GENERAL PRINCIPLES FOR TREATMENT OF EQUINE JOINT DISEASES

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1 GENERAL PRINCIPLES FOR TREATMENT OF EQUINE JOINT DISEASES Martin Waselau, Dr.med.vet, MS Diplomate ACVS, Diplomate ECVS - University of Helsinki - Eläinlääketieteellinen tiedekunta / Faculty of Veterinary Medicine

2 OUTLINE Clinical presentation of joint disease Pathophysiology General goals of treatment Expectations Conservative treatment Controlled exercise programs Systemic and local medications Shock wave; orthobiologics etc. Surgical treatment 2

3 CLINICAL PRESENTATION OF JOINT DISEASE Typically: Joint effusion Pain on palpation and/or manipulation Lameness But also: Exercise intolerance Poor performance IMPORTANT: Detailed history Clinical and lameness examination Radiographs, ultrasonography etc.... 3

4 CLINICAL PRESENTATION OF JOINT DISEASE 4

5 PATHOPHYSIOLOGY Traumatic joint diseases Trauma & inflammation Enzymatic cartilage degradation... 5

6 PATHOPHYSIOLOGY Traumatic joint diseases Enzymatic cartilage degradation Articular cartilage degeneration will result in DJD 6

7 PATHOPHYSIOLOGY Degenerative joint diseases 7

8 GENERAL TREATMENT GOALS AND OPTIONS Treated joints Osteoarthritic joints mainly treated +/- Healthy joints Two main goals: Relief pain and inflammation Stop progression of the disease Maintain joint health Options: Conservative/Medical management (Generalized OA) Surgical intervention (Full-thickness cartilage damage) 8

9 CONSERVATIVE THERAPY 9

10 I. SYSTEMIC TREATMENTS NSAIDs Mechanism of action: 10

11 I. SYSTEMIC TREATMENTS NSAIDs Indications: Typically used for acute injuries (reduce inflammation) Management of chronic OA (pain relief) Drugs and dosages: COX-1/2 inhibitors +/- selective COX-2 inhibitors 11

12 I. SYSTEMIC TREATMENTS NSAIDs Adverse effects: Gastrointestinal, renal and hematological Long-term use Rule out underlying disease Ensure appropriate water and food consumption 12

13 I. SYSTEMIC TREATMENTS Hyaluronic acid Hyaluronic acid = HA Normal component of joint fluid and articular cartilage Mechanism of action = not 100% known Anti-inflammatory - Granulocytes and macrophages - Inhibition of chemotaxis and phagocytosis - Lymphocytes - Reduction in stimulation, proliferation and migration - Free radical scavanger - Decreases formation and release of prostaglandins Stimulation of HA synthesis... 13

I. SYSTEMIC TREATMENTS Hyaluronic acid Indications: Acute synovitis Maintain general health; supportive therapy Treatment of multiple lesions (tendon

14 I. SYSTEMIC TREATMENTS Hyaluronic acid Indications: Acute synovitis Maintain general health; supportive therapy Treatment of multiple lesions (tendon sheaths/joints) Adjunct therapy Drugs and dosages: i.v. application of Hyonate 40mg/horse every 2 weeks (2-3x) Adverse effects: Not observed after i.v. administration 14

15 I. SYSTEMIC TREATMENTS PSGAG PSGAG: = Polysulfated glucosaminoglycane From bovine lung and trachea Contains mainly chondroitin sulfate Mechanism of action = not 100% known: HA synthesis Anti-inflammatory - Inhibition of interleukines, matrix metalloproteinases, prostaglandins etc. - Effect on synthesis and degradation of proteoglycane 15

I. SYSTEMIC TREATMENTS PSGAG Indications: Maintain general health; supportive therapy Treat multiple lesions joints Adjunct therapy Drugs and dosages: Adequan

16 I. SYSTEMIC TREATMENTS PSGAG Indications: Maintain general health; supportive therapy Treat multiple lesions joints Adjunct therapy Drugs and dosages: Adequan 500mg i.m. every 3-5 days for at least 5 treatments Practical: - 1 st month = 1 injection/week - 2 nd month =1 injection/2 weeks - 3 rd months = 1injection/month 16

17 I. SYSTEMIC TREATMENTS Glucosamin/chondroitin Mechanism of action: Provide components for cartilage synthesis Building bocks Poor scientific evidence Indications: See PSGAG Drugs and dosages: Several available products; oral application Poor bioavailability 17

18 I. SYSTEMIC TREATMENTS Future therapies Pentosan sulphate Multiple joint involvement 3mg/kg i.m. nce weekly for 4 weeks Bisphosphonates E.g. Tildren for NB-syndrome and bone spavin Adapted from human medicine osteoporosis therapy Reduces osteoclastic action Single injections or infusion Tetracyclines Anti-inflammatory effect 18

19 II. LOCAL TREATMENTS Corticosteroids Mechanism of action: 19

20 II. LOCAL TREATMENTS Corticosteroids Mechanism of action: Potent anti-inlammatory = pain relief Being used since 1950 s Indications: Mainly for management of clinically confirmed joint changes - OA - Not acute traumatic joint diseases Contraindication: Infectious arthritis 20

II. LOCAL TREATMENTS Corticosteroids Drugs:

Medrol - Potentially chondrodestructive - Low

21 II. LOCAL TREATMENTS Corticosteroids Drugs: Betamethasone = Celestone Triamcinolone = Vetalog - Chondroprotective? - High-motion joints Methyl prednisolone = Depo Medrol - Potentially chondrodestructive - Low motion joints - Long-acting Combinations: Frequently with hyaluronic acid 21

22 II. LOCAL TREATMENTS Corticosteroids Dosages: Aftercare 1-3 days stall rest 22

23 II. LOCAL TREATMENTS Corticosteroids Adverse effects: Mainly local and not systemically Cartilage damage - Prevents anabolism - Potentially not true for inflammed or abnormal joints... Laminitis (0.5%) - Excessive dosages not 100% clear - Ponies - General guidlines - > 18mg triamcinolone?? - > 200mg methyl prednisolon?? - > 30mg betamethasone?? 23

24 II. LOCAL TREATMENTS Hyaluronic acid Mechanism of action: Refer to systemic therapy Viscosupplementation Indications: Refer to systemic therapy Adjunctive, rarely single use 24

II. LOCAL TREATMENTS Hyaluronic acid Drugs: Large variety of products available molecular weight differs General rule - The higher molecular weight, the better effect - < 500kDa = little

25 II. LOCAL TREATMENTS Hyaluronic acid Drugs: Large variety of products available molecular weight differs General rule - The higher molecular weight, the better effect - < 500kDa = little effect Could, but should not be used as single intraarticular therapy - Excessive synovitis and pain joint flare... - Better: in combination with corticosteroids - Simultaneously anti-inflammatory 25

26 II. LOCAL TREATMENTS Hyaluronic acid Dosages: Mostly - Single injection and re-evaluate lameness Most benefit - 20mg/ once weekly for 3 weeks, but 26

27 II. LOCAL TREATMENTS Orthobiologics IRAP: Mechanism: Interleukin-1 receptor antagonist Blocks inflammatory receptor and thus, inflammation Produced from patients own blood 27

28 II. LOCAL TREATMENTS Orthobiologics 28

29 II. LOCAL TREATMENTS Orthobiologics IRAP: Indication - Early stages of joint disease - High motion joints Application treatments (1-8ml) 8-14 days apart - Left overs can be -18 C for later use 29

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31 II. LOCAL TREATMENTS Orthobiologics PRP: Platelet rich plasma Degranualation of platelets = release of growth factors Growth factors support healing / anti-inflammatory? No clear evidence in equine Adapted from human medicine 31

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33 II. LOCAL TREATMENTS Shock wave Mechanism of action: Mainly unknown anecdotal reports... Analgesia Reduction in synovial protein levels... 33

34 SURGICAL THERAPY 34

35 SURGICAL TREATMENT Diagnostic arthroscopy Gold standard direct evaluation of joint health Benefit of lavage inflammatory mediators flushed out Surgical arthroscopy Removal of osteochondral fragments Reconstruction of articular fractures Synovectomy Joint resurfacing Articular grafting 35

36 SURGICAL TREATMENT 36

37 SURGICAL TREATMENT Arthrodesis Fusion of joint = salvage procedure 37

38 REFERENCES Textbooks Further study material Upon request 38

39 Q U E S T I O N S? 39

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