dose of injectable diazepam at a 450 00:22:33,568 --> 00:22:35,108 similar dose and wait 5 to 10 minutes. 451 00:22:35,128 --> 00:22:38,758 So if you, if you’re following this strictly, 20 minutes might have passed. 452 00:22:38,758 --> 00:22:39,808 Well, the dog is still fitting. 453 00:22:40,528 --> 00:22:41,338 I don't like doing that. 454 00:22:41,338 --> 00:22:44,068 And I’ll be honest, my experience is diazepam isn't quite the drug 455 00:22:44,128 --> 00:22:45,298 there that will stop everything. 456 00:22:45,298 --> 00:22:49,378 And that's not, you may get lucky, but it isn't so what you want to be doing is 457 00:22:49,378 --> 00:22:51,298 you want to be loading some medication. 458 00:22:51,298 --> 00:22:54,418 Now, if the dog's never had phenobarbital in its life, we can give 459 00:22:54,418 --> 00:22:56,668 IV phenobarbital at a loading dose. 460 00:22:57,898 --> 00:22:59,998 This is when doses get very boring on a podcast, 461 00:23:00,898 --> 00:23:03,438 Dr Emma Hancox: But people love doses 'cause it's something 462 00:23:03,438 --> 00:23:05,308 Dr Mark Lowrie: If people are driving now, I'm gonna have to ask them to 463 00:23:05,308 --> 00:23:09,498 pull over onto the hard shoulder, grab a pen, but no, the, the, the 464 00:23:09,508 --> 00:23:14,263 loading dose is, I mean, we give 20 to 24 mgs per kg as a loading dose. 465 00:23:14,308 --> 00:23:14,928 Dr Emma Hancox: That sounds massive. 466 00:23:15,318 --> 00:23:17,363 Dr Mark Lowrie: It is and that's why we don't give it all at once 467 00:23:17,423 --> 00:23:17,773 Dr Emma Hancox: Okay. 468 00:23:18,453 --> 00:23:21,343 Dr Mark Lowrie: So we want to divide that up and so we do it into like bite-sized 469 00:23:21,343 --> 00:23:23,353 chunks of four mgs per kg at a time. 470 00:23:23,923 --> 00:23:28,423 So you give a four mgs per kg dose of Phenobarbital IV, you’re 471 00:23:28,423 --> 00:23:30,793 meant to wait 5 to 10 minutes. 472 00:23:30,798 --> 00:23:32,803 So loads of time has passed now and dogs still fitting. 473 00:23:33,283 --> 00:23:36,463 What I do is I give it, if the dog is still fitting, when I finish giving 474 00:23:36,463 --> 00:23:38,023 it, I’ll slowly give another dose. 475 00:23:38,863 --> 00:23:41,833 I’ll keep going until either the seizure has stopped, which 476 00:23:41,833 --> 00:23:42,943 is hopefully what happens. 477 00:23:43,723 --> 00:23:49,483 Or until I’ve reached that 24 mg per kg total, it’s very possible 478 00:23:49,483 --> 00:23:50,713 the dog could still be fitting then. 479 00:23:51,463 --> 00:23:55,513 Now, I would say at that point you just wanna do what you are good at. 480 00:23:55,723 --> 00:23:58,613 And I think what vets do really, really well is anaesthesia. 481 00:23:58,993 --> 00:23:59,803 You’re doing it daily. 482 00:23:59,833 --> 00:24:02,563 It’s something that happens in the practice all of the time, and I think 483 00:24:02,563 --> 00:24:05,623 that’s when you’re in your, kind of, in your zone where you function best. 484 00:24:06,253 --> 00:24:08,623 There’s nothing wrong with anaesthetising that dog then because 485 00:24:08,623 --> 00:24:13,093 with generalized tonic-clonic seizures in status anaesthesia will fix it 486 00:24:13,333 --> 00:24:15,523 only temporarily, but it will fix it. 487 00:24:15,523 --> 00:24:16,663 It gives you thinking time. 488 00:24:17,098 --> 00:24:17,458 Dr Emma Hancox: Yeah, 489 00:24:17,473 --> 00:24:19,213 Dr Mark Lowrie: And this is where I go right back to the beginning when 490 00:24:19,213 --> 00:24:23,383 that dog first presents, because if you know all of this great, you can 491 00:24:23,383 --> 00:24:25,753 keep it in your head and you can do it in the steps I’ve described. 492 00:24:26,123 --> 00:24:30,133 But if a dog presents in status, actually one of the easiest things to do right 493 00:24:30,133 --> 00:24:33,073 from the beginning is anaesthetise the dog, because then it's stopped fitting. 494 00:24:33,133 --> 00:24:37,483 It allows you to find notes, look in books, look up doses, and get everyone 495 00:24:37,483 --> 00:24:38,803 on board to get that dog managed. 496 00:24:38,803 --> 00:24:40,093 And there's nothing wrong with doing that. 497 00:24:40,513 --> 00:24:43,813 And then hopefully you'll be giving that dog the best care without 498 00:24:43,813 --> 00:24:45,083 everyone panicking around you. 499 00:24:45,303 --> 00:24:46,348 Dr Emma Hancox: That's really good advice. 500 00:24:46,543 --> 00:24:48,883 Dr Mark Lowrie: So I quite like that with status, but it, it's just meant 501 00:24:48,883 --> 00:24:50,213 I’ve gone completely off piste again. 502 00:24:51,988 --> 00:24:54,648 Dr Emma Hancox: We've gone into really good information, I feel like I would 503 00:24:54,648 --> 00:24:57,728 never have thought to go straight to anaesthesia, but you are right, it's 504 00:24:57,728 --> 00:24:59,048 gonna stop that seizure activity. 505 00:24:59,048 --> 00:25:00,098 It's gonna buy us some time. 506 00:25:00,308 --> 00:25:03,368 I just wonder how do you then stop? 507 00:25:04,298 --> 00:25:08,048 Do you give your phenobarbital or diazepam or whatever first? 508 00:25:08,678 --> 00:25:10,598 Dr Mark Lowrie: So I think in that scenario, so if you've now got a 509 00:25:10,598 --> 00:25:12,498 dog intubated and anaesthetised. 510 00:25:12,888 --> 00:25:14,138 And the seizures stopped. 511 00:25:14,438 --> 00:25:18,428 What I'd do is I'd, if the dog hasn't been on phenobarbital before, I'd give it the 512 00:25:18,548 --> 00:25:22,688 the first loading dose of phenobarbital IV, and then I'd start to recover the dog. 513 00:25:23,318 --> 00:25:26,868 But what I'd do is I'd keep it in sternal because there's this propofol 514 00:25:26,888 --> 00:25:28,238 paddling thing that people talk about. 515 00:25:29,528 --> 00:25:31,958 And so if you've got a dog that's just been given propofol and then you 516 00:25:31,958 --> 00:25:33,608 recovering it, it might start to paddle. 517 00:25:34,208 --> 00:25:35,438 You won't know is that propofol? 518 00:25:35,528 --> 00:25:36,248 Is it the seizure? 519 00:25:36,998 --> 00:25:40,998 And if you keep them in sternal, then if it is sort of paddling in 520 00:25:40,998 --> 00:25:43,988 sternal, that probably is more the seizure as opposed to the propofol. 521 00:25:44,178 --> 00:25:45,173 Dr Emma Hancox: Yeah, that makes sense. 522 00:25:45,413 --> 00:25:46,613 Dr Mark Lowrie: And then if you’re seeing that, it tells you, 523 00:25:46,613 --> 00:25:49,013 well, let's give another four mgs per kg as you are recovering. 524 00:25:49,073 --> 00:25:51,513 But actually you might find you need to induce it back in 525 00:25:51,513 --> 00:25:52,573 and wait a little bit longer. 526 00:25:52,943 --> 00:25:53,183 Dr Emma Hancox: Yeah. 527 00:25:53,223 --> 00:25:56,363 Dr Mark Lowrie: And so I'd keep recovering the dog intermittently, hoping it will 528 00:25:56,363 --> 00:25:57,683 come around fully without fitting. 529 00:25:57,893 --> 00:26:01,183 But if it does, you give another loading dose, hopefully that will fix it. 530 00:26:02,303 --> 00:26:02,573 Dr Emma Hancox: Perfect. 531 00:26:02,573 --> 00:26:03,353 No, that makes sense. 532 00:26:03,353 --> 00:26:03,803 Thank you. 533 00:26:04,313 --> 00:26:04,493 Yeah. 534 00:26:04,493 --> 00:26:06,903 I feel like we have gone a little bit off piste. 535 00:26:06,923 --> 00:26:10,283 We were talking about management of the seizures, management of 536 00:26:10,283 --> 00:26:13,073 the underlying cause and because then we went on to toxicities 537 00:26:13,073 --> 00:26:14,693 and status and things like that. 538 00:26:14,693 --> 00:26:18,703 I think we are a little bit off course, but I think your last thing you wanted 539 00:26:18,703 --> 00:26:21,943 to talk about, correct me if I'm wrong, is management of the owner. 540 00:26:22,373 --> 00:26:22,663 Dr Mark Lowrie: Yeah, 541 00:26:22,903 --> 00:26:24,358 Dr Emma Hancox: We've kind of touched on it, but if you 542 00:26:24,358 --> 00:26:25,403 wanted to say any more there 543 00:26:25,618 --> 00:26:27,658 Dr Mark Lowrie: We do well, well, when we're going on about this. 544 00:26:27,718 --> 00:26:33,223 Every owner has different circumstances, so the reason why you never get any vet 545 00:26:33,283 --> 00:26:37,843 say, this is when to start medication or this is what you do with epilepsy. 546 00:26:38,353 --> 00:26:41,653 It's because there is no right answer and it depends on so many things. 547 00:26:42,643 --> 00:26:46,603 One owner will want a very different strategy to another owner. 548 00:26:47,023 --> 00:26:51,103 So you do need to kind of sit down with the owners, find out their concerns. 549 00:26:51,583 --> 00:26:53,293 That may sound silly because you'll say, well, of course it's 550 00:26:53,293 --> 00:26:55,183 the seizures, but it isn't always. 551 00:26:55,243 --> 00:26:58,183 It could be the postictal phase is their concern. 552 00:26:58,903 --> 00:27:00,943 So what you'd have to say is, well, there's no way we, because I’ll 553 00:27:00,943 --> 00:27:03,763 have owners that approach me and say, we don't mind the fits at all. 554 00:27:03,763 --> 00:27:05,713 They're fine, they're infrequent, they're not a problem. 555 00:27:05,743 --> 00:27:08,293 But it's how my dog is in that postictal phase, and the aggression 556 00:27:08,293 --> 00:27:09,823 is the common one that comes up. 557 00:27:10,603 --> 00:27:15,013 But we can't give medication to stop postictal phases without, 558 00:27:15,493 --> 00:27:16,723 we have to stop the fit. 559 00:27:16,723 --> 00:27:18,193 So it comes back to the same thing. 560 00:27:18,193 --> 00:27:20,803 But the owner would need to understand that and they might even ask for something 561 00:27:20,803 --> 00:27:24,223 to administer during the fit that will make the postictal stage go away. 562 00:27:24,523 --> 00:27:26,863 And it's like, no, that the, the horse has already bolted then. 563 00:27:26,863 --> 00:27:26,923 Yeah. 564 00:27:26,983 --> 00:27:27,913 You know, the fit started. 565 00:27:27,913 --> 00:27:28,783 We know what's to come. 566 00:27:29,353 --> 00:27:33,223 So you have to talk through strategies to try and reduce the risk with an 567 00:27:33,223 --> 00:27:37,953 aggressive dog in that temporary postictal period but by doing that, speaking 568 00:27:37,953 --> 00:27:41,943 to owner and actually listening to the owner, might seem really obvious, but 569 00:27:42,153 --> 00:27:46,173 it just engages the owner much more with you, and it allows a much more 570 00:27:46,173 --> 00:27:50,013 collaborative environment in which you can actually get on top of the 571 00:27:50,013 --> 00:27:51,813 dog's epilepsy one way or another. 572 00:27:52,233 --> 00:27:56,343 And that doesn't mean you'll necessarily be successful in your own, so you might 573 00:27:56,348 --> 00:27:58,593 think, well actually, you know, the seizures still don't feel well controlled, 574 00:27:58,593 --> 00:28:02,343 but the owner can feel better managed and that's what's important, that they know 575 00:28:02,343 --> 00:28:04,023 that you are doing everything you can. 576 00:28:04,773 --> 00:28:08,973 You might not be the super vet that you need to be to fix it, but none of us are. 577 00:28:09,303 --> 00:28:10,863 No one, no one has those skills. 578 00:28:10,863 --> 00:28:14,493 You know, we're not God, we're just trying to get things managed as best we can. 579 00:28:15,033 --> 00:28:19,743 So by doing that, hopefully it allows an owner to understand that we are doing 580 00:28:19,743 --> 00:28:23,883 our best, it may not be the cure that they want, but it's the best we can 581 00:28:23,883 --> 00:28:25,553 do and hopefully everyone is on board. 582 00:28:26,433 --> 00:28:27,043 Dr Emma Hancox: Great. 583 00:28:28,163 --> 00:28:28,863 Thanks, Mark. 584 00:28:28,923 --> 00:28:33,318 That's a really useful summary, I think splitting it down into those three stages. 585 00:28:33,318 --> 00:28:37,458 So management of seizures, management of that underlying cause, and then not 586 00:28:37,458 --> 00:28:41,058 forgetting to manage the owners and their expectations is really useful. 587 00:28:41,058 --> 00:28:46,033 And I think sometimes we can forget as first, first opinion, clinicians as well. 588 00:28:46,213 --> 00:28:51,893 And that for us, as much as it's uncommon, it's not as uncommon for our owners and 589 00:28:51,893 --> 00:28:53,513 for them it's completely new information. 590 00:28:53,513 --> 00:28:55,283 So no, that was really useful. 591 00:28:56,483 --> 00:29:00,023 But unfortunately, I think that's all we've got time for really on this podcast. 592 00:29:00,023 --> 00:29:05,063 So just a plug, please tune in next time where we'll be discussing and moving onto 593 00:29:05,063 --> 00:29:08,873 the fourth instalment of the S.M.A.R.T Approach, which is to be realistic. 594 00:29:09,713 --> 00:29:14,688 It is maybe as you've picked up, we are always talking about the owners 595 00:29:14,688 --> 00:29:18,333 and being realistic with them, but just a little cliffhanger, hopefully we're 596 00:29:18,333 --> 00:29:22,353 gonna talk about some of the other, perhaps non medicinal therapeutic 597 00:29:22,353 --> 00:29:25,983 options, where they might fit, how to be realistic with those as well. 598 00:29:25,983 --> 00:29:28,623 So do tune in for that next episode. 599 00:29:29,503 --> 00:29:30,553 Thanks again, Mark. 600 00:29:30,653 --> 00:29:31,013 Dr Mark Lowrie: Thanks, Emma. 601 00:29:31,013 --> 00:29:31,493 Bye-bye. 602 00:29:31,783 --> 00:29:32,263 Dr Emma Hancox: See you soon. 603 00:29:32,263 --> 00:29:32,653 Bye.