FAKULTET VETERINARSKE MEDICINE UNIVERZITETA U BEOGRADU. Doc dr Nenad Andrić, DVM
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1 FVM FAKULTET VETERINARSKE MEDICINE UNIVERZITETA U BEOGRADU EEG Doc dr Nenad Andrić, DVM
2 2/16 EPILEPSIJA - 0,5% do 5,7% kod pasa - 0,5% do 1% kod mačakaaka % epilepsija su refraktarne Berendt M. Epilepsy.In: Braund KG, ed. Clinical Neurology in Small Animals-Localization, Diagnosis, and Treatment. Ithaca, NY:IVIS;2004. Thomas, W. Seizures and narcolepsy. In: Dewey CW, ed. A Practical Guide to Canine and Feline Neurology.Ames, IA:Wiley- Blackwell;2008:
3 3/16 NEPROGRESIVNO OBOLJENJE MOZGA Epilepsija Sa morfološkim promenama u mozgu Bez morfoloških promena u mozgu Simptomatska epilepsija, sekundarna, stečena napadi jedini ili dominantan simptom Verovatno simptomatska epilepsija napadi jedini simptom Primarna, prava, Idiopatska epilepsija napadi jedini simptom
4 4/16 IZBOR NAČINA TERAPIJA EPILEPSIJE Hirurški pristup Dijetalna ishrana Simptomatska terapija Akupunktura Acupuncture for Epilepsy in dogs, 2007, Narda Robinson, DO, DVM, MS
5 5/16 - Cilj terapije? - Kada započeti terapiju? - Izbor antiepileptika? - Monitoring antiepileptika? - Sporedni efekti? - Edukacija vlasnika? - Sterilizacija, kastracija?
6 6/16 IZBOR ANTIEPILEPTIKA Fenobarbiton Kalijum/Natrijum bromid BENZODIAZEPINI Diazepam Bensedin, Bromazepam Klonazepam - Rivotril Karbamazepin Karbapin,Tegretol Valproinska kiselina Eftil Gabapentin - Neurontin Levetiracetam (Keppra) Zonisamide (Zonergan) Imepitoin (Pexion)
7 7/16 Fenobarbiton # % pozitivan odgovor, podnošljivost, interval aplikacije, cena - Psi: 2-3 mg/kg x 2, početna doza - Mačke: 2-3 mg/kg/24h ili na 12h, početna doza - Prolazni sporedni efekti? - Provera koncentracije leka nakon 2 nedelje - Terapeutska koncentracija u krvi : Psi: 15 to 35μg/ml (65 150μmol/L) Mačke: μg/ml ( μmol/l)
8 8/16 Metabolite Drug Potencijalni trajni sporedni efekti? Metabolism Excretion KREIRANJE NOVE PER OS DOZE LEKA - Povećanje per os doze za 25 do 50% - Postizanje željene koncentracije leka Nova per os doza ( ) x trenutna per os doza Planirana konc. leka Izmerena konc. leka
9 9/16 KALIJUM BROMID (KBr) Indikacije Psi: 20-40mg/kg/dan, početna doza (poli terapija) mg/kg/dan monoterapija Stabilna koncentracija nakon 4 meseca mg/kg/24h/ 5 dana Smanjenje doze fenobarbitona? Kada? Mačke: izbegava se upotreba kod mačaka 50% - eozinofilni bronhoalveolitis
10 Bromid Dijetalna ishrana? Ekskrecija Sporedni efekti? Kako nastaviti terapiju kod pojave sporednih efekata?
11 10/16 Psi: hronična per os terapija - NE (W.B.Thomas, 2010; M.Podell,2013; Riviere J and Papich M, 2009) Mačke: Diazepam per os doza: mg/kg/8-12h PO Hepatotoksičnost??? Riviere J and Papich M, Veterinary Pharmacology & Therapeutic, 2009, M. Podell, Antiepileptic drug therapy and monitoring. Topics in Compan An Med 28 (2013), W. B. Thomas, Idiopathic Epilepsy in Dogs and Cats, Vet Clin Small Anim 40 (2010)
12 11/16 Valproinska kiselina - Eftil Psi: per os doza: Politerapija mg/kg /8h (Linda Shell, 2012) Fenobarbiton + eftil Monoterapija nije efikasna (Nafe LA and Parker A, Kay, 1981). Mačke: Nema podataka Sporedni efekti: alopecija i hepatotoksičnost Nedostaju klinički podaci o njenoj daljoj upotrebi kod pasa!!! Nafe LA, Parker A, Kay WJ. Sodium valproate: a preliminary clinical trial in epileptic dogs. J Am Anim Hosp Assoc 1981;17: Linda Shell, Maintenance Anticonvulsant Therapy, The Veterinary Merk Manual, 2012.
13 12/16 Gabapentin (Neurontin) - Sintetski analog GABA - Metaboliše se i izlučuje preko bubrega delimično se metaboliše u jetri - Doza kod pasa: 10 to 30mg/kg /6-8h, max doza 60mg/kg/8h - Doza kod mačaka: aka: 10 to 30mg/kg /8h 12h - Monoterapija - Politerapija (Govendir M 2005; Platt 2006) - Uvođenje u terapiju: jedna doza/tokom 3 dana, 2 doze/tokom 3 dana - 100, 300,400 mg/50 kapsula/cena oko RSD prevelika cena kod velikih pasa, interval aplikacije Govendir M et all., Improving seizure control in dogs with refractory epilepsy using gabapentin as an adjunctive agent. Aust Vet J Oct;83(10): Platt SR et all, Treatment with gabapentin of 11 dogs with refractory idiopathic epilepsy, Vet Rec 2006, Dec 23-30; 159(26):881-4.
14 13/16 Levetiracetam (Keppra) Refraktarne epilepsije, netolerancija na sporedne efekte Ph/ KBr Početna per os doza 20mg/kg/12h/tokom 7 dana a onda 20mg/kg/8h Može se povećavati po 20mg/kg svake 2 nedelje Max per os doza ~ 400 mg/kg/24h Metaboliše se i izlučuje preko bubrega (minimalno preko jetre) Nije neophodno pratiti koncentraciju leka u krvi cena / RSD, pak. 60 tableta "Honeymoon effect"
15 14/16 Zonisamid (Zonergan) Sulfonamid, monoterapija ili kombinaciji sa fenobarbitonom Multipli mehanizam delovanja Metaboliše se breko jetre i bubrega Psi: per os oza 5-10 mg/kg/12h Mačke: Nema validnih podataka Efekat se prati preko koncentracije u krvi (10-40µg/ml) CENA 25$ Pas 25kg/mesečno/180 $
16 15/16 Imepitoin (Pexion) Veterinarski lek za idiopatsku epilepsiju pasa Kao mono ili poli terapija 10-30mg/kg/12h Nema praćenja koncentracije leka u krvi!!! Ne kod postojanja oboljenje jetre i kardiovaskularnog sistema Preparat nije ispitivan kod pasa lakših od 5 kg Cena 40 eura (100mg) i 85 eura (400mg)/pack 100 tableta - Tipold, A., Keefe, T. J., Lȍscher, W., Rundfeldt, C., de Vries, F. Clinical efficacy and safety of imepitoin in comparison with phenobarbital for the control of idiopathic epilepsy in dogs. J. vet. Pharmacol. Therapy, 2014, Rundfeldt, C., Gasparic, A., Wlaz, P. Imepitoin as novel treatment option for canine idiopathic epilepsy: pharmacokinetics, distribution, and metabolism in dogs, J. vet. Pharmacol. Therap.37,
17 RAZLOZI ZA NEADEKVATAN ODGOVOR NA TERAPIJU??? Neadekvatna doza /koncentracija leka Neadekvatan izbor antiepileptika Tolerancija na lek Neadekvatna primena terapije od strane vlasnika Pogrešna dijagnoza
18 Hvala na pažnji
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