Systemic Arthrotherapeutic Medications
Several advancements have been made in the field of systemic joint therapy over the last decade. We will review a few of these strategies.
Any medication administered outside the joint (by mouth, intravenously, or intramuscularly for example) for the purpose of improving joint function and/or comfort is considered a form of systemic arthrotherapy. Anti-inflammatory medications (such as phenylbutazone and Banamine), topical pain relievers (such as capsaicin and diclofenac), and joint supplements (such as Adequan®, Legend®, and Cosequin®) are included in this category.
Joint supplements have seen wide use in recent years, and are most often the client's first line of treatment for DJD in their horse(s). The primary goal of the joint supplement is to stimulate normal activity and function of the synovial membrane thereby enhancing the integrity of the joint environment. Topical, oral, intravenous, and intramuscular forms exist.
1) NONSTEROIDAL ANTIINFLAMMATORY DRUGS (NSAIDs)
Non-steroidal antiinflammatory drugs (NSAIDs) such as Bute, Banamine, Ketofen, etc.) are frequently used to alleviate the clinical signs (namely inflammation and pain) associated with arthritis in horses. However, consistent use can result in gastric ulceration as well as kidney and liver dysfunction. Therefore, we recommend this form of therapy only for horses that perform very infrequently, such as once or twice weekly (or less).
There is a relatively new product called EQUIOXX (firocoxib) that was developed by Merial. Equioxx has been shown to reduce inflammation and pain associated with osteoarthritis in horses. At the same time, it offers a much better safety profile when compared to other (more traditional) NSAIDs. Equioxx is the first coxib class nonsteroidal antiinflammatory drug that is highly selective against Cyclooxygenase-2 (Cox-2) prostaglandins which are responsible for inflammation. Unlike other NSAIDs, however, Equioxx spares the beneficial Cox-1 prostaglandins required for normal gastric, renal (kidney), and hepatic (liver) function. A single dose lasts for 24 hours and can be administered for up to 14 days in a row. Equioxx comes in an oral paste form; each tube contains 1500 pounds of medication. Each marking on the syringe treats 250 pounds of body weight, and each notch corresponds to a 50-lb weight increment. Equioxx can be administered with or without food. Equioxx can be ordered through our Pharmacy by calling 678-867-2577 or by contacting email@example.com
For more information, contact our office or visit http://www.equioxx.com/
At The Atlanta Equine Clinic, we have observed a comparable effect of a much lower (and less-expensive) dose of the small animal preparation of firocoxib, known as PREVICOX, to that of its large-animal counterpart (Equoxx). In our experience, a 57-mg dose of Previcox (which costs less than 67 cents) produces similar clinical results to that of an extire tube of Equioxx (which costs $9.75). This product can also be ordered through our pharmacy.
SURPASS® (diclofenac sodium) is a topical medication that has gained popularity in recent years due to its ease of administration (simply rub it on the affected joint) and its effectiveness for certain types of arthritis in horses. In our experience, Surpass generally works better under the following circumstances:
a) In higher-motion joints. For example, we would expect a better response when treating a fetlock joint (which is very high-motion in nature) than we would when treating the lower hock joints (which are very low-motion in nature).
b) In joints that are closer to the skin surface. If there is less tissue through which the product is required to diffuse then more will be delivered to the affected area. Consequently, we would anticipate a better clinical response if more product is reaching the joint. For example, we would expect a better response when treating a fetlock joint (which is just under the skin surface) than we would a stifle joint (which is much further/ deeper from the skin surface).
c) In joints with a high topical surface area:size ratio. We typically observe a higher concentration of therapeutic medication in synovial (joint) tissue (and therefore a better clinical response) when the joint is smaller and very well exposed under the skin surface. For example, we would expect a better response when treating a fetlock joint (small and just under the skin surface) than we would a stifle joint (large and deep under the skin surface).
d) When used prophylactically (as a preventative) rather than subsequent to the onset of joint inflammation. In other words, we would expect a better response if we applied the product prior to exercising the horse than we would if we applied the product after we finished riding.
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2) ORAL JOINT THERAPIES (i.e. Given by Mouth)
Most studies show that the oral medications (e.g. Cosequin®, MSM, Flex Free®, Corta-flex®, etc.) are quite effective when absorbed into the system. This type of arthrotherapy works especially well in people and dogs, who are able to absorb relatively large molecules (like glucosamine and chondroitin sulfate) through their intestinal wall easily. Horses, on the other hand, are generally not proficient at absorbing large molecules into their system from the intestinal tract. Therefore, a portion of the oral medication (and the client's investment) may not be completely utilized. Many companies are continually working to find ways to improve absorbability of oral supplements in the horse.
In many cases clients are limited to the administration of oral medications due to various circumstances which include barn protocol, difficulty/ danger in administering shots, lack of adequate assistance and/or restraint, etc. In our opinion, one of the best oral medications for the money is called MEGA-FLEX and is produced by Spectra Animal
Health. Please visit http://www.americanlivestock.com/m-15147-.aspx for more information.
3) INJECTABLE JOINT THERAPIES
Medications which bypass the intestinal tract of horses (and therefore do not rely on intestinal absorption) are generally preferred at present. These are injectable (i.e. given as a shot) and include both LONG-TERM/maintenance and SHORT-TERM forms.
SHORT-TERM medications are administered intravenously (IV) and therefore typically have a greater positive effect on joints. In other words, we generally observe more improvement in the horse's comfort following administration of short-term therapy (such as Legend®) than we do following administration of long-term therapy (such as Adequan®). The positive effect of short-term therapy, however, is only about one-half as long as that of long-term therapy.
It is for this reason that we recommend short-term therapy and long-term therapy with different goals in mind.
We currently recommend LONG-TERM joint therapy for the following:
a) In horses with no current evidence of joint disease. The purpose of the medication is to delay the onset of joint disease.
b) In horses with mild joint disease. The purpose of the medication is to alleviate symptoms enough for the horse to perform well in his/her intended capacity.
c) In horses with moderate to severe joint disease that have previously been treated with local therapy (i.e. injection). The purpose of the medication is to prolong the effect of the injection and delay the recurrence of clinical signs.
Long-term/ maintenance medications include Adequan®, Acetylglucosamine, Chondroprotec®, and Glucosamine (among others). Most treatment protocols involve one injection (5cc or 500mg) in the muscle once weekly for 4
consecutive weeks and then once or twice monthly thereafter (indefinitely). Cost varies anywhere from $12 to $50 or more per dose.
These products can be ordered through our pharmacy at 678-867-2577 or firstname.lastname@example.org
*The ATLANTA EQUINE CLINIC is currently conducting a research study on the effects of PENTOSAN. To learn more about this product click HERE. To participate in our research study (and receive discounted medication) click HERE.
We recommend SHORT-TERM joint therapy for the following circumstance:
a) 36-48 hours prior to a race, clinic, or show. The purpose of the medication is to maximize the performance of the horse for a selected event.
Short-term medications include Legend, MAP-5, and (among others). These medications are generally administered intravenously (in the vein) at varying doses. The cost of a single dose can range from $35 to $95. In our opinion, the best product for the money is a generic version (MAP-5) which runs $75 for 50mg (versus $95 for 40mg Legend).
These can also be ordered through our pharmacy.
If regular short-term treatment (i.e. an IV dose administered every 2-4 weeks or sooner) is required to produce and/or maintain soundness or does not result in a satisfactory response, then local arthrotherapy (i.e. joint injection) may be considered.
4) TILDREN (TILUDRONATE)
Tildren is designed to normalize bone metabolism, thereby alleviating clinical signs associated with osteitis (bone inflammation) and osteoarthritis (joint inflammation).
Healthy bone undergoes continual metabolic readjustment in response to stress/ exercise. Bone is constantly being broken down (via osteoclastic activity) and rebuilt (via osteoblastic activity). Normally, there is a balance between bone loss and bone redevelopment. Some pathologic conditions (disease processes), however, can result in excessive bone loss (known as "osteolysis") and/or abnormal bone remodeling (cell turnover). Horses with chronic navicular inflammation, for example, often experience abnormal bone remodeling as well as development of osteolytic lesions (areas of bone loss) within the navicular bone. These lesions are visible radiographically and may represent an imbalance in bone metabolism (i.e. increased bone resorption relative to bone redevelopment).
"Tildren" (or tiludronate) inhibits excessive bone resorption and promotes rebalancing of bone metabolism. At The Atlanta Equine Clinic, the use of Tildren has proved beneficial in cases of navicular inflammation, nonadaptive bone remodeling, and severe osteoarthritis.
For more information on Tildren, visit http://www.tildren.com. It should be noted that Tildren is not approved in the United States for use in horses, so any clinical use would be considered off-label.