FDA Update on Grain-free Diets and Heart Disease in Dogs

The FDA has released a new update about the ongoing investigation into dogs developing the dilated cardiomyopathy (DCM), a serious heart disease, which appears to be associated with the use of grain-free or exotic protein diets. The agency has received reports of 560 dogs and 14 cats with DCM, and of these 199 dogs and 5 cats have died from the condition.

The agency has also released a list of all the diets being fed to these pets:

Brands reported fed in at least 10 reported cases of DCM: 

The specific relationship between diet and DCM in these cases is not yet understood, so it is impossible to say if the food is a primary cause of DCM and, if so, how this is happening. However, the common thread among the diets involved seems to be the use of legumes or pulses (e.g. peas, lentils) in place of grains in the diet.

While many of the diets contain common protein sources (e.g. chicken and lamb), a surprisingly high proportion have unusual and uncommon meats as their main protein source. Again, the significance of this is not yet clear.

There is a concentration of cases among golden retrievers, though dogs of many other breeds have been affected as well.

Further data collection and research will be necessary to determine the precise relationship between diet and DCM in these cases. There are likely multiple factors involved, including the ingredients in the diet, the genetics or particular breeds and individuals, and others we may not yet know about. Pet owners feeding these diets don’t need to panic, since far more dogs on these diets do NOT have DCM than do. However, if you are feeding one of these foods, or a diet similar in composition, and especially if you are feeding this to a golden retriever, it would be a good idea to talk to your vet about screening your pet for DCM and considering a change in diet.

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37 Responses to FDA Update on Grain-free Diets and Heart Disease in Dogs

  1. Jack Sofsky says:

    I read the FDA reports and my impression is the FDA should have kept the names of the kibble manufacturers confidential because of likely referral bias. I’d like to hear their rationale for this.

    Note that almost all the kibbles listed are high quality/high cost kibbles. I would have expected to see some of the mass market brands one can find in WalMart, Petco or your local grocery store. 3 days ago I took my Newf for a routine check for her SubAortic Stenosis at a multi-specialty clinic. The cost was $291.75. The FDA link isn’t totally clear, but it appears that most of the cases being studied are those for which the dogs have been evaluated with a cardiac echo study. I think it is likely that the same socioeconomic group that can afford cardiac echo studies correlates highly with the socioeconomic group that purchases costly boutique kibble.

  2. skeptvet says:

    Good points. Lots of possible confounders here. I think another one is that many of the brands on the list have made a reputation/market niche out of being “natural” or alternative to traditional diets in some way, and the grain-free claim tends to appeal to the same market segment–namely, mostly affluent owners who are drawn to alternative or unconventional practices and who find words like “natural” and “holistic” appealing.

    However, it is important not to lose sight of the fact that strongest common thread here is not brand or market segment but grain-free and legumes/pulses. Lots of other foods by the same manufacturers are not on the list and do not have this ingredient profile. It is also interesting to see “kangaroo” as a common ingredient in foods on the list given how rare it is in dog food generally (especially compared to beef and pork, which occur less often in the suspect foods), so the exotic protein source angle is still worth investigating.

  3. Pugtese says:

    I was talking to my dad about this, he’s a doctor and said that there is a condition in people who eat too many sweet peas. It can cause aortic aneurism as it contains a chemical called Aminopropionitrile which inhibits the action of Lysil oxidase in the body. There are also other peas that also cause lathyrism, interestingly the effects can be lessened by adding certain grain to the diet. I’m not a scientist so can’t really understand much of the science but I thought it was interesting and I can see how perhaps peas or lentils could be causing the issues. Also if I read peas on the ingredients of dog food I imagine the green peas you buy frozen but do they even use that variety of pea or a totally different kind?

  4. Edward Wright says:

    Typo: “DCN” instead of “DCM”.

  5. Laura says:

    I am old and tired of doing dog food online research, Sleptvet- any chance of a kibble recommendation for picky elderly dogs (havanese and mini schnauzer) who need small pieces and for years enjoyed (to the possible detriment of their health and definite harm to my finances) Merrick Tx beef and sweet potato? Thanks.

  6. skeptvet says:

    Sorry, but the reality of animal nutrition is that there is no one “right” food. Tens of thousands of dogs thrive on hundreds of different diets, and there is very little evidence to support one being better than another. Something your pet will eat that supports a healthy body weight and good quality coat and stools is the best, whatever that may be.

    For picky little dogs who are not overweight, you can try Just Food for Dogs, a fresh cooked diet. They make a lot of unsupported claims, but they at least have a reliable nutritionist watching over their formulations.

  7. Alice says:

    Wow I never considered that but boy does that make sense

  8. Jill says:

    The thing about this that I find most mysterious is the chart in the FDA article (not shown here) that shows a HUGE uptick of DCM in the last two years. How can this be? If this were an issue, would it not be represented for many years? Grain-free has been an (unnecessary, I agree) fad for many years; would we not have seen this years ago if this were diet linked?

    I also find the omission of charts that show the relative population of dogs fed those brands of dog food and whether they have this issue to be rather puzzling. That seems to be a key piece of data that is nowhere to be found. I find the analysis of this issue to be consistently incomplete and misleading (not here on skeptvet, but in the general discussion).

    And, finally, just a general complaint. Let’s say I would like to have my dogs off a grain-free diet but I can’t afford Hills or Royal Canin (don’t I wish). My options are..what? Seems like every decent brand of dog food is grain-free. So, most of my dogs (I’m a pro trainer, so I have a lot of dogs around) are on grain free because that’s what Costco has. Switching to grain-inclusive diets that aren’t bottom of the barrel would literally cost me thousands more a year (which KILLS me as these ingredients are CHEAPER to produce! Augh). It seems as though the Dunning-Kruger crowd really have a vice grip on the market.

  9. skeptvet says:

    The chart doesn’t show an increase in the number of cases of DCM, only an increase in the number reported to the FDA. Prior to the recent discovery of the association between diet and DCM, there was no reason to report cases of this disease to the agency, so the change reflects not the number of cases but the public awareness of the issue and the subsequent reports being made to the FDA.

    There are no statistics on the relative proportions of dogs being fed each brand of food, and no one collects that data. Again, these data are not the results of a planned scientific study, simply the data available from public reporting, and as such there are lots of gaps in the information. This is why the agency is not recalling brands or claiming that specific foods cause DCM, because this kind of data cannot be used to make causal conclusions. The purpose of the information is to recognize that something is happening and to stimulate public awareness and controlled research studies to figure out what.

  10. peka says:

    Hi Jill,

    I don’t know what you might consider a “decent” brand, but if you’re looking for brands that are *not* grain free, Iams has a senior formula with no legumes listed in the ingredients. I’m guessing they have legume-free adult formulas as well. I think Pedigree and Purina also have “traditional” formulas with grains and no legumes.
    Unfortunately, it does seem that many grocery store brands, even those that include some grains, also have legumes and/or pulses somewhere in the ingredient list.

  11. Jill Missal says:

    @peka, it was more like a rhetorical question seeing as how the grain-free fad is so pervasive 🙂

    I’m not terribly worried about it. I do wish I could afford RC or Hill’s for all my dogs, but I can’t, so I get the best that I can afford. Even though it’s grain free and has peas they all seem to do great on it. At this point in the situation I don’t think there’s much of a percentage in scrambling to change foods until more is known. All my dogs are doing well on the food they are on so far so I’ll just hold the course.

  12. Jill Missal says:

    @skeptvet yes, that was my (poorly made) point. IMO the reporting on this has been misleading to people who don’t, or can’t, read more closely into the situation.

    I know there’s no way of knowing how MANY dogs are eating those and other foods, but there are ways of knowing which dog foods are purchased more than others; for instance if Acana has a HUGE market share it makes sense they are at the top of the list of reported brands. If they have a teeny market share then it’s notable if they are at the top of reported brands. I just feel the reporting on this is, as you said, generally incomplete and it’s confusing and alarming to people for no real reason yet.

  13. Jen Robinson says:

    Decent tends to be synonymous with expensive around dog fanciers. I’ve long been in the habit of going to a country feed store and seeing what rural folks feed their working (and retired working) dogs. You won’t find much grain free. This strategy has kept my crew healthy with good coats and solid stools.

  14. Jill says:

    @jen I guess I don’t see that connection. Decent means, well, decent. Something that doesn’t have baling wire or mothballs falling into it or what have you. It doesn’t mean “boutique brand;” not sure how you’d make that connection.

    I am a working dog trainer and handler, I already know what we feed our dogs. The stuff I consider “best” for dogs is rather spendy and, feeding this many dogs, I have to watch the budget so I can’t really go with what I think is “best” for all of them, sadly. I’m not one to get too worked up about dog food brands so I just feed what I think they do well on that I can afford. My point was I wouldn’t mind getting off grain free but there are few options that don’t seem like just junk without spending more money.

  15. Jen Robinson says:

    In the dog fancy, I associate the term ‘decent food’ with Veblenian snobbery, not evidence based decision making. The groups advocating raw foods, grainfree diets, home cooked diets, and even, to an extent, making decisions based on dogfoodadvisor.com all seem to be pushing for more expensive and or troublesome diets with little experimental evidence. I’ve known dogs to live to a healthy 18+ years on supermarket dry dog food and table scraps. Anecdotal evidence, yes. But there are precious few long-term feeding trials, and the criteria used to decide what food is decent and what is not appear to be arbitrary.

  16. Jill c Missal says:

    @jen We had dogs live to be 15 and 16 on Purina Dog Chow but I don’t consider that to be a decent food I’d feed my dogs. Nothing to do with snobbery, more to do with quality. Given the stories of baling wire etc in the bottom of the barrel brands I think we can conclude that’s not what we want.

    Again, I wish Hills and RC weren’t so darn expensive. I can manage to put a few of my guys on the Hills but I save thousands a year by having the rest of them on a Costco option and they’re all doing fine.

  17. Sheila says:

    Purina ProPlan Sport 30/20 has served my pack well. Their stools are consistently firm and they seem to be in good health. For more than a decade, I fed these boutique brands and as the pea content increased my dogs tolerance decreased. Being the loyal Dog Food Adviser follower I thought my dogs’ were the problem rather than the food. I eventually made the connection between peas and GI upset. I also realized that my dog fed boutique foods for her whole life didn’t live any longer or have better quality of life than the dogs I owned and fed Purina One or Iams prior to discovering Dog Food Adviser’s (DFA) rating system. I made the switch just before all this DCM information came out. I’ll admit after receiving all this “internet education” about the evils of big dog food manufacturers and big pharma,I half thought my dogs were going to explode or something equally as dramatic eating a Purina product but I decided to go rogue LOL. They’ve actually done much better and now I plan to stick with companies that actually have a veterinary nutritionist on staff.

  18. Michelle Mahaffey says:

    Is Rachael Ray Nutrish Natural Beef, Peas & Brown Rice Recipe Dry Dog Food a problem? Is it not grain free.

  19. skeptvet says:

    I’m not aware of any specific reports about problems with that dogs.

  20. Jo Amsel says:

    We have a dog boarding kennel and I have bred and shown dogs for over 40 years. We also have a dog breed rescue so get Rescue dogs of all ages and conditions. There isn’t much we haven’t seen and not much we haven’t fed. My own pack is currently 15 with age ranges from 1 to almost 15. My Veteran Show dogs are renowned and for the past 10 or so years my pack have been use for dog food trials.

    So what have I learned. There are some dogs that hate kibble however well formulated and complete. There are some that live happily and healthily on a one star product. We have saved a good number of dogs with chronic IBD from being PTS by switching them to raw. Why it works, who knows. We have found that rescue puppies recovering from Parvo whose poops don’t come right, fed raw green tripe for a few days, become normal. Probiotics don’t seem to have any effect so what bacteria/ other which are in raw unwashed tripe that work, we don’t know.

    My own dogs are brought up on a huge variety of food from weaning. I fed raw for many years without an issue.I have never had one sensitive to anything. In any two weeks they will eat, lamb, beef, chicken, turkey, duck, rabbit , venison, and other game in season. If I use a dry it will be a cold pressed. The have tinned, home cooked, raw and dehydrated with lots of different veg. Foods with grain like rice and oats and food without. Supplements like seaweed, omegas, fruit powder, seeds and nuts I could go on! I don’t feed lentils, or beans or wheat and eggs only rarely.Their diet is around 75% -80% meat with offal. I don’t believe in puppy foods or senior foods. Puppies get more and veterans get some extras but not glucosamine for which there is no evidence.

    A friend had a healthy dog who was naturally vegetarian and successfully reared litters.
    My dogs are healthy, have great appetites, long lived and only two developed cancer in extreme age. Variety is the spice of life.

    I recently went to a lecture given by a professor who specialises in epilepsy.His clinic only treats severe epileptics. By putting dogs on a high ketogenic diet ( no grains and only green leafy veg ) 1/3rd had no more seizures, 1/3rd had a reduced number and 1/3 rd stayed the same, so it seems that diet can play a big part in issues that we wouldn’t think might be affected by it.

  21. L says:

    @Jo Amsel

    I don’t believe a word of what you have to say.
    You have the right to your opinions but I caution others to be aware that opinions are not facts.

  22. skeptvet says:

    Jo,

    Unfortunately, as you know, such anecdotal evidence really doesn’t prove anything. People claim random changes in diet, lifestyle, supplements, etc. cure all manner of diseases, and often when such claims are investigated scientifically, they don’t turn out to be true. When you say “why it works, who knows” what you are acknowledging is that there is no scientific reason to suggest it should work. Trying things without a good reason and then “validating” them with anecdote has failed spectacularly throughout history in terms of finding truly effective medicine, so it really isn’t a good strategy for our pets. If things like raw diets and ketogenic diets really do what is claimed, it shouldn’t be hard to prove this with science. If we don’t, then we are potentially harming our pets regardless of what our personal, anecdotal experience tells us.

  23. Jo Amsel says:

    I understand what you are saying however I have probably cared for, fed more dogs than the vast majority of vets and as far as I am concerned, if it works we will use it.

    That’s how some drugs were discovered. Plants that made people feel better……..anecdotal but subsequently the chemical responsible was isolated. Science has to start somewhere does it not ? No doubt had someone told you that feverfew brought down their temperature, you would have scoffed. As far as the green tripe is concerned well maybe it’s coincidence but since no-one has researched it as yet, well as my own vet says, use it because he had nothing we tried that got their gut back to functioning properly.

    I am all for evidence based science and treatment however while you are quick to point to cognitive dissonance and confirmation bias in others, well we all have it even if we try not to have it do we not ?

    As far as the epilepsy and ketogenic diet is concerned, that is currently under research. It was to do with the effect of sugars on the glial cells or how the glial cells process it.. The professor did try to explain the basis of it but we in the audience were mostly there as breed health representatives not scientists although six vets were also present at the lecture.

  24. Jo Amsel says:

    L

    Sorry I should have responded to you first. I do not make ad hominem attacks on people. I put my full name to any comments that I make, I do not make things up nor do I intentionally lie.

    Thank you

  25. v.t. says:

    Jo, you might want to do some research on human ketogenic diet dangers – why do humans always extrapolate human diet FADS onto their pets! Nearly every dumb fad that pet-owners fall into, will eventually prove to have been ineffective and oftentimes dangerous.

  26. skeptvet says:

    “I have probably cared for, fed more dogs than the vast majority of vets and as far as I am concerned, if it works we will use it.”
    This indicates that you don’t understand my point. Sadly, most people, including vets, don’t understand why “I tried it and the patient got better” isn’t good evidence that a therapy works. It is a cognitive flaw we all have, as you point out, but unless we admit it and accept that only controlled research evidence can overcome it, we will continue to make use of ineffective therapies that “seem” like they work anecdotally.

    “That’s how some drugs were discovered. Plants that made people feel better……..anecdotal but subsequently the chemical responsible was isolated. Science has to start somewhere does it not ?”
    Not exactly. Traditional use of herbal remedies has almost always proven ineffective. Thousands of plants used broadly for many different conditions over centuries did occasionally stumble on something useful, but the vast majority were harmful or ineffective, which is why scientific medicine has done far more to improve our health and longevity than thousands of years of trial and error with plants. Pharmacognosy, the derivation of medicine from botanical sources, is a rigorous and complex science. The process may start with “Hey, I wonder if this plant might have some useful medicinal compound sin it?” but it doesn’t stop there, and it doesn’t have anything to do with “Hey, people have used this plant for Disease X for centuries, and it seems like it works to them and to me, so let’s do it!”

    Feverfew is actually a great example. It has been historically used for a hodgepodge of unrelated problems, including fever, constipation, diarrhea, skin infections, toothaches, headaches, dizziness, etc. There is mixed evidence regarding migraines, and it might or might be helpful. There is no evidence to support any other uses. It can also cause nausea, bloating, and mouth sores. It is a classic example of why we shouldn’t use traditional nd anecdote to pick judge our treatments.

    Ketogenic diets are also interesting. There is evidence that they can reduce seizures in humans. However, the majority of patients don’t continue to use them even if they help because it is unpleasant to eat and difficult to stick to. And since dogs and cats are obviously very different from humans, why would we expect these diets to have the same metabolic effects? Isn’t the whole argument for raw diets based on the notion (false though it is) that they are carnivores and so should eat differently than people? Without controlled research evidence, we can’t just assume these diets have the same effects on dogs as they do on humans.

    Every failed treatment in medical history has had anecdotes that suggested it worked. We are all a lot better off now that we rely more on science to guide our healthcare, and the same is true for veterinary healthcare.

  27. Jo Amsel says:

    Skeptvet

    I meant meadowsweet not feverfew, my bad. I could have mentioned foxglove and other plants that have been the basis for finding drugs. I am not disputing that most plants will prove not to have useful properties for producing new drugs but that applies to the millions of compounds that are stored and tried by drug companies before they find the very few that do work in the test tube and of those only a minute proportion pass the safety test. That’s why drugs are often so expensive. So what is the difference? A few plants = a few compounds.

    Then you make great play of the side effects of Feverfew.I don’t know as I have never used it or thought of using it however there are side effects and some of them severe side effects including fatal ones from scientifically proven drugs. I lost a dog with acute kidney failure after one dose of meloxicam. My husband almost died from taking Augmentin after a reaction to Clavulanic Acid. Every drug has a side effects list as long as your arm.

    Re the ketogenic diet. I was reporting the interesting dietary protocol that a veterinary professor whose specialty is epilepsy, told us about in a lecture I am not sure why you should be critical of it but I can certainly find his details if you would like to question him about it.

  28. Jo Amsel says:

    A breakthrough that could help manage canine epilepsy by reducing seizures has been described by an RVC scientist involved in the research as “the most exciting thing I have done in my career”.
    Professor Volk was inspired to explore the effects of diet on epilepsy after breeders and owners claimed the food they gave their epileptic dogs influenced the control of their seizures.
    Research from the RVC canine epilepsy clinic, which identified neurological therapeutic nutrition as a way of helping manage epilepsy, has “given hope” to thousands of patients – particularly those that do not respond to traditional treatment, said neurology and neurosurgery specialist Holger Volk.

    “Canine epilepsy is a complex condition and can be very distressing for the dog and its owner,” said Prof Volk, who is head of the department of clinical science and services at the RVC.

    Anecdotal evidence
    Anti-epileptic drugs (AEDs) have traditionally been used to treat the chronic neurological condition in dogs, but consistent remission can be difficult to attain via this method. Therefore, Prof Volk said, it is vital to keep developing new management options to improve seizure control and patients’ quality of life, and hand control back to owners.

    Prof Volk was inspired to explore the effects of diet on epilepsy after collating anecdotal evidence from breeders and owners who said they thought the food they gave their epileptic dogs influenced the control of their seizures.

    A six-month randomised, placebo-controlled, double-blinded crossover study was conducted in dogs with idiopathic epilepsy receiving AEDs. It demonstrated a test diet with medium-chain triglycerides oil can have positive effects on reduction of seizure frequency when fed as an adjunct to veterinary therapy.

    Seizure reduction
    The findings revealed 71% of dogs showed a reduction in seizure frequency, 48% showed a 50% or greater reduction in seizure frequency and 14% achieved complete seizure freedom.

    Prof Volk said: “This is the most exciting thing I have done in my career. This approach gives you another weapon in the arsenal against epilepsy.”

    The research, which was carried out in partnership with Nestlé Purina, provided the basis for the development of the first diet to help nutritionally manage dogs with idiopathic epilepsy as an adjunct to veterinary therapy.

    Read the full story in the 20 February issue of Veterinary Times.

  29. Jo Amsel says:

    Professor Volk described this as a ‘high ketogenic ‘ diet, as he pointed out dogs normally have a ketogenic diet. To us he did also say approximately. 1/3rd 1/3rd and 1/3rd. Interesting that he did not dismiss anecdotal evidence from owners.

  30. L says:

    Here is an update to the “research” done by Holger Volk and others on canine epilepsy

    https://www.isvma.org/wp-content/uploads/2017/10/Canine_Seizure_Management-1.pdf

    If you scroll down to page 8 you will see it says “Level of evidence: Insufficient data to recommend”
    Regarding ketogenic diet and other alternative treatments.

    Standard treatment with medications is still recommended with Phenobarbital being the first medication to try.

    I only scanned through it (small print) but maybe others will find something of interest. The article is from 2017

  31. Jo Amsel says:

    L,

    The lecture I attended was in 2018. I can only report what he said and that is what I found on the net. You accused me of lying. Perhaps you would like to put your name to your posts and not hide behind an initial.

  32. Jo Amsel says:

    His talk is a 52 minute read and unless you subscribe you cannot access it. If you have managed it please post the link.

  33. skeptvet says:

    “So what is the difference? A few plants = a few compounds.”

    The difference is that no one would ever claim any of the chemicals banked by the Pharma industry that are untested or have failed to prove safety and efficacy should be used anyway because of historical use, folk mythology, or personal experience. Yet most herbal remedies, to the tune of billions of dollars a year, are used despite the lack of evidence or the existence of negative evidence based on exactly such poor reasoning, and this harms many, many people every year. I have no objection to the scientific evaluation of chemical compounds in plants as potential medicines, but you were implying that one herbal remedy which proved successful (which isn’t any more true for meadowsweet than for feverfew) somehow validated the idea that traditional use herbal remedies could be viewed as a promising source of medicines, and that simply isn’t the case.

    As for the issue of side effects, you make a false equivalence between science-based and alternative remedies. For science-based medicine, we know there is some benefit and we often have a good idea of what the risks are, though there is always some degree of unpredictability. For alternative treatments (e.g. herbs, raw diets, etc) we have no evidence of benefits in most cases, and yet the common perception is that they are safer than drugs, which is a dangerous fallacy. Information is always imperfect, but scientific information, and treatments based on it, are a lot safer and more reliable than tradition, anecdote, etc.

    “Re the ketogenic diet. I was reporting the interesting dietary protocol that a veterinary professor whose specialty is epilepsy, told us about in a lecture I am not sure why you should be critical of it but I can certainly find his details if you would like to question him about it.”
    I am critical because there is a lack of evidence to support claims of benefits. The credentials of the person making the claims isn’t very relevant since this is not evidence the claims are true. I am happy to look at specific evidence supporting the claims, but it really doesn’t matter who made them.

  34. skeptvet says:

    Yes, you are referring to this study from 2015. It got a lot of press, and Purina has based a diet on this and similar research. However, there are a number of problems with the study.

    For one thing a lot of patients dropped out of the study, which can skew the analysis of whether or not the treatment worked. One third of the dogs (n=10) withdrew before study completion. Five of the withdrawn dogs were started on the study diet — 2 were euthanized due to uncontrolled seizures, 2 because of difficulty adhereing to the diet, and 1 because of side effects (lethargy). The most conservative approach would be to consider these treatment failures, not just remove them from analysis. In the “real world” if a patient is euthanized, the client can’t comply with the treatment or you have to stop treatment because of side effects … that’s a treatment failure in my mind.

    Also, the difference in seizure frequency was minuscule (2.3 seizures per month on the diet, 2.7 seizures per month on the control diet), so it’s hard to imagine this making much difference in the life or a patient with epilepsy.

    In any case, the study suggests this specific diet might have some small benefits, but it is not a validation of the general concept of ketogenic diets even for epilepsy, much less other medical problems, especially since other studies have failed to find any benefit to ketogenic diets in dogs with epilepsy. The devil is always in the details in medicine.

  35. v.t. says:

    Jo,

    “L” did not accuse you of lying, L simply provided a link that clearly shows the diet is not recommended as treatment.

  36. L says:

    @v.t.
    Thanks, but I think it is best to let it go.
    Obviously Jo A is passionate about her beliefs.
    Hopefully she won’t find out the hard way that she may be wrong, as many of us have.

  37. L says:

    PS: Anecdotal, I know.
    But I had a small breed that was diagnosed with idiopathic epilepsy at 9 months, he was started on phenobarb (a low dose) daily and he lived to be 13 years old.

    We never observed any side effects, he was a happy dog. He did experience breakthrough seizures a few times a year but they were mild.

    Sure, there were triggers like thunderstorms, however, food never seemed to be the issue.

    Just saying, I will never understand why some folks think that medication is bad.

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