Published by the Florida Association of Equine Practitioners, an Equine-Exclusive Division of the Florida Veterinary Medical Association Issue 2 â€¢ 2016 LUMBOSACRAL AND SACROILIAC DISEASES IN HORSES JEAN-MARIE DENOIX | DVM, DACVSMR, PHD, ISELP CERTIFIED INSTRUCTOR, FOUNDER AND PRESIDENT OF ISELP
INDICATIONS FOR BISPHOSPHONATES: WHAT IS THE EVIDENCE? TARALYN MCCARREL | DVM, DACVS-LA
HOW TO MANAGE THE CHALLENGING COLIC WHEN REFERRAL IS NOT AN OPTION DAVID E. FREEMAN | MVB, PHD, DACVS
Your Invitation to
A tte n d
SAN JUAN, PUERTO RICO
OCTOBER 19-23, 2016
WORLD-CLASS EQUINE-EXCLUSIVE CONTINUING EDUCATION
OSPHOS® (clodronate injection)
The new FDA approved intramuscular bisphosphonate injection for navicular syndrome from Dechra Veterinary Products
Bisphosphonate For use in horses only. Brief Summary (For Full Prescribing Information, see package insert) CAUTION: Federal (USA) law restricts this drug to use by or on the order of a licensed veterinarian. DESCRIPTION: Clodronate disodium is a non-amino, chloro-containing bisphosphonate. Chemically, clodronate disodium is (dichloromethylene) diphosphonic acid disodium salt and is manufactured from the tetrahydrate form. INDICATION: For the control of clinical signs associated with navicular syndrome in horses. CONTRAINDICATIONS: Horses with hypersensitivity to clodronate disodium should not receive OSPHOS. WARNINGS: Do not use in horses intended for human consumption. HUMAN WARNINGS: Not for human use. Keep this and all drugs out of the reach of children. Consult a physician in case of accidental human exposure. PRECAUTIONS: As a class, bisphosphonates may be associated with gastrointestinal and renal toxicity. Sensitivity to drug associated adverse reactions varies with the individual patient. Renal and gastrointestinal adverse reactions may be associated with plasma concentrations of the drug. Bisphosphonates are excreted by the kidney; therefore, conditions causing renal impairment may increase plasma bisphosphonate concentrations resulting in an increased risk for adverse reactions. Concurrent administration of other potentially nephrotoxic drugs should be approached with caution and renal function should be monitored. Use of bisphosphonates in patients with conditions or diseases affecting renal function is not recommended. Administration of bisphosphonates has been associated with abdominal pain (colic), discomfort, and agitation in horses. Clinical signs usually occur shortly after drug administration and may be associated with alterations in intestinal motility. In horses treated with OSPHOS these clinical signs usually began within 2 hours of treatment. Horses should be monitored for at least 2 hours following administration of OSPHOS. Bisphosphonates affect plasma concentrations of some minerals and electrolytes such as calcium, magnesium and potassium, immediately post-treatment, with effects lasting up to several hours. Caution should be used when administering bisphosphonates to horses with conditions affecting mineral or electrolyte homeostasis (e.g. hyperkalemic periodic paralysis, hypocalcemia, etc.). The safe use of OSPHOS has not been evaluated in horses less than 4 years of age. The effect of bisphosphonates on the skeleton of growing horses has not been studied; however, bisphosphonates inhibit osteoclast activity which impacts bone turnover and may affect bone growth. Bisphosphonates should not be used in pregnant or lactating mares, or mares intended for breeding. The safe use of OSPHOS has not been evaluated in breeding horses or pregnant or lactating mares. Bisphosphonates are incorporated into the bone matrix, from where they are gradually released over periods of months to years. The extent of bisphosphonate incorporation into adult bone, and hence, the amount available for release back into the systemic circulation, is directly related to the total dose and duration of bisphosphonate use. Bisphosphonates have been shown to cause fetal developmental abnormalities in laboratory animals. The uptake of bisphosphonates into fetal bone may be greater than into maternal bone creating a possible risk for skeletal or other abnormalities in the fetus. Many drugs, including bisphosphonates, may be excreted in milk and may be absorbed by nursing animals. Increased bone fragility has been observed in animals treated with bisphosphonates at high doses or for long periods of time. Bisphosphonates inhibit bone resorption and decrease bone turnover which may lead to an inability to repair micro damage within the bone. In humans, atypical femur fractures have been reported in patients on long term bisphosphonate therapy; however, a causal relationship has not been established. ADVERSE REACTIONS: The most common adverse reactions reported in the field study were clinical signs of discomfort or nervousness, colic and/or pawing. Other signs reported were lip licking, yawning, head shaking, injection site swelling, and hives/pruritus.
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The President's Line Ruth-Anne Richter, BSc (Hon), DVM, MS - FAEP President
Dear Fellow Equine Practitioners, In this issue, we have provided you with our first detailed look at our 12th Annual Promoting Excellence Symposium (PES) program, to which I am extending a personal invitation for you to attend. It would be great to welcome you to San Juan, Puerto Rico for PES, which we have designed to offer you an exceptional CE opportunity coupled with a unique ‘getaway’ experience, where you can enjoy all that a beautiful tropical environment has to offer. This year for the first time, PES is offering a scientific program that includes two wet labs. We are excited to be able to offer a detailed, full-day ultrasound wet lab that will incorporate in-depth musculoskeletal as well as abdominal and thoracic ultrasound techniques. Our reproduction lab will provide veterinarians with instruction, discussion of equipment and supplies, and hands-on practice for ultrasound guided transvaginal oocyte aspiration, oocyte recovery, and handling and processing. Our collaboration with 14 leaders in equine veterinary medicine will provide attendees with new knowledge to optimize the care of the equine athlete. We are proud that our symposium has evolved to establish itself as a world-class CE provider, and we look forward to seeing you in Puerto Rico. The center spread of this issue provides you with all the information about our program’s wet labs and lectures, as well as registration, room reservations at our remarkable host hotel, and the special activities we have planned for your relaxation, pleasure and networking with colleagues and friends. FYI, US citizens do not require a passport to travel to Puerto Rico. FAEP is grateful for the backing of our educational partners which enables us to hold these quality CE events, and the work of the FVMA staff that make them happen. We also appreciate your continued support of our conferences. We welcome your questions, comments and suggestions and encourage you to make contact with our FAEP council members or the FVMA staff. Ruth-Anne Richter
FAEP Council President 2016
DVM, MS, DACT FAEP COUNCIL PAST PRESIDENT
Suzan C. Oakley, DVM, DACVSMR, MS, DABVP(Equine), Cert. ISELP email@example.com
Anne L. Moretta, VMD, MS, CVSMT firstname.lastname@example.org
Armon Blair, DVM email@example.com
Adam Cayot, DVM firstname.lastname@example.org
Amanda M. House, DVM, DACVIM REPRESENTATIVE TO FVMA EXECUTIVE BOARD email@example.com
Mr. Philip J. Hinkle EXECUTIVE DIRECTOR firstname.lastname@example.org
Jacqueline S. Shellow, DVM, MS email@example.com
Opinions and statements expressed in The Practitioner reflect the views of the contributors and do not represent the official policy of the Florida Association of Equine Practitioners or the Florida Veterinary Medical Association, unless so stated. Placement of an advertisement does not represent the FAEP’s or FVMA’s endorsement of the product or service. FAEP | 7207 MONETARY DRIVE, ORLANDO, FL 32809 | PH: (800) 992-3862 | FAX: (407) 240-3710 | EMAIL: INFO@FVMA.ORG | WEBSITE: WWW.FAEP.NET
A NEW dual ingredient injectable corticosteroid approved by the FDA exclusively for use in horses
The link between FAST-ACTING and
LONG-LASTING relief 1, 2
New BetaVet ® (betamethasone sodium phosphate & betamethasone acetate injectable suspension) is indicated for the control of pain and inflammation associated with osteoarthritis in horses. Learn more at www.betavetequine.com or call 1-800-458-0163.
Please see Brief Summary of Full Prescribing Information on the following page. From the manufacturer of Adequan® (polysulfated glycosaminoglycan)
INDICATION: BetaVet® is indicated for the control of pain and inflammation associated with osteoarthritis in horses.
IMPORTANT SAFETY INFORMATION For Intra-Articular (I.A.) Use in Horses.
CONTRAINDICATIONS: BetaVet ® is contraindicated in horses with hypersensitivity to betamethasone. Intra-articular injection of corticosteroids for local effect is contraindicated in the presence of septic arthritis. WARNINGS: Do not use in horses intended for human consumption. Clinical and experimental data have demonstrated that corticosteroids administered orally or parenterally to animals may induce the first stage of parturition when administered during the last trimester of pregnancy and may precipitate premature parturition followed by dystocia, fetal death, retained placenta, and metritis. Additionally, corticosteroids administered to dogs, rabbits and rodents during pregnancy have resulted in cleft palate in offspring and in other congenital anomalies including deformed forelegs, phocomelia and anasarca. Therefore, before use of corticosteroids in pregnant animals, the possible benefits to the pregnant animal should be weighed against potential hazards to its developing embryo or fetus. Human Warnings: Not for use in humans. For use in animals only. Keep this and all medications out of the reach of children. Consult a physician in the case of accidental human exposure. PRECAUTIONS: Corticosteroids, including BetaVet , administered intra-articularly are systemically absorbed. Do not use in horses with acute infections. Acute moderate to severe exacerbation of pain, further loss of joint motion, fever, or malaise within several days following intra-articular injection may indicate a septic process. Because of the anti-inflammatory action of corticosteroids, signs of infection in the treated joint may be masked. Due to the potential for exacerbation ®
of clinical signs of laminitis, glucocorticoids should be used with caution in horses with a history of laminitis, or horses otherwise at a higher risk for laminitis. Use with caution in horses with chronic nephritis, equine pituitary pars intermedia dysfunction (PPID), and congestive heart failure. Concurrent use of other anti-inflammatory drugs, such as NSAIDs or other corticosteroids, should be approached with caution. Due to the potential for systemic exposure, concomitant use of NSAIDs and corticosteroids may increase the risk of gastrointestinal, renal, and other toxicity. Consider appropriate wash out times prior to administering additional NSAIDs or corticosteroids. ADVERSE REACTIONS: Adverse reactions reported during a field study of 239 horses of various breeds which had been administered either BetaVet ® (n=119) or a saline control (n=120) at five percent (5%) and above were: acute joint effusion and/or local injection site swelling (within 2 days of injection), 15% BetaVet ® and 13% saline control; increased lameness (within the first 5 days), 6.7% BetaVet ® and 8.3% saline control; loose stool, 5.9% BetaVet ® and 8.3% saline control; increased heat in joint, 2.5% BetaVet ® and 5% saline control; and depression, 5.9% BetaVet ® and 1.6% saline control. DOSAGE AND ADMINISTRATION: Shake well immediately before use. Use immediately after opening, then discard any remaining contents. RX ONLY References: 1.Houdeshell, JW. Field trials of a new long-acting corticosteroid on the treatment of equine arthropathies. Vet Med Small Anim Clin. Sept. 1969: 782-784. 2. Trotter GW. Intra-articular corticosteroids. In: McIlwraith CW, Trotter GW, eds. Joint Disease in the Horse. Philadelphia, PA: W.B. Saunders, 1996;237–256. BetaVet ® is a registered trademark of Luitpold Pharmaceuticals, Inc. © Luitpold Animal Health, division of Luitpold Pharmaceuticals, Inc. 2015. BVT003 Iss. 7/2015
LUITPOLD ANIMAL HEALTH
BRIEF SUMMARY OF PRESCRIBING INFORMATION (Betamethasone Sodium Phosphate and Betamethasone Acetate Injectable Suspension) 6 mg betamethasone per mL For Intra-Articular (I.A.) Use in Horses CAUTION: Federal law restricts this drug to use by or on the order of a licensed veterinarian. DESCRIPTION: BetaVet ® is a sterile aqueous suspension of betamethasone acetate in betamethasone sodium phosphate injection. The combined betamethasone content of the suspension is 6 mg/mL where each mL contains 3.15 mg betamethasone (as betamethasone sodium phosphate); 2.85 mg betamethasone (as betamethasone acetate); 7.1 mg dibasic sodium phosphate; 3.4 mg monobasic sodium phosphate; 0.1 mg edetate disodium; and 0.2 mg benzalkonium chloride, as a preservative in water for injection. The pH is adjusted to between 6.8 and 7.2. INDICATION: BetaVet ® is indicated for the control of pain and inflammation associated with osteoarthritis in horses. DOSAGE AND ADMINISTRATION: Shake well immediately before use. Using strict aseptic technique, administer 1.5 mL BetaVet ® (9 mg total betamethasone) per joint by intra-articular injection. BetaVet ® may be administered concurrently in up to 2 joints per horse. Use immediately after opening, then discard any remaining contents. CONTRAINDICATIONS: BetaVet ® is contraindicated in horses with hypersensitivity to betamethasone. Intra-articular injection of corticosteroids for local effect is contraindicated in the presence of septic arthritis. WARNINGS: Do not use in horses intended for human consumption. Clinical and experimental data have demonstrated that corticosteroids administered orally or parenterally to animals may induce the first stage of parturition when administered during the last trimester of pregnancy and may precipitate premature parturition followed by dystocia, fetal death, retained placenta, and metritis. Additionally, corticosteroids administered to dogs, rabbits and rodents during pregnancy have resulted in cleft palate in offspring. Corticosteroids administered to dogs during pregnancy have also resulted in other congenital anomalies including deformed forelegs, phocomelia and anasarca. Therefore, before use of corticosteroids in pregnant animals, the possible benefits to the pregnant animal should be weighed against potential hazards to its developing embryo or fetus. Human Warnings: Not for use in humans. For use in animals only. Keep this and all medications out of the reach of children. Consult a physician in the case of accidental human exposure. PRECAUTIONS: Corticosteroids, including BetaVet ®, administered intra-articularly are systemically absorbed. Do not use in horses with acute infections. Acute moderate to severe exacerbation of pain, further loss of joint motion, fever, or malaise within several days following intra-articular injection may indicate a septic process. Because of the anti-inflammatory action of corticosteroids, signs of infection in the treated joint may be masked. Appropriate examination of joint fluid is necessary to exclude a septic process. If a bacterial infection is present, appropriate antibacterial therapy should be instituted immediately. Additional doses of corticosteroids should not be administered until joint sepsis has been definitively ruled out. Due to the potential for exacerbation of clinical signs of laminitis, glucocorticoids should be used with caution in horses with a history of laminitis, or horses otherwise at a higher risk for laminitis. Use with caution in horses with chronic nephritis, equine pituitary pars intermedia dysfunction (PPID), and congestive heart failure. Concurrent use of other anti-inflammatory drugs, such as NSAIDs or other corticosteroids, should be approached with caution. Due to the potential for systemic exposure, concomitant use of NSAIDs and corticosteroids may increase the risk of gastrointestinal, renal, and other toxicity. Consider appropriate wash out times prior to administering additional NSAIDs or corticosteroids. ADVERSE REACTIONS: Adverse reactions reported during a field study of 239 horses of various breeds which had been administered either BetaVet ® (n=119) or a saline control (n=120) were: acute joint effusion and/or local injection site swelling (within 2 days of injection), 15% BetaVet ® and 13% saline control;
increased lameness (within the first 5 days), 6.7% BetaVet ® and 8.3% saline control; loose stool, 5.9% BetaVet ® and 8.3% saline control; increased heat in joint, 2.5% BetaVet ® and 5% saline control; depression, 5.9% BetaVet ® and 1.6% saline control; agitation/anxiety, 4.2% BetaVet ® and 2.5% saline control; delayed swelling of treated joint (5 or more days after injection), 2.5% BetaVet ® and 3.3% saline control; inappetance, 3.4% BetaVet ® and 2.5% saline control; dry stool, 1.7% BetaVet ® and 0% saline control; excessive sweating, 0.8% BetaVet ® and 0% saline control; acute non-weight bearing lameness, 0.8% BetaVet®and 0% saline control; and laminitis, 0.8% BetaVet® and 0% saline control. CLINICAL PHARMACOLOGY: Betamethasone is a potent glucocorticoid steroid with anti-inflammatory and immunosuppressive properties. Depending upon their physico-chemical properties, drugs administered intra-articularly may enter the general circulation because the synovial joint cavity is in direct equilibrium with the surrounding blood supply. After the intra-articular administration of 9 mg BetaVet ® in horses, there were quantifiable concentrations of betamethasone (above 1.0 ng/mL) in the plasma. EFFECTIVENESS: A negative control, randomized, masked field study provided data to evaluate the effectiveness of BetaVet ® administered at 1.5 mL (9 mg betamethasone) once intra-articularly for the control of pain and inflammation associated with osteoarthritis in horses. Clinical success was defined as improvement in one lameness grade according to the AAEP lameness scoring system on Day 5 following treatment. The success rate for horses in the BetaVet ® group was statistically significantly different (p=0.0061) than that in the saline group, with success rates of 75.73% and 52.52%, respectively (back-transformed from the logistic regression). ANIMAL SAFETY: A 3-week target animal safety (TAS) study was conducted to evaluate the safety of BetaVet ® in mature, healthy horses. Treatment groups included a control (isotonic saline at a volume equivalent to the 4x group); 1X (0.0225 mg betamethasone per pound bodyweight; BetaVet ®); 2X (0.045 mg betamethasone per pound bodyweight; BetaVet ®) and 4X (0.09 mg betamethasone per pound bodyweight; BetaVet ®). Treatments were administered by intra-articular injection into the left middle carpal joint once every 5-days for 3 treatments. Injection site reactions were the most common observations in all treatment groups. Injection site reactions were observed within 1 hour of dosing and included swelling at the injection site, lameness/stiffness of the left front limb, and flexing the left front knee at rest. The injection site reactions ranged from slight swelling (in many horses on multiple days in all treatment groups) to excessive fluid with swelling, pain, and lameness (4x group only). Injection site reactions were observed most commonly on treatment days, and generally decreased in number and severity over subsequent days. The incidence of injection site reactions increased after the second and third injection (number of abnormalities noted on day 10 > day 5 > day 0). In the BetaVet ® treated groups the number and severity of the injection site reactions were dose dependent. The 4X BetaVet ® group had the highest overall incidence of and severity of injection site reactions, which included heat, swelling, pain, bleeding, and holding the limb up at rest. The control group and 4X group (which received similar injection volumes) had a similar incidence of injection site reactions; however, the severity of reactions was greater in the 4X group. Absolute neutrophils were statistically significantly higher in the BetaVet ® treated groups as compared to the control group. Trends toward a decrease in lymphocytes and eosinophils, and an increase in monocytes were identified in the BetaVet ® treated groups after the initial dose of BetaVet ®. Individual animal values for white blood cells generally remained within the reference range. BetaVet ® treated horses also had a trend toward increased blood glucose after the initial dose. Some individual animals showed mild increases in blood glucose above the reference range. STORAGE CONDITIONS Store at 20° to 25°C (68° to 77°F) (See USP Controlled Room Temperature). Protect from light. Use carton to protect contents from light until used. HOW SUPPLIED BetaVet ®, One 5 mL vial containing 30 mg betamethasone; packaged in boxes of 1. SHAKE WELL BEFORE USING NADA 141-418, Approved by FDA
A Division of Luitpold Pharmaceuticals, Inc. One Luitpold Drive | P.O. Box 9001 | Shirley, NY 11967
Lumbosacral and Sacroiliac Diseases in Horses J.-M. DENOIX | DVM, DACVSMR, PhD, ISELP CERTIFIED INSTRUCTOR Introduction An objective assessment of back pain and a clear identification of the cause(s) of the pain are not easy in horses. Osteoarticular thoracolumbar lesions have been well documented in horses (Jeffcott 1975, 1980, Denoix 1999). Several papers have been published on the clinical and nuclear scintigraphic evaluation of the sacroiliac joint (Dyson, 2003). But little attention has been given to the lumbosacral junction (Denoix, 2004). Our routine diagnostic approach of low back pain in horses includes a complete radiographic examination of the lumbar spine, down to the fourth lumbar vertebra (L4) (Denoix, 1999), and a transrectal ultrasonographic evaluation of the caudal part of the lumbar spine (from L4 to L6), lumbosacral junction and sacroiliac joint (Denoix, 2004). In a lot of sport and race horses, nuclear scintigraphy is also used to help localize bone pathology in these areas.
Complaints-Anamnesis There are a number of different problems that can be related to lumbosacroiliac (LSI) pain. Generally speaking, affected horses present performance limitations (such as asymmetrical lateral bending, lack of engagement, lack of propulsion and defenses for sport horses, or asymmetrical gait at high speed for trotters without hind limb lameness.
Clinical Examination At physical examination, muscle atrophy can be seen in the lumbosacral area and can involve the gluteal muscles. But a number of horses with LSI lesions do not present any muscle atrophy (amyotrophy). Amyotrophy of the gluteofemoralis muscle is more specific of sacroiliac (SI) lesion. Asymmetry of the tuber sacrale can be seen in acute pelvis lesions such as fractures and interosseus SI ligament rupture; it is more often found in
horses with chronic hind limb lameness or asymmetrical gait; the tuber sacrale being higher on the side of the sounder limb. Some horses with lumbosacral (LS) pain show a reduction of flexion and extension movements during active mobilization induced by digital stimulation; pressure over the tuber sacrale more often induces sinking (flexion) of the hind limbs in trotters than in sport horses. Dynamic evaluation is first made during walking. Horses with LSI pain can present a restricted gait with short strides, especially on short circles. At examination from the side at trot, the passive flexion and extension movement of the LS joint can be assessed, as well as the gait amplitude, engagement, and propulsion of the hind limbs. If lameness is present, it will be investigated using a classical approach, but horses with LSI pain often do not present specific asymmetry at walk and trot. Cantering in lunge in a deep footing is a useful situation to assess the horse's power and strength on the hind legs. Defect of dissociation or engagement of the hind limbs or wrong placement of the inside hind limb is often seen in horses with LSI problems. Examination of the horse being ridden, or on the track (for Standardbred trotters), may help to highlight the gait abnormalities.
Diagnostic Imaging Our routine approach is based on the combination of radiographic examination of the lumbar spine (down to L4) on the standing horse and transrectal ultrasonographic examination of the joints of the pelvis (Figure 1). Abnormal radiographic findings in the lumbar vertebral column include: • kissing of the spinous processes, especially between L4-L5 or L5-L6; • osteoarthrosis of the articular process joints; • ventrolateral spondylosis on the vertebral bodies.
Figure 1: Median ultrasonographic section of a normal lumbosacral disc. The disc is homogenously echogenic between the sixth lumbar vertebra (L6) and the first sacral vertebra (S1) and moderately convex ventrally. 1- Lumbosacral disc.
FLORIDA-ASSOCIATION -OF-EQUINE-PRACTITIONERS | The Practitioner 7
Figure 2: Median ultrasonographic section of a pathologic lumbosacral disc presenting extensive fissuration (arrowheads) in a 6 year-old Standardbred trotter. On the in vivo ultrasound scans (images on the right) the cranial part of the disc is anechogenic and a hyperechogenic line (arrowhead) indicates the limit between the disc material and the fluid cavity. On the post mortem specimen (image on the left) there is an extensive fissuration of the lumbosacral disc between the sixth lumbar vertebra (L6) and the first sacral vertebra (S1). 1- Lumbosacral disc. Figure 3: Normal appearance of the sacroiliac joint at transrectal ultrasonographic examination. The joint margin of the sacrum and ilium are smooth and regular and the ventral sacroiliac ligament is homogenous and clearly imaged. 1Sacral wing (transverse process of S1); 2- Ilium; 3- Ventral sacroiliac ligament; 4- Cranial gluteal vessels.
Figure 4: Marked periarticular remodeling of the auricular surface of the ilium (arrowhead) on 2 different horses. The ventral sacroiliac ligament looks heterogenous. 1- Sacral wing (transverse process of S1); 2- Ilium; 3- Ventral sacroiliac ligament; 4Cranial gluteal vessels.
Figure 5: Marked remodeling at the distal insertion of the ventral sacroiliac ligament on the ilium (arrowhead). 1- Sacral wing (transverse process of S1); 2- Ilium.
Abnormal ultrasonographic findings seen at the LS junction detected with ultrasonography include: • congenital abnormalities such as lumbosacral ankylosis (sacralisation of L6) or intervertebral ankylosis between L5 and L6; • disc-degenerative lesions, especially of the lumbosacral disc. These lesions, include fissuration or cavitation of the disc (Figure 2), dystrophic mineralization, and ventral herniation; • intervertebral malalignment (spondylolisthesis) of the
lumbosacral joint or the joint between L5 and L6; • intertransverse lumbosacral osteoarthrosis: periarticular osteophytes, remodeling on the joint margins, and even synovitis can be seen. Abnormal findings seen at the ventral aspect of the sacroiliac joint (Figure 3) as assessed with ultrasonography include: • bone remodeling of the sacrum and/or ilium (Figure 4); • periarticular osteophytes of the auricular surfaces; • ventral sacroiliac ligament desmopathy or enthesopathy (Figure 5).
8 The Practitioner
Issue 2 • 2016
Several grades of lesions have been recognized on ultrasonographic images. Grade 3 and 4 are more correlated to clinical manifestations and uptake on scintigrams. Nuclear scintigrams are performed using a dorsal approach of the pelvis (camera horizontal), a dorsocaudal approach (camera parallel to the sacrum), and 2 symmetrical dorsolateral approaches (camera parallel to the coxal bone). Different locations can be identified in the lumbosacroiliac area, taking into account that the ilium is surimposed to the lumbosacral joint. Uptake over the auricular surfaces of the sacroiliac joint is in relation with osteoarticular changes of this joint. Uptakes can be seen between the auricular surfaces and tuber sacrale; these are correlated either to the insertion of the interosseus sacroiliac ligament or the lumbosacral joint. Uptake detected cranially to the auricular surfaces is correlated to the transverse processes of the last 2 lumbar vertebrae and the corresponding intertransverse joints.
Treatment and Management a- Systemic treatment Treatment of lumbosacroiliac pain with systemic administration of non-steroidal anti-inflammatory drugs (NSAIDs) is usually disappointing. When bone lesions are identified, especially involving the sacroiliac joint, biphosphonates are indicated. Tiludronate is injected intravenously in slow perfusion at a total dose of 1mg/Kg bw.
b- Local injections
Lumbosacral conditions Intertransverse arthropathies or disc lesions of the lumbosacral joint are treated by deep paramedian injections of corticosteroids. Injections are made on each side, 4 cm apart from the median plane, using 15cm long needles. These local injections are performed using ultrasonographic guidance (Denoix and Jacquet 2008). Ultrasonographic guided local infiltrations can be performed alone, or in association with mesotherapy (Denoix and Dyson 2011). Sacroiliac conditions To treat sacroiliac joint problems, periarticular injections can be made using cranial and caudal approaches (Denoix and Jacquet 2008). For the cranial approach, needle penetration through the skin is made on a transverse line, joining the cranial aspect of two tuber coxae, 6 cm apart to the median plane. The caudal approach is performed 8-10 cm caudally to the tuber sacrale, 3 cm apart, to the median plane. On each site, a 10x5cm area is clipped short and prepared aseptically. Care should be taken to avoid placing the needle caudal to the sacroiliac joint to avoid any trauma of the sciatic nerve or penetration in the restum.
c- Training management In conjunction with the medical treatment, modification of the training program is an essential part of the management of low back and sacroiliac problems to reduce pain and maintain muscle power. The aims of exercise management are to avoid further muscle atrophy and to develop the back’s proprioceptive control and joint stability. Rest is contra-indicated, except
in untreatable horses that are not improved by any kind of treatment and management.
d- Alternative medicines These techniques have gained a lot of interest in the last years. Once a clear diagnosis of the clinical troubles and lesions is made, if appropriately applied and objectively assessed for each pathological entity, they may be useful in the management of low back and sacroiliac problems in horses.
Selected References: Denoix J.-M, Audigié F. Imaging of the musculoskeletal system in horses. In:Equine Sport Medicine and Surgery, ed Hinchcliff,KW, Kaneps AJ, Geor RJ, Saunders. 2004,161-187 Denoix JM and Dyson S: Thoracolumbar spine. In : Equine lameness. Edited by M. Ross and S. Dyson, Saunders ed., Philadelphia 2011, 592-605 Denoix J.-M. Ultrasonographic evaluation of back lesions. Vet Clin North Am : Equine pract. 1999; 15(1)131-159. Denoix JM: Spinal biomechanics and functional anatomy. Vet Clin North Am: Equine Pract 15:27-60, 1999 Denoix JM: Lesions of the vertebral column in poor performance horses. In Proceedings of the World Equine Veterinary Association, Paris, 1999, 99-109 Denoix J.-M. Ligament injuries of the axial skeleton in the horse : supraspinal and sacroiliac desmopathies. Dubaï International Equine Symposium 1996 ; 273-286. Denoix J.-M. Approche sémiologique des régions lombosacrale et sacro-iliaque chez le cheval. Pratique Vétérinaire Equine 1992 ;24(1)23-28. Dyson SJ. Pelvic injuries in the non-race horses. In: Diagnosis and management of lameness in horses, ed Ross MW, Dyson SJ, Saunders. 2003, 491-500 Haussler KK, Stover SM, Willits NH (1997) Developmental variations in lumbosacropelvicanatomy of thoroughbreds racehorses . Am J Vet Res 58, 1083-1091 Jeffcott LB. The diagnosis of diseases of the horse back. Equine Vet J 1975 ;7(2)69-78. Jeffcott LB. Disorders of the thoracolumbar spine of the horse - a survey of 443 cases. Equine Vet J 1980 ;12(4)197-210.
Jean-Marie Denoix DVM, DACVSMR, PhD, ISELP Certified Instructor, Founder and President of ISELP Dr. Denoix of the CIRALE (Center of Imaging and Research on Equine Locomotor Affections) in Normandy, France is considered the world’s foremost equine musculoskeletal system anatomist as well as a leading equine diagnostic ultrasonographer. Dr. Denoix is a founder and current president of ISELP and was also the 2006 recipient of the Schering Plough Equine Research Award from the World Equine Veterinary Association for outstanding applied research work in Equine Diagnostic Imaging. He has been the invited speaker at many international meetings in more than 30 countries around the world on topics related to clinical examination and imaging of equine locomotor problems.
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10 The Practitioner
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Issue 2 • 2016
SAN JUAN, PUERTO RICO
OCTOBER 19-23, 2016
a Tropical Escape on an Enchanted Isle…
ANN E. DWYER DVM
LAURIE R. GOODRICH DVM, MS, PhD, DACVS
JOHN MADIGAN DVM, MS, DACVIM
ROBERT MACKAY BVSc (Dist), PhD, DACVIM
NEWS HOUR FRIDAY 8:00 AM - 9:45 AM
LAURIE R. GOODRICH DVM, MS, PhD, DACVS
ROBERT MACKAY BVSc, PhD, DACVIM
A presentation of timely topics in equine internal medicine, surgery and sports medicine; and research.
SARAH LE JEUNE DVM, DACVS, DACVSMR, CVA, Cert Vet. Chiro
ALISON MORTON RICHARD D. MITCHELL DVM, MRCVS, DACVSMR DVM, MSpVM, DACVS, DACVSMR
JOHN F. PERONI DVM, MS, DACVS
CONTINUING EDUCATION CREDITS CE Approval:
AAVSB RACE Sponsor of Continuing Education in New York State Florida Board of Veterinary Medicine, DBPR FVMA Provider # 31
SHEILA SCHILS PhD, MS
JENNIFER SKEESICK PT, DPT, SCS
MARY BETH WHITCOMB DVM, MBA, ECVDI(LA-Associate)
~~Registration RegistrationNow NowOpen Open~~
For More Details Visit Our Website WWW.FAEP.NET
Stay Connected on our Social Media Pages
47 Hours of World-Class Equine-Exclusive Continuing Education
No Passp Required ort U.S. Citiz for ens
Indications for Bisphosphonates: What Is the Evidence? TARALYN MCCARREL | DVM, DACVS-LA Bisphosphonates have been the first line of therapy for disorders characterized by excess bone resorption in humans for approximately 40 years. Specific indications include osteoporosis, tumor associated bone resorption, Legg-Calve-Perthes disease, and Paget’s disease.1 The use of bisphosphonates in horses in the United States has become popular more recently, following licensing of tiludronate (Tildren®) and clodronate (Osphos®) for control of the clinical signs associated with navicular syndrome. Tiludronate has been licensed in Europe for several years for the treatment of equine navicular syndrome and distal hock joint osteoarthritis.2 In addition, zoledronate and pamidronate have been investigated for use in horses, but a licensed equine product does not currently exist.2-4 Compared to many medications used on- and off-label in equine practice, the bisphosphonates are very new, with limited research and clinical data published to date. While we currently extrapolate some information from human use, important differences exist between the horse and human, and the disease processes that are being targeted. There are two major classes of bisphosphonates, nitrogenous and non-nitrogenous, that differ in their mechanism of action. The nitrogenous bisphosphonates (zoledronate and pamidronate) interfere with bone resorbing osteoclast metabolism, leading to disruption of activity and death of the cell. The non-nitrogencontaining bisphosphonates (tiludronate and clodronate) produce a toxic ATP analogue that results in osteoclast apoptosis. The nitrogen-containing bisphosphonates have a greater affinity for hydroxyapatite in bone, making them more potent than the non-nitrogenous bisphosphonates. Zoledronate is the most potent bisphosphonate available and has been shown to decrease a plasma biomarker associated with bone resorption (CTX-1) for at least 1 year in horses after a single dose.2 In contrast, tiludronate administered as a slow intravenous infusion, at a dose of 1 mg/kg, significantly decreased CTX-1 levels from baseline for 3 days after treatment in normal horses.5 Bisphosphonates are cleared rapidly from the systemic circulation but persist in bone, being released and active when bone resorption occurs. A preliminary study was able to detect tiludronate in bone biopsies from the tuber coxae, with no decrease detected over time.6 Further investigation on bone levels of bisphosphonates and pharmacokinetics/pharmacodynamics will be important to guide future dosing regimens and to consider possible long-term effects on equine athletes. Bone remodeling is a normal physiologic process that requires a balance between osteoclast and osteoblast activity. Bone remodeling occurs throughout life and is increased during growth, bone healing, and in response to stress. The point at which physiologic bone remodeling becomes pathologic is not clear. Therefore, careful consideration of appropriate timing of inhibition of bone remodeling, based on pathophysiology of the disease process, will be important to maximize benefit and limit complications of therapy. Bisphosphonates are most often used 18 The Practitioner
in aged and relatively sedentary people, while their use in the horse is focused on young to middle-aged athletes. Tiludronate and clodronate are licensed for use in horses over 4 years of age due to concerns for potential negative effects on a growing skeleton. Despite this, some have turned to bisphosphonate therapy for young horses with sesamoiditis. Significantly more work is needed before use of these drugs in young athletes can be considered safe. Bone remodeling is also an essential process during adaptation of bone to stress. The normal response to stress involves microcrack formation and repair via osteoclast-mediated remodeling of these sites. When remodeling is suppressed or microdamage outpaces repair, microcrack accumulation occurs.7 Accumulation of microcracks could ultimately lead to disastrous consequences. In humans, bisphosphonates are predominantly used to treat systemic disease processes. However, in the horse, we are often addressing a focal disease process, admittedly often occurring in more than one limb or multiple locations in the spine. The one exception is bone fragility syndrome. A single intravenous dose of zoledronate has been reported in 10 clinical cases of bone fragility syndrome.3 Improvement or resolution of lameness and improvement in findings on nuclear scintigraphy exam were reported in 9 and 8 horses respectively. Tiludronate was administered twice, 28 days apart, to horses placed on stall rest with one forelimb immobilized in a cast for 8 weeks, to study the effect on disuse osteopenia (cast disease).8 Tiludronate treatment did result in decreased CTX-1 compared to horses that received placebo, and may have improved retention of bone mineral density. However, due to difficulties with some outcome measurements, firm conclusions cannot be drawn at this time regarding the efficacy of tiludronate for ameliorating the effects of immobilization on bone. Tiludronate and clodronate have both been investigated in clinical trials for treatment of navicular syndrome, to obtain FDA approval. A peer-reviewed study evaluating tiludronate for the treatment of navicular syndrome used a total dose of 1 mg/kg IV divided over 10 days, while the study performed for FDA approval utilized a single bolus dose delivered over 30-60 minutes.9,10 Corrective shoeing was permitted, and success was defined as an improvement by 1 or more grades of lameness at 2 months, compared to baseline. At 2-month evaluation, 63.87% of tiludronate-treated horses were classified as successes, compared to 48.39% of the placebo group (p = 0.0479).9 A similar study was performed to investigate clodronate at a dose of 1.4 mg/kg IM (or maximum 900 mg/horse) divided over 3 sites (note: the label dose is 1.8 mg/kg IM or maximum 900 mg/horse).11 Horses were not permitted to have shoeing changes made 2 weeks prior to, or during the study. Treatment success was defined as improvement of 1 or more grade of lameness at 56 days posttreatment. Clodronate treated horses had a 74.7% treatment success rate while placebo horses had a 3.3% success rate (p Issue 2 • 2016
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FLORIDA-ASSOCIATION -OF-EQUINE-PRACTITIONERS | The Practitioner 11
Your Invitation to Attend ENTAL SAN JUAN, PUERTO RICO – INTERCONTIN
AN EXCEPTIONAL SCIENTIFIC PROGRAM FEATURED LECTURE TOPICS:
Comprehensive Ultrasound WET LAB
WEDNESDAY, OCTOBER 19, 2016 | 8:15 AM - 4:30 PM
■ DIAGNOSTIC IMAGING ■ INTERNAL MEDICINE ■ OPHTHALMOLOGY ■ SPORTS MEDICINE Reproduction WET LAB ■ TREATMENT AND REHABILITATION ■ BUSINESS OOCYTE COLLECTION FOR ASSISTED REPRODUCTION AND PROCESSING FOR SHIPMENT ■ & MUCH MORE OF THE EQUINE ATHLETE
THURSDAY, OCTOBER 20, 2016 | 8:15 AM - 12:15 PM
WET LAB VENUE HACIENDA SANTA FE, CARR. 941 KM. 4.8 BO. JAGUAS, GURABO, PR
ur Special Thanks to O
-17 6 1 20
tional Partner a c u s Ed GOLD PARTNERS
LUITPOLD ANIMAL HEALTH
SYMPOSIUM HOST HOTEL
InterContinental San Juan Resort & Spa
5961 ISLA VERDE AVENUE, SAN JUAN, 00979, PUERTO RICO
The 12th Annual Promoting Excellence Symposium, takes us offshore to an enchanted isle famous for its tradition of breeding Paso Fino Champions, and possessing some of the most beautiful shoreline vistas in the world – Puerto Rico! PES 2016 provides attendees an exceptional ‘getaway’ CE opportunity in this Caribbean paradise. RESORT FEE: Resort Fee includes complimentary wireless internet services throughout the hotel, complimentary access and use of fitness center 24-hours a day, complimentary use of chaise lounges at the pool and the beach, complimentary towel service at the pool and beach and complimentary coffee and tea service in the room replenished daily.
FAEP SPECIAL ROOM RATES Rates Include the Hotel's $18 Daily Resort Fee.
Single & Double Occupancy Rates
SELF PARKING: available to conference attendees for $20.00 per day VALET PARKING: attendees may utilize the resort's valet for $25.00 per day The room block is available through September 23, 2016.
Reserve Your Room Today! Call (787) 791-6100, and ask for the special FAEP rates.
ONLY $ 175
Thursday, October 20 7:30 AM – 12:00 PM Cost: $175 per person (6 people per boat) Limited Availability - Reserve Your Reel Today! From October to early March, you experience the finest fishing off San Juan, Puerto Rico. Big game fish are found close to shore where a mile off the San Juan coast, the ocean floor drops 600 feet!! A twenty-minute ride to where the big game fish bite! Anglers will be competing in three award categories: the biggest fish; the most unusual fish; the most fish caught.
Includes: - tackle & gear; - fishing licenses; - bait/chum; - cleaning fish;
LA CAJA CHINA PIG ROAST
A TRADITIONAL CARIBBEAN EXPERIENCE Friday, October 21 7:00 PM – 10:00 PM Cost: Adults: $65 per person Children (3-12yrs): $35
Unique in substance and in style… The FAEP invites you to our Traditional Island Celebration! On the boardwalk of the Intercontinental San Juan Resort overlooking the Caribbean, only steps away from a gorgeous private beach. Featuring: Caja China Pig Roast – Lechón Asado, which is a part of Puerto Rico's national dish! Delicious traditional native cuisine, tropical melodies, dancing, & the exotic ambiance of the Intercontinental San Juan Resort!
FAEP’S ANNUAL FISHING TOURNAMENT
WEDNESDAY, OCTOBER 19, 2016 THURSDAY, OCTOBER 20, 2016 COMPREHENSIVE ULTRASOUND 8:15 AM - 4:30 PM SPONSORED BY:
W E T
WET LAB FEES
L A B
Distinguished imaging instructors will provide intensive handson instruction and guide participants through five stations where theyâ€™ll be trained in the ultrasonography of five distinct anatomical areas of the horse.
STATION 1: Abdomen and Thorax
RUTH-ANNE RICHTER BSc (Hon), DVM, MS STATION 2:
Foot and Pastern
W E T
OOCYTE COLLECTION FOR ASSISTED REPRODUCTION AND PROCESSING FOR SHIPMENT
8:15 AM - 12:15 PM
L A B
ROB FOSS DVM
WET LAB FEES
Assisted reproductive techniques, predominantly ICSI, have become clinically effective and more common in the last several years. Practitioners can now collect oocytes in their practices and ship them to a laboratory for ICSI, and resulting embryos can be shipped back for transfer. This wet lab will provide veterinarians with instruction, discussion of equipment and supplies, and hands on practice for ultrasound guided transvaginal oocyte aspiration (TVA), oocyte recovery and handling, and processing for shipment.
DVM, DACVSMR, DABVP (Equine), Cert. ISELP STATION 3:
Neck and Back
ALLISON MORTON DVM, MSpVM, DACVS, DACVSMR STATION 4:
Metacarpophalangeal Joint and Digital Flexor Tendon Sheath JOHN PERONI DVM, MS, DACVS STATION 5:
THURSDAY, OCTOBER 20, 2016 Time
Grand Ballroom A
1:45 p.m. 2:35 p.m.
Trigeminal Mediated Headshaking Dr. Madigan
2:40 p.m. 3:30 p.m.
Fear Studies/NAD and Other Weird Things Dr. Madigan
WET LAB VENUE: HACIENDA SANTA FE GURABO, PR
For More Details Visit Our Website WWW.FAEP.NET
3:30 p.m. 4:00 p.m.
4:00 p.m. 4:50 p.m.
Seeing Differently (Equine Ophthalmology Basic Exam) Dr. Dwyer
4:55 p.m. 5:45 p.m.
Contracts, Compensation, and Contentment Dr. Dwyer
5:35 p.m. 7:00 p.m.
Reception & Social Hour - Visit the Exhibit Hall
-A-GLANCE FRIDAY, OCTOBER 21, 2016 Time
Grand Ballroom A
Grand Ballroom B-C
Distinguished Panelists 8:00 a.m. - 9:45 a.m.
➢ Dr. Goodrich ➢ Dr. MacKay
SATURDAY, OCTOBER 22, 2016 Time 8:00 a.m. 8:50 a.m.
8:55 a.m. 9:45 a.m.
Grand Ballroom A
Grand Ballroom B-C
Best Practices in Equine Ultrasound
The Biomechanics of Protocol Development
When You Can’t Find the Elephant: Ultrasound and the Challenging Hind Limb Lameness
Current Topics in Human Rehabilitation and the Application to Equine Practice
Dr. Whitcomb 9:45 a.m. 10:30 a.m. 10:30 a.m. 11:20 a.m.
11:25 a.m. 12:15 p.m. 12:15 p.m. 1:45 p.m. 1:45 p.m. 2:35 p.m.
2:40 p.m. 3:30 p.m.
AM Break - Visit the Exhibit Hall Evaluation and Treatment of Pastern Lameness
Tracks of My Tears Corneal Conditions Seen in the Field
Update on Biologic Therapies
The Many Faces of Uveitis
Complimentary Lunch in the Exhibit Hall Stem Cells - Latest Research and Applications - What/ When Does it Work?
Neurosteroids, Maladjustment, and Squeezing
Regional Limb Perfusion
New Neurological Findings Associated with Pentobarbital Euthanasia and a New Method for Field Euthanasia When Barbiturates Cannot Be Used
Dr. Madigan 3:20 p.m. 4:00 p.m. 4:00 p.m. 4:50 p.m.
PM Break - Visit the Exhibit Hall Laminitis: a Workshop on the Wooden Shoe
Dr. Peroni Lameness Panel
9:45 a.m. 10:30 a.m. 10:30 a.m. 11:20 a.m.
11:25 a.m. 12:15 p.m. 12:15 p.m. 1:35 p.m.
Neurologic Case Studies
4:55 p.m. 5:45 p.m.
Dr. Peroni & Dr. Morton
5:45 p.m. 7:00 p.m.
Reception & Social Hour - Visit the Exhibit Hall
CE CREDITS / HOURS This program 532-26211 is approved by the AAVSB RACE to offer a total of 43.00 CE Credits (31.00 max) being available to any one veterinarian: and/or 43.00 Veterinary Technician CE Credits (31.00 max). This RACE approval is for the subject matter categorie(s) of: Category One: Scientific Category Three: Non-Scientific-Practice Management/Professional Development using the delivery method(s) of: Seminar/LectureLab/Wet Lab. This approval is valid in jurisdictions which recognize AAVSB RACE; however, participants are responsible for ascertaining each board's CE requirements.
Ultrasound of Rehabilitation Protocols for Musculoskeletal Various Treatment Methods Infections: Synovial Sepsis and Modalities: WHY? and Osteomyelitis
Dr. le Jeune
Update on Surgical Procedures in the Performance Horse
Distal Limb Rehabilitation Protocols
Complimentary Lunch in the Exhibit Hall
1:35 p.m. 2:25 p.m.
Evidence and Applications for Bisphosphonate Therapy
2:30 p.m. 3:20 p.m.
The Use of Complimentary Imaging Modalities for the Diagnosis of Lameness
Dr. Morton 3:20 p.m. 4:20 p.m. 4:20 p.m. 5:10 p.m.
EPM: Diagnosis, Treatment, and Relapses
AM Break - Visit the Exhibit Hall
5:15 p.m. 6:05 p.m.
Biomechanical Evaluation of Rehabilitation Timelines
Dr. Schils Select Rehabilitation Protocols From Human Practice
PM Break - Visit the Exhibit Hall Rehabilitation Protocols for Various Treatment Methods and Modalities: WHEN?
Dr. le Jeune The Elite Athlete Rehabilitation: Rehabilitation Techniques When Preparing for Competition vs Rehabilitation Techniques During Competition
SUNDAY, OCTOBER 23, 2016 Time 8:00 a.m. 9:45 a.m. 9:45 a.m. 10:30 a.m. 10:30 a.m. 12:15 p.m.
Grand Ballroom A Rehabilitation Case Studies 1-2
Dr. Schils, Dr. Mitchell, Dr. Skeesick, Dr. le Jeune AM Break Rehabilitation Case Studies 3-4
Dr. Schils, Dr. Mitchell, Dr. Skeesick, Dr. le Jeune
EASY WAYS TO REGISTER
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FAEP/FVMA Member On or Before September 19 q $495.00 After September 19 q $545.00 To register at the discounted member rate, your 2016 FAEP/FVMA dues must be current!
FAEP/FVMA New Membership Fee
q My FAEP/FVMA membership is current q Yes, I would like to take advantage of the FAEP/FVMA joint membership special offer and register for the 12th Annual Promoting Excellence Symposium as a member! I qualify for the following Membership Category (please check one) q Regular Member $255.00 q Recent Graduate (within last 2 years) $141.00 q State/Federal Employee $141.00 q Part-Time Employed $141.00 q Non-Resident 104.00
One registration per form. Please duplicate this form for additional registrants.
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Your Registration Includes All of the Following Functions
& SAVE $50 !!
SEPTEMBER 19TH, 2016
PRE-REGISTRATION DEADLINE SEPTEMBER 19, 2016
October 19-23, 2016
OCTOBER 19-23, 2016 • INTERCONTINENTAL SAN JUAN RESORT, PR
Spouse/Guest Registration Fee
CANCELLATION POLICY: CANCELLATION DEADLINE FOR A FULL REFUND OF REGISTRATION FEES MINUS A $50 ADMINISTRATIVE CHARGE IS SEPTEMBER 29TH, 2016. CANCELLATIONS SHOULD BE RECEIVED IN WRITING AND ACKNOWLEDGED BY THE FAEP BY THE ABOVE DATE TO BE ELIGIBLE FOR A REFUND. CANCELLATIONS AFTER THAT DATE AND NO-SHOWS ARE NON-REFUNDABLE.
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Children (Ages 3-12) $35.00 _____
q Check Enclosed Charge my credit card q VISA q MC q AMEX q DISCOVER
( Make checks payable to the FAEP/FVMA)
Adults $65.00 _____
FAEP La Caja China Pig Roast - Friday, October 21, 7:00 PM - 10:00 PM
Wet Lab Fee
Rehab Only Fee
FAEP’s Annual Fishing Tournament – Thursday, October 20, 7:30 AM - 12:00 PM Includes - Transportation, License, Tackle, Bait and 1/2 Day of Fun!
Reproduction Wet Lab – Thursday, October 20, 2016 Lunch and Transportation Included (Space Limited)
Comprehensive Ultrasound Wet Lab – Wednesday, October 19, 2016 Lunch and Transportation Included (Space Limited)
Rehab Track Only – Rehab Professionals (Non-Veterinarians). Includes Exhibit Hall access & Lunch on Saturday (Veterinarians who wish to attend the Rehab Track only, must pay full registration fee.)
Spouse/Guest Registration – Includes Lunch on Friday and Saturday and allows entrance to the Exhibit Hall. Spouses who wish to attend C.E. sessions must pay full registration fee.
12th Annual Promoting Excellence Symposium
= 0.0028). Evaluation of tiludronate for ameliorating clinical signs of distal tarsal joint osteoarthritis found a significantly (p = 0.0318) lower lameness grade in the treated (2.6±1.7) group, compared to placebo (3.3±2.0), based on a 10 grade lameness scale 60 days after treatment. Importantly, these investigations all focus on clinical signs, however to date, there is no published material demonstrating a measurable effect on the structure of bone in horses. Many of the disease processes being targeted for bisphosphonate therapy are focal or multifocal in nature and commonly involve some component of osteoarthritis. Local delivery, either via joint injection or intravenous regional perfusion, has been investigated as well as the effects of bisphosphonates on the articular cartilage.12-14 Investigation of various concentrations of tiludronate applied to interleukin-1 exposed cartilage explants in vitro, found a positive effect of low doses, while higher doses increased chondrocyte death and signs of matrix degeneration.14 High doses of tiludronate (50 mg) injected into normal middle carpal joints resulted in concentrations in the synovial fluid greater than that determined to be safe in vitro. Low-dose tiludronate (0.017 mg) however, achieved concentrations believed to be safe in one study.13 Two doses of tiludronate, 50 mg and 0.5 mg, were delivered to the distal limb of normal horses using intravenous regional limb perfusion.12 There were no differences in synovial fluid parameters between treated and control limb for the coffin and fetlock joint. However, synovial fluid from the coffin joint of 2 horses receiving the high dose treatment had synovial fluid values above that considered to be safe, based on in vitro work.12 These studies were small and preliminary in nature, but further investigation is warranted to determine if bisphosphonates may be used safely intra-articularly; or using intravenous regional limb perfusion, if treatment will be efficacious; and if systemic adverse effects can be avoided using this method of delivery. Adverse events associated with bisphosphonate therapy in humans include renal toxicity and acute phase reactions. Less common but serious complications include osteonecrosis of the jaw, atypical femur fracture, hypocalcemia, gastrointestinal upset, and esophageal cancer.1 Osteonecrosis of the jaw may be related to dental work being performed close to the time of bisphosphonate dosing. Based on the adverse reactions reported in humans, it is prudent to determine renal function and calcium levels prior to delivering bisphosphonate therapy to horses, and monitor postadministration. Self-limiting colic signs are currently the most common adverse event reported in horses. However, continued close monitoring and reporting of potential related complications is essential to detect currently unknown potential consequences.
1. Xu XL, Gou WL, Wang AY, et al. Basic research and clinical applications of bisphosphonates in bone disease: what have we learned over the last 40 years? J Transl Med. 2013;11:303. 2. Nieto JE, Maher O, Stanley SD, Knych HK, Snyder JR. Pharmacokinetics, pharmacodynamics, and safety of zoledronic acid in horses. Am J Vet Res. 2013;74(4):550-556.
3. Katzman SA, Nieto JE, Arens AM, et al. Use of zoledronate for treatment of a bone fragility disorder in horses. J Am Vet Med Assoc. 2012;240(11):1323-1328. 4. Gray AW, Davies ME, Jeffcott LB. Generation and activity of equine osteoclasts in vitro: effects of the bisphosphonate pamidronate (APD). Res Vet Sci. 2002;72(2):105-113. 5. Delguste C, Amory H, Guyonnet J, et al. Comparative pharmacokinetics of two intravenous administration regimens of tiludronate in healthy adult horses and effects on the bone resorption marker CTX-1. J Vet Pharmacol Ther. 2008;31(2):108-116. 6. Delguste C, Doucet M, Gabriel A, Guyonnet J, Lepage OM, Amory H. Assessment of a bone biopsy technique for measuring tiludronate in horses: a preliminary study. Canadian journal of veterinary research = Revue canadienne de recherche veterinaire. 2011;75(2):128-133. 7. Laverty S. Osteoarthritis across the species: Should we be treating subchondral bone? Paper presented at: ACVS Surgery Summit2015; Nashville, TN. 8. Delguste C, Amory H, Doucet M, et al. Pharmacological effects of tiludronate in horses after long-term immobilization. Bone. 2007;41(3):414-421. 9. Tiludronate disodium powder for injection, Horse: For the Control of clinical signs associated with navicular syndrome in horses. Ceva Sante Animale;2014. 10. Denoix JM, Thibaud D, Riccio B. Tiludronate as a new therapeutic agent in the treatment of navicular disease: a double-blind placebocontrolled clinical trial. Equine Vet J. 2003;35(4):407-413. 11. Clodronate injection, Horse: For the control of clinical signs associated with navicular syndrome in horses. Dechra, Ltd.;2014. 12. Hunter BG, Duesterdieck-Zellmer KF, Larson MK. Tiludronate concentrations and cytologic findings in synovial fluid after intravenous regional limb perfusion with tiludronate in horses. PeerJ. 2015;3:e889. 13. Duesterdieck-Zellmer KF, Moneta L, Ott JF, et al. Effects of low and high dose intraarticular tiludronate on synovial fluid and clinical variables in healthy horses-a preliminary investigation. PeerJ. 2014;2:e534. 14. Duesterdieck-Zellmer KF, Driscoll N, Ott JF. Concentrationdependent effects of tiludronate on equine articular cartilage explants incubated with and without interleukin-1beta. Am J Vet Res. 2012;73(10):1530-1539.
Taralyn McCarrel, DVM, DACVS-LA Dr. Taralyn McCarrel is a board-certified large animal surgeon and assistant professor in the Department of Large Animal Clinical Sciences at the University of Florida, College of Veterinary Medicine. Dr. McCarrel received her DVM from the Ontario Veterinary College, following which, she completed a rotating internship in large animal medicine and surgery. She performed equine orthopedic and regenerative therapy research at Cornell University, and then transitioned from academia to private practice to complete a residency in equine surgery at Rood and Riddle Equine Hospital. Dr. McCarrel’s major clinical and research interests include regenerative therapies, orthopedic surgery and lameness, and upper airway evaluation and surgery of performance horses.
FLORIDA-ASSOCIATION -OF-EQUINE-PRACTITIONERS | The Practitioner 19
HOW TO MANAGE THE CHALLENGING COLIC
WHEN REFERRAL IS NOT AN OPTION DAVID E. FREEMAN | MVB, PhD, DACVS
Most horses with colic can be treated medically on the farm; but we all can recognize when a horse should be referred to a surgical facility. When that point is reached and the owner declines referral, you must then establish some very clear guidelines for how to proceed. The following questions need to be addressed: Possible reasons why referral is not an option are: 1. Colic surgery is rarely successful. 2. Horse will never be the same after colic surgery. 3. This is a pregnant mare and it will be impossible to save the mare and foal. 4. This is an old horse and old horses do not handle colic surgery well. 5. This horse is much loved/valued, but we cannot justify spending the money on colic surgery in our present financial circumstances. Reason 5 is the only one that is valid. The others are untrue and need to be corrected before the final decision is made. Once the owner elects treatment at home over referral, the following questions arise for the owner to answer: How much am I prepared to spend? What is my financial limit on this horse? How much of my time am I prepared to commit to around-the-clock monitoring and care? Can I handle watching a horse suffer? Is my family supportive of this decision? Will I change my mind or stick to the course? The last question is critical because if referral is a possible option at any point, it should be performed early in the disease process……not after all other medical treatment options have been exhausted and the horse’s cardiovascular status has begun to deteriorate.
Specific Diseases and Recommended Approaches Displacements that are occasionally treated by surgery, such as right dorsal displacement, and impactions of the ileum, cecum, large colon, and small colon can respond to medical treatment, if managed appropriately and given enough time. Entrapment of the colon over the nephrosplenic ligament is usually treated nonsurgically (rolling or phenylephrine) at referral hospitals and could be managed in the same way at home. In very rare cases, large colon volvulus can spontaneously correct. On the other hand, some horses can start with an impaction that produces sufficient gas build-up to cause displacement or volvulus. Strangulating lesions of the small and large intestines are the challenge if surgery is not
20 The Practitioner
an option because, these will not resolve medically and should be candidates for euthanasia as soon as the diagnosis is made. Euthanasia should be considered for horses with evidence that supports a diagnosis of strangulating lipoma. Horses older than 10 years should be considered as having a strangulating lipoma, unless proven otherwise, and the likelihood of this diagnosis increases with increasing age. Supportive findings are small intestinal distention, reflux, congested mucous membranes, and increased heart rate. Pain can be absent or mild in older horses. It is not unusual for horses with this lesion, despite the severity of intestinal ischemia, to survive for 3 days or more with reflux and increased heart rate, but little evidence of worsening in disease severity. A horse that cribs is at risk of colic more than non-cribbers, especially epiploic foramen entrapment (EFE). Strongly supportive findings for EFE are small intestinal distention, male horse, and Thoroughbred of any age, usually ≤ 20 years old; however, all other breeds and genders can be affected. Pain can be highly variable in these horses, from mild to severe. Horses that meet these criteria should be under consideration for euthanasia, if they fail to improve over time and all other findings support a diagnosis of small intestinal strangulation. A postpartum mare with extreme pain and worsening abdominal distention probably has a large colon volvulus. Such cases respond poorly to analgesics, and euthanasia is warranted early in the disease course. Male intact Standardbreds, Tennessee Walkers, and Saddlebreds are at risk of inguinal hernia and therefore must be examined for this lesion, as should all intact male horses with colic. Although most affected horses are treated with surgery, this condition can be managed by anesthetizing the horse, placing it in dorsal recumbency, and manually reducing the hernia by external massage along the cord as it is stretched taut. Alternatively, intestine can be drawn away from the vaginal ring per rectum with the horse anesthetized and in dorsal recumbency, although this carries a high risk of intestinal or rectal injury. American Miniature Horses are prone to fecaliths in the small colon and typically present with marked abdominal distension. Colic in these horses can be very complicated because food deprivation is recommended as part of treatment, but can cause hyperlipidemia, liver disease, and death. Euthanasia is recommended in these horses with colic of any cause once signs of hyperlipidemia develop (icterus, depression, lipids in serum) when referral is not an option.
Issue 2 • 2016
In general, enteroliths might be indistinguishable from an impaction with digesta based on clinical signs. Arabian horses in California on alfalfa hay are at risk of developing enteroliths, and this should be high on the list of differential diagnoses for such cases. Radiographs of the abdomen can be helpful, although the absence of supportive radiographic findings are not conclusive. A foal or weanling that appears parasitized and has a history of recent worming or worming with Ivermectin only could be at risk of having an ascarid impaction. All available evidence that supports a diagnosis of small intestinal obstruction should be sought in such cases (reflux, ultrasound examination). Although typically treated by surgery, medical treatment with laxatives should be worth trying. Foals are notoriously difficult to assess as they can alternate between periods of violent colic and periods of depression. Inability to perform a rectal palpation in foals complicates their examination although the ability to perform a more complete ultrasound and abdominal radiographic examination compensates for this. Horses with proximal enteritis can have a fever and leukocytosis and a greater volume of gastric reflux than horses with other SI diseases. Horses with proximal enteritis may suffer from severe abdominal pain initially and this progresses to depression and less pain than in horses with strangulation obstruction.
can be difficult to interpret if you have limited experience with this diagnostic modality. A low-frequency probe (2 to 3.5 MHZ) is employed in adult horses to demonstrate deeper structures, although the resolution is low. Higher-frequency probes (5 to 10 MHz) can be used in small horses and foals for more detail, but with less depth of penetration. Although abdominocentesis is useful in diagnosis of a strangulating small intestinal lesion and ruptured viscus, visual assessment of the fluid is not recommended for this purpose, despite some support for this approach. Normal-appearing fluid does not rule out these lesions, and laboratory assessment is needed, including cytological examination in some cases, and this might not be feasible in all field situations. An 18-gauge 1.5–inch needle, a teat cannula (7.5 cm) or female canine urinary catheter is inserted into the abdominal cavity on the midline or just to the right of midline in the most dependent part of the abdomen, behind the xiphoid cartilage. Restraint by twitch is usually sufficient, although local anesthetic is required for the cannula methods. Abdominal ultrasonography can identify fluid pockets to be sampled and help avoid enterocentesis. Fluid from most horses with nonstrangulating lesions is normal on gross inspection, but fluid from horses with strangulated small intestine is usually serosanguinous. A fluid sample from horses with a ruptured viscus is cloudy and
Palpation per rectum, repeated as needed, is a critical procedure in a horse with SI Strang. Serosanguicolic to detect distended Opaque nous loops of small intestine, Obstruction tight bands, impactions, and other findings that could indicate life threatening changes. Ultrasonography is Peritonitis White with very useful for diagnosis of from Opaque pink tinge intestinal strangulation (disabscess tended, thick-walled intestine), peritonitis (increased volume of peritoneal fluid and decreased intestinal motility), intussusceptions Intestinal (jejunojejunal, ileocecal, and necrosis Orange Opaque cecocolic), displacements, renosplenic entrapment of and leakage the large colon, peritoneal effusion, diaphragmatic hernia, cholelithiasis, ruptured bladder, ascarid impactions, inguinal and scrotal Proximal Slightly hernias, and abdominal Yellow enteritis cloudy neoplasia.1 However, transabdominal ultrasonography WWW.FAEP.NET |
Total pro- RBC (cells/ WBC (cells/ Cytologic findings tein (g/dl) µL) µL)
Degenerative neutrophils with rare intracellular cocci
Cellular, mostly neutrophils with many intracellular and extracellular bacteria
Numerous RBCs neutrophils not degenerate
FLORIDA-ASSOCIATION -OF-EQUINE-PRACTITIONERS | The Practitioner 21
green-tinged, but can be normal if diluted out by a large volume of peritoneal fluid, or if intestinal contents are entrapped by omentum, or intestine close to the site of rupture (hence the importance of cytological examinations). Peritoneal fluid with nucleated cell counts greater than 5,000 cells/μl should be considered elevated in foals. Peritoneal fluid protein is usually below 2.0 g/dL. Cytologic evaluation should detect degeneration of cells and bacteria (in rupture), and allow classification of cell populations. Interpret with awareness that many horses with a surgical lesion, such as large colon volvulus, can have normal peritoneal fluid. Table 1. Examples of peritoneal fluid from horses with various abdominal diseases. Modified from Adams SB and Sojka JE. Abdominocentesis, in Colahan PT et al. (editors). Equine Medicine and Surgery, ed. 5. Mosby Co., St. Louis, 1999, pp. 586-589. SISO = Small intestinal strangulation obstruction. Peritoneal fluid lactate can be a better predictor of intestinal ischemia secondary to a strangulating obstruction (SISO) than blood lactate, and therefore could be used for early detection of such lesions, and even rupture. Horses with SISO had a higher peritoneal lactate value (8.45 mmol/l) than those with nonstrangulating obstruction (2.09 mmol/l).
Medical Treatment – Visceral Analgesia Control of pain and restraint play a crucial role in the management of horses with colic, and for most colics, the drugs of choice are flunixin meglumine and/or xylazine. All forms of pain control should be interrupted so that progress can be monitored repeatedly and frequently. The response to analgesics is critical and a poor response indicates an unfavorable prognosis. Horses with abdominal pain should be allowed to roll at will if they are considered to have a colonic displacement, contrary to owners’ desires to keep them walking. They might need to be placed in a round pen or paddock for this purpose to minimize the risk of injury. Although unsubstantiated, the impression is that vigorous rolling can correct some colonic displacements. Horses with large colon trapped over the nephrosplenic or renosplenic ligament can have pain of variable intensity and mild to moderate abdominal distension. Treatment by “wait and see” approach, phenylephrine injection, or rolling the horse while anesthetized with short-acting intravenous anesthetic are successful, depending on severity. The spleen can be effectively reduced in size by phenylephrine at 3µg/kg/minute for 15 minutes. The horse is then lunged for 10 to 15 minutes or rolled. Lunging is less effective than rolling under anesthesia and phenylephrine does carry a small risk of fatal hemorrhage in old horses.
Decompression by Enterocentesis Some relief can be achieved in selected cases by decompression of the distended cecum. This procedure is risky and can cause lifethreatening peritonitis, but can also be valuable when financial constraints preclude surgery. For cecal tympany, decompression 22 The Practitioner
is through a 14 gauge catheter (5 inches long at least) through the right paralumbar fossa, after the site has been prepared for aseptic surgery and infiltrated with local anesthesia. The catheter is connected to an IV tube immersed under water below the level of centesis so that gas egress can be continually monitored and air ingress is prevented. A small volume of gentocin should be flushed through the catheter before withdrawal to remove any aspirated intestinal contents that could drain into the abdominal wall.
Basic Guidelines in Pain Assessment and Prognosis Pain is the most important indicator of colic severity, but must always be assessed with full regard for some guidelines: 1. Young horses, especially those of racing breeds, tend to manifest pain more severely and persistently than draft breeds with similar lesions. Pain can be mild or even absent in old horses, smaller breeds, Tennessee Walking Horses, American Miniature Horses, draft breeds, and horses with severe endotoxemia. 2. Pain, cardiovascular status, and abdominal distension should be used in combination as measures of the severity of colic. Worsening abdominal distension is always a concern. An adult horse of average size with increasing heart rate or a heart rate persistently above 60 beats/ minute (12 to 24 hours) generally has a poor prognosis. Draft horses are prone to all types of colic but are very difficult to assess. Even with mild lesions, they will have very high heart rates. Normal or mild elevation in heart rate can be found in some horses with a surgical lesion, including strangulating lesions of the small intestine. With time, these would be expected to develop an increased heart rate. 3. Response to analgesics, such as flunixin meglumine or xylazine, is extremely important in assessing pain. If pain is severe enough to require repeated analgesics,
Issue 2 • 2016
or response to analgesics is poor, the prognosis for survival is poor. 4. Do not repeat analgesics without assessing the horse's progress when their effect is diminished. Do not underestimate the degree of improvement in pain and cardiovascular status brought on by medication. 5. Horses with self-inflicted trauma from violent pain with colic typically have strangulating lesions and should be considered for euthanasia if all other supportive evidence can be established. 6. Horses with persistent reflux and small intestinal distension, with or without pain, but with mucous membrane congestion and other signs of endotoxemia are candidates for euthanasia, especially if they do not respond rapidly to fluid therapy and flunixin meglumine. Even if these horses have proximal enteritis, the cost of treatment for that disease can approach that for colic surgery quite rapidly. 7. Horses with persistent reflux and small intestinal distension, with or without pain, but without evidence of endotoxemia and have a history of eating coastal Bermuda grass hay, can be managed conservatively, as many of these will resolve with medical therapy. 8. Because the only option in these cases is euthanasia, more time can be allowed for spontaneous recovery than would be allowed before referral. This could extend to days, provided the horse can be kept comfortable and inhumane suffering is prevented. 9. If some doubt persists about the need for euthanasia, the horse can be transported to a referral hospital to confirm the need for euthanasia. This could be less expensive than continued non-productive treatment and disposal is handled by the referral hospital. 10. The last provides the horse one treatment option that can be very effective – a trailer ride!!
2. 3. 4. 5. 6.
Fischer AT. Colic: diagnosis, preoperative management, and surgical approaches. In Auer JA and Stick JA, Equine Surgery, edition 3, WB Saunders Co, St. Louis, 2006, pp. 387-395. Pease AP, Scrivani PV, Erb HN, Cook VL. Accuracy of increased largeintestinal wall thickness during ultrasonography for diagnosing largecolon torsion in 42 horses. Vet Radiol Ultrasound. 2004;45:220-224. Abutarbush SM. Use of ultrasonography to diagnose large colon volvulus in horses. J Am Vet Med Assoc 2006;228:409-413. Latson KM, Nieto JE, Beldomenico PM, Snyder JR. Evaluation of peritoneal fluid lactate as a marker of intestinal ischemia in equine colic. Equine Vet J. 2005;37:342-346. Saulez MN, Cebra CK, Dailey M. Comparative biochemical analyses of venous blood and peritoneal fluid from horses with colic using a portable analyzer and an in-house analyzer. Vet Rec. 2005;157:217-223. Sanchez LC, Elfenbein JR, Robertson SA. Effect of acepromazine, butorphanol, or N-butylscopolammonium bromide on visceral and somatic nociception and duodenal motility in conscious horses. Am J Vet Res 2008;69:579-85.
Sellon DC, Roberts MC, Blikslager AT, Ulibarri C, Papich MG. Effects of continuous rate intravenous infusion of butorphanol on physiologic and outcome variables in horses after celiotomy. J Vet Intern Med. 2004;18:555-563.
Cook VL, Blikslager AT: Use of systemically administered lidocaine in horses with gastrointestinal tract disease. J Am Vet Med Assoc 2008;232:1144-1148. 10. Milligan M, Beard W, Kukanich B, et al. The effect of lidocaine on postoperative jejunal motility in normal horses. Vet Surg 2007;36:214–220. 11. Rusiecki KE, Nieto JE, Puchalski SM, Snyder JR. Evaluation of continuous infusion of lidocaine on gastrointestinal tract function in normal horses. Vet Surg 2008;37:564-570. 12. Freeman DE, Ferrante PL, Palmer JE: Comparison of the effects of intragastric infusions of equal volumes of water, dioctyl sodium sulfosuccinate, and magnesium sulfate on fecal composition and output in clinically normal horses. Am J Vet Res 1992;53:13471353. 13. Lopes MA, Walker BL, White NA 2nd, Ward DL. Treatments to promote colonic hydration: enteral fluid therapy versus intravenous f luid therapy and magnesium sulphate. Equine Vet J. 2002 Jul;34(5):505-509. 14. Frederick J, Giguere S, Butterworth K, et al. Severe phenylephrineassociated hemorrhage in five aged horses. J Am Vet Med Assoc 2010;237:830-834.
David Freeman, MVB, PhD, DACVS Dr. David Freeman graduated from the Veterinary College of Ireland, Dublin and completed an equine internship at the New Bolton Center of the University of Pennsylvania in 1975, and a residency in large animal surgery in 1977. He was awarded a PhD from the University of Pennsylvania in 1985. He was an equine surgeon at New Bolton Center from 1981 to 1994, became board certified by the American College of Veterinary Surgeons in 1989, then joined the faculty of the University of Illinois, College of Veterinary Medicine in 1994, becoming Head of Equine Medicine and Surgery in 1998. In 2004, Dr. Freeman joined the Department of Large Animal Clinical Sciences at the University of Florida, College of Veterinary Medicine (UFCVM), as Professor of Equine Surgery and Associate Chief of Staff. He is currently Chief of Large Animal Surgery at UFCVM, Martha and Arthur Appleton Endowed Professor in Equine Studies, and Director of the Island Whirl Equine Colic Research Laboratory. Dr. Freeman has developed 4 widely used surgical procedures in horses and has described improvements and modifications in many others. His main areas of clinical interest are diseases and surgery of the equine gastrointestinal and upper respiratory tracts, with special emphasis on improving survival after colic surgery.
Sellon DC, Monroe VL, Roberts MC, Papich MG. Pharmacokinetics and adverse effects of butorphanol administered by single intravenous injection or continuous intravenous infusion in horses. Am J Vet Res. 2001;62:183-9.
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