Managing Equine Joint Disease

Transcription

1 May 19, 2009 Managing Equine Joint Disease Comment from Guest: I ve been told about injections and a supplement called ramard total joint care. Are either of these worthwhile? We ve done the bute therapy and she moves more comfortably but she is still young to be on something that aggressive. Any help would be so appreciated! Dr. David Frisbie: You would have to be more specific about injections ie what is being injected. In general injections into the joints are done with compounds that are typically more potent than oral products. I assume you are referring to ramard equine total joint care, i am unaware of any published literature that proves this formulation works. Bute is not a long term solution fo soreness; i would consult you veterinarian for more specifics. Dr. Craig Shoemaker: Depending on your horses problem injections could be very useful. I NSAID s are helping that is a good sign. If you are concerned about potential side effects you might consider topical treatment with a product like Surpass Comment from Guest: Can joint disease also occur in the equine back? What area is most prone to arthritic changes and how are these detected and managed? Dr. David Frisbie: Yes they can. I would suggest a diagnostic work up by a veterinarian that is comfortable working up back issues. It is important to remember that most back problems are secondary to lower limb soreness. Comment from Guest: 1.) Can you give a GENERAL Ballpark of pricing for the treatments? 2.) IRAP: How many injections are required? Is it a one time treatment or several injections? Thank you!! Dr. David Frisbie: The typical intraarticular therapy of steroid and HA runs from depending on region of the US and is usually a one time treatment/injection. 2) IRAP usually is around 1,200-1,800 for drawing, processing and 3 treatments/injections. Comment from Guest: I have a 5 year old quarter horse gelding with a hock that is almost fused, but still sore in spite of corticosteroid injections. Is the next step surgery, and if so, what is the success rate? I would like to use him for competitive trail. Dr. David Frisbie: The success rate for the surgery is between 50-70% Comment from Guest: I have a 26-year old Arabian Mare who seems to have generalized arthritis in her right front leg. Is there a oral supplement that you could recommend? She is an amazing horse to ride with a lot of power. She h-a-t-e-s shots! Dr. David Frisbie: The two oral supplement I recommend are Cosequin ASU and Platinum Performance ASU. Comment from Guest: Can surpass be used with ultrasound treatments? For more information on equine health, care and management, visit TheHorse.com 1

2 Dr. Craig Shoemaker: Yes, Surpass can be used with Ultrasound. Comment from Guest: Is it true that if proteoglycans (specificially arta perone) are injected into the muscle they will find their way to the needed area? Dr. David Frisbie: Substances that are building blocks for joint tissues when injected in remote sites such as muscle can make their way to the joints. Comment from Guest: is surpass a prescription drug? Dr. Craig Shoemaker: Surpass is safe for use in race horses but it can test. I recommend you speak with your veterinarian about specifics regarding racing. Comment from Guest: How often should x-rays be done to keep an eye on DJD or just one to diagnos? Dr. David Frisbie: I typically follow-up using x-rays once every year or every other year if things don t seem to have changed much clinically. Comment from Guest: My horse just started adequan a few days ago for his arthritis/bone spurs from prior injuries to his fetlock joint -- and our vet is suggesting a combination of adequan and legend injections changing each month. I m confused on what to do, just adequan, just legend or both. Dr. David Frisbie: Good question, although there is no definative anwser at this point. The products are different and we believe there are values of both. Alternating the products seems to be a common approach that has some merit. Comment from Guest: Will IRALP work for the beginning of ringbone? Dr. David Frisbie: IRAP can be an effective treatment for early ring bone. Comment from Guest: regarding H.A... have you used oral H.A with any good results? or is only, in your opinion, effective when injected. Dr. Craig Shoemaker: Oral HA products have been shown to be effective, however, intra-articular treatment is in my opinion the best approach Comment from Guest: What are the side effects of Equioxx? Dr. Craig Shoemaker: All NSAID s have the potential for side effects. Equioxx is more specific in its action so has some safety advantages. Comment from Guest: I have a 26 year old retired mare with both knees that look like softballs, and completely fused. Despite all that she Comment from Guest: she is soundish. Just wondering what I can do to keep her comfortable? Dr. David Frisbie: I would suggest consulting your veterinarian about injecting the affected joints. Typically knee joint don t fuse without surgical intervention. Comment from Guest: I have an older upper level dressage horse who has a bone spur in his rf coffin joint. Should i be considering irap? For more information on equine health, care and management, visit TheHorse.com 2

3 Dr. David Frisbie: Would not do anything unless the horse is showing soreness but if this is present irap is a good consideration. Comment from Guest: Can you provide some guidance on the use of Adequan IM? I understand the loading dose, however, where things are fuzzy is how to continue use. I ve heard once monthly every month, but I ve also heard to give injections one a week for four weeks every four months. Dr. David Frisbie: If you have active soreness that you are treating with Adequan I would treat every 4 days for 7 treatments and then continue twice a month. If you are using it in a preventative method I would start treating twice a month. Comment from Guest: My 13 yr old 1300# tb gelding had open joint repair of the meniscus by drs. Meulyzer and laverty at st. Hyacithe s of univ of montreal large animal vet school in dec He is still not fully recovered in that with moderate exercise he is uneven. This is despite hand walking 2x day for past 6 months gradually increasing up to 1 hr day. Is there something to repair the meniscus--(my vet thought stem cell was iffy)-such as supplements or injections that will return him to real work? Dr. David Frisbie: I have had a 60-70% return to work in horses with menical damage, so i would consider this option Comment from Guest: I can t get my computer speaker to work, so I apologize if you have covered this. Is Surpass used before and after riding or daily? I would guess there is no problem in using it in conjunction with oral therapy? Dr. Craig Shoemaker: Actually, Surpass can be used a number of ways, it really depends on the individual case. It can be used after riding if needed or daily for the recommended treatment period. There really isn t a problem using with other oral products. Comment from Guest: Have you had any experience with iv injection of polyglycam? I have been told of injection of 5 ccs once a week for 4 weeks, then once a month as maintenance. Dr. David Frisbie: There is evidence that intraarticular polyglycan is beneficial. I am unaware of any peer reviewed work that has been published on the benefits of iv polyglycan even though it is being used this way. It is worth while noting this product is labeled for intraarticular use. Comment from Guest: Is it true that once you start injecting hocks you always will have to inject? Dr. David Frisbie: No that is not true. You should only inject when inflammation and soreness are present. It is true that once arthritis starts is can be an ongoing process, like in people. This is independent of treatment. Comment from Guest: Do you need to shave the area prior to applying Surpass? Dr. Craig Shoemaker: You do not need to shave the site prior to applying surpass to the indicated joint Comment from Guest: Am i wasting my money giving oral ha, and other chrondroprotectives? Would i be better off giving legend or adequan when i can afford it? Dr. David Frisbie: I believe that of the products that are available today you would be better of giving legend or adequan because they are more potent. For more information on equine health, care and management, visit TheHorse.com 3

4 Comment from Guest: How long do you recommend resting a horse after hock injections and what do recommend regarding starting them back into work? Dr. David Frisbie: I usually rest them for prior to return to work. Comment from Guest: My horse has had 3 hock injection treatments in the last 18 months. The last one was in February, he never has come back to being completly sound after this last treatment.he moves a little stiff on the forhand, which I was told is an indication of being hock sore.i have started using Acetyl-d- glucosamine, im once a week. I m still not getting the results I need. Jack is 16, family pet as well as my 13 year old daughters hunter / 2 6 jump heights. Any sugestions? Dr. David Frisbie: I would suggest that you have Jack worked up including diagnostic blocks to pinpoint exactly what region and or joint (s) are involved and then develop a plan from there. Comment from Guest: Whats the effectiveness about injections of GAG s into joints, compared with IM. Sorry about the english. Dr. Craig Shoemaker: PSGAG s have been shown in certain studies to be effective given both IM and IA. In most cases the IA approach is best in my opinionbeth Comment from Guest: what meds would be useful for a 9 month old colt with ocd as well as locked stifles Dr. David Frisbie: I would consider surgery for the stifle OCD if that is what is causing the locking problem. Meds are typically not the answer for OCD. Comment from Guest: Do you know anything about Vaxamine Eq? I m looking for a safe bute alternative for my pregnant mare. Dr. Craig Shoemaker: I personally don t know a lot about Vaxamine EQ. Other NSAID s like topical Surpass might provide you with additional comfort when treating your horse. Comment from Guest: I have a 9 year-old arabian mare that has djd in a hind fetlock joint. She is currently a 4.5/5 On the lameness scale. Is stem cell therapy a feasible possibility for this level of the disease? She has had adequan injections and arthroscopic surgery (last july) to clean up a small cyst on the joint but there are arthritic changes on the joint. She was shown western pleasure from the previous breeder/ owner and i have had her since age 4 and was doing training-level dressage. I realize this is difficult to speculate without radiographs, etc. Thank you for your help. Dr. Craig Shoemaker: Stem cell would be a consideration, although i will warn you arthritis in the fetlock joint can be tough. Comment from Guest: i have a mare with upward fixation of the patella. Would adequan or Legend be of any help? she is not lame - but still seems reluctant to work. Dr. Craig Shoemaker: I prefer IA steroids...internal blister might also be of benefit Comment from Guest: I just signed on to the live chat, but I watched the presentation already. Do you recommend shock therapy for hock pain that does not respond to injections? Dr. David Frisbie: I would try Surpass 1st and then shockwave if that did not work. Fusion or surgery would be a final step. For more information on equine health, care and management, visit TheHorse.com 4

5 Comment from Guest: How effective is oral hyaluronic acid (such as hyalun)? Do you recommend it? Dr. Craig Shoemaker: We have done some controlled testing on conquer oral ha and have found not signficant beneficial responses in horses with oa, thus i cant recommend it based on my scientific experience. paula Comment from Guest: Have 9yr old with Lyme s disease and front end lameness. any suggestions? Dr. Craig Shoemaker: Lyme disease can be very difficult; usually it is a shifting lameness. I would pursue further diagnostics to make sure it is Lyme. kris Comment from Guest: When my 10 yo gelding walks I can hear a popping noise from i think his stifle. Is this considered a problem? Dr. David Frisbie: Noise or popping can be independent of soreness so if your horse is not sore I would not worry about it. Comment from Guest: Should all horses be on an oral supplement for the joints (such as a mix of glucosamine, chondroitin, and msm)? Dr. Craig Shoemaker: Much like people not all horses require supplements. A role of thumb might be as the level of work/athletic activity increase the chances of joint related problems can increase. This might be the time to start joint supplements. Definitive evidence that oral supplements can protect against disease is sparse although evidence that they can help once disease is present is more convincing. Comment from Guest: What kind of foods can you feed a horse with joint problems to help them? Dr. Craig Shoemaker: A well balance diet is sufficient. Comment from Guest: Have you studied the effects of msm/dmso on the joints of equines with chronic joint pain and or stiffness? Dr. Craig Shoemaker: Little work has been done with these products. Comment from Guest: Is it possible to use herbal extracts and msm/dmso blends (a mixture of msm/dmso and herbal extracts) safely to help treat an equine with joint problems? Dr. Craig Shoemaker: There are other oral supplements that provide more scientific evidence of a significant beneficial effect such as asu (avocado/soybean unsaponifiables). Comment from Guest: I hear so much about nsaid s, and side effects, what is the safety of surpass in that aspect? Dr. Craig Shoemaker: It appears to have less of the side effects you mention. This is believed to be because of less systemic absorption. Comment from Guest: Is there any benefit from Perna mussel which is a component of Synovi G3? Dr. David Frisbie: There is more supportive evidence for ASU products (avocado/soybean unsaponifiables).kris For more information on equine health, care and management, visit TheHorse.com 5

6 Comment from Guest: What about heel pain or what used to be called Navicular. Can these products help horses who are severely afflicted with navicular? Dr. Craig Shoemaker: Yes, injections of the joint can be beneficial for navicular syndrome Comment from Guest: Could I associate PSGAG s, HA and costicoids at same joint (IA) and at same time? Dr. Craig Shoemaker: HA and corticoid steroids are often times given together. It is possible to treat the horse with PSGAG s at the same time as well. Comment from Guest: What is the cost of stem cell therapy? Dr. David Frisbie: The cost to have the cell harvest, processing and injection usually runs from 1,900 2,500. This would be bone marrow based, which is what I would recommend. Comment from Guest: Can you explain at what point you fuse a hock (is it done naturally or surgically) and how successful is it? Dr. Craig Shoemaker: In most instances the lower hock joints will fuse naturally over time. Surgical fusing of joints is successful 50-70% of time. Comment from Guest: I tried injecting a mare through the coffin joint with HA - got 3 days of relief and that was it. What about shock wave for navicular? Dr. David Frisbie: I might consider having the navicular bursa injected with HA and steroid if you veterinarian feels this area is the source of pain. Comment from Guest: We race our horses. Is Surpass safe (does it test) for race horses? Dr. Craig Shoemaker: Surpass is safe for use in race horses, however, you need to be aware of testing issues surrounding its use in this group. I would suggest that you speak with your veterinarian about the specific rules and regulation in your state. Comment from Guest: If a horse does not respond to hock injections, how would surpass be beneficial? Dr. David Frisbie: It works on the soft tissue around the joint which can be the issue if the horse is nonresponsive to joint injection. Comment from Guest: Do you think the topical NSAIDS would be effective for soft tissue injury of the leg not involving the joint? My old gelding is currently taking 1/2 bute tab bid. Is the cost comparable? Dr. Craig Shoemaker: The topical product, Surpass, has been used successfully to treat soft tissue injuries. Surpass is more expensive than Bute but the technology and added safety are benefits other NSAIDs don t provide Comment from Guest: how often would I apply Surpass Dr. Craig Shoemaker: The label use of Surpass is a fiven inch ribbon twice daily for up to 10 days. The nice thing about Surpass is that you can tailor the treatment based on your horses issue and use For more information on equine health, care and management, visit TheHorse.com 6

7 Comment from Guest: 26 year old Arabian gelding, both hocks and stifles sore. Given him (1) IV of Polyglycan and followed up with (1) IM injection one week later and then (1) IM injection each month for the past 3 months. He is moving better, but still not 100%. Awesome atittude, weight etc. Should I consider Polyglycan IA or switch to Legend or Adequan or just shut up and do IRAP?! My friend who has a retired endurance horse had fabulous results with IRAP. Thank you! Dr. David Frisbie: I would suggest trying injecting the joints that are sore directly, I use Vetalog and Hyvisc. Comment from Guest: Why do you feel that fetlock joints are difficult to treat for arthritis? Dr. David Frisbie: The fetlock joint is a little less forgiving than other joints. Comment from Guest: Is fusion of the hock best for the horse or using other medications in a moderate/ significantly DJD hock. And would you happend to know how much a fusion cost and is it a high risk surgery? Dr. Craig Shoemaker: In moderate DJD of hock intra-articular injections (corticosteroids/ha) are helpful. Surgical fusion runs approx. $ Comment from Guest: Can surpass be used on backs? Dr. Craig Shoemaker: The penetration of the liposomes used in Surpass have a limited depth...however, surperficial inflammation can be responsive to treatment. Comment from Guest: I thought Legend had no long term benifits? how often wold you sugest for a 17 year old active horse for pervention of stifle problems? Dr. David Frisbie: It has been show to have effects that last for greater than a month after administration. I would suggest using it twice a month IV. Comment from Guest: I hear so much about NSAID s, and side effects, what is the safety of Surpass in that aspect? Dr. Craig Shoemaker: Surpass has ad vantages due to the liposomal delivery technology. This allows you to treat locally without a great deal of systemic uptake. Comment from Guest: What is the process for joint fusion? Dr. David Frisbie: It depends on the joint you are fusing. This would be something to discuss with you veterinarian regarding all of the surgical and potentially non-surgical options. Comment from Guest: If I am applying surpass topically, how does it get to the joint? Dr. Craig Shoemaker: Liposomes help deliver the NSAID diclofenac across the skin to the deeper structures. Comment from Guest: What is your advice with hocks and osteophytes? My showjumping mare starts to buck when pain arises in hocks. She has osteophytes and we have injected her with Hyvisc and Depomedrol. She is better. We have also used Tildren. For more information on equine health, care and management, visit TheHorse.com 7

8 Dr. David Frisbie: Some horses have osteophytes in their hock without signs of pain. So hock spurs are not always the same as soreness. I would retreat the hock when it becomes sore again. Comment from Guest: Would you use Surpass for a while before injections, then? Dr. Craig Shoemaker: Early inflammation or when swelling/heat appear is when you d initially want to start Surpass treatment. IA steroids/ha have a different mechanism of action. I would continue use of Surpass in conjunction with these other products...there is an additional benefit with Surpass in these cases. Comment from Guest: Would Surpass be an appropriate alternative for chronic pain management? (more then 10 days?) Dr. Craig Shoemaker: Absolutely, in the older horse population or with chronic OA Surpass is a great choice due to the lower amount of systemic absorption. You can treat the joint, not the entire body Comment from Guest: I most often see ultrasound as beneficial to tendon issues. Do you agree and do you feel it has any benefit for arthritis? Dr. David Frisbie: It can be helpful in the right hands for diagnosing joint issues, especially in the stifle. It is joint dependant. Comment from Guest: which drug company makes Surpass Dr. Craig Shoemaker: Boehringer-Ingelheim. Comment from Guest: You still never answered the question about the beginnigns of Ringbone. Dr. Craig Shoemaker: Sorry, ringbone is typically associated with repetitive trauma/stress or acute injury. Factors like conformation also play a role Comment from Guest: What evidence of anti-inflammatory/chondroprotective properties of avacodo soybean unsuponifiables has been shown in vivo in horses? Dr. David Frisbie: Try this reference evaluation of avocado and soybean unsaponifiable extracts for treatment of horses... Kawcak CE, Frisbie DD, McIlwraith CW, Werpy NM, Park RD. Am J Vet Res Jun;68(6): Comment from Guest: How long does the typical IA of corticosteriods and HA work? And which one has been shown to be most successful? Dr. Craig Shoemaker: Depends on the corticosteroid used and the degree of disease and use of horse. For high motion joints I recommend triamcinolone (Vetalog)tion such as hock Depomedrol. Vetalog has been shown in studies to be protective. Comment from Guest: Can a vet see cartiledge thinning on an x-ray? Dr. David Frisbie: You can not actually see cartilage on an x-ray but in some joints they are more narrow when the cartilage is missing. Comment from Guest: May I associate Surpass and DMSO (as a carrier) for joints, or even soft tissues? For more information on equine health, care and management, visit TheHorse.com 8

9 Dr. Craig Shoemaker: You should not use Surpass in conjuction with other topicals especially DMSO. DMSO use will damage the liposomes that carry the drug and render the product ineffective. It also has the potential to change testable drug levels in performance horses Comment from Guest: What are the long term side effects of using corticosteroids IA? Dr. David Frisbie: Corticosteroids, specifically Vetalog, when used appropriately are safe and effective and have not been proven to have long term side effects on the joints.i would go with Legend 2X a month if you need to use one or the other. Comment from Guest: Would you recomend and how often combination of Adequan and Legand? I understand both are recomended two times a month. would you use one of each or 2 doses of one or the other? Not sure I can aford to give 4 doses every month. Dr. David Frisbie: I would go with Legend 2X a month if you need to use one or the other. For more information on equine health, care and management, visit TheHorse.com 9