Equine Vet www.modernequinevet.com
Vol 10 Issue 5 2020
Reducing Fecal Shedding of R. equi Can Prepurchase Exam Predict Long-Term Cardiac Outcomes? Extractions: Patience, Planning and Time Lead to Success Can Honey Prevent Infections After Colic Surgery? Will COVID-19 Affect Veterinary Drug Supply?
CHECK OUT: ASK THE NUTRITIONIST? DIET FOR HYPERINSULINEMIA
TABLE OF CONTENTS
4 Hyper-Immune Plasma Could Decrease R. equi Fecal Shedding Cover: Shuttersotck/Yuriy Bartenev
ASK THE NUTRITIONIST
What Feeding Program Would You Recommend for a Sedentary, Hyperinsulinemic (Fasting), 14-Year-Old Quarter Horse?.................................................. 3 CARDIOLOGY
How Good Are You at Predicting Long-Term Outcome From the Cardiac Prepurchase Exam?................................................................... 8 DENTISTRY
Patience, Planning and Time: Tips for Successful Extractions........................................12 Complications Compared for Cheek Teeth Extractions.....................................................18 INFECTION
Can Honey Prevent Surgical Site Infections After Colic Surgery?..................................16 NEWS NOTES
American Regent to Acquire a Daiichi Sankyo Affiliate....................................................14 503B Outsourcing Facilities Help Counter Drug Shortages Due to COVID-19..................19 ADVERTISERS Purina Sponsored Content.........................................3 Zoetis/iSTAT.....................................................5 American Regent Animal Health/Adequan...........7
American Regent Animal Health/BetaVet.............9 Epicur Pharma............................................................13 AAEVT............................................................15
Equine Vet SALES: Matthew Todd • Lillie Collett EDITOR: Marie Rosenthal ART DIRECTOR: Jennifer Barlow CONTRIBUTING WRITERS: Paul Basillo • Adam Marcus COPY EDITOR: Patty Wall Published by PO Box 935 • Morrisville, PA 19067 Marie Rosenthal and Jennifer Barlow, Publishers PERCYBO media publishing
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SPECIAL ADVERTISING SECTION
Nutritionist KAREN DAVISON, PH.D., EQUINE TECHNICAL SOLUTIONS, PURINA ANIMAL NUTRITION
Ask the Nutritionist is a monthly column featuring questions answered by PhD equine nutritionists and sponsored by Purina Animal Nutrition. Have a nutrition question you want to see featured? Email Marie Rosenthal. For clinics looking for specific nutritional advice, visit purinamills.com/ask-an-expert.
What feeding program would you recommend for a sedentary, hyperinsulinemic (fasting), 14-year-old Quarter Horse, 1,235 pounds, BCS 8/9, no history of laminitis? It’s important to educate horse owners to recognize obesity and understand the associated health risks. Teaching them to objectively evaluate their horse’s body condition can be critical for long-term success. The goal is to achieve and maintain a more moderate 6/9 BCS. For light horse breeds, each BCS unit change represents about 45 lbs of body weight. Research suggests horses can lose 1.0 lb/day with proper diet management or 1.5 lbs/day with diet and exercise.1 Using these guidelines, implement a diet and exercise program to achieve the target BCS within 60 to 90 days. EXERCISE PROGRAM The attending veterinarian should approve any exercise regimen. Exercise doesn’t need to be overly strenuous to achieve weight loss. A reasonable program could be a 10-minute walk, 30 minutes of light trotting and a 10-minute cool down. Exercise intensity and duration can gradually increase if needed. Any exercise is better than none, though, especially when insulin dysregulation (ID) is a concern. DIET CONSIDERATIONS The National Research Council recommends 17.0 Mcal/day digestible energy (DE) for the horse described above. Consuming 2% of his BW in moderate-quality, warm-season grass hay would supply about 18.5 Mcal/day. Since this diet and intake level would not decrease weight, hay intake would need to be restricted. The extent of the restriction depends on horse response, which can vary significantly. A recommended approach is to gradually reduce DE intake to 70% of what has been maintaining the current condition. If needed, intake can be reduced further to induce weight loss, provided a minimum of 1% BW in forage dry matter intake (DMI) is maintained. Hay typically averages 90% DM, whereas pasture forages may be less than 40% DM. Also, consider the level of soluble carbohydrate in the hyperinsulinemic horse’s diet. Data from controlled research is conflicting, and specific targets for starch and sugar intake are not well identified. Common recommendations for horses with ID suggest target dietary starch plus ethanol soluble carbohydrates in the range of
10 % to 12%. Note, this suggestion disregards meal size, which affects insulin response to a meal. With no history of laminitis and the implementation of a diet and exercise program, insulin sensitivity is likely to improve. Also, if this horse eats and tolerates warm-season grass hay (typically lower in soluble carbs than other varieties), continue with the hay source and restrict access to green pasture. However, a hay-only diet will be deficient in vitamins and minerals and likely won’t meet amino acid recommendations, even though crude protein is adequate. A ration balancer can provide the nutritional balance necessary to support lean tissue without adding significant calories. Purina® Enrich Plus® Ration Balancing Feed is low in soluble carbohydrates, and a 1-lb meal produces a low postprandial glucose and insulin response.
RECOMMENDED DIET Restrict hay intake to 16 lbs/day and add 1.5 lbs/day of Purina® Enrich Plus® Ration Balancing Horse Feed. • Use feeders or hay nets to limit the rate of intake and extend mealtime. • Utilize Purina® Outlast® Gastric Support Supplement to help support gastric health and proper pH. • Monitor BCS and further reduce hay intake if needed, minimum of 13 to 14 lbs/day. • Use a grazing muzzle to restrict intake during pasture turnout. Horses can consume up to 50% of their daily DE requirements in just hours of grazing, so restricting turnout time may not reduce calorie intake enough for weight loss.
UPCOMING TOPICS June: Infections July: Colic August: Lameness
Have a question you want to see featured? Send them to firstname.lastname@example.org.
ME Gordon, ML Jerina, RH Raub, KA Davison, JK Young and KK Williamson. 2009. The effects of dietary manipulation and exercise on weight loss and related indices of health in horses. Comparative Exercise Physiology 6(1); 33–42
ABOUT THE AUTHOR Dr. Karen Davison, PhD, is a director and nutritionist on the Equine Technical Solutions Team at Purina Animal Nutrition. She enjoys working directly with horses and horse owners to tweak individual feeding programs to help each horse reach its true potential. SPONSORED BY PURINA ANIMAL NUTRITION
ModernEquineVet.com | Issue 5/2020
HYPER-IMMUNE PLASMA Could Decrease R. equi Fecal Shedding The administration of Rhodococcus equi specific hyper-immune plasma (Re-HIP) to neonatal foals decreases fecal shedding, lowering environmental contamination, which could mean fewer pneumonia cases on endemic farms, according Macarena G. Sanz, DVM, PhD, DACVIM, assistant professor of equine medicine of Washington State University in Pullman. “I think it's a beneficial effect of this plasma that nobody has looked at before,” she said at the American Association of Equine Practitioners 65th Annual Convention. R. equi grows slowly, so many foals do not develop B y
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pneumonia until about 3 months old or so, but they become infected with the bacteria early in life, likely within the first few weeks of life, according to Dr. Sanz, and easily shed the bacteria in their feces, contaminating the environment and infecting other foals.
“We are very well aware that foals are getting infected with these bacteria pretty much as they hit the ground,” she said. “So that first week or 2 is extremely important.” Dr. Sanz and her colleagues’ previous work, while
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at the Gluck Research Institute, showed that foals given Re-HIP within 24 hours of experimental infection were less likely to develop severe pneumonia if challenged with R. equi that had the vapA gene, because that is the strain that causes pathogenesis.
The researchers saw a strong association between administering re-HIP and decreased fecal shedding of R. equi.
“VapA is what makes Rhodococcus pathogenic,” Dr. Sanz explained. “In the environment there are multiple strains of Rhodococcus, but the one that will cause disease is the one that carries the vapA gene.” They thought about that result and wanted to know if they could take it one step farther, if the foals were given Re-HIP prophylactically and this lowered the clinical pneumonis, would it lower the fecal shedding of these experimentally infected foals? “I looked back at this study and tried to put 2 and 2 together. I started thinking: if the plasma decreases the severity of pneumonia and these pneumonic foals are the foals that contaminate the environment would the administration of plasma lower that [shedding],” she said. “We thought decreased pneumonia would result in a reduced shedding of pathogenic R. equi.” They separated research foals into two groups: 12 received Re-HIP and 9 foals did not. Then they challenged them with R. equi that they knew contained the vapA gene, and therefore, was more likely to cause disease in the foals. All of the foals that received Re-HIP received the plasma within 48 hours of birth; some within 24 hours. The horses were experimentally challenged with pathogenic R. equi that was placed in their trachea during the first week of life. “We sedated them, put the Rhodococcus down their trachea, and then we monitored the foals weekly,” she
said, adding that very little bacteria were needed to infect the foals because the organism is so virulent. In addition, they collected fecal samples right before infection and then 2, 3, 5 and 7 weeks after they were challenged with the bacteria. They tested the 101 fecal samples by quantitative PCR; 20 prechallenge and 81 post challenge. They found 11 out of 81 samples were positive for the vapA gene. Most of the positives were from the control group: 9 versus only 2 from the treatment group, she said, which was statistically significant (P=0.031) “So we found a fairly strong association between the administration of plasma, and this decrease of fecal shedding, and that was statistically significant,” Dr. Sanz said. “The other thing we found is the administration of hyper-immune plasma decreased the amount of virulent bacteria [shed during the study],” she added. Typically with this experimental model about half of the challenged foals would go on to develop clinical pneumonia, she said, which was pretty close to the number of penumonias in the control group. Among the control group, 4 out of 9 developed pneumonia; and only 2 out of 12 developed pneumonia in the Re-HIP group. “So the plasma was very protective for pneumonia in our study,” she said. “They still developed clinical pneumonia, but it was a lot less severe,” she said, and as a result, there was less R equi shedding. As in any study, there were limitations she admitted, mostly that the animals were experimentally infected vs. animals that are infected naturally. MeV The study was funded by the Advancement in Equine Research Award, Boehringer Ingelheim.
For more information: Sanz MG, Bradway DS, Horohoy DW, et al. Rhodococcus equi-specific hyperimmune plasma administration decreases faecal shedding of pathogenic R. equi in foals. Vet Rec. 2019 Jul 6;185(1):19. doi: 10.1136/vr.105327. Epub 2019 Apr 17. https://pubmed.ncbi.nlm.nih.gov/30995996/?from_term=Sanz+MG+and+Rhodococcus&from_pos=2 Sanz MG, Oliveira AF, Loynachan A, et al. Validation and evaluation of VAPA-specific IgG and IgG subclass enzyme-linked immunosorbent assays (ELISAs) to identify foals with Rhodococcus equine pneumonia. Equine Vet J. 2016 Jan;48(1):103-108. https://pubmed.ncbi.nlm.nih.gov/25257622/?from_term=Sanz+MG+and+equine&from_pos=3 6
Issue 5/2020 | ModernEquineVet.com
There’s nothing else like it. Over the past 30 years, Adequan® i.m. (polysulfated glycosaminoglycan) has been administered millions of times1 to treat degenerative joint disease, and with good reason. From day one, it’s been 2, 3 the only FDA-Approved equine PSGAG joint treatment available, and the only one proven to. Reduce inflammation Restore synovial joint lubrication Repair joint cartilage Reverse the disease cycle When you start with it early and stay with it as needed, horses may enjoy greater mobility 2, 4, 5 over a lifetime. Discover if Adequan is the right choice. Talk to your American Regent Animal Health sales representative or call (800) 458-0163 to order. BRIEF SUMMARY: Prior to use please consult the product insert, a summary of which follows: CAUTION: Federal law restricts this drug to use by or on the order of a licensed veterinarian. INDICATIONS: Adequan® i.m. is recommended for the intramuscular treatment of non-infectious degenerative and/or traumatic joint dysfunction and associated lameness of the carpal and hock joints in horses. CONTRAINDICATIONS: There are no known contraindications to the use of intramuscular Polysulfated Glycosaminoglycan. WARNINGS: Do not use in horses intended for human consumption. Not for use in humans. Keep this and all medications out of the reach of children. PRECAUTIONS: The safe use of Adequan® i.m. in horses used for breeding purposes, during pregnancy, or in lactating mares has not been evaluated. For customer care, or to obtain product information, visit www.adequan.com. To report an adverse event please contact American Regent, Inc. at (800) 734-9236 or email email@example.com. Please see Full Prescribing Information at www.adequan.com.
www.adequan.com 1 Data on file. 2 Adequan® i.m. Package Insert, Rev 1/19. 3 Burba DJ, Collier MA, DeBault LE, Hanson-Painton O, Thompson HC, Holder CL: In vivo kinetic study on uptake and distribution of intramuscular tritium-labeled polysulfated glycosaminoglycan in equine body fluid compartments and articular cartilage in an osteochondral defect model. J Equine Vet Sci 1993; 13: 696-703. 4 Kim DY, Taylor HW, Moore RM, Paulsen DB, Cho DY. Articular chondrocyte apoptosis in equine osteoarthritis. The Veterinary Journal 2003; 166: 52-57. 5 McIlwraith CW, Frisbie DD, Kawcak CE, van Weeren PR. Joint Disease in the Horse.St. Louis, MO: Elsevier, 2016; 33-48. All trademarks are the property of American Regent, Inc. © 2020, American Regent, Inc. PP-AI-US-0372 02/2020
ModernEquineVet.com | Issue 5/2020
How Good Are You at Predicting
OUTCOMES FROM THE CARDIAC PREPURCHASE EXAM?
A thorough prepurchase cardiac examination
provides a unique opportunity to identify at-risk horses prior to competition. If found, the cardiac disease is likely to be mild, but performance-limiting and life-threatening conditions can be present in seemingly normal horses. Fe ter Woort, DVM, DVSc, DACVIM, (LAIM), and colleagues recently completed a study to identify the most and least common cardiac findings on prepurchase examinations, and gauged how accurate cardiac prognoses are in predicting athletic outcomes. “Over the years, we’ve found some really spectacular cardiac disease in horses that looked healthy on the outside,” Dr. ter Woort said here at the 65th Annual AAEP Convention in Denver.
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The retrospective study included 174 horses from her Equine Sports Medicine Practice in Belgium, as well as horses treated at the New Bolton Center in Kennett Square, Penn. Show jumpers, eventers, show hunters and dressage horses were represented, among others. Horses that had undergone complete cardiac examination with echocardiography (ECG) as part of a prepurchase exam or within 4 weeks of purchase were included. Outcomes were assessed by an owner interview conducted by phone call or email. “I also used FEI [International Federation for Equestrian Sports] data,” she said. “For those who are not familiar with that data, it’s like Facebook stalking for horses. You enter the name and you can see
B a s i l i o
The only dual ingredient injectable corticosteroid approved by the FDA for use in horses
The link between RAPID ONSET and LONG-ACTING RELIEF of pain & inflammation1 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.
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. Trotter GW. Intra-articular corticosteroids. In: McIlwraith CW, Trotter GW, eds. Joint Disease in the Horse. Philadelphia: W.B. Saunders; 1996; 237–256.
BetaVet® and the Horse Head design are registered trademarks of American Regent, Inc. © 2019 American Regent, Inc. PP-BV-US-0027 5/2019
5/17/2019 9:15:15 AM
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. INDICATION: BetaVet® is indicated for the control of pain and inflammation associated with osteoarthritis in horses. DOSAGE AND ADMINISTRATION: Shake well immediately before use. 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. SHAKE WELL BEFORE USING NADA 141-418, Approved by FDA For customer care or to obtain product information visit www.betavetequine.com or call 1-800-458-0163. To report an adverse event please contact American Regent Animal Health at (800) 734-9236 or email firstname.lastname@example.org.
A Division of American Regent, Inc. 5 Ramsey Rd. | Shirley, NY 11967
where they’ve competed, who rode them, what class they were in, and what their results were, provided they were competing in an FEI-sanctioned event. All these data are freely available.”
In 86% of the cases, a murmur was found on auscultation. Of those horse, the most common murmur by far was systolic (85%), followed by diastolic (14%) and continuous (1%). About 8% had an arrhythmia, 3% had both an arrhythmia and a murmur, and 3% had neither. More than 80% of cases of mitral regurgitation and 70% of cases of tricuspid regurgitation were classified as insignificant or mild. In these cases, there is trace regurgitation and no cardiac changes present, or a jet of regurgitation but no significant cardiac changes. Severe regurgitation was seen in around 5% for each type.
“In 82% of the cases, we gave them an excellent or good prognosis based on the recommendations of the 2015 American College of Veterinary Internal Medicine consensus statement,” Dr. ter Woort said. “That was based on the diagnosis, the severity of disease, and the horse’s intended use.” Horses were classified in the “good prognosis” category, even when there may have been mention of a small risk for the development of atrial fibrillation (AF) later in their career, for example. A guarded prognosis was given to 11% of the horses with moderate or severe mitral regurgitation, moderate aortic regurgitation, cardiomyopathy, moderate tricuspid regurgitation, myocarditis, AF or frequent premature ventricular contractions (PVCs). Approximately 6% of the horses received a poor prognosis. These were horses with severe mitral regurgitation, large ventricular septal defect, AF, aortocardiac fistula, atrial tachycardia, or frequent PVCs.
To gauge the success of the prognoses given at the time of the PPE, Dr. ter Woort contacted the owners of horses who had at least 1-year of follow-up on record. She reached 42 owners of horses with good or excellent prognoses, and 8 owners of horses with guarded or poor prognoses. “I wanted that number to be higher, but that’s the reality of calling owners and asking them how a horse that they brought in 9 years ago is doing,” she said. Most of the horses with good or excellent prognoses were performing well or had been retired or euthanized for what the owners described as non-cardiac reasons.
Murmur Diagnosis • Mitral regurgitation • Physiologic flow murmur • Tricuspid regurgitation • Aortic regurgitation • Ventricular septal defect • Other
(50%) (22%) (12%) (8%) (5%) (3%)
Arrhythmia Diagnosis • Sinus arrhythmia • Frequent APCs • Frequent PVCs • Atrial fibrillation • Atrial tachycardia
(3%) (3%) (2%) (2%) (1 horse)
“One horse that we gave a good prognosis to was not doing well,” she added. “That horse had mild aortic regurgitation on the pre-purchase exam and developed an aortocardiac fistula 3 years later that was picked up on a routine recheck. We went back and looked at the echocardiogram to see if we had missed anything, but we did not find anything.” Of the 8 horses with guarded or poor prognoses, 7 did not do well. Three had heart failure and were euthanized, 2 had heart-related poor performance, and 2 had sudden death. “We had 1 horse with a poor prognosis due to atrial tachycardia that did do well,” Dr. ter Woort said. “The reason it did well was because we treated it with a transvenous electrical cardioversion. After treatment, it was in normal sinus rhythm and did well.” One interesting finding was that the grade of the murmur was not necessarily a good predictor for diagnosis or outcomes. Murmurs in horses with a good or excellent prognosis ranged from grade 1/6 to 6/6, murmurs in the guarded group ranged from grade 2/6 to 6/6, and the poor group showed grade 5/6 and 6/6. “The horses with a poor prognosis only had loud murmurs, but the grade of the murmur did not predict the diagnosis or the outcome,” she explained. “If you have a horse with a Grade 5/6 murmur, you cannot say whether it has an excellent or poor prognosis. Just based on auscultation alone, you can’t tell whether it’s going to be no big deal or whether it will have a guarded prognosis, which is not something you want for an athletic horse.” For most cases, a complete cardiac prepurchase exam can provide reassurance for the prospective buyer, but it also provides an opportunity to remove at-risk horses from sporting events, according to Dr. ter Woort. “I think it’s clear that you can tell your clients at the time you hear a murmur that in 94% of the cases it will be no big deal,” she said, “but we should perform echocardiography to make sure your horse is not in the other 6%.” MeV ModernEquineVet.com | Issue 5/2020
Patience, Planning and Time:
TIPS FOR SUCCESSFUL EXTRACTIONS B y
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B a s i l i o
Travis J. Henry, DVM, DAVDC (NSS),
DACVDC- EQ, has some invaluable insight to help you plan for equine intraoral extractions in your practice. “Find somebody in your area that likes to perform extractions, get their phone number, and refer all your patients to them,” he joked here at the 65th Annual AAEP Convention in Denver. In all seriousness, Dr. Henry touts a calm head, a solid plan and a clear day. “You have to have patience in planning when you’re going to perform these,” he said. “These are not procedures you do at the end of the day when you’re tired, and they’re not procedures that you do when you’re the primary on-call veterinarian that day. They are procedures that you do when you’ve got an hour or 2 cushion on each side of the procedure so that you are not rushed.”
Any plan for extraction should start with a thorough oral exam. “You’re not going to jump in there and rip a tooth out of a horse’s head without looking at the rest of the oral cavity,” said Dr. Henry, owner of Midwest Veterinary Dental Services in Elkhorn, Wis. Imaging is another necessity. Even if a tooth feels like it could come out with mild digital pressure, Dr. Henry still recommended a radiograph to see what lies beneath the gumline. 12
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“I also make a point to obtain postoperative films,” he added. “I want to make sure that I’ve completed the job.”
When a plan is in place and it’s time to start the extraction, patience and a balanced application of force is crucial. For cheek teeth, the spreaders are often employed to provide interproximal pressure to push the tooth mesially and distally. “You want to perform this procedure carefully and judiciously when you’re starting out,” he said, because it is easy to fracture crowns when too much force is applied. “I like to start with the thinnest [spreaders]. Don’t buy a clunky pair of spreaders. Buy a thin pair when you’re starting out, because you want to apply that force carefully.” Rotating the tooth to stretch the periodontal ligament is the next step. The ligament is great for holding teeth in place during normal chewing forces, but the fibers begin to break down after applying a force in a different direction for a certain time.
The broken down fibers then allow the tooth to have some mobility. “We’re also misshaping the alveolus,” Dr. Henry added. “We’re stretching the bone slightly away from the tooth to give ourselves more space.” Once the tooth can be moved several millimeters in all directions, a lifting force applied with forceps and a fulcrum will hopefully lift the tooth into the mouth.
Advanced periodontal disease
It’s reasonable to expect a loose tooth in a horse with periodontal disease, but mobility does not always equal a cut-and-dry extraction. “On radiography in a horse with periodontal disease, we’re looking for horizontal bone loss, vertical bone loss, widening of the periodontal ligament space and periodontal-endodontal lesions,” he said. Dr. Henry described a case in which a horse was presented with a diastema between the 8 and 9 on the 300 quadrant. When he applied minimal digital pressure, the tooth was markedly mobile, and he thought he was in for an easy afternoon.
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“When I performed the imaging, I could see that the tooth was not playing nicely,” he said. “There was a dilaceration of the distal root. Which means a severe curve in the shape of the root. I get concerned about these, because if you loosen the tooth and try to pull it straight up, you’re going to separate the root.” To get the tooth out safely, he grabbed the tooth to see which way it could move easily. In this particular horse, the tooth was tipping and curving with the distal root, since most of the disease process was occurring along the mesial root. “When I was spreading the tooth, I was careful not to spread a lot on the distal side, because I was going to increase the force on the curved root,” he explained. “When I got the tooth quite loose with axial movements, I grasped it as mesially as I could. With a small fulcrum—as little as 0.5 cm—I tried to lift the tooth. It curved its way up and out.”
Extraction may often be the easy part in horses with tooth resorption. The hard part is going back and finding all the leftover bits and pieces. “If you don’t get those out, they’ll continue to fester,” he explained.
In 1 case, Dr. Henry had a patient whose presenting complaint was the teeth were falling out of its head. The horse had wide periodontal ligament spaces, marked tooth resorption and loss of attachment. Following extractions, it appeared as if the procedure had gone cleanly, but a piece of tooth was still visible on postoperative radiography. The piece was not as dense as normal tooth roots, and it got left behind because of the resorptive process. “When you recheck these horses in 2 to 4 weeks, I would caution you to recheck with a radiograph,” he said. “Not all tooth resorption is the same, and it is vital to remove all of the dental material for proper healing.” Dr Henry emphasized the need to be patient and proactive in the extraction process. Don’t just keep doing the same thing over and over in the same surgery. If something is not working be ready to move on to another method to get the tooth extracted. It is always wise to think through the entire process before starting the surgery so that your plan includes several ways to accomplish the task and have the necessary instruments ready. One final note is that there are several hands-on courses that happen every year that are very beneficial for honing one’s skills at oral surgery. MeV
American Regent to Acquire a Daiichi Sankyo Affiliate American Regent Inc., a U.S. manufacturer of pharmaceuticals for human and veterinary use with manufacturing sites in New York and Ohio, will acquire Daiichi Sankyo Altkirch SARL, a Daiichi Sankyo company that has an active pharmaceutical ingredient (API) manufacturing plant in Altkirch, France. The facility, previously owned by Daiichi Sankyo Europe, an affiliate of American Regent, produces the API for Adequani.m. and Adequan Canine. Adequan is an FDA-approved PSGAG (polysulfated glycosaminoglycan) with formulations for joint health in horses and dogs. “With substantial investment in our capabilities to raise customer awareness about Adequan, including hiring a sales force focusing on small animal veterinarians, our Animal Health division has been experiencing double-digit growth for several years,” said Ken Keller, president and CEO of American Regent. “Acquiring Daiichi Sankyo Altkirch supports the company’s continued investment in our future. By 14
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modernizing and expanding the Altkirch facility, we will be able to increase production to ensure that we can fill the increasing demand for Adequan in dogs and horses, and secure the long-term capabilities of this growing business,” he said. “We now have the ability to directly collaborate with colleagues in France,” added Joel Steckler, vice president of Animal Health. “This vital connection will allow us to more quickly mobilize production resources in getting Adequan to veterinarians and, ultimately, patients. Additionally, this acquisition provides the opportunity to explore other products for manufacture, so American Regent can continue to find innovative ways of responding to customer needs.” In line with American Regent’s recent investment and expansion in its Ohio and New York manufacturing facilities, the acquisition of Daiichi Sankyo Altkirch is a move designed to integrate with, and positively impact, the company’s lines of business in a growing product portfolio. MeV
Prevent Surgical Site Infections
AFTER COLIC SURGERY? B y
A d a m
M a r c u s
into the incisions of horses undergoing colic surgery can dramatically reduce the risk of postoperative infections, a new study has found. Researchers at Hebrew University of Jerusalem's Koret School of Veterinary Medicine, in Israel, found that horses that received standard therapy were about 4 times more likely to develop post-operative infections as those given the honey solution. “It’s quite clear that the group receiving medical grade honey suffered significantly less from incisional infections,” said Kajsa Gustafsson, DVM, who presented her group’s findings at the 2019 annual meeting of the American Association of Equine Practitioners. Colic surgery is one of the most commonly performed emergency procedures in horses. Roughly 3% of equids suffer colic in a given year, and up to 17% require surgery to correct the problem, Dr. Gustafsson said. Of those, between 11% and 42% will develop a post-operative infection, with the range reflecting how those infections are defined, she said. These infections carry their own morbidity and mortality,
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The application of medical grade honey (MGH)
Courtesy of Dr. Kajsa Gustafsson
Applying medical grade honey to the surgical incision.
Horses that received standard therapy were 4 times more likely to develop a post-op infection.
but also can lead to other complications, such as incisional hernias, that carry high costs to treat and prolong hospitalizations. Although the use of MGH to treat established wound infections has been studied in both humans and animals, it had not previously been assessed as a prophylactic treatment to battle incisional infections in horses, according to Dr. Gustafsson. For the new study, she and her colleagues compared the use of MGH to conventional therapy in 89 horses undergoing colic surgery at their institution. All of the animals received a regimen of antibiotics, and 49 also received local application of sterile MGH, at a dose of approximately 1 mL/2 cm of incision length, intraoperatively on the abdominal wall (linea alba) prior to skin closure. Why MGH might be effective as an antimicrobial agent is not entirely clear. The elevated osmolality created by the high sugar content creates an unfavorable medium for the growth of bacteria, Dr. Gustafsson told Modern Equine Vet. The substance also contains
glucose oxidase, which converts to hydrogen peroxide, an antiseptic; has a low pH, which is helpful for healing; and is rich in a protein called bee-defensin 1, which is instrumental in the immune system of honeybees, Dr. Gustafsson reported. The researchers followed the horses for 2 weeks, during which time 17 (19.1%) developed an incisional infection. Of those, 4 animals (8.2%) had received MGH, whereas 13 (32.5%) had received standard therapy (P=0.02; adjusted odds ratio, 0.265). Dr. Gustafsson said the severity of infections did not differ between the two groups; 12 of the 17 incisional infections were bacterial, and of those 11 were multidrug resistant organisms—3 were methicillin resistant Staphylococcus aureus, all of which occurred in horses that received standard treatment, she added. “Applying medical grade honey on the linia alba intraoperatively is a simple, easy and rapid procedure that does not appear to have any adverse effects,” Dr. Gustafsson concluded. MeV ModernEquineVet.com | Issue 5/2020
COMPLICATIONS COMPARED FOR
Cheek Teeth Extractions op severe mandibular osteomyelitis post-extraction. Two horses developed sinusitis following maxillary cheek teeth exodontia. Overall, the complication rate was 10.8% for oral extraction, 24.4% for Steinmann pin repulsion, 20% for standard repulsion and 25.6% for MTE. Post-extraction complications caused a longerterm clinical problem in 34/428 (7.9%) of horses and were asymptomatic or quickly self-resolving in the other 24 (5.6%) cases. The risk of developing a post-extraction alveolar disorder was increased following extraction of the mandibular 06s, 07s or 08s compared with all other cheek teeth combined (P=0.001); for cheek teeth with apical infections (P=0.002) compared with those without; and following repulsion or minimally invasive transbuccal extraction (MTE) than following oral extraction (P=0.01 and P=0.02 respectively). Improved knowledge of the prevalence, types and risk of development of post extraction complications may help reduce these complications, the researchers said. MeV
Source: Courtesy of the Equine Veterinary Journal
Oral extraction of cheek teeth had the lowest risk of complications compared with other extraction techniques, according to a recent study. In a retrospective study, veterinarians at the University of Edinburgh Veterinary School in the United Kingdom looked at the complications of equine cheek tooth exodontia techniques. They reviewed the clinical records of all cheek teeth extractions performed at the university between February 2004 and September 2018. Afterward, owners were asked to complete a followup questionnaire regarding complications. In all cases, oral extraction was initially attempted prior to Steinman pin repulsion or minimally invasive transbuccal extraction (MTE). A total of 428 cheek teeth extractions were performed over the study period, 58 (13.6%) of which had complications post-extraction. The most frequent complication was the formation of intra-alveolar bony sequestra (32/58). The most severe post-extraction complications were seen in 4 horses that had swollen mandibles pre-extraction due to apical infections, which went on to devel-
Figure S4: (Left) Oral endoscopy of the alveolus that has now developed mandibular osteomyelitis with sequestration 10 weeks post extraction. The left image shows the non-healing alveolus containing debris and fibrin with exposed white-colored, alveolar bone on its buccal aspect (arrow). (Right) At 16 weeks post extraction, the alveolus has healed except for a midline cleft that is draining purulent material. Used with permission.
For more information: Kennedy R, Reardon RJR, James O, et al. A long-term study of equine cheek teeth post-extraction complications: 428 cheek teeth (20042018). Equine Vet J. 2020 March 6 (Epub ahead of print). https://beva.onlinelibrary.wiley.com/doi/10.1111/evj.13255 18
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Source: Image courtesy of Epicure Pharma
503B Outsourcing Facilities Can Help Counter Drug Shortages Due to COVID-19 Demand on the human side will continue to challenge the availability of veterinary medications, due to COVID-19. Pain medications, such as hydromorphone and fentanyl, as well as sedatives and anxiolytics, such as midazolam are among those on the short list. Even as the supply chain begins to catch up with demand, it is anticipated that wholesalers will allocate stock to physicians before veterinarians, according to Melissa King, PharmD, director of Manufacturing Operations at Epicur Pharma, a 503B outsourcing facility. The FDA recently issued guidance that encourages 503B outsourcing facilities to help close the gap in the supply chain. Veterinarians are used to working with 503A compounding facilities to compound human drugs in doses and routes of administration for individual veterinary clients. They may be less aware of the 503B outsourcing facility where they can purchase and stock larger quantities for distribution by the veterinarian at the clinic. 503A facilities create 1 product for an individual patient prescription; 503B outsourcing facilities can create products in bulk. They must operate in accordance with current FDA Good Manufacturing Practices (cGMP) just like a pharmaceutical manufacturer does, which ensures that clients receive consistent drug therapy over time. They essentially follow the same rules as manufacturers of generic and branded medications do. Therefore, 503B outsourcing facilities can fill a critical need for veterinarians. Since the FDA guidance was released, 503B outsourcing facilities are ramping up production of the drugs in shortage, including hydromorphone, ketamine, fentanyl and midazolam. There are 76 registered outsourcing facilities in the United States, some of which specialize in veterinary medicine.
Stokes Healthcare, a 503A facility, in Mount Laurel, NJ, recently opened Epicure Pharma, a 503B outsourcing facility. Epicur Pharma brings a unique advantage to the veterinary industry because it has a large selection of manufactured drugs that are traditionally compounded for animal health. Every drug manufactured by Epicur must meet FDA standards and practices. The facilityâ€™s offerings include tacrolimus ophthalmic drops, buprenorphine injection, and gabapentin MINI-MEDS tablets among others. Epicur products are distributed directly to veterinary hospitals from its outsourcing facility and are offered through Stokes Pharmacy for individual patient prescriptions. MeV For more information, visit www.epicurpharma.com to see the complete product portfolio.
these websites for more information
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