While many influencers blame flea, tick, heartworm, vaccines, and other medications as the cause of many seizures in dogs, it is important to recognize that there are many more things that can cause seizures in both dogs and cats.

Before even discussing epilepsy, it’s important to understand that there are other conditions that can and are confused with epilepsy, even by many veterinarians. This represents a significant problem, as some treatments may appear to work for epilepsy when, in fact, it’s working on another condition or vice versa. It’s also possible that the condition was self-limiting.

Estimates are that around .6% -.75% of all dogs suffer from epilepsy, with some breeds being more likely. Like humans, many dogs also suffer from drug-resistant epilepsy, with the estimate being around 36% of dogs with epilepsy.

The first treatment goal will always be to get the seizures under control as quickly as possible.

Contrary to what some influencers say, don’t try several things (excluding the diagnostic tests to rule out other potential causes) and wait a couple of months before finally deciding to use ASDs if your dog has been diagnosed with epilepsy after multiple seizures.

While there isn’t yet definitive research in dogs, in humans, the earlier AEDs are started, the better the outcome. As the seizures can worsen, in addition to being more likely to become drug resistant if allowed to continue unchecked.

This often means starting with higher levels of ASDs and then dialing back the dose. The reason is that it is statistically more likely to become drug-resistant the longer it goes unchecked.

The goal of managing epilepsy, besides reducing seizures, should always be to reduce the amount of ASD prescribed, whether it is drug-resistant or not, as they are not without side effects. That means taking a multimodal approach, even for those with epilepsy who respond to drugs.

Drug Resistance: Importance of seeing a specialist

In a Retrospective study, only 73% were truly drug-resistant, while 27% were pseudo-resistant, with 42% having low serum anti-seizure drug medication, 22% were inadequate choice of drug or dosage, misclassification 22%, Misdiagnosis 9%, while 9% were due to poor compliance. All cases of pseudo resistance, except for one, responded to a modification of the initial therapy protocol.

One of the key differences between human medicine and veterinary medicine is that human medicine recognizes the importance of specialists. While in Veterinary medicine, both the clients and the veterinarians themselves often expect too much. Most Veterinarians are general practitioners, and while they can and do treat a wide variety of medical conditions, there is no way that any of them can truly know the ins and outs of every single condition.

Gluten Free: Paroxysmal Dyskinesia

While a diet completely free of Gluten isn’t a requirement for most dogs, some dogs can actually benefit from a gluten-free diet.

Paroxysmal Dyskinesia is one of many movement disorders that can be confused with epilepsy. While Epilepsy often responds to Anti-Seizure Drugs, Paroxysmal Dyskinesia does not typically respond to ASDs.

PD can and is misdiagnosed as Epilepsy due to lower general awareness of the condition. There are ongoing attempts to raise awareness of the condition within the veterinary community, but that will take time.

Unlike Epilepsy, when a dog is experiencing an episode of PD, they do remain conscious and thus able to respond to stimuli, and the episodes are typically longer in duration. 

PD can occur in any dog but has been increasingly described in several breeds such as the Cavalier King Charles Spaniel, Border Terrier, Chinook, Cairn Terrier, Scottish Terrier, Dalmatian, Norwich Terrier, Boxer, Bichon Frise, and Pugs. It has also been reported in Jack Russell Terriers, and Labrador Retrievers to a lesser extent. While there are intermittent reports of many other breeds.

There is currently a genetic test for Kerry Blue Terriers, Chinese Crested Dogs, Cavalier King Charles Spaniels, Soft-Coated Wheaten Terriers, and Shetland Sheepdogs.

Multiple published case reports over the last several years have shown that Border Terriers, in particular, respond well when fed a strict gluten-free diet. However, other dog breeds with PD have also seen an improvement when fed a gluten-free diet.

In addition to Border Terriers, other dog breeds that have been diagnosed with PD have also tested positive for gluten sensitivity 14 of 31 dogs in one study tested positive, representing nine different breeds. 5/14 of the dogs had no further episodes, while 3/14 had a reduction in episode frequency of greater than 50%. 2/ 14 had no reduction, but the episodes were described as less intense. 2/14 dogs did not change to a gluten-free diet. 1/14 experienced a diet change too close to the follow-up, while 1/14 dog showed no improvement.  2/7 of the dogs with questionable serological results did have no more episodes after switching to a gluten-free diet. 1 dog with a negative serological result had no more episodes after switching to a grain free diet.

The misdiagnosis of epilepsy, is most likely at least partially responsible for the belief that gluten is linked to epilepsy in dogs.

 

Treatment Strategies

Keto Diet/MCTs

While the ketogenic diet has been studied in humans and has had positive effects on seizure frequency, a true ketogenic diet hasn’t been extensively studied.  A large part of this is because maintaining a true ketogenic state in dogs has been difficult to achieve. If you see a company make a claim about putting and keeping a dog in ketosis, ask to see the evidence.

Given the above issue, the use of MCTs has been evaluated both as a supplement and as part of a complete and balanced diet. The doses have ranged from 9% to 12% of energy provided. The length of the studies have ranged from 84 days to 6 months.

Supplement 9% of daily calories from MCTs

82.1% were fed Dry Food and or wet and raw food, while 10.1% were fed Raw Food exclusively, and 7.1% were fed Home Cooked Food.

·        7% Seizure Free

·        10% Reduced Frequency Greater than 50%

Complete Diet 10% of calories from MCTs

·        14% Seizure Free

·        33% Reduced Frequency Greater than 50%

Open Label Complete Diet 12%

In an open-label study of Dogs without cluster seizures. Dogs with cluster seizures are more likely to be drug-resistant. A commercially available diet. Purina Pro Plan Neurocare contains 12% of calories from MCTs.

·        9.5% Seizure Free

·        33.3% Reduced Frequency Greater than 50%

o   5 of the dogs 21% did experience a cluster seizure during the trial.

One important thing to note about the above study is that there were palatability issues for some of the dogs, with 23% of the dogs consuming less than 90% of the food. (50%-83%) It’s unclear from the study as to the cause, but dogs do not often find MCTs to be very palatable.

Supplement vs part of Complete Diet

There is also a difference between providing the MCTs as part of a complete and balanced food vs as a supplement is that the supplement study did show a decrease in PB concentration. This did not occur when the MCTs were part of the diet. This might have two effects, i.e., reduce side effects of PB or have an effect on the required dosing to get the same reduction in seizures.

Another thing to note is that it wasn’t successful in all dogs;

Supplementing MCTs for Epilepsy and Canine Cognition

The effects of providing MCTs as a supplement are always going to be limited to an extent, as it’s not enough to just add them. While MCTs are not metabolized the same as long-chain fatty acids ie they do not depend on carnitine transport, and are more easily oxidized (Good Oxidation).  The MCTs need to actually be replacing a portion of the daily calories in order to actually alter the metabolic pathway so that the brain utilizes them instead of other fatty acids. It is not the same as providing fish oil for the effects of EPA and DHA.

Other Ketogenic Diets

There are currently two other dry ketogenic brands, Visionary Pet and Ketona, and one raw food brand that claims to be Ketogenic Bones and Co.

There is one very important distinction between those diets and the above diets. While the other diets might include more fat and fewer carbohydrates. The type of fats used in those diets is different. Ie, they contain very minimal levels of MCTs. This is important as part of the seizure lowering and cognitive effects are a result of the MCTs, which are metabolized differently than other fats in the diet, not just the total amount of fat in the diet. This would also apply to most of the ketogenic diet dog food recipes available online.

In fact the study where 10% of the calories were from MCTs the control diet was isoenergetic, using lard for fat instead of MCTs, which is further evidence that the type of fat matters.

Key takeaways Keto/MCT diet Supplement

Some dogs achieved seizure freedom, some had a greater than 50% reduction, some dogs had less than a 50% reduction in seizures, some had no change, and some did get worse. This is why a multi-modal approach is necessary.

Fecal Microbiota Transplant/Probiotics

There have been promising results in human medicine, but for dogs, it hasn’t yet been truly evaluated. While there have been studies showing a difference in the gut microbiome between healthy dogs and those with epilepsy, there are as of now, no studies that have tested the effect of FMT or probiotics in the management of epilepsy. There are studies that have looked at the changes in the microbiome when fed a diet high in MCTs, which has shown a slight shift towards that of healthy controls.

There are, however, some studies currently in progress or in the planning stages. There is work to be done as to how best to modify the canine microbiome to reduce seizure frequency. I.e., this is what the microbiome should look like to have the greatest reduction in seizures.

Antibiotics

One recent study involved the use of antibiotics in dogs with Drug-resistant epilepsy. This study was undertaken after one dog at the hospital was free of both isolated and cluster seizures while on amoxicillin-clavulanic acid; while the seizures resumed post-treatment, they were at a lower rate. Based on the results, another four dogs were recruited. The researchers described the dogs as having a severe epilepsy phenotype, and the owners were considering euthanasia.

	Pre-Antibiotics (2 Months)		During Antibiotics		Post Antibiotics (2 Months)
	IS/Week	CS/Week	IS/Week	CS/Week	IS/Week	CS/Week	Antibiotic
Dog 1	2.5	.9	0	0	.9	.4	28 Days
Dog 2	6.5	1.5	0	0	1.6	.4	21 Days
Dog 3	2.6	.4	4.9	1	2.8	.6	64 Days
Dog 4	2.5	.6	.5	.1	1	.4	21 Days
Dog 5	2.6	1	0	0	1.4	.3	28 Days

 

Dog 1, while dogs 2, 4, and 5 were fed a commercial diet Purina NeuroCare the food used in the above study.  Dog 3 started and ended with Purina NeuroCare but was raw-fed and partially raw-fed during portions of the study, which could have had an effect.

Purina NC NeuroCare is the same food used in the above study.

While the sample size was small (5 dogs), the fact that antibiotics were able to drastically reduce seizure frequency in four out of the five dogs, where a combination of ASDs and diet had largely failed to reduce the seizures, is interesting.  However, long-term or even long-term intermittent use of antibiotics isn’t ideal; but it could be a useful tool as it’s unclear how long it would take for the seizures to return to the pre-antibiotic levels. Unfortunately, they did not sample and compare the microbiome pre, during and post-antibiotic use to the healthy controls.

EPA + DHA

Have not been thoroughly investigated in dogs. There is one case report of a Great Dane receiving 2 grams of fish oil daily, but the exact dosing and weight were not reported, but 2 grams of fish oil for a Great Dane is a very small amount.

One trial was conducted, 65 Mgs EPA+DHA/per kg/bw. While there was a reduction, it was not a significant reduction. The trial was only for 24 weeks, so it’s possible, based on studies in mice, that the duration wasn’t long enough. Interestingly, in humans’ low doses of fish oil, 1080mgs EPA +DHA per day was more effective than higher doses of fish oil 2160mgs EPA +DHA per day. Meaning for dogs, there is a need for research as to the optimal dosing level of EPA+DHA.

This makes epilepsy unique as, unlike many other conditions adding in more EPA + DHA isn’t going to cause an issue, assuming its below the safe upper limit; with epilepsy, it appears that above a certain level, it begins to have a negative effect. This is contrary to what is recommended by some holistic veterinarians.

The diet used in the open-label study above did contain .4% EPA and DHA, while the first study made no mention as to the EPA and DHA content of the diet.

CBD/Hemp Oil

While there are plenty of internet reports, the studies that have been conducted to date are largely mixed. Some have shown improvement over the placebo, while others have shown little to no improvement.

One study at 2.5 mgs/kg twice daily did show a 33% reduction of seizure frequency in the placebo group, while 22% of the dogs did have a greater than 50% reduction in seizure frequency. This was, however, identical to the placebo group. There are a couple of issues with this study; however, one, there were a large number of dropouts, and two, it counted multiple seizures in a 24-hour period as one seizure instead of multiple seizures.

In a second study at 2 mgs/kg twice daily, 42% of the dogs had a greater than 50% reduction in seizure frequency. This study did not have the same issue with dropouts.

One positive aspect is that there are no negative drug interactions between CBD and phenobarbital.  There is a significant need for more research into proper dosing as well as larger and longer studies.

Dietary Changes

It is important to actually stay consistent and keep track of dietary changes as there are interactions between the composition of the diet and ASDs, namely Chloride, Protein, Fat, and piperine (found in many supplements containing turmeric curcumin). This can result in having to modify the doses for any ASDs currently prescribed.

Conclusion

There have been developments, but there is still a lot of work to be done toward finding more ways to help manage epilepsy, particularly in regard to the gut microbiome and CBD. While six months is a good length, there could be improvements in the sample size. The fact that there were a large number of dropouts in one of the CBD studies   Ultimately the key takeaway is that if your dog has epilepsy, it can be a great benefit to consult with a board-certified neurologist for two primary reasons.

1.      There are other conditions that are very easily confused with epilepsy, so when you do see a board-certified neurologist, they are more likely to get the correct diagnosis as they will have more experience with the other conditions.

2.      It would be impossible for any veterinarian to stay up to date on the research into every health condition. Meaning a board-certified neurologist is going to have more tools in their treatment toolbox. This is important as no one treatment is going to be effective in all dogs. They will have significantly greater experience in managing the condition as well as getting the correct dosing for the various ASDs.

3.      For all of the treatment strategies, some dogs improved, some dogs stayed the same, some got worse, and some suffered from side effects such as ataxia.

4.      Two important caveats to keep in mind is that the placebo effect is very real in canine epilepsy, and two none of these approaches is ultimately a replacement to Anti-Seizure drugs, contrary to the claims of advocates of CBD and the Ketogenic diet. They are all adjunct treatments.  

As of now, the only food available commercially with high enough levels of MCTs is Purina NC Neurocare which has demonstrated an effect on seizures. That doesn’t mean that in the future, there won’t be other commercially available options, but it will take time for any company to find the right balance due to the palatability issues of including high levels of MCTs.

The Ketogenic diet is becoming more and more popular. It’s important to understand that most of the ketogenic diet dog food recipes online are nutrient deficient, and this will eventually cause other issues. One thing that is extremely important to understand is that the ketogenic diet is not without issues. In both humans and mice, it has been shown to cause nutritional deficiencies, even in those whose diets were carefully monitored to ensure they were receiving adequate levels of essential nutrients. This has not been evaluated in dogs, as the concentration has been on the effect on seizures. The studies to date have also only been at most six months. For more information on the effect of the ketogenic diet on nutritional deficiencies, read our blog post on the Keto diet for dogs.    

While research in canines often lags behind humans and other animals, like cancer, where dogs are significantly greater models of disease than mice, dogs with naturally occurring epilepsy will likely be used in clinical trials evaluating future medications to treat drug-resistant epilepsy in humans, which will hopefully have fewer side effects than the current ASDs. OF note is a clinical trial in the UK testing a drug that targets microRNA, which has had very promising results in other animal models. If effective, this will be the first new epilepsy drug in decades, and it shouldn’t require daily dosing.

This doesn’t just apply to Neurological conditions but other conditions as well. There are Veterinarians board certified in Dermatology, Small Animal Internal Medicine, Cardiology, Oncology, Nutrition, Anesthesia, Reproduction, Nephrology, Ophthalmology, Radiology, Behavior, Dentistry, Surgery (Soft Tissue, Neuro, orthopedic), Rehabilitation, emergency. There are others, such as pathology, microbiology, toxicology, shelter medicine, etc., but you are unlikely to need to consult with them. Nephrology and Urology are becoming their own boarded specialty instead of being included in small animal internal medicine.