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  • Imaging referrals
    more they seek advice Magnetic Resonance Imaging referrals Access to magnetic resonance imaging MRI has been available through specialist referral centres for many years Mobile MR scanners touring the country are making the facility available to practitioners in their own town As MR imaging remains one of the most expensive imaging modalities it is of particular importance that the most appropriate and highest quality study is performed at the first attempt There are many indications for MR scanning but each case must be considered individually to decide whether the study will be of value to a particular individual If all other investigative alleys have been followed there is little point in pursuing an MR scan in the hope of a diagnosis if the client is unlikely to consider treatment Where the information gained from the scan will not alter case management there may be little point in having a scan If an animal is referred for MR scanning it is highly unlikely that an inappropriate study will be performed Some centres only accept scan requests from recognised second opinion referral centres to reduce the risk of inappropriate studies However if you are requesting a scan yourself there are a number of additional factors to consider above whether or not the study is appropriate The quality of the image produced is highly dependent both on machine characteristics basically the strength of the magnet and the type of the coils and the skill of the person acquiring the images It may be impossible to get diagnostic images of some anatomical sites using certain machines If the diagnosis is likely to indicate that further treatment is necessary consider if you are able to perform this treatment An animal with a suspected brain tumour for which the owner s are likely to want treatment if this is appropriate is best referred to a centre that is able to assess the case perform the scan and then provide appropriate treatment Considerations for MRI referrals Is MRI the most appropriate study or would other imaging studies be more useful Is the correct part of the body being imaged if the animal is collapsing have you correctly differentiated seizures from other causes When you refer the animal for the scan consider if the machine is able to provide a suitable quality of image for the area to be scanned Will the person who scans the animal be able to interpret the images for you in some cases scans are performed by physicists who are trained to optimise images but will not be able to comment on the study or its results MRI needs some degree of interpretation whilst performing the scan otherwise lesions may be missed or special sequences not performed The person who reads the film should have experience in reading animal MR scans for the region presented if you do not have this experience the scans are often meaningless When sending films for interpretation elsewhere it is worth asking the radiographer to print all the

    Original URL path: http://www.canineepilepsy.co.uk/imaging-referrals.html (2016-02-08)
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  • Standard management
    ideal anticonvulsant drug can be given once daily is cheap and has few side effects A wide range of drugs are available for the control of human epilepsy but few of these are effective in dogs due to altered pharmacokinetics The most commonly used anticonvulsants in dogs are phenobarbital and bromide Primidone is not recommended for the treatment of seizures in dogs or cats for a number of reasons 1 it is rapidly metabolised by the liver into phenobarbital and PEMA 2 it is phenobarbital that is responsible for more than 85 of primidone s anticonvulsant effect 3 primidone is more expensive than phenobarbital 4 it is less well tolerated particularly with regard to its potential hepatotoxicity Dogs receiving primidone can be safely converted to phenobarbital treatment with no loss of anticonvulsant effect It is generally safe to simply swap animals from primidone to phenobarbital 250 mg of primidone is approximately equivalent to 60 mg of phenobarbital Alternatively conversion may be done gradually over 2 3 weeks Withdrawal of anticonvulsants If the patient has been seizure free for a year drug withdrawal may be considered Before withdrawing the drug therapy weigh up the pros potential reduction in side effects and cost and cons potential seizure recurrence Drug doses must be tapered slowly and withdrawal should take around 6 12 months to complete Information and guides for owners The following downloads should answer many of the most common questions asked by your client DOWNLOAD About epilepsy DOWNLOAD Living with an epileptic dog DOWNLOAD Owner Questionnaire DOWNLOAD Seizure Diary DOWNLOAD Sample of the Seizure Diary DOWNLOAD Fact Sheet Bromide DOWNLOAD Datasheet Phenobarbital DOWNLOAD Fact Sheet Phenobarbital DOWNLOAD Datasheet Phenobarbital Sol DOWNLOAD Imepitoin Owner information sheet References Bagley RS Harrington ML Moore MP 1996 Surgical treatments for seizure Adaptability for dogs Vet Clin

    Original URL path: http://www.canineepilepsy.co.uk/standard-management.html (2016-02-08)
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  • Refractory epilepsy
    in as many as 1 in 4 epileptic dogs Known risk factors in dogs include CSF GABA concentration dogs with initial low CSF GABA concentrations do not respond as well to treatment Frequency and total number of seizures prior to the onset of treatment dogs with few widely separated seizures generally respond well to therapy Age of the animal at the onset of the first seizure the later the onset of epilepsy onset the better the outcome Management of refractory and cluster seizures Recurrent seizure activity can lead to functional and pathological changes in the brain that can potentiate refractoriness In animals with refractory or cluster seizures therapy may be tailored to specifically address these issues Short term The use of diazepam per rectum has been proven to significantly decrease the total number of seizure events and total number of cluster seizures Rectal absorption is comparatively faster than IM or PO absorption within 10 minutes and potentially avoids some of the first pass effect observed after oral administration The use of clorazepate in addition to phenobarbital for chronic treatment of seizures has been studied in dogs Tolerance seems to develop to this drug at a slower rate than with diazepam The main use of this drug is for short term control of breakthrough seizures with short term control development of tolerance is not an issue When clorazepate is used in conjunction with phenobarbital in dogs serum concentrations of phenobarbital are increased Start chlorazepate at 1mg kg q12hrs orally and measure serum concentrations of both phenobarbital and clorazepate at 2 and 4 weeks Long term Bromide has been shown to have particular value in reducing the severity and frequency of cluster seizures Clinical trials with gabapentin in dogs indicate its effectiveness in controlling refractory seizures Levetiracetam Pregabalin and zonisamide have all been used with some good effect to manage animals with seizures refractory to more conventional treatment Drug comparisons A variety of anticonvulsants are now available to assist in the management of refractory epilepsy The table below gives an indication of their relative merits and drawbacks References Bateman SW Parent JM 1999 Clinical findings treatment and outcome of dogs with status epilepticus or cluster seizures 156 cases 1990 1995 JAVMA 15 215 10 1463 8 PubMed Platt SR McDonnell JJ 2000 Status epilepticus Managing refractory cases and treating out of hospital patients Compendium on Continuing Education for the Practicing Veterinarian 22 8 732 Compendium Stefen F Grasmueck S 2000 P ropofol for treatment of refractory seizures in dogs and cats with intracranial disorders JSAP 41 496 499 PubMed Drug Dose Therapeutic range Formulation Side effects Indication Contraindication Cost Phenobarbital 3mg kg BID 20 35 ug ml PO tablets or solution IV solution PUPD sedation ataxia polyphagia hepatotoxicity bone marrow dyscrasia Drug of first choice impaired hepatic function reasonable for everyday use Potassium Bromide 30 mg kg SID 880 3000mg ml PO liquid capsule or tablets PUPD sedation ataxia hyperactivity pruritus vomiting With phenobarbitone in refractory cases or in animals with liver

    Original URL path: http://www.canineepilepsy.co.uk/refractory-epilepsy.html (2016-02-08)
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  • Status epilepticus
    0 5 1 0 mg kg intranasally or per rectum 1 2 mg kg This dose can be repeated 5 10 minutes later This is followed by an IV bolus of phenobarbital 5 10 mg kg although this takes 10 15 minutes to have an effect the anticonvulsant effects will be prolonged The combined effects of diazepam and phenobarbital may produce pronounced cardiac and respiratory depression Probably the most common and most dangerous error made in the management of SE is to treat repeated seizures with repeated doses of IV diazepam without administering an adequate loading dose of a longer acting anticonvulsant In this situation the patient will continue to have seizures toxic concentrations of diazepam or diazepam metabolites will accumulate and serious morbidity may result from diazepam over dosage Continuous patient monitoring is important assessing the following Clinical and neurological status Blood pressure Blood gases if available A cerebral mass such as a tumour Standard laboratory blood tests should be performed including evaluations for glucose sodium and calcium level abnormalities renal and hepatic dysfunction and serum acetylcholinesterase levels Liver enzyme concentrations might be increased shortly after seizure activity because of the effects of hypoxia and hypotension If hypoglycaemia is a potential cause of SE or if blood glucose determination is unavailable give 500 mg kg of 50 dextrose preferably diluted to 25 IV over 15 minutes If the patient has been receiving phenobarbital or other anticonvulsants prior to the development of SE serum levels of these drugs should be obtained If encephalitis is suspected a cerebrospinal fluid analysis should be considered as soon as seizure stabilisation is achieved CSF may be abnormal in more 1 in 3 dogs with sudden onset SE or cluster seizures Patients with new onset seizures should be considered for brain imaging procedures such as computed tomographic CT scanning or a magnetic resonance imaging MRI Concurrently a medical history should be obtained from the owners or retrieved from available medical records Treatment of the refractory status epilepticus patient Status epilepticus SE that does not respond to a benzodiazepine or phenobarbital is considered refractory and requires more aggressive treatment Potential reasons for resistant seizure activity include inadequate doses of anticonvulsant an uncorrected metabolic abnormality a cerebral mass such as a tumour Short acting anaesthetic drugs eg propofol infusion 0 1 0 6 mg kg min are the most commonly used agents for treating resistant SE as they have a rapid onset of action short half lives and reduce cerebral metabolic rates These drugs should be used only in an intensive care setting because of the need for continuous blood pressure monitoring and ideally central venous pressure monitoring General anaesthesia prevents tonic clonic movements and allows manual control of respiration Barbiturates Thiopentone and pentobarbitone have potential though unproven cerebral protective effects in the management of SE In adequate doses these drugs will almost always control the physical manifestations of seizures but severe hypotension limits their safety Pentobarbitone should be given to effect not as a specific dose

    Original URL path: http://www.canineepilepsy.co.uk/status-epilepticus.html (2016-02-08)
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  • Monitoring therapy
    determining the optimal dose Monitoring should be performed When steady state blood levels are reached after starting treatment or after changing oral dosage 12 to 15 days in dogs This provides a baseline to guide further changes in doses according to clinical circumstances If seizure frequency increases Every 3 to 6 months to verify that blood concentrations are maintained in the therapeutic range If drug related side effects are suspected If drugs are added that might interfere with phenobarbital s pharmacokinetics corticosteroids cimetidine chloramphenicol Recommended therapeutic range in dogs is 20 to 35 ug ml 65 194µmol l Most dogs will respond reduction in frequency intensity and severity of the seizures with minimal side effects when the serum level of phenobarbital is within this range However some dogs might need to be in the upper limit of this range while others might need to be below the lower limit This therapeutic range is only an indication of changes required in the oral dosage It has been recommended that blood samples for measuring serum concentrations should be taken at the time of trough serum phenobarbital concentrations up to 2 hours before the next dose is due A study by Levisitski and

    Original URL path: http://www.canineepilepsy.co.uk/monitoring-therapy.html (2016-02-08)
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  • Monitoring protocol
    recovery between Client should not alter the treatment without veterinary advice Skipping doses or stopping drugs abruptly can precipitate seizures Serum Monitoring Scheme Phenobarbital Therapeutic and toxic effects of phenobarbital are related to serum concentrations and not the quantity of drug administered orally Therapeutic monitoring of serum phenobarbital concentration can be helpful in determining the optimal dose Monitoring should be performed When steady state blood levels are reached after starting treatment or after changing oral dosage 12 to 15 days in dogs This provides a baseline to guide further changes in doses according to clinical circumstances If seizure frequency increases Every 3 to 6 months to verify that blood concentrations are maintained in the therapeutic range If drug related side effects are suspected If drugs are added that might interfere with phenobarbital s pharmacokinetics corticosteroids cimetidine chloramphenicol Recommended therapeutic range in dogs is 20 to 35 ug ml 65 194 µmol l Most dogs will respond reduction in frequency intensity and severity of the seizures with minimal side effects when the serum level of phenobarbital is within this range However some dogs might need to be in the upper limit of this range while others might need to be below the lower limit It has been recommended that blood samples for measuring serum concentrations should be taken at the time of trough serum phenobarbital concentrations up to 2 hours before the next dose is due A study by Levisitski and Trepannier 2000 showed that there was no therapeutically relevant change in serum concentrations during the 12 hour period between phenobarbital doses in 33 epileptic dogs Analysis of data from over 1400 dogs in the Vetoquinol serum monitoring scheme has confirmed that at oral doses 10mg kg there was no significant difference between trough and non trough serum phenobarbital levels on

    Original URL path: http://www.canineepilepsy.co.uk/monitoring-protocol.html (2016-02-08)
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  • Introduction to the scheme
    SUPPORT REFERENCES SERUM MONITORING INTRODUCTION Related Pages Monitoring protocols expectations Serum scheme FAQ Scheme findings Formulary Phenobarbital Conditions mimicking epilepsy Neurology specialists Practice support Introduction to the scheme One of biggest advances in improving the control of canine epilepsy in recent years has been the more widespread use of monitoring of anticonvulsant levels Since the introduction of Epiphen in the UK a scheme has been run by Vetoquinol to reduce the costs of sampling for serum phenobarbital levels The scheme has three aims to Increase awareness of the significance of serum level monitoring of phenobarbital Assist veterinary surgeons that use Epiphen to help them optimise control of epilepsy in their patients Generate data for subsequent review of serum phenobarbital levels How the scheme works Submission forms can be found in the dispensing packs of both strengths of Epiphen tablets There is one submission form in a 30mg pack and two submission forms in a 60mg pack Types of sample that can be submitted are Clotted plain samples Separated serum Please avoid using serum gel tubes The ideal sample needs to be able to provide at least 0 5ml of serum Send the blood sample along with the submission forms to

    Original URL path: http://www.canineepilepsy.co.uk/introduction-to-the-scheme.html (2016-02-08)
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  • Monitoring scheme FAQ
    into the gel Current advice is to avoid this type of submission tube Can a phenobarbital assay be run on a haemolysed sample Ideally all samples submitted should show no signs of haemolysis however mildly haemolysed samples may be acceptable When is the best time in the dose cycle to take a sample The most useful single sample is the trough phenobarbital concentration i e immediately before a dose is due If it is not practical to collect a sample at this time then try to take subsequent samples at the same time in the dosing cycle Some authors advocate the use of peak phenobarbital levels as well 2 to 4 hours post pill to check the maximal serum concentration A recent article Levitski RE Trepanier LA 2000 suggested that in most cases this is not necessary I often get lipaemic samples from epileptic dogs is it OK to submit these Yes this is a common finding Lipaemic samples usually don t present a problem They may need to stand for 24 hours after arrival at the laboratory to settle out before they can be tested Hence there may be a delay in receiving the result What can I do if I need advice on the results Please contact one of the veterinary advisors at Vetoquinol who will be very happy to try to help Have all the case details to hand when you call to facilitate case discussion What is the normal therapeutic range for serum phenobarbital concentrations Different laboratories and books quote reference ranges using a variety of reference units You should always be careful to check the reference ranges for each individual laboratory The references ranges for therapeutic serum phenobarbital concentrations in the two common units in use are micromol l typical reference range 65 194 micromol

    Original URL path: http://www.canineepilepsy.co.uk/monitoring-scheme-faq.html (2016-02-08)
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