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Seizures - Potassium Bromide and Phenobarbital effects
Seizure control
Seizure control
Dilantin and seizure control
Seizure contol and diet
Seizure control
seizure control
also see Page 1 seizure
also see Page 2 seizure
also see Epilepsy
also see Neurological Problems
Seizures - potassium bromide and Phenobarbital effectsQuestion: Dear Dr. Richards,
Our 12 year old female Old English Sheepdog is having a terrible
problem. About eight months ago she began having seizures. Petit Mal at first
but progressing into Grand Mal in the last three months. She has had them
about six weeks apart, the last one being three weeks ago. In this last one
she showed all the symptoms of Status Epileptus and it went on for 20
minutes. With the two Grand Mals she had previously, she came around in about 2
or 3 hours but with this one she bit her tongue and could not seem to shake
it off several hours later . We took her to an emergency animal hospital.
They checked her and said it did not look like there was any permanent brain
damage and sent her home. She seemed to come around pretty well in the
next couple of days but was still disoriented and could not get up on her
own. Once up she was able to walk okay, just not very far, as she would fall
down. She has had arthritis in her back legs for the last 3 years,
being treated with Adequan and acupuncture, so we thought perhaps she had
just over exerted herself with the seizure as she was paddling her legs so
hard.We took her back to the animal hospital several days later where she
underwent a battery of tests. They did an MRI, CSF, liver panel,
checked for encephalitis etc. Everything came back normal, so the conclusion was
that she had just developed Epilepsy due to age. They sent her home from the
hospital with a prescription for Potassium Bromide, 3000 mg loading
dose for 5 days and 1000 mg maintenance dose thereafter. From the first day
home she started exhibiting additional symptoms. She was totally lethargic and
sedated. She would vomit an hour after we gave her the Kbr, and
couldn't keep food down. Diarrhea went along with this (very dark, almost black)
and now when we helped her up usually she would fall down again almost
immediately. When she could walk, she kept walking in circles and was
very uncomfortable when lying down, constantly falling over on her side.
Finally she got to the point where she was vomiting every hour and couldn't
even keep water down, and we rushed her back to the animal hospital again.
They kept her overnight and stabilized her with fluids and anti-vomiting
medicine. They did additional blood work and checked for
pancreatititis. Again every test came back normal. They took her off the Kbr and put
her on Phenobarbitol and sent her home.Now she can't even stand. She does not seem to want to put weight on
her paws, she falls down when you lift her up, and whines constantly,
wanting to get up but unable. She will eat and drink but only when I give it to
her by hand (this has been going on since after the MRI). Last night she kept
moving her head from side to side, her eyes were moving back and forth,
and she kept falling on her side. Once there she seemed uncomfortable and
would lift her head up again, whining all the time. She has been shaking her
head occasionally as if there is water in her ears but when I have checked
them for infection they are clean.I took her back to the animal hospital today, where they were going to
have an orthopedic surgeon check her out, but she was showing so little
reaction that the surgeon could not make any kind of diagnosis. They have
suggested I take her back in two weeks when she builds up a tolerance to the Pheno
or that I gradually taper the Pheno off over a few days. I don't want to
take her off the Pheno as I am afraid she will have another seizure and I
don't think she could survive another major one. She is still completely
sedated and sleeps a lot. When awake she is alert but very listless.She has been taking thyrosine for many years due to hypothyroidism and
I wondered about the potential for Peripheral Vestibular Syndrome, but
the Vets don't seem to think that's a possibility and are looking for an
underlying neurological or orthopedic cause. I have moved her paws
around and she is not responding as if there is any pain except for her hips
which have always been uncomfortable due to arthritis.Please help. She is totally sedated on the pheno and I hate to see her
with so little interest in the world. She seems totally depressed that she
can't get up and I don't think she can go on like this for very long. I don't
want to put her down as I don't feel it is her time but at this point I'm at
a loss. She can't even get up to urinate or defecate, and she is so
uncomfortable when she has to go where she lies.Although she's not in pain her quality of life is severely impaired. I
would appreciate any thoughts you have on this, as I know you have helped
many people through your web site.Sincerely,
Mary and Mel
Answer: Mary-
Depression and lethargy are expected side effects during the first three
to four weeks of use of potassium bromide. Dogs may appear to be
intoxicated or extremely drowsy for a few hours after bromide dosing during the
first couple of weeks as an effect of the bromide. It is helpful to give the
bromide at night before bedtime so that the worst of the drowsiness
occurs at times the dog should be asleep, anyway.Vomiting occurs in some dogs, especially during the loading dose phase
of bromide administration. It is possible to reduce the possibility of
vomiting by dividing up the daily loading dosage into several smaller
doses and giving them over the course of the day, in most dogs. If it is
necessary to reconsider the use of potassium bromide in the future due
to continued seizure activity it may be possible to use it with some
adjustments to the way that it was being used.Testing serum levels of bromide can allow adjustment of the dosage of
bromide, just in case the dose level was producing higher than expected
blood levels and that was contributing to the problem. When potassium
bromide is used in conjunction with phenobarbital it is usually possible
to use lower levels of bromide and doing so may reduce the potential for
side effects. This is important in your dog's case because the potassium
bromide levels decrease very slowly after withdrawal of the drug, so part of the
side effects you are seeing with the phenobarbital are probably due to
both drugs being in the blood stream at the same time. Potassium bromide has
a half-life (time until 1/2 of the bromide is out of the system) of about
3 weeks, which means that it will have significant serum levels for some
time after withdrawal.Phenobarbital has several side effects, as well. It causes most dogs to
be lethargic or to appear depressed and it causes some dogs to appear to be
intoxicated. It is not unusual for rear leg weakness to be present and
this effect is sometimes noticeably worse when phenobarbital and potassium
bromide are given at the same time. It can cause increased drinking,
increased urination and an increase in appetite. It often causes
elevations in serum alkaline phosphatase (SAP) levels which is noted when blood
chemistries are tested. It can cause difficulty balancing. Usually the
side effects are worse in the first two or three weeks of administration
and then the dog adjusts to them or gets better at processing the
phenobarbital and they are reduced due to that. The increased drinking,
urinating and appetite tend to continue, as does the increase in SAP
levels. There are some dogs who can not overcome the other side effects
but this is unusual. In a small number of patients phenobarbital causes
severe liver disease and the unwillingness to eat and unusual movements of the
head are potential signs of this. Checking for liver damage would be a
good idea, if it has not been done.I think that I might discount the possibility of coincidental peripheral
vestibular syndrome but it sure sounds like you might be describing
that, especially with the back and forth eye movements. The other possibility
that comes to mind is that there is a brain lesion (tumor or other
problem) affecting the cerebellum, which could cause similar signs. I can't
explain why that wouldn't show up on an MRI but it still seems like a
possibility. An inner ear infection or inner ear inflammation seems possible, as
well. Hopefully these particular signs will clear up and it will be possible
to look back and see that they were just coincidental peripheral vestibular
syndrome. That would take some luck, but that doesn't stop me from
hoping it is the case. When dogs are having balance problems they often seem to
lack an appetite and to require hand feeding. Part of the reason for
this is their inability to accurate control head motion, which makes it a
little scary to try to drink water from a bowl and unpleasant to eat
from one, too. It is good that she will eat when hand fed and I would
continue to do this, trying to feed her a normal daily amount of food over the
course of the day.It seems reasonable to consider going ahead and testing the
phenobarbital serum levels, even though it would ordinarily be a little early to do
that. If they are too high the phenobarbital could be causing the symptoms, as
well.Due to the fact that there is still a strong possibility of high bromide
serum levels it is possible that the combination of the two drugs
(bromide, phenobarbital) is producing more severe symptoms than either one would
cause, alone. If this is the case, you should see a lot of improvement
as the bromide levels drop off over the next three to six weeks. To me,
this is the thing you really need to keep in mind -- many of the effects you
are seeing are expected and there is good reason to think they will get less
severe as time goes on and even to hope they will go away. Some of the
effects aren't as expected and it may be possible to find a cause for
them as time goes on, as well.We worry a lot about our older patients who have pre-existing orthopedic
problems, including arthritis, when we start medications like bromides
and phenobarbital that can cause weakness and balance problems. These
effects put more strain on already sore joints and it may be a good idea to
consider using a more potent pain reliever, such as etodolac (Etogesic
Rx) or carprofen (Rimadyl Rx). It seems best not to add too many
medications whenever possible but I think that this is a situation in which it may
really be necessary to use something for pain relief, at least until
balance problems are less of an issue. You and/or your vet may feel
differently and there are good reasons to feel that way, too. We really
think it helps to use the more effective arthritis medications based on
our own experiences, though.It is OK to use a sling to help her get around. This can be as simple as
putting a towel under her abdomen to help lift her and steady her, if
she will tolerate it. If she won't, she might let you help her up and allow
you to hold her hips to help steady her.When seizures start as a new problem in a dog in your dog's age range
there is usually an underlying cause and it would be best to continue to look
for one, although I know that gets frustrating after a while. Over time,
though, there are often changes in blood chemistries, X-rays, MRIs or
other test procedures that finally give some clue as to the nature of the
problem, or symptoms of a disorder may become more clear on further
examinations. It just seems more likely that there is a primary problem
causing seizures than that epilepsy (unexplained seizures) are suddenly
occurring at this age.I hope that this helps some.
Mike Richards, DVM
11/1/2001
Question: Hi Dr. Mike,
Since I last corresponded with you, one of my other dogs has been
diagnosed with epilepsy. I feel as though I have been in a crash-program
of animal healthcare training for the last year and a half or so. The vet
at first put Crystal on Pb, but we are now transitioning her onto KBr. I'm
happy about this, since I know that it is so much less toxic. Crystal's
seizures never recurred since we started the Pb, so I'm very hopeful that
she'll live a normal life, or at least as normal as a sedated dog can be.
As usual, I enjoy reading the newsletters and the material on your
website. Your newsletter is the best one I've ever come across. You
really know how to communicate well with a non-medical audience; each
newsletter is a fun educational experience.Catherine
Answer: Catherine-
I hope that the potassium bromide works well for Crystal. If it doesn't
totally control the seizures on its own, it does often make it possible to
use a lower dosage of phenobarbital and still maintain good control of the
seizures.You are obviously passing your crash course!
Mike Richards, DVM
1/18/2001
Q: Good afternoon, we have a German Short Hair Pointer, l25 pounds has been
labeled as a dog who has seizures, why we do not know, started last
June, has been on phenobarbital, as many as 7 to l0 a day depending on
the seizure, we were told to increase at time of seizures. Only about 6
months ago was Potassium Brimide added, as of to date we have no reason
to him having the seizures, but for the last few months, they happen 20
to 30 day apart, last month they were 30 days to the day, June he had it
on the 2lst, July the 2lst and August the l6th, he can have as many as
I a l/2 hr. the continue all day, in usually into the second day, this
month which they started on Monday A.M. one at 6:00, he was put out and
as far as I know the second was at 8:30, and had who knows how many
during the day,,, they only last about a minute, kicks feet and foam at
the mouth, and some time loses bladder control. Very unstable after,
this time with out the increase of medicine he is the same as he has
been in the past. Sleeps all the time, very unsure on feet and is not
barking, all will come back in about a week..... Please advise if you
have any sugestions or any questions,,,, we just don't know for sure
what is going on.... Looking forward towards hearing from you.
Thanks
Linda Sanderson, I hope I have may myself clear enough....
--
A: Linda-
I do not know of any seizure disorders that are hereditary or specific to
German shorthair pointers. It is possible that a problem like this exists
that I do not know about as there is a great deal of new information on
genetic tendencies and it is very hard to keep up with. If I run across
something I will try to remember to post it or send it to you.There are some things that you can do to help ensure that the seizure
control medications are working properly.With phenobarbital, the thing you have to remember is that it takes several
days for dose changes to really effect the average serum levels. Therefore,
it is really important to try to establish a regular dosage that keeps the
amount of phenobarbital in the bloodstream in the therapeutic range. The
only way I know of to do that in any individual dog is to test the blood
levels. Blood is drawn about 4 to 8 hours after administration of
phenobarbital in order to judge the peak serum levels and prior to
administration of the medication to judge the lowest serum levels. Ideally,
neither sample would be out of the therapeutic range but it can be hard to
achieve that. It is less expensive to test just once and if that is done it
is probably best to check the serum level an hour or two prior to giving
the evening pill and try for a level around 30 ug/ml (middle of the
therapeutic range). Checking the serum level every six months and also
checking for liver enyzme levels at the same time is the recommended
procedure when using phenobarbital. Some dogs require really high oral
dosages of phenobarbital to maintain normal serum levels.I would worry that some of the signs you are seeing after seizure activity
are due to phenobarbital overdosage if you are giving 7 to 10 pills at
those times. It is better to try to keep a steady dosage that is in the
therapeutic range. If that is done and seizures still occur then adding a
second medication is better than increasing the dosage of phenobarbital. If
the serum level is low and seizures are occurring, then it is better to
increase the dosage of phenobarbital alone and wait to see if that will
control the seizures.Potassium bromide serum levels should also be monitored if signs of
toxicity occur, such as incoordination, skin rashes or irrational behavior.
They should also be monitored if seizure control is not adequate. It
probably is just a good idea to check them three or four weeks after
starting on the potassium bromide. The combination of phenobarbital and
potassium bromide is a good choice in many dogs with difficult to control
seizures. There are other choices if this doesn't work, so keep working at
this.The last thing to consider is further diagnostic testing. A complete blood
panel and general physical exam are very good but for seizures that don't
respond to therapy it may be helpful to have a neurologist examine your dog
or even to consider testing such as magnetic resonance imaging (MRI) to
look for problems.Seizures that start before a year of age or during a dog's geriatric years
are more likely to occur secondary to another problem, such as infectious
diseases, congenital brain or nervous system disorders, liver problems,
cancer, etc.Hope this helps some. If serum phenobarbital levels have not been checked,
that would be a really good way to start checking into why the seizures
aren't controlled by medications.Good luck with this.
Mike Richards, DVM
8/16/99
Dilantin for seizure control - Eddie update
Q: Dear Mike,
I have been wondering if Dilantin is a viable drug to be used for seizures
in dogs. I guess I am getting ahead of myself; I wrote you earlier to
inquire about seizures in our dog, Eddie. He is a Lhasa Apso, is 9 yrs old
& developed sudden seizures just since December. We have him on
Phenobarbital now & that is showing some signs of damaging the liver. We
started him on potassium bromide 2 wks ago & he seems to be tolerating that
well. I give it to him in the am with a syringe directly in his mouth. In
another week, I think we will start to cut back on the phenobarb if all
continues to go well. He had one very small seizure about a week or so ago
& that was the lst one since being on the KBr.Eddie seems to also have developed stiffness in his hind qtrs as well. Is
there a connection with the phenobarb & the stiffness? He also had
forgotten what to do with dog food since starting the phenobarb. I feed
him rice & some kind of meat mixture which he tolerates well. Is this
common? Any advice you can provide will be greatly appreciated & keep up
the good work. We do appreciate your site very much.
Thanks very much. Doris
A: Doris-
Phenytoin (Dilantin Rx) is not commonly used for seizure control in dogs
and cats. It will work for seizure control if administered properly but it
has to be given in pretty high dosages every 8 hours, making it costly in
comparison to phenobarbital or potassium bromide. For most people, a
medication used chronically three times a day is hard to manage. Due to the
cost and the inconvenience, phenytoin doesn't get used much.I have not seen a reference to muscular stiffness or joint pain associated
with phenobarbital. That doesn't mean it couldn't cause problems such as
this but it does make them somewhat unlikely. There is some chance that the
problem causing the seizures is also causing the stiffness. It might be
worth asking your vet to re-examine Eddie.Mike Richards, DVM
4/30/99
Q: We just adopted my brothers 5 year old male yellow lab. He's large as
labs go. My brother says that about twice a year he has epilepsy. It
involves loss of all motor coordination, and bowels etc. Just prior to
the fit he is seen running wildly as if trying to run away from it.He is not on any medication for this because it occurs so infrequently.
A friend told me he put is dog on a special diet that was able to stop
their frequent fits and his dog was taken off medication. I also was
reading articles on alternative medicine that say diet can help. I
asked our vet and he said he had never heard of diet controlling
seisures. Another article said vitamin therapy might help.Since we're not treating him with medication, I wondered if there is a
recommended diet or vitamin treatment we could try to possibly head of
these siesures. What are your feelings about this.I sincerely appreciate your help in the past.
Thank you
JoAnne
A: JoAnne-
I have seen references to seizures resulting from food allergies. In these
cases, a hypoallergenic diet is very helpful. Some pets seizure as the
result of liver disorders such as portosystemic shunts in the liver's blood
supply. These pet's seizures will usually diminish if they are fed a low
protein diet such as Hill's k/d or Purina's NF diets. Seizures can be
associated with renal failure and may respond to the same low protein diets
to some degree. Other than that these special instances, I am unaware of
any diet that helps with seizure control. I have seen or heard of seizure
control claims for a lot of dietary supplements and dietary plans but have
not seen any real attempt to prove the claims.There is a dietary approach to seizure control in humans that I am not
overly familiar with but which works something like this: The patient with
seizures is starved sufficiently to begin tissue fat breakdown and then is
fed a very high fat, low carbohydrate, moderately low protein diet, which
causes excessive production of ketones. The state of simulated response to
starvation has to be maintained, which is apparently a difficult task.
This somehow helps to alleviate the seizure condition. I am not familiar
enough with this to know if it only benefits a select few patients or if it
is beneficial to most seizuring humans. The articles on this available
online from PubMed (http:www.ncbi.nlm.nih.gov/PubMed/) seem to indicate
that its most common use is in children with difficult to control seizures.
Again, I am not an expert by any means but my interpretation of the
articles is that this is not meant to be a lifelong method of seizure
control but rather a way to get through difficult short-term crises. Dogs
may not benefit from this approach even if it would otherwise work because
they don't react to starvation in the same way as humans and there may not
be a good way to induce consistent ketone production in the dog.It is going to be very hard to evaluate the effect of any dietary changes
in a dog with seizures as infrequent as your new dog since they will appear
to work for several months even if they are exerting no effect at all.The good news is that dogs with seizures this infrequently probably do not
need to be medicated to control the seizure activity and are very unlikely
to suffer serious harm due to the seizures.Mike Richards, DVM
Q: Dear Dr. Mike: Thank you for providing us with such an informative web site. Our dog will be 3 years old next month. He is a terrier mix and a healthy little guy, with the exception of occasional seizure-like episodes which have recently become more frequent. The first incident occurred when he was 11 weeks old. We took him to the vet the following day and they took some blood tests which came back normal. They advised us to keep an eye on him and make a log of any future incidents. The next didn't occur for over a year, and the next one after that didn't occur until February of 1997. We could deal with the thought of these happening once a year, but it was at this point that they became more frequent. He had another one in April, on Mother's Day in May, on June 10th, and then two so far in July... one on the 3rd and one on the 8th. We are very concerned now because they have become so frequent. In addition, we don't know if he has any seizures while we are at work and can't be with him. Our vet had told us that medication for this should be a last resort, since sometimes these medications shorten the life of the dog.
About the seizures (they may not be classified as "seizures", please let us know)... they aren't as severe as some of the cases we have read about on your web site, however they are very scary. He does not lose consciousness but his muscles tighten up and he becomes very scared that he cannot pull himself up. They usually last around 3-5 minutes (although they seem like forever, just like earthquakes) and he sometimes appears to be clenching his teeth. Other times he has control of his tongue and licks his lips frequently during the course of the occurrence (probably because he is salivating so much when this happens, but not "frothing" at the mouth). His arms and legs look like they are cramped and we can't tell if he is in pain or not. All my husband and I can do is hold him and comfort him throughout these occurrences. When they are over, he is fine and happy again but doesn't want to let us out of his sight and wants to be held and hugged for awhile.
One other thing, on the night of June 9th he chased a skunk into the bushes and got completely sprayed right in the face. It took about a week to finally get all the skunk smell off him, after buying all kinds of products and potions. :) Anyway, after the last 2 seizures, 7/3 & 7/8, the skunk smell seemed to come back (maybe from his pores) for about 10 minutes. We noticed that another person wrote to you about an "odor" after their dog's seizures and wondered if this skunk thing means anything. We would appreciate any advice you could give us or any information about these symptoms. I guess what we'd really like to know is -- at what point do you consider the medication a necessity? We really don't want to put him on any medicine if we can avoid it. If the seizures are less harmful than the medication, we will continue to deal with them unless they become even MORE frequent. He is like our little child and we want only the best for him. Many thanks, Jill & Luke
A: Jill and Luke- My little terrier mix has seizures very similar to those you describe. She has them about 10 times a year but sometimes two or three in a short period of time. So far, I am still reluctant to use seizure control medications because I don't like the idea of constant medications and possible side effects -- so you can see I basically agree with your vet's approach. When to use seizure control medication is always a tough decision. Many veterinary neurologists now advise starting more quickly than we did in the past since there appears to be some indication that allowing seizures to continue makes it easier and easier for them to occur, causing the shortening in inter-seizure interval that you are seeing. I am not sure what the best approach is so I try to judge how the owner feels about the seizures, how the dog or cat handles them and the chance for drug reactions and for compliance with medication requirements (phenobarbital is addictive and it is very important that the owner follow directions for its use). When the time seems right considering all of these things, we medicate.
The smell may have been the expression of your dog's anal sacs. This happens when dogs are frightened, sometimes. The smell may resemble that of a skunk to some people. On the other hand, perhaps some other effect is responsible for the odor.
The best you can do when not at home is to try to make sure that your dog's habitat is as safe as possible for a dog that might lose conciousness -- try to block access to any areas of the house that could be dangerous. Death during a seizure is pretty unusual so it isn't worth worrying too much about seizures that occur when you are not around.
Mike Richards DVM
Q: Dr. Mike, Our 11 month old Weimaraner has been having seizures since he was 6 months old. The vet started him on Phenobarbitol about five months ago and Potassium Bromide about one month ago. HIs phenobarbitol level was within the therapeutic range which led to the Potassium Bromide treatment. I spoke to a neurologist who suggested we immediately ween him off the phenobarbitol, since it obviously was not working. He also suggested that we administer the KBr once per day at a higher dosage than the vet originally prescribed. He said to look for a "dozy" effect. In addition, the neurologist also said that since the dog started having seizures at such an early age, it is unlikely that is it genetic or a tumor (which is more common in older dogs). That it is possible that it was acquired; from a possible birth trauma or distemper despite having been vaccinated.
I have several questions: 1. Our dog is exceptionally energetic and I can't reallly tell what "dozy" is. What should I look for? 2. If he isn't getting "dozy", does it mean the dosage is not high enough? 3. What can we do to help the dog since his seizures are going to keep happening until the appropriate dosage is determined? 4. Can you explain how the KBr works? 5. Is there an advantage/disadvantage to weening him off the phenobarbitol now? 6. Does genetic necessarily mean congenital? 7. Are there other possible causes for this "acquired" seizures? I realize I have so many questions. We are really feeling helpless and would appreciate any information you could provide us with. Thank you. MC
A: I am not a neurologist but I don't understand the desire to stop the phenobarbital since potassium bromide and phenobarbital seem to work well in conjunction. There may be a reason for this that I am totally unaware of, though.
The anti-seizure effect of potassium bromide seems to be due to competition with chloride ions for transport across nerve cell membranes which keeps them hyperpolarized, making it harder for the seizure activity to spread within the central nervous system.
Congenital just means an animal is born with a condition, for any reason, as I understand it. Genetic or hereditary indicates it is passed through inherited traits.
There are literally hundreds of causes of seizures. It is hard to really specific about possibilities due to that. It just takes careful examination and labwork to try to rule out any that may be treatable. I am pretty sure your vets have done that.
It is usually best to wean a dog off phenobarbital since stopping it abruptly can lead to seizures as it is addictive. Potassium bromide takes 2 to 3 months to reach stable blood levels but is reported to exert an anti-seizure effect prior to stabilization. The recommended dose is the dose that just causes drowsiness initially. That does seem rather non-specific, though. I have seen dosages recommended from 10mg/kg to 30mg/kg so there seems to be a wide range of possible effective doses.
Remember that if you are dealing with a board certified neurologist it is very likely that he or she knows much more than I do about this and would be a better reference!
Mike Richards, DVM
Last edited 08/30/02
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