Feline Neurology

What are your baseline tests for cat presenting with neuro signs - i.e. infectious disease screening?

-        It of course depends on if brain, spine, or other but basic considerations include:

  • For All:

    • CBC/Chemistry

    • UA

  • Others

    • Ensure diet is appropriate (thiamine)

    • +/- bile acids if indicated

    • Toxo, fungal (cyrpto, especially if nec pain is present) +/- tick

    • Thyroid panel/ other endocrine screening

    • Chest Rads/Ultrasound

  • Baseline testing will vary based on how the patient presents but every cat should start with blood and urine monitoring -> go looking for common things first. Past that I would consider all other diagnostics mid-tier and select based on the presentation and localization.  

 

What are your indications for starting treatment in cases of Paroxysmal dyskinesia? First signs or monitor for severity or frequency?

-       There is no true treatment consensus recommendation yet; however, the vast majority of neurologists use the same indications as they do for seizures.

 

Are you using steroids for treatment of hippocampal necrosis?

-       Yes, standard anti-inflammatory dose (~1mg/kg/day – though in cats some debate exists on if we should be higher) to start while screening for infectious etiologies, then move to an immunosuppressive dose, slow weaning over the course of months given the autoimmune-based condition.

 

What kind of systemic conditions are you looking to rule out when working up feline hyperesthesia?

-       Metabolic disorders, electrolyte derangements, other inflammatory conditions, flea-allergy dermatitis, other allergic conditions. Anything that takes the cat out of normal homeostatic balance/increases systemic stress.

 

What Pregabalin dosing range are you using?

-       Depending on the condition, it can vary. 1-2 mg/kg PO q12 is a good starting place and titrate as needed; however, data to support this dose is very limited. You will see higher published doses for different uses, but I start small and work up.

 

Had Prednisolone been used for hyperesthetic cases?

-       It has been reported, but the response is likely more associated with the underlying reason. Animals with allergic or immune-based conditions are more likely to respond more. It is not considered a specific treatment.

 

Regarding Hippocampal Necrosis, has a catalyst been identified?? i.e. Is type of diet a factor causing autoimmune inflammation similar to human condition??

-       This is a great question, and we do not yet know. We are still pretty early in understanding the condition in cats, and the underlying pathophysiology is not fully fleshed out. It is theorized that it is an underlying immune-mediated process, thought to be against the voltage-gated potassium channel (specifically the leucine-rich glioma inactivating factor 1, which is a big part of that channel). A few papers have thrown out possible triggers, but none have made a definitive connection.

  

What are your treatment approaches or thoughts about kittens with neurologic symptoms/seizures?

-       Step 1: Make a great differential list

-       Step 2: When applicable, perform supplemental diagnostics that may help support or refute this list.

-       Step 3: Treat the treatable, specifically for seizures:

  • Select an anti-seizure medication. There are pros and cons for each!

    • Levetiracetam: High safety margin, high frequency of administration

    • Phenobarbital: Considered most effective, requires monitoring

    • Zonisamide: Can be used once a day, sulfa drug/required monitoring

 

Canine and Feline Cognitive Dysfunction

Are there any wet food options for CCD? Often these patients have horrific dental disease and can’t chew the kibbles.

-       Not a great one! We have mentioned this multiple times regarding the various conditions. It is surprising because a moist environment might make many of the good supplements more stable, but of course, high fat doesn’t always look appetizing in canned form. I do think this is where supplements can come into play on soft food.

 

Would softening the kibble with warm/hot water dilute the nutrients too much?

-       Possible, and certainly the hotter, the more likely it could break down some of the more volatile components. I can’t comment on this fully and feel that I am being 100% accurate. This would be an amazing and quick summer student study!

 

Down Dog Considerations          

Do you prefer Pred or NSAID for IVDD flare-up/medical management??

-       I’m a steroid fella. I especially prefer them for the fully down dog with no imaging option as it can help treat other conditions. I prefer NSAIDs when there is significant muscle trauma involved. If dealing with a mild flare-up, I may use a short course, and if really mild, I may not use either (focusing on multimodal pain).

-       If going to a referral or want to have a referral option, neither may be best. Remember that they can hide or make the diagnosis of some conditions more difficult (lymphoma, other cancers, inflammatory disease). I always mention this when using these medications for these conditions.

-       If you have a patient who is flaring up every time you get off steroids, you may have a case of myelitis.

Favorite or preferred company for DM testing?

-       The University of Missouri and OFA have both been good to me. That said, it is a pretty straightforward screening, so if it is a reputable lab then you can likely trust it.

 

Decision Making in Seizures

In geriatric onset seizure patients which anticonvulsant do you reach for first?

-       I often shoot for levetiracetam as it seems to be the least sedating. Though I don’t shy away from any of them for age alone.

 

If an owner calls to say their pet had a seizure yesterday, but is fine now. Should they come in right away for evaluation Or wait to see if they have another?

-       I think there is always a benefit to being seen, so we don’t miss anything mild or strange. For example, the Frenchie or Yorkie that has absent menace response, vision issues, and mild proprioceptive deficits may allow us to start the MUO talk sooner. I do struggle with can owners effectively tell if it was a seizure or something else whenever we can struggle from time to time. So if having them wait to come in later, I think the team still has to do due diligence to have enough support that it truly was a seizure, and if you are going to take that much time to talk with them about it, might as well have them come in for an evaluation.

 

Can you use keppra just BID as I find clients schedules don’t allow for TID dosing

-       Officially, the answer is no. The pharmacokinetics don’t support it. Unofficially, I have had a few clients who have gone to BID with adequate seizure control (more commonly these are cats). This is, however, anecdotal.

How much do you see vomiting or GI upset with KBr and how do you manage it when it happens?

-       Not too frequently, but it does happen. I will split the dose so it is half in the am and half in the pm and make sure it is given with food. Once, we had a client give it in the AM, when they got home from work, and then before bed to split it out. If dogs are sensitive to GI issues, then I would consider another medication.

 

Which drug should you not use in dogs/cats with pancreatitis

-       Potassium bromide and Zonisamide. Potassium bromide, especially, is bad (and should never be used in cats). Zonisamide makes animals inappetent

 

Since KBr is a salt, do you try and avoid this in heart disease patients?

-       I certainly would avoid NaBr (one of the versions we can get). The potassium bromide is a little less clear, however, if in a state where they may need furosemide, then KBr won’t be great because anything that increases GFR in the kidney will affect the serum level of bromide.

 

Topamax is nicknamed Dopamax in people. Is it similar in pets?

-       It certainly can cause lethargy, though I would argue that many can. In terms of the degree of “brain fog”, that is harder to answer in animals.

 

What is your take on the neurological diets out on the market aka purinas bright minds etc?

-       They are better for general brain health. Many do have higher percentages of what we know to be nutritionally beneficial for the brain. Do I think it is a cure-all – no, do I not. Do I think they can be used as part of a multimodal approach? Absolutely! Regarding NeuroCare for seizures, it is more that most of my clients can’t afford it.

 

What would be your ideal level of phenobarbital in a patient without liver disease?

-       If they have good seizure control, then as long as they are <35, I’m happy as I treat the patient, not the number.

-       If just starting to get control or modulating, I shoot for 20 to 30

 

Colorado Paper on CBD: Here

 

Can you give recommendations for flea/tick control in epileptic dogs? What do you tell owners about flea/tick meds?

-       Currently, I have my clients use topical treatments for fleas and ticks. I have no issues using Heartguard

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Have you ever used rectal keppra for cluster seizures that border on status epilepticus and cannot take oral?

-       I’ve not due to concerns for absorption. We talked about doing a study on this, but funding has not yet been identified.

 

For CBD. Do you have any experience with Charlottes web? Any studies on entourage effect?

-       I’m not familiar with that product

-       The entourage effect has been discussed, but not explored (that I know of), as we have not answered basic questions in veterinary medicine. We do believe in synergistic effects of antiseizure medications for sure, but in terms of CBD I don’t think we are there yet.  While animal studies have been reported, they were around analgesia, not epilepsy.