Need the inside scoop on how to best administer intranasal midazolam

This is the place for general questions about drugs, long-term treatment concerns, possible influences of other drugs (such as antibiotics, heartworm preventatives, or anesthetics) for epileptic dogs, and other concerns. Please note that we cannot make specific recommendations for individual dogs - for this, please consult your veterinarian.

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Need the inside scoop on how to best administer intranasal midazolam

Post by jeffoire » Sat Mar 30, 2019 9:14 am

Hello folks,

Soon after Li Ban started having seizures, my vet gave me clonazepam in order to try to prevent clusters, but it wasn't long before she was either having other seizures during the 24 hour period or even having seizures within minutes of the first dose before the clonazepam had time to get into her system. So I told my vet I wanted something faster acting.

My vet had me purchase an atomizer in order to administer intranasal midazolam. However, my dog is very sensitive to having medicine given as a liquid either orally via syringe or nasally. She jerks her head pretty strongly, and it seems like more of the medicine ends up all over us than in the intended orifice. I am having to give her daily liquid K-Bro mixed in with a couple of teaspoons of ice cream at the recommendation of my vet (cue the Mary Poppins song...).

I've seen a YouTube video where a guy has trained his dog to sit, point his nose straight up, and calmly accept drops into his nostrils, but it is "too perfect", and I suspect that it took many, many weeks to accomplish and probably many, many takes to film; plus the dog looked like a more tractable breed than an Irish Setter.

For the moment, I've gone back to putting tablets of clonazepam in a hot dog, but ultimately I would like to return to something more fast acting, so I was wondering if anyone knows of a very detailed tutorial that covers every aspect of getting a dog to tolerate an intranasal medicine, or what other options I can explore.

Jeff, Fand & Li Ban

Chris Douglas
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Joined: Tue Aug 27, 2013 8:50 pm

Re: Need the inside scoop on how to best administer intranasal midazolam

Post by Chris Douglas » Tue Apr 02, 2019 2:04 am

Hi jeffoire,

I wouldn't normal post since I've never dealt with intranasal midazolam ... but when you asked about other options you could explore I wondered if you have talked to your vet about rectal diazepam for a "cluster buster" Just a thought for what it's worth ... ¯\_(?)_/¯
Chris & Molly
Brittany 27 lbs female DOB Mar.2008,
Pb 32.4 mg(1/2 grain) BID
regular Keppra 2/250mg BID
Valium tab's 5 mg orally/rectally as needed
Melatonin 5mg SID

1st seizure 8/20/12
last seizure 12/14/13

Rainbow Bridge 12/28/13

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Joined: Sat Feb 11, 2012 9:25 am
Location: South Australia

Re: Need the inside scoop on how to best administer intranasal midazolam

Post by SpencerBhumi » Thu Apr 04, 2019 5:48 am

Hi Jeff,

Sorry you have to be here. I hope you can get some good help and reassurance from this amazing group of people.

This is a lovely photo of you with Fand & Li Ban – a gorgeous pair of dogs.

Your story echoes our story: Spencer first fitted the evening we arrived home from a camping holiday; we trialed Zonisamide with no great success; we trialed regular Keppra as a maintenance drug but could not manage it three times daily; we settled on high doses of Phenobarb and KBrom; we used Valium plus a bolus of Keppra to break clusters (HERE, CBD oil is still just becoming available to people now so I never had the opportunity to consider it for Spencer); we grieved and panicked and shed tears; we spent untold dollars on his treatment. Spencer was a de-sexed male English Springer Spaniel, aged 4 when he first fitted and we struggled on for seven more years until unrelated issues (complicated by epilepsy & medication) ended his life peacefully but a bit earlier than planned.

I think all of us here have two grievances: 1) epilepsy! 2) treatments, and how poorly we have this disease under any form of control ((Oh, and 3) no two stories are really alike)).

After many years of trialing treatments, managing ugly clusters and hoping to control this disease, we settled on an established high dose of Pheno & KBrom plus an aggressive cluster buster of Valium & Keppra. When we got to this point our hospital admissions were reduced to about 6 monthly maintenance visits and the realization that he was going to fit again so we just planned for aggressive cluster busting/status avoiding/cost reducing care. We averaged about 4 weeks between fits and our best run were a few episodes of about 7 weeks. But we travelled, camped, had picnics & beach days and carried on – carefully… with an emergency kit always with us.

Now to answer some of your question… I never thought about it much back then but today I would classify our medications as A) general maintenance, B) urgent management and C) emergency intervention.
A) Pheno & KBrom 8am & 8 PM with breakfast & Dinner – pheno 12 hourly strictly, and with food for the KBrom. This worked for us. If I had the ability I would have done the two drugs on alternate six hours – 6 & 6 and 12 & 12 o’clock to level out the peaks & troughs.
B) A Valium tablet & High dose Keppra (+ Keppra for 3 days) after the first witnessed fit was given. A further valium was given for any further fit during that cluster and occasionally a second pulse of 3 day Keppra was extended. Invariably Spencer roused from most fits with his first sense being to seek food & eat, so this early urgent dosing was easy.
C) I kept a liquid valium dose for rectal use in the event of status or severe clustering and I think I resorted to this only twice in 7 years (I did not have access to Clorazepam here either). When Spencer had a fit I’d gather my emergency box and give oral Valium & Keppra. If he had a second fit (I would give another valium tablet if able) and/or if he was too slow to rouse I would assemble my emergency rectal valium kit - and watch. When he failed to rouse and went into another fit or if he fitted a third time I would give him rectal valium and organize an important vet consult – not so much for seizure control but to look for underlying causes that might be causing such instability (infections, electrolyte issues etc.). No speeding, no running red lights. Mostly a grand mal seizure will last a minute or two and then proceed into the post ictal state.
*Sure, if status epilepticus persists after emergency actions are made it becomes an emergency vet visit.
We had some really ugly clusters but he never had such a status episode. Most of our grief was in Spencer’s diabolical post ictal confusion, discoordination and oblivion related secondary threats to his welfare.

Midazolam or Valium? They are essentially cousin drugs but Midazolam is about 10X more potent, quicker acting and shorter lasting (it does not hang around in the system so long causing the prolonged sedation that valium does).

Route of administration? Intravenous is most effective & rapid – but hospital/doctor based. Absorption of liquid in oral/nasal/rectal mucosa is next best and manageable in the community/home. Ingestion/digestion/absorption of tablets/pessary/gel is slower and subject to being eaten or inserted rectally.

Oral, nasal or rectal? If your dog is awake enough, well behaved/trained, and not so post-ictally-confused that they will sit & happily receive a nasal spray then I would be going for the eating option first - if Li Ban is able to eat soon after a fit, maybe start with oral medication. If safe oral administration is not practical then, if necessary, definitely proceed to the emergency dose.

Nasal or rectal? Most of our medicines are designed for people use. If a person is fitting in public it is more practical and dignifying to use a nasal spray than rectal dosing. (I don’t think a rectal dose with a dog will be any more distressing to the public than the dog just fitting).
As you have the nasal spray then use that in an emergency – but become mindful of overusing/wasting/not having reserve/cost of this nasal spray where you might be able to an alternative urgent intermediate medicine or less expensive emergency medicine. *Anybody else, chip in here with your current management plans*

Have I just overwhelmed you with seven years (& more) of experience?

If you need clarification on any of this or if you want deeper info, let me know. If you need to just talk and grieve, let us all know. If you have any great successes, share the good news with everyone. This forum is a great place with amazingly strong, grievingly needy, and awesomely experienced and caring friends.

I hope you & Li Ban (and everyone on this forum) progress well and that you will become more confident and less stressed in your care. Unfortunately the grief does not go away but our confidence will drive out fear and make us stronger, vigilant, intuitive and amazing carers. I have come to recognize that most of these epi-dogs have chosen us to care for them – they know that you are here for them.

Your capacity will strengthen in the tough times even though our hearts cry continually.

Regards, Trevor.
In memory of Spencer
7-12-2005 – 22-8-2017

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