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  Discussion on Further seizure while on anti-convulsant therapy
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Posted on Monday, May 15, 2000 - 6:48 am:

Dear Dr O,

I'm sorry to have to report that after almost exactly one year of twice daily phenobarbitone poor Cara had a terrible seizure on Saturday morning, at breakfast time as usual. I noticed that she was vigorously pawing her bedding and when she didn't stop I went into the stable to check her out. She turned her face a bit to look at me and her top lip was tremoring like mad so I got out quick. She reared up and fell over backwards against the door giving the front of her face a terrible whack against the wall. A friend called the emergency vet and he gave her 3 syringes of valium which eventually halted the progression of the tremors. She is ok now, but not surprisingly a bit grumpy and bored and her poor face is a bit of a mess.
The vet is coming this afternoon to do a blood test to check the level of phenobarb after 5 hours since ingestion. Do you think she can be put up a level - have I been lucky to keep her on the minimum for a whole year? With the benefit of hindsight I can see that the couple of very brief pawing episodes with no other symptoms must have been mini-fits. She has been doing so well, her general health is 100% and I cannot believe that she could have had such a violent seizure. I would have expected the one that got through the protective wall to be much less prolonged. I had been warned that she would gradually need more and more and had been meaning to ask the vet to do a routine test. I feel really bad that she has suffered like this and the mental stress for me is something I could do without right now.

As usual any thoughts on this would be more than welcome.

Thanks,
Helen and Cara

Posted on Monday, May 15, 2000 - 12:52 pm:

Helen,

I am so sorry to hear this has happened. It really is too awful for both of you. I wish there was something I could do to help - but stuck the other side of the world from you, I can't even visit. My thoughts will be very much with you and Cara and I shall be looking to hear what the vet says and how she is doing.

All the very best,
Alexa

Posted on Monday, May 15, 2000 - 3:42 pm:

If it is like human epilepsy it seems to be very difficult to balance the levels for a 'normal' life against the seizure frequency. Can the vet give you something to give her if she shows early signs of fitting? or perhaps try another drug. She probably does not percieve it as a human would so try not to worry and good luck. Claire :-}

Posted on Monday, May 15, 2000 - 7:05 pm:

Hello Helen,
I think checking the levels is just the thing to do. If there is no current discernible sedation from the drug, going up should not be a problem.
DrO

Posted on Tuesday, May 16, 2000 - 7:49 am:

Thanks everyone for your support and kind words. Cara is perky and back to 'normal' for the time being and I rode her out yesterday with no problem. Her face is already healing and looking better. Just to be on the safe side I am feeding her at breakfast time in the indoor arena. I hope to have the results of her blood tests by the end of this week. Dr O, she shows no sign of sedation at all (she was her old self just a few weeks after starting her treatment last year) although she falls asleep very quickly after exercise. Mind you at 18 perhaps that isn't too unusual? She has been able to lead a totally normal life thanks to her tablets.
Claire and Alexa, if you take a hike to www.grove-end-farm.freeserve.co.uk click on photoshows and then on results 28/4/00 and scroll a longish way down eventually you will come across my favourite picture of her. She is the plaited-up chestnut, sideways on and looking at the camera.
Sadly I really think she knows that something is happening to her when she has a seizure. At first she is paralysed by it and falls down but once this muscle spasm is past she gets up and blunders about, usually towards the door. She is hypersensitive to any stimulus, touch or sound and is certainly not unconscious during all the ticcing and jerking. If she slips she panics and the tremors get worse again. I used to be able to stand with her at this stage and talk very quietly to her but now its too dangerous so she has to cope on her own. I'm sure she knows that I am there. Afterwards she touches me constantly with her nose for comfort. I really wish that like a dog or person she would fall down and stay there, it would be so much safer for her. I don't think there is anything I can give her to stop it once I see the warning signs. Her vet injected her into the jugular with valium and it still took many minutes to completely stop her despite the fact that her lip was sagging and she was very drunk. I wish with all my heart that I could do more to help her at these times of crisis.

I'll let you know how we go on of course.

Helen and Cara

Posted on Thursday, May 18, 2000 - 8:48 am:

Its good news. The blood test came back this morning and Cara was right at the bottom of the range (5.5 per 15 after 5 hours and 5.4 after 9 hours Dr O)so from tonight she goes from 30 tablets per day to 44 ! This is to allow a little extra just in case and I will have her tested again in 6 months time. The only drawback (apart from being permanently sleepy for a week or two) is that this will now cost me over £100 per month. Apparently the UK drugs market is being deliberately starved by the manufacturers to artificially force the cost and thus the profits. These people disgust me.

Posted on Thursday, May 18, 2000 - 3:02 pm:

I'm very pleased to hear the good news and hope the increased dose prevents another seizure - I agree with you that she must know that something is happening and that it must be deeply upsetting for her. But the increased cost to you is not such good news. Is there no way you can get the drug manufacturer to subsidise the cost? I know you were working on this possibility.

Posted on Thursday, May 18, 2000 - 4:08 pm:

Glad her levels were so low and you can up the dose - hope this will do it - bad about the ££ though - what drug is it she has?

Posted on Friday, May 19, 2000 - 11:50 am:

Hello again. Yes Alexa, I did contact the drug company and explain my situation and they let me have a 30% discount, so at her previous dosage I was paying about £75 every month - don't forget that 12 months ago the same amount cost just £18 - I think someone is ringing my bell so now I'm off to the national press.

Claire, she has good old fashioned phenobarbitone, trade name Epiphen. There is also a problem in that Brussels likes inflicting ridiculous rules on animals - remember the bute problem? Apparently a vet cannot prescribe a human generic drug (ie. the cheapest) if there is an equivalent licenced for animal use, even if it isn't licenced for that particular species. So the manufacturers sell the generic product to a drug company who simply repackage it and up goes the price yet again. They were really surprised to hear that Cara was being treated with a product meant for dogs. Don't we just love red tape and beaurocracy???
ps. Where in the UK are you?

Posted on Thursday, May 25, 2000 - 10:34 am:

Hi Helen,

I spoke to one of my vets about Cara’s problems and your problems with the cost of phenobarbitone. We looked at the prices here, and a 30 mg tablet of a generic brand called Sedobarb is R0.35.

The current rate of exchange is +/- GBP1 = R10.70. So 100 tablets would cost in pound terms approximately GBP3.27, 44 tablets times 30 days = 1320 tablets would cost, say, R462.00 or GBP43.18. That is one big difference !

Should we talk more about this privately? My vet says to confirm the strength of the tablet you are giving Cara.

Incidentally, I looked at the photo of her - a MOST attractive couple!!

Alexa

Posted on Thursday, May 25, 2000 - 11:26 am:

Hi there Alexa, what a kind person you are doing all that work for us - thanks!!
Cara has 60mg tablets, not 30mg, otherwise she would be on 88 per day which would take me forever to count out. Luckily they are only small and she gobbles them up in her feeds without any problems.
You are right, that is a big price difference but some might be accounted for in taxes. At the old rate of 30 per day plus my discount from the drug company 1000 tablets cost around £60 but when VAT was added on at 17.5% what I was paying was around £75. She cannot have generic phenobarbitone thanks to EC rules and regulations, so I have to pay extra for another drug company to repackage them.
By all means lets have a private chat, although in this country phenobarb is a class 3 controlled drug and if I fetched them in myself I would be prosecuted for illegal importing. I'm not sure if vets can import from abroad or not, but knowing my luck just lately they can't!
Cara says hello. She is doing well and not in the slightest bit sleepy so I've been riding her gently and turning her out with her numerous male admirers. Her face is healing quite nicely and I'm just waiting for the hair to regrow.

Regards,
Helen

ps. You might have looked at the wrong photo - I'm not in it!! She is wearing only her bridle and has a large white star on her forhead. Behind her is a wooden fence and bushes (and if you look closely several piles of DrOppings all produced by her during the course of the day!)

Posted on Thursday, May 25, 2000 - 3:40 pm:

I've now looked at the right photo! I had looked at the one below, and thought it must be you riding! She is certainly a most attractive mare.

Sorry I can't help with cheaper pills but I guess you are right and vets won't be able to import, specially if controlled by the EU. That's not very fair on you, though, when there are much cheaper generics world-wide.

Hope she continues to keep well.

Regards,
Alexa

Posted on Monday, Jun 5, 2000 - 5:47 am:

Hello again Dr O,

Cara had a fit for breakfast again this morning. Luckily she was in the indoor arena as per plan A and I was able to help her to a controlled DrOp. After she has been down just a few seconds she got up and did her usual stuff and then made it safely to the wall for the last stages. At least in the safety of so much extra space I was able to stay with her and comfort her and I'm sure that helped alot. It was all done in less than 5 minutes and apart from a graze to her hind leg (the one I've been treating for lymphangitis all week of course!) she was fine. She had thought about having one a week ago and just did a bit of compulsive pawing before changing her mind luckily. I shall notify my own vet later in the day and try to call his predecessor who got Cara on the phenobarbitone in the first place. I'm so disappointed and worried that we don't seem able to control things now. She hasn't had them only a week apart since I removed carrots from her diet two years ago. Any bright ideas or suggestions to cheer me up?

Posted on Monday, Jun 5, 2000 - 8:38 am:

Hello Helen,
Well it could be the other meds for the lymphangitis are inducing pharmacodynamic changes in the barbituates and once discontinued she will return to good control. Also these type setbacks are to be expected and stick with getting a controlling level of phenobarb. I am sure we have plenty of room for change still.
DrO

Posted on Monday, Jun 5, 2000 - 8:53 am:

Consider me cheered Dr O! I'm very grateful for you prompt reply. I had wondered about her recent medication too as everything gets processed by the liver doesn't it? She has had an oral anti-inflammatory/painkiller ( like bute but stronger apparently)since last Tuesday preceded by two into the jugular, 4 days of antibiotics into the quarter (hey I'm a whizz at that now so every cloud has its silver lining) and now a further 4 days of oral antibiotics. I have just found out that a certain type of wormer is to be avoided (Eqvalan here in the UK) as the drug doesn't mix well with phenobarbitone. I don't give up easily but I am aware that we are on borrowed time together. I really will do anything for my little horse though. Thanks again, I'd be a poorer person without this site and all your help.

Posted on Friday, Jun 23, 2000 - 7:34 am:

Hi there Dr O, guess who had another seizure had breakfast time this morning? There is no doubt that she is running to a 9 or 10 day cycle. The last proper seizure was 10 days after a ground pawing session, which was followed 10 days later by more pawing but nothing else and now another seizure 9 days later. This is just the same timescale as before when the chemical-laden carrots were the source of the problem so I'm suspicious that she is eating something again. Have you ever heard of any animal having seizures in such a pattern? (unless I suppose hormonal cycles were the trigger). The good thing is that the seizure was at least sufficiently dulled by the phenobarbitone to be much less severe (she stayed on her feet this time) and shorter lasting so she is far less upset and frightened by it all. My vet warned me that the drug level can take up to a month to stabilize in her blood and since this was upset recently by the use of anti-inflammatories a couple of weeks ago we may yet control the dratted things but I don't understand why such a big jump up from the original level hasn't had a better effect and sooner. What I really can't fathom too is why there has been no sedative effect at all since she went up from 30 to 44 tablets per day? Could her body be so adapted to their effect? Her seasons have stopped again as they did after she first started on the medication but I think they will be back next time around. She is due to be blood tested again but I may as well wait a couple more weeks to let things settle more.
I could scream, she looks so fit and well and in between seizures everthing is A-OK!
Sorry to be a nuisance but I really value your opinion!!
Thanks, Helen

Posted on Saturday, Jun 24, 2000 - 8:51 am:

A pattern is very common Helen and there is nothing unusual about the difficulties you are having controlling them: this is routine. You go with the flow, learn to rejoice in the good times and be strong in the bad. I think you confuse yourself somewhat looking for relationships that may not exist, I am not saying don't look but be objective.
DrO

Posted on Thursday, Jun 29, 2000 - 10:04 am:

Thanks again Dr O. I'm very interested in your comments about patterns being common - that's something I've never heard of before in any species except where it was hormones causing the seizures. The trouble is, over here in the UK most vets still do not accept that horses can have epilepsy and are not aware that phenobarbitone treatment is even a possibility. At the first sign of trouble such cases are destroyed so few people ask any questions and even fewer people try to answer them. The vet who has been treating Cara for the last few weeks has only been qualified for 6 months, bless him, and he freely admitted to knowing less about it all than I did! That's why I always come running to you to see what pearls of wisdom you have for me - you are my sanity saver (what a guy)!!

Posted on Thursday, Jun 29, 2000 - 5:30 pm:

Thanks for the kudos. I too do not see many horses with seizures with the exception of narcolepsy. Besides my equine hospital, I own a small animal hospital and though my associate runs it I have to ocassionally help out. Seizures of unknown causes (epilepsy) are very common in dogs and they all seem to have patterns that are pretty regular. When the medication begins to fail they become more common when the medicine is reregulated they become less common.
DrO

Posted on Wednesday, Jul 26, 2000 - 9:10 am:

Hello Dr O, hope you had a good trip and caught a whale!

I understand what you have said about patterns of seizures and Cara's consultant at the equine hospital has confirmed what you told me. The thing that makes me suspicious about her is that previously her seizures were quite random, the only ones that ran to this same pattern coincided with the feeding of human-grade carrots and as soon as these were removed the seizures vanished. Now I have my suspicions about a dried grass product that is available over here. It is just pure chopped grass which is flash dried but a nutritionist warned my friend against it as it is dairy-quality grass and so far too rich for horses. Another source has since confirmed that several cases of laminitis in ponies have been linked to it. My theory is that fertilizers etc have been sprayed on it to increase the feed value and this may be the cause of Cara's recent seizures. Prior to the last seizure she missed one at day 10 and then had a much worse one at day 20 - prior to this I had drastically reduced her intake (small though it is anyway) and then increased it again 3 fold at about day 16. Obviously I would be the first person to warn against jumping to such an obvious conclusion after just one trial but in the meantime have cut it out altogether and she has gone safely passed day 10 again. The test is still far from perfect as I increased her evening tablet dose by 6 for 1 night before day 10 and 3 after but I reckoned that just a few extra would lessen the severity of a seizure rather than stop it (my vet says I can give up to 10 extra if I suspect she is brewing a seizure). Now I must just wait and see - that's the bit I hate the most!

Posted on Thursday, Aug 3, 2000 - 8:00 am:

Back again I'm afraid Dr O to pick further at your brains :) I seem to be able to get Cara through the 10 day barrier OK but have failed miserably at 20 days. As before I gave her 6 extra tablets on the pm of day 19 and she got through the breakfast time of day 20 no problem. I thought I'd play safe and gave her 5 extra that night and the next am she seemed to have a short spell of distractedness when she started eating. I walked her about and it came to nothing so I thought, good - a really mild version, I can breathe again for a few days so put her back on her normal doseage. This morning she had a seizure again which would be day 24, and scuffed her poor eye socket again. It seems to me to be like a build up of static electricity - she has to discharge it or it just keeps on building and looking for a weakness to escape through - does this seem like a logical scenario to you? Obviously she needs a higher background drug level anyway but I'd hoped that the few higher dose days to damp things down would do the trick and it is probably a healthier form of treatment too plus a bit less costly for me!
Have you any thoughts on the above?

Thanks (as usual)
Helen

Posted on Friday, Aug 4, 2000 - 6:41 am:

I think it is important that the daily dosage should remain steady and when changes made, under the advice of your veterinarian, that they be kept that way until expereince or testing dictate a different course. Due to certain pharmocological features, phenobarb is slow to reach its "steady state" blood level after change and as you have seen trying to figure out optimal dosages is hard enough without flucuating dosage (blood) levels.
DrO

Posted on Monday, Aug 7, 2000 - 8:46 am:

Hi Dr O, sorry to take so long to say thank you. I've arranged for Cara to have more blood tests tomorrow so that we can see what the drug level is in her at the moment. Meanwhile I remembered what you said in an earlier post about enjoying the good times and using them to help me get through the bad ones so we went out for a good gallop on Saturday and came home from a show yesterday with a big trophy. I'm not looking forward to tomorrow all that much, not least because I know it isn't very nice for Cara to have needles stuck in her several times during the day but am keeping positive that we can raise her drug intake and stop the seizures again.
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