Is the vet always right? Help please

[mrat128]

2 years ago my oldest MinPin took a fall and knocked herself out. She walked crooked for a few days and seemed to recuperate. Then she developed seizures. My vet did some tests and could not find a cause. Before ordering more expensive testing we decided to put her on Phenobarb. The vet ordered 1/2 of a 1/4gr tablet twice a day. I'm leary of over medicating so I started her on 1/2 a tablet once a day. That stopped the seizures but I still took her up to the twice a day as ordered by the vet. She was very groggy at that dose so I went back to 1/2 a tablet once a day. That has been working fine- no seizures. I had her blood work done this week and my vet is unhappy because her pheno level is only 7 and the vet claims the therapeutic level should be a 15.

Here's the question. The vet wants me to up the dose to achieve the 15 level. I feel that if she has no seizures at 7 why not leave it alone. It's at the point where my vet is saying up the dose or she won't prescribe it at all and I don't want to up a dose that is working. Am I wrong in not wanting to up the dosage?

[bendyfoot]

Wow, I'd be looking for a second opinion. IMO, you should use the lowest possible EFFECTIVE dose with most medications. If there are no signs of seizures at the lower dose, and negative side-effects at the higher dose, it sounds like it's doing more harm than good. I'm with you on this one.

[clm]

Did the vet explain why it's important to get the level up to 15?

Cindy

[Love4himies]

I agree with bendyfoot, get a second opinion.

[TacoGrl]

People Dr.s do this as well...if nothing is conclusive, it is an educated guess from past experience...Mooki ended up spending the night at the vet's because of mis-dosing I would discuss the side effects with the vet and if they are uncooperative, I second the get another opinion idea...you know your pet and what behaviour is "normal" and it is not feasible to go through life doped up!

...as a side note...I don't blame the vet for mis-dosing...she did work with us and was flexible on many levels...I could tell she was very upset things went the way they did, but if she hadn't been willing to work with us, I would have a different opinion of her.

[mrat128]

The best reason the vet would/could give is that the therapeutic level should be 15. I've had a relationship with this clinic for many years, I'd hate to lose them but I'm so uncomfortable with this whole situation.

[bendyfoot]

very informative handout here:

http://www.canine-epilepsy.com/Pheno...#anchor3431012

Some selected text I thought was relevant (bold added by me):

How do I know that my dog is receiving the proper doseage?
Each dog is different, so is their ability to metabolize medications. The only way to determine if your dog is getting the proper dosage is to monitor the PB serum concentrations (levels). This is done with a blood test. The first level is usually taken 2 weeks after initially starting PB therapy.

Based on the level results and also on how well the seizures are controlled, the dosage can be adjusted. By the way, if the PB blood serum level results come back and are not what you expected and there is no known reason for them to be 'off', ask to have the test re-run. Levels should be taken at least twice a year, if not more often.

Levels...what do the numbers mean?
When the lab sends your veterinarian the results from a PB serum level test, they will also note the range that the lab uses. One suggested range is 20-35 ug/ml (86-150umol/l in countries that use micromoles), another is 15-45 ug/ml and yet another is 15-40 ug/ml. In general the low level of the therapeutic range means that 50% of the dogs at the low level will exhibit some benefit (ie: seizure control) from the PB. Likewise, 50% of the dogs that are at the upper limit will NOT show signs of PB toxicity. As you can see, these lower and upper therapeutic ranges are a little vague. Therefore it is just as important to take into consideration your dog's seizure control and side effects rather than just relying on the numbers.

[rainbow]

I have never had a dog that had to deal with seizures. Maybe this website will be of some help....

http://www.canine-epilepsy-guardian-...nobarbital.htm

[Adriann27]

I totally empathize with your situation. I would get a second opinion as well. My little one suffers from seizures and when the vet first prescribed Diazepam for them, he asked me to only give him 1/4 tablet at night before bed so he (and I) got a full nights rest. However, when Horton still continue to seize during the day, he uped the dosage to twice a day.
I wouldn't want to over medicate my dog either, and we just got the new dosage today so I don't know how that's going to go.

If the seizures where caused by head trauma, isn't possible that the leasion or "trauma" could be healed by now?? I'm no expert but, I've had to do quite a bit of reaserch on seizures in dogs this week.:sad:

Hope this helps a little!!! I say...if it ain't broke, don't fix it!

[mrat128]

Thank you- both web sites were very helpful. I did call a vet in another town-his opinion was not to raise the dose if it was working no matter what the numbers said.

I guess I'll give my vet a call and see if we can reach a meeting of the minds.

[Dr Lee]

Originally Posted by bendyfoot

IMO, you should use the lowest possible EFFECTIVE dose with most medications. If there are no signs of seizures at the lower dose, and negative side-effects at the higher dose, it sounds like it's doing more harm than good. I'm with you on this one.

The normal phenobarbitol level should often be 15-25 with up to 45 still being normal. However what is normal? Why do we want this level?

The level becomes important in a few ways. First we want to make sure it is not too high. Depending on who you talk to 30 to 45 to greater can place the pet at risk. Second reason to take the level is for a baseline value. This way if the pet starts to have seizures again, we can compare the values. Did the level go down? Often the patient's phenobarbitol level will decrease 3-6 months after instituting the medication. The liver adapts to the constant influx of phenobarbitol and is able to upregulate the enzymes that deal with it. And finally it gives us a level with which to evalute the patient that is having problems.

This final reason is where the 'normal' levels come in useful. If the patient is having seizures while on a normal dose of phenobarbitol - what do we do? Do we increase the phenobarbitol? Do we add on another medication? Do we perform more tests? This is were these values are useful.

In this particular case, the pet is responding well to the medication. I typically use phenobarbitol with the saying, "use as much as we need but as little as possible". (with certain limitations, of course). If the patient is seizure free and without side effects, what more could we ask for? The 'sub-normal' level is fine as long as these conditions persist. It is important to note that the level is 'low' in so far as it tells us that if the seizures recur - then we have plenty of room to increase the phenobarbitol without risking the pet.

So - to sum up... I aggree with bendyfoot. I just thought some background information on using phenobarbitol might be useful to someone.

Good luck.

[mummummum]

I think way too many dogs are prescribed with phenobarbital without cause. Particularly given the potential liver damage.

Seizures, specially one-time seizures, are caused by a whole range of reasons and do not always require anti-convulsants at the level they are prescribed.

If it were my dog, I would feel more comfortable dealing with a neurologist.

[Dr Lee]

Originally Posted by mummummum

I think way too many dogs are prescribed with phenobarbital without cause. Particularly given the potential liver damage.

Seizures, specially one-time seizures, are caused by a whole range of reasons and do not always require anti-convulsants at the level they are prescribed.

If it were my dog, I would feel more comfortable dealing with a neurologist.

Always good thoughts mummummum. When do we need anticonvulsant therapy? In general, if one of the following conditions are met: 1) having seizure more frequently than one every 3 months, 2) if the pet has cluster seizures (having multiple small seizures one after another. This is separately defined than the first condition because cluster seizures are often grouped as 'one incident' ), or 3) if the duration of the active seizure (the grand mal clinical signs of unconsciouness and convulsions) is greater than 10-15 minutes. If one or more of these conditions is met, then the pet should likely be on anticonvulsant therapy.

While phenobarbitol is typically the drug of choice, approximately 11 % of dogs on phenobarbitol will have some liver problems with the medication. Potassium Bromide has begun to be used again as a single agent to treat seizures. It has a higher level of safety. In severe cases it might not be the best sole therapy medication. I do like this medication though. Neurologists will have even more options.

Good point though.

[mrat128]

Dr. Lee thank you for weighing in. Everyone has been so great. I'm glad to have found you all.

[Dr Lee]

we are glad to have you here. Welcome.

[Karin]

Thank you Dr. Lee, I try to keep up with animal sciences and you have enlighten me once again. As with many other topics addressed.