There are recommendations, after all......

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Auburn University
College of Veterinary Medicine
Clinical Pharmacology Laboratory

Updated results for Accession 2010-46053

Accession Informtion
Accession Number:   2010-46053
Internal ID Number:

Veterinarian:       Dr. Donald G

Date Received:      8/26/2010
Date Updated:       8/31/2010 3:21:22 PM
Animal Name:        Milkshake
Owner Name:        Species:            Feline

Results
Test: Feline Phenobarbital,  (mcg/ml)
Result: 26.1
Normals: 15 - 45
Last Updated: 8/27/2010

Recomendations
The concentration of phenobarbital is in the mid therapeutic range (15 to 40-45 mcg/ml) most commonly associated with seizure control in dogs or cats.

The current concentration is about 25% less  compared to the last recheck.

If all is well, maintain the current dose and current drug concentrations.  Re-check at 6 to 12  month intervals, or in the event of therapeutic failure.

Thank you for your continued support of our laboratory. It is much appreciated.  August 30, 2010 DMB

 
Test: Feline Keppra,  (mcg/ml)
Result: 32.5
Normals: 5.5 - 21
Last Updated: 8/26/2010

Recomendations
The mid interval concentration of levetiracetam is in high to above the high therapeutic range most commonly associated with seizure control in humans (5.5 to 21 mcg/ml). The relevance of these concentrations to canine or feline epileptics has yet to be  confirmed.

The half-life of levetiracetam is short (1 to 8 hr) and may drop  > 75% during an 8 or 12 hr dosing interval. Consider collecting both a peak and trough such that a half-life can be used to predict the lowest concentrations that occur during an interval.

Accordingly, althouth the current concentration is approxiamtley 40% lower compared to the last recheck, these comparisons can not be made unless the previous sample also was collected at 4 hrs.  If only one sample can be collected, then consider collecting a true trough (just before the next dose) such that the lowest concentration to
which the patient is exposed during a dosing interval can be verified.


If all is well, maintain the current dose and current drug concentrations.   Re-check at 6 to 12  month intervals, or in the event of therapeutic failure.

Thank you for your continued support of our laboratory. It is much appreciated.  August 30, 2010 DMB

Additional Recomendations: Multi-Test Discount
UPS 1z5vx3572310064219
 
Comments:                  4hrs post.  Seizure free since 10/1/08.

Levetiracetam dosage (125mg) reduced to BID (from TID) on July 1, 2010. Current dosage 125mg (approx) at 10AM and 10PM. Phenobarbital given at the same time, approx. 8mg BID. Continuing weight loss despite very healthy appetite. Appears to have some balance/strength issues. No other drugs.  Controlled.

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I'm quite happy with the phenobarb levels.   Dr. G, has felt for some time that I should be aiming for reduction of the amount of phenobarbital, rather than trying to lower the Keppra/levetiracetam dosage, but I'm really hesitant to even consider that, because it's my admittedly unscientific feeling that the phenobarb is what's working at this point.  I don't actually understand the recommendation about the Keppra and trough levels, even though I've reread it six times.  What difference would it make to know the lowest amount of levetiracetam available over the 12 hour period?  I must be missing something here.  Maybe they mean that knowing the lowest amount available/functional would indicate if further reduction might be possible?  I have no idea.

At any rate, I am (with fingers crossed!) feeling pleased that  #1 - most of all! - there have not been any seizures for 700 days!, and #2 - the dosages have been significantly reduced and still appear to be working effectively.  I don't know, at this point, what more I could ask.  Well, except for maybe Milk could gain a couple of pounds, and Busy could stop chewing on his neck,  and he could be just a smidge less wobbly......

Finally!

At last, I managed to get Milk's blood sent to Auburn.  (I took both Milkshake and Scruffy to the vet for the same appointment and purpose.  Scruffy started spitting and hissing before we even started to drag him out of his carrier, where as my sweet little Milkshake, practically catatonic from the trip in the car, the traffic noises, and strangers trying to handle him, laid down on a towel fragment  - I forgot the kitty pi this trip - and just shivered uncontrollably non-stop.  Like two different species, they were!)

My intention was to have blood drawn also for the vet to use his own machine for analysis - I wanted to see what the liver values looked like, because I've been giving Milk Denosyl on a mostly regular basis for weeks now.  Unfortunately, I forgot to ask, and it's such an ordeal getting blood out of him, even from the vein in his neck whose name I can't recall right now.  Tiny little veins in his wispy body......

Anyway, here are the results from Auburn:

Date Updated:       8/27/2010
Animal Name:        Milkshake
Owner Name:         Guckert
Species:            Feline

Results
Test: Feline Phenobarbital,  (mcg/ml)
Result: 26.1
Normals: 15 - 45
Last Updated: 8/27/2010

Test: Feline Keppra,  (mcg/ml)
Result: 32.5
Normals: 5.5 - 21
Last Updated: 8/26/2010

Phenobarb level is good!  Keppra level, well, considering that the Keppra dosage has been reduced by 1/3 (125mg),  I'm not particularly unhappy with that either.   Given that the Keppra  standards are based on human data, I'm not going to worry about it.


One of the options on the Auburn analysis application is "Do you want suggestions/recommendations?"  I checked that, hoping that maybe there would be some interesting suggestions.  (Aside from something like, "Wow, that's a lot of Keppra!")   What I got was just an email report of the results.  Maybe Dr. G. will get something more detailed because he's a professional?  I hope, I hope.

And next, to see what the bill turns out to be....... 

Finally dropped that 6PM dose of Keppra.....

Not intentionally - I probably never would have screwed up the courage to do it unless forced to by a crisis.  Which was, unfortunately, exactly what happened:  my mother had a heart attack on June 27.  With the ensuing hospitalization and the irregular hours I was spending at home, there was no way to get that 6:00 levetiracetam into Milk.  Actually, for more than six weeks, there has only rarely - almost never, actually -  been a 10:00 PM dose of phenobarb, either.   Without alternatives, I settled for twice a day dosing, whenever those two times might occur.  So, we're now down to somewhere between 9:00 and 10:00 AM for the first two pills, and somewhere between 10:00 and 11:00 PM for the second two.  It seems to be working.  Fingers crossed. Because the keppra generic is a large chunk of pill, I appear to have stopped giving him the liver-protective Denosyl that I do think can be a benefit to him.  Seeing if using it had reduced his ALT/AST levels, which have been elevated since he started on phenobarbital was one of my goals in doing the bloodwork.  Didn't happen........                           

I had arranged to bring Milk to the vet for blood-taking to send to Auburn to check his phenobarb and keppra levels.  The University has some sort of new arrangement that requires that the vet's office have  special address labels or something; at any rate, by the time the stickers had arrived at Dr. G's office, I was into spending all my time at the hospital, and the bloodwork never got done.  Hopefully, within the next week or two, I will be able to get Milk there and get the stuff done. 

He has seemed wobblier in recent months.  I have seen him attempt to jump up on the bathroom sink or the kitchen counter and fall at least once a week. (Did he misjudge the distance?  Was he too weak?)   He seems scrawnier than ever, although I weighed him tonight and he was 8 pounds, 13 ounces - not a wonderful weight for a cat as tall and long as he is, but not as awful as it might have been.  His appetite is very sturdy.   He has also - to my sincere distress - been doing a good bit of aggressive chasing of OneBun and even mimicking Busy's gnawing on his neck.    (Despite the addition of  prozac to Busy's daily routine, Milk turned up with a new dime-sized scab on his neck last week.)

Anyway, as far as I can tell, there is no indication that any seizures have occurred even with the reduced dose of levitiracetam (generic keppra).  He still sleeps every night draped over my ankle, and he tends to be the one who wakes me in the morning, standing on my chest.  It is such a relief and pleasure to realize that we're coming up on two years since his last seizure (on October 1.)