Client Communication Surrounding Seizure Management
Client communication is critical during the initial seizure consultation. Many clients arrive in my exam rooms with one or more of the following expectations:
Their pet will not have any more seizures (this is a common one)
Medications should not have side effects (yes, this is often requested)
Inexpensive medication
Easy to administer, once to maybe twice daily medication (this is key for cat owners)
These goals do not align with our expectations, do they? Here are my goals:
Seizures will likely continue, if they've had 2 or more already.
Realistically, everybody gets 1 free seizure in their life. If you've had 2, or more, we probably should see your dog or cat and have a chat. If we place the pet on anticonvulsant drugs (ACD), our goal is to have 1 seizure or less every 3 months. That is a reasonable goal. The other option is to have a 50% reduction in seizure activity. This means that we need to know the interval of the seizures before treatment, and then calculate what a 50% reduction looks like for that individual. I am a goal oriented person and most clients also respond favorable to setting appropriate goals. This allow us to feel a sense of success when we achieve them, and a reason to continue to modify treatment if we don't.
Side effects WILL happen.
Any ACD has side effects, our goal is to have tolerable side effects for that family and pet. Tolerable may mean that they are okay with PU/PD, or it may mean that a level of sedation is acceptable. Each family is unique so this approach is tailored directly to the family I am working with. I am diligent outlining known side effects of the drugs at the time they are prescribed. Be sure to tell the client that many side effects improve or resolve by the time the pet reaches steady-state. This means we can set goals for resolution of signs, too. If the time to steady-state is 14 days (phenobarbital) then give clients that information so that when they see side effects (they will) they know to hang in there for 14 days and it is likely to get better. If it isn't, we can adjust after evaluating the serum drug concentration at steady-state (when applicable for the drug prescribed).
Cost
The cost of ACD varies over time. Phenobarbital when through a period where it was difficult to obtain and was, therefore, very expensive compared to previous and subsequent years. The fluctuation in cost is really due to production, availability and (as with all things right now), shipping costs. It can be helpful to outline the cost of the drug up front, but ensure that the client knows this can change over time depending on the aforementioned causes.
Administration is key!
If an owner cannot administer the medication, it doesn't matter how effective it SHOULD be because the pet isn't taking it. This concept is especially near and dear to cat owner's. In human medicine, when a prescription was recommended 1x daily, the compliance was over 80% (the drug was given as prescribed over 80% of the time). However, when the prescription was recommended at a 3-4x daily dosing, the compliance dropped as low as 10-15% in some studies. This becomes especially true in the pediatric world, in which an individual is having something given TO them. I think it is reasonable to translate this to our veterinary world and realize that three times a day levetiracetam, even if the perfect drug for other reasons, may not be a good option for some clients simply because compliance will be low. It has been well established in neurology that the variation between peak and trough can be just as important as one serum concentration at one time point. If there is a wide swing between peak and trough, there may be a greater chance of breakthrough seizures or poor control. Missed doses can result in wide swings of the peak and trough serum concentrations and therefore should be avoided.
So there you have it! I hope this pep talk has been helpful for you as you help clients navigate the (at times) choppy water of seizure management. If you need help with a seizure case, or feel the client would benefit from a second opinion, please reach out. Seizure management is one of my favorite aspects of neurology!
Have a great week and keep those consults coming!