Equine Vet www.modernequinevet.com
Vol 8 Issue 11 2018
Open Wide Dentistry Should Be an Important Part of Care
Reducing Salmonella Spread Employment Contracts: Put It in Writing
TABLE OF CONTENTS
Wide: Importance 4 Open Of Equine Dentistry Cover photo: Shutterstock/Casey Bollig
You Can Reduce S. enterica Spread........................................................10 THE BUSINESS OF PRACTICE
Put It in Writing..........................................................................................13 ENDOCRINOLOGY
Regulating Insulin Dysregulation in Ponies: More Than Just Diet...................................................................................16 NEWS
Mosquitoes Bite More When They Are Thirsty......................................................................19 New Project Looks at Equine Wound Management...........................................................19 ADVERTISERS Luitpold Animal Health..............................................3 Purina Animal Nutrition.............................................5 Boehringer Ingelheim/Gastroguard.......................7
Boehringer Ingelheim/Marquis..............................11 Boehringer Ingelheim/Vetera................................15 Boehringer Ingelheim/Equioxx..............................17
Equine Vet SALES: Matthew Todd • ModernEquineVet@gmail.com Lillie Collett • ModernEquineVetSales@gmail.com EDITOR: Marie Rosenthal • email@example.com ART DIRECTOR: Jennifer Barlow • firstname.lastname@example.org CONTRIBUTING WRITERS: Paul Basillo • Carol Jean Ellis Jason Mazda COPY EDITOR: Patty Wall Published by PO Box 935 • Morrisville, PA 19067 Marie Rosenthal and Jennifer Barlow, Publishers PERCYBO media publishing
Issue 11/2018 | ModernEquineVet.com
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Startwith it. Staywith it.
For thirty years, Dr. Marvin Beeman, a founder of Littleton Equine Medical Center, has counted on Adequan® i.m. (polysulfated glycosaminoglycan) for his patients. He even uses it on his own horse, Foxy, his beloved third-generation homebred mare. Adequan® has helped keep Foxy perfoming into her teens—so together, they’re still galloping strong. Only Adequan® may help improve joint function by: 1, 2 REVERSING the disease cycle REPAIRING cartilage RESTORING joint lubrication and REDUCING inflammation to help keep joints moving and horses performing.
Thirty years of love and Adequan i.m. says it all.
When you and your veterinarian start with Adequan® i.m. and stay with it, your horse may enjoy greater mobility over a lifetime.3, 4
Ask your veterinarian if Adequan® is the right choice for your horse. Visit adequan.com. 1 Adequan® i.m. [package insert]. Shirley, NY: Luitpold Animal Health; 2008; 2017. 2 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. 3 McIlwraith CW, Frisbie DD, Kawcak CE, van Weeren PR. Joint Disease in the Horse. St. Louis, MO: Elsevier, 2016; 33-48. 4 Kim DY, Taylor HW, Moore RM, Paulsen DB, Cho DY. Articular chondrocyte apoptosis in equine osteoarthritis. The Veterinary Journal 2003; 166: 52-57.
INDICATIONS Adequan® i.m. (polysulfated glycosaminoglycan) 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. IMPORTANT SAFETY INFORMATION There are no known contraindications to the use of intramuscular Polysulfated Glycosaminoglycan. Studies have not been conducted to establish safety in breeding horses. WARNING: 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. CAUTION: Federal law restricts this drug to use by or on the order of a licensed veterinarian. Proud Sponsor Please see Full Prescribing Information at www.adequan.com. Adequan® and the Horse Head design are registered trademarks of Luitpold Pharmaceuticals, Inc. © Luitpold Animal Health, division of Luitpold Pharmaceuticals, Inc. 2018. PP-AI-US-0132 7/2018
OPEN WIDE: The Importance of Dentistry
M a r i e
Courtesy of Dr. Chris Pearce
If veterinarians want horses to live long, healthy, happy lives, they have to take care of the mouth, according to Chris Pearce, BVSc, MRCVS, DEVDC
Issue 11/2018 | ModernEquineVet.com
R o s e n t h a l ,
(equine), director and founder of the Equine Dental Clinic in the United Kingdom. And floating the teeth or doing a cursory examination just wonâ€™t cut it, Dr. Pearce said at the BEVA Congress 2018.
This unique honeycomb structure supports proper gastric pH.
Gastric discomfort may keep horses from performing at their best. Now you can offer your clients an additional way to help their horses. Purina® Outlast ® Supplement is formulated with a proprietary mineral complex with a unique honeycomb structure to support gastric health and proper pH in stressful situations. Give your clients the power of nutrition to keep their horses performing. See the science behind the solution. Visit feedoutlast.com © 2018 Purina Animal Nutrition LLC. All rights reserved. Slick By Design. Owners Jason Martin & Charlie Cole. Michele McLeod, Purina Ambassador.
Dental Tools of the Trade
Courtesy of Dr. Chris Pearce
A good dental examination requires a range of equipment, according to Chris Pearce, BVSc, MRCVS, DEVDC (equine), director and founder of the Equine Dental Clinic. “The lips are very far forward and the teeth extend a long way back. Without sedation, without the right equipment, this is not a simple examination. We have to understand the anatomy, to be very skilled to be able to look in the mouth, and it does require a range of equipment,” he explained.
A headstand with a flat, padded top is essential and a halter might also be needed. In addition, a good mouth speculum will improve the vision of the mouth. “There are a lot on the market. Spend the money. Buy the best one that you can find. Something that is really strong and is going to last you forever,”he suggested. Another tool that should be a good quality tool is a headlight. Speculum lights are also helpful, especially when trying to explain pathology findings to clients. “I would recommend spending money on a surgical headlight that is very bright and will illuminate the oral cavity,” Dr. Pearce said. A dental mirror is essential for every oral examination. Consider a small dental mirror that takes a human size 4 or size 5 dental mirror. Some designs have the mirror screw onto the end of a lightweight handle. “[The smaller size] takes a bit of getting used to, but once you’ve got the hang of it, you can perform detailed examinations of every tooth—very far back into the mouth— without a horse resenting it or stimulating the chew reflex,” he explained. “Horses don’t even realize it is there,” he said. “Verterinarians should also have an occlusal explorer, banded periodontal probe and K-flex or Hedstrom endodontic files, a scaler, a small incisor diagnostic kit, rubberized incisor plates, two buckets and mouthwash. “Consider a small stool to sit on during the examination and a small folding table for tools. “If you are out and about doing dentistry, don’t make life difficult. Oral examinations are not that easy to do unless you have the right equipment. “Make your life easier, carry a little picnic table to put your dental charts and paper towels on, and rubbish bins, these will all go into the car very easily. Use a stool. “The client will see that you are working a safe, controlled, environment, and you will actually enjoy dentistry,” he predicted.
Issue 11/2018 | ModernEquineVet.com
Modern equine dentistry is about prevention and early diagnosis, according to Dr. Pearce. “The earlier we can diagnose problems and make decisions about treatment, the more the horse is going to thrive into old age,” he said. Owners want and expect their horses to be competing, living healthy, happy lives well into their 20s or 30s. “The only way that is going to happen is if we can diagnose developing dental disease at the earliest stages possible,” he said.
If donkeys are included, up to 90% of equids have some dental pathology. “Dental diseases are extremely common—up to 90% in some studies if you include donkeys [have some dental pathology],” he explained. “They can cause serious problems if left unidentified, such as weight loss, sinus disease, poor performance and —from a welfare perspective—pain.” Most equine dental disease develops slowly, and while it is developing, there may be few or no symptoms. In addition, horses are prey animals, so they are good at hiding pain—even extreme pain. Because they are prey animals, “horses are incredibly skilled at avoiding eating on painful areas to disguise that they are in pain,” Dr. Pearce explained. “They will alter their mastication patterns to avoid eating on painful areas of their mouths.” This means that if a horse isn’t eating because of dental disease, it must be pretty severe. “The longer things are left [unchecked], the more serious they become,” he warned. Clinical signs of dental dis-
R E A L T R E A T M E N T. R E A L P R E V E N T I O N . GASTROGARD is the only treatment for equine ulcers that is proven to be safe, effective and approved by the FDA.
ULCERGARD is the only prevention for equine gastric ulcers that is proven to be safe, effective and approved by the FDA.
• GASTROGARD healed or significantly improved equine stomach ulcers in up to 99% of treated horses1 • GASTROGARD promoted healing of equine stomach ulcers that compounded versions did not2 • Gastric ulcers may recur if therapy to prevent recurrence is not administered after the initial treatment is completed
OMEPRAZOLE FORMULATION MATTERS LABEL CLAIMS AND STABILITY STUDY 3
• Our patented omeprazole formulation is protected from
stomach acid, so that it can travel to the small intestine for adequate absorption • Proven efficacy based on thorough scientific research and review • Precaution, the safety of GASTROGARD paste has not been determined in pregnant or lactating mares. For use in horses and foals 4 weeks of age and older • ULCERGARD is for use in horses that weigh at least 600 lbs. ULCERGARD is intended for use only in prevention of gastric ulcers in healthy horses. If signs of illness are observed prior to or during the use of this product, consult your veterinarian for appropriate diagnosis and treatment recommendations. Safety in pregnant mares has not been determined
ARE YOU REALLY GETTING WHAT YOU’RE PAYING FOR?4
In a study of compounded omeprazole pastes, radiographs show incomplete fill, air pockets and lack of homogeneity. GASTROGARD paste syringes had complete fill, no air pockets and were homogenous.
PERCENT OF LABELED VALUE
GASTROGARD and ULCERGARD contain a unique patented paste formulation that stabilizes omeprazole to allow absorption.
100 80 60 40
RADIOGRAPHIC APPEARANCE OF GASTROGARD PASTE
COMPOUNDED OMEPRAZOLE PASTE PRODUCTS OFTEN HAVE PRODUCTION QUALITY-CONTROL PROBLEMS AS DOCUMENTED BY INCOMPLETE FILLING OF SYRINGES, AIR POCKETS AND VARIATIONS IN HOMOGENEITY 4
Compounded Products (Low)
Compounded Products (High)
FDA Acceptable Range
In a 60-day study, compounded formulations started as low as 63% of labeled concentration and dropped to as low as 17% on day 60. GASTROGARD concentrations remained stable throughout.3 ULCERGARD and GASTROGARD product labels. Nieto JE, et al. Comparison of paste and suspension formulations of omeprazole in the healing of gastric ulcers in racehorses in active training. J Am Vet Med Assoc. 2002;8:1-5. 3 Stanley SD, Knych HK. Comparison of pharmaceutical equivalence for commercially available preparations of omeprazole. AAEP Proceedings. 2011;57:63. 4 Wallace MA. Radiographic evaluation of compounded and illegal over-the-counter omeprazole products. ACVIM Poster Presentation. June 2017. 1 2
RADIOGRAPHIC APPEARANCE OF SEVERAL OVER-THE-COUNTER OMEPRAZOLE PASTE PRODUCTS
Recommending compounded ulcer products?
TIME FOR A GUT CHECK.
GET REAL. Real treatment with GASTROGARD. Real prevention with ULCERGARD. WARNING: Not for use in humans. Keep this and all medications out of the reach of children. In case of ingestion by humans, contact a physician. Do not use in horses intended for human consumption.
Merial is now part of Boehringer Ingelheim. ®ULCERGARD and GASTROGARD are registered trademarks of Merial. ©2018 Boehringer Ingelheim, Inc., Duluth, Ga. All rights reserved. EQU-0652-EGUS0518
ADVERSE REACTIONS: In efficacy trials, when the drug was administered at 1.8 mg omeprazole/lb (4 mg/kg) body weight daily for 28 days and 0.9 mg omeprazole/lb (2mg/kg) body weight daily for 30 additional days, no adverse reactions were observed.
The Dental Examination in
STEP 1: SEDATE THE HORSE
Sedation is mandatory to do a thorough equine dental examination. “It can be dangerous not to sedate the horse for an oral examination,” warned Chris Pearce, BVSc, MRCVS, DEVDC equine, director and founder of the Equine Dental Clinic. “Your chances of performing a clinical examination in this situation is pretty much zero. You can have a feel. You can get a little bit of an idea, but you are never going to diagnose any kind of serious pathology.”
STEP 2: EXAMINE, PALPATE, AND SMELL
side to the other and palpate the width of the mandibles from front to back by pinching them underneath. “You are looking for similarities or differences and asymmetry, as well as observing the edges of the maxillary teeth, focal maxillary teeth, lumps, bumps, swellings and discharging tracts,” Dr. Pearce said. Smell the nostrils, even if there is no nasal discharge. “They may have a foul smell suggesting a sino-nasal problem, but without a nasal discharge,” he said. Discharging sinus tracts can be easily missed. Sometimes the hair will need clipping to see exactly what is there.
STEP 3: PERFORM AN INCISOR EXAMINATION
Begin with an external examination, which includes palpating the entire head. Look for symmetry of the various head muscles. Also examine from one
Count all of the incisors. Do a good incisor examination and consider the use
ease include quidding, weight loss, poor performance, facial swelling and sinus infections, but most dental pathologies are incidental findings discovered during routine dental examinations.
He discussed a 21-year-old pony mare with no clinical signs of illness that had to be euthanized because of a malignant oral cancer. Her appetite was fine, and the owner never realized that she had a problem,
Courtesy of Dr. Chris Pearce
Caution Federal (USA) law restricts this drug to use by or on the order of a licensed veterinarian. Storage Conditions Store at 68°F – 77°F (20-25°C). Excursions between 59°F – 86°F (15-30°C) are permitted. Indications For treatment and prevention of recurrence of gastric ulcers in horses and foals 4 weeks of age and older. Dosage Regimen For treatment of gastric ulcers, GastroGard Paste should be administered orally once-a-day for 4 weeks at the recommended dosage of 1.8 mg omeprazole/lb body weight (4 mg/kg). For the prevention of recurrence of gastric ulcers, continue treatment for at least an additional 4 weeks by administering GastroGard Paste at the recommended daily maintenance dose of 0.9 mg/lb (2 mg/kg). Directions For Use • GastroGard Paste for horses is recommended for use in horses and foals 4 weeks of age and older. The contents of one syringe will dose a 1250 lb (568 kg) horse at the rate of 1.8 mg omeprazole/lb body weight (4 mg/kg). For treatment of gastric ulcers, each weight marking on the syringe plunger will deliver sufficient omeprazole to treat 250 lb (114 kg) body weight. For prevention of recurrence of gastric ulcers, each weight marking will deliver sufficient omeprazole to dose 500 lb (227 kg) body weight. • To deliver GastroGard Paste at the treatment dose rate of 1.8 mg omeprazole/ lb body weight (4 mg/kg), set the syringe plunger to the appropriate weight marking according to the horse’s weight in pounds. • To deliver GastroGard Paste at the dose rate of 0.9 mg/lb (2 mg/kg) to prevent recurrence of ulcers, set the syringe plunger to the weight marking corresponding to half of the horse’s weight in pounds. • To set the syringe plunger, unlock the knurled ring by rotating it 1/4 turn. Slide the knurled ring along the plunger shaft so that the side nearest the barrel is at the appropriate notch. Rotate the plunger ring 1/4 turn to lock it in place and ensure it is locked. Make sure the horse’s mouth contains no feed. Remove the cover from the tip of the syringe, and insert the syringe into the horse’s mouth at the interdental space. Depress the plunger until stopped by the knurled ring. The dose should be deposited on the back of the tongue or deep into the cheek pouch. Care should be taken to ensure that the horse consumes the complete dose. Treated animals should be observed briefly after administration to ensure that part of the dose is not lost or rejected. If any of the dose is lost, redosing is recommended. • If, after dosing, the syringe is not completely empty, it may be reused on following days until emptied. Replace the cap after each use. Warning Do not use in horses intended for human consumption. Keep this and all drugs out of the reach of children. In case of ingestion, contact a physician. Physicians may contact a poison control center for advice concerning accidental ingestion. Adverse Reactions In efficacy trials, when the drug was administered at 1.8 mg omeprazole/lb (4 mg/kg) body weight daily for 28 days and 0.9 mg omeprazole/lb (2 mg/kg) body weight daily for 30 additional days, no adverse reactions were observed. Precautions The safety of GastroGard Paste has not been determined in pregnant or lactating mares. Efficacy • Dose Confirmation: GastroGard ® (omeprazole) Paste, administered to provide omeprazole at 1.8 mg/lb (4 mg/kg) daily for 28 days, effectively healed or reduced the severity of gastric ulcers in 92% of omeprazole-treated horses. In comparison, 32% of controls exhibited healed or less severe ulcers. Horses enrolled in this study were healthy animals confirmed to have gastric ulcers by gastroscopy. Subsequent daily administration of GastroGard Paste to provide omeprazole at 0.9 mg/lb (2 mg/kg) for 30 days prevented recurrence of gastric ulcers in 84% of treated horses, whereas ulcers recurred or became more severe in horses removed from omeprazole treatment. • Clinical Field Trials: GastroGard Paste administered at 1.8 mg/lb (4 mg/kg) daily for 28 days healed or reduced the severity of gastric ulcers in 99% of omeprazole-treated horses. In comparison, 32.4% of control horses had healed ulcers or ulcers which were reduced in severity. These trials included horses of various breeds and under different management conditions, and included horses in race or show training, pleasure horses, and foals as young as one month. Horses enrolled in the efficacy trials were healthy animals confirmed to have gastric ulcers by gastroscopy. In these field trials, horses readily accepted GastroGard Paste. There were no drug related adverse reactions. In the clinical trials, GastroGard Paste was used concomitantly with other therapies, which included: anthelmintics, antibiotics, non-steroidal and steroidal anti-inflammatory agents, diuretics, tranquilizers and vaccines. • Diagnostic and Management Considerations: The following clinical signs may be associated with gastric ulceration in adult horses:inappetence or decreased appetite, recurrent colic, intermittent loose stools or chronic diarrhea, poor hair coat, poor body condition, or poor performance. Clinical signs in foals may include: bruxism (grinding of teeth), excessive salivation, colic, cranial abdominal tenderness, anorexia, diarrhea, sternal recumbency or weakness. A more accurate diagnosis of gastric ulceration in horses and foals may be made if ulcers are visualized directly by endoscopic examination of the gastric mucosa Gastric ulcers may recur in horses if therapy to prevent recurrence is not administered after the initial treatment is completed. Use GastroGard Paste at 0.9 mg omeprazole/lb body weight (2 mg/kg) for control of gastric ulcers following treatment. The safety of administration of GastroGard Paste for longer than 91 days has not been determined. Maximal acid suppression occurs after three to five days of treatment with omeprazole. Safety • GastroGard Paste was well tolerated in the following controlled efficacy and safety studies. • In field trials involving 139 horses, including foals as young as one month of age, no adverse reactions attributable to omeprazole treatment were noted. • In a placebo controlled adult horse safety study, horses received 20 mg/kg/ day omeprazole (5x the recommended dose) for 90 days. No treatment related adverse effects were observed. • In a placebo controlled tolerance study, adult horses were treated with GastroGard Paste at a dosage of 40 mg/kg/day (10x the recommended dose) for 21 days. No treatment related adverse effects were observed. • A placebo controlled foal safety study evaluated the safety of omeprazole at doses of 4, 12 or 20 mg/kg (1, 3 or 5x) once daily for 91 days. Foals ranged in age from 66 to 110 days at study initiation. Gamma glutamyltransferase (GGT) levels were significantly elevated in horses treated at exaggerated doses of 20 mg/kg (5x the recommended dose). Mean stomach to body weight ratio was higher for foals in the 3x and 5x groups than for controls; however, no abnormalities of the stomach were evident on histological examination. Reproductive Safety In a male reproductive safety study, 10 stallions received GastroGard Paste at 12 mg/kg/day (3x the recommended dose) for 70 days. No treatment related adverse effects on semen quality or breeding behavior were observed. A safety study in breeding mares has not been conducted. For More Information Please call 1-888-637-4251 Marketed by: Merial, Inc., Duluth, GA 30096-4640, U.S.A. Made in Brazil ®GastroGard is a registered trademark of Merial, Inc. ©2016 Merial, Inc. All rights reserved. Rev. 05-2011
Issue 11/2018 | ModernEquineVet.com
Probe and look at any occlusal defects and see if there is any depth to them. Then, grade it according to the published guides, such as the modified Honma classification system for carries. Perform an endodontic examination, an infundibular examination, a periodontal examination, all the time consider what is there and what other diagnostics might be needed. Use a small dental mirror because the small mirrors are well tolerated.
Courtesy of Dr. Chris Pearce
STEP 6: LOOK FOR ABNORMALITIES AND FOCUS ON PATHOLOGIES
of a small incisor diagnostic kit. “This is much easier to use than your long-handled periodontal probe, for example.” A small mirror allows a better view of the occlusal surface, the retained deciduous teeth, etc.
STEP 4: FLUSH THE MOUTH, PLACE THE HORSE ON THE HEADSTAND AND TAKE A SEAT
Place the full-mouthed speculum. Make sure the horse is sedated and flush the mouth carefully with syringes or a dental flushing tool connected to a hose or pump. “You should have no food anywhere in the mouth," he said. There might be some strands of forage material trapped, however. There should be an unobstructed view of the soft tissue. Assess the general symmetry of the mouth and teeth.
STEP 5: COUNT THE TEETH AND USE THE TRIADAN NUMBERING SYSTEM
“It’s important to count the teeth,” he said, adding that one might be surprised at how easy it is to miss teeth. despite many teeth being displaced out into the cheek. Therefore, a careful oral dental examination is the key. “Our ability to see things now are completely
Look for abnormalities of wear, document them, and then focus on pathologies, fractures, misplacements, supernumerary teeth, missing teeth, periodontal disease, and an endodontic assessment of every pulp canal. Once you become proficient at this exam you might consider oral endoscopic imaging, which enables you to take and store baseline images of the mouth and teeth in close-up for comparison with the next examination, as well as to show clients the pathology while you discuss diagnostics and work up a treatment plan. “Oral endoscopy or oroscopy gives your clients an immersive experience when they bring their horses to the clinic and once your clients see these images, then they really understand more about what is going on. And that engages them. This engages them and gets them on the page with you,” Dr. Pearce said.
STEP 7: RECORD FINDINGS ON A CHART, MAKE A TREATMENT PLAN AND DISCUSS IT WITH THE OWNER
Electronic health records are a little limited for recording dental pathology, so that makes the oral endoscopy even more important. Images and video should be kept in the records. MeV
different [than they were 30 years ago] so the incentive is on us as veterinary surgeons to make sure that when we do an oral examination, it is a clinical oral examina-
tion rather than just a quick cursory look,” Dr. Pearse said. “You will find all types and all ranges of pathology when you start looking,” he said. MeV ModernEquineVet.com | Issue 11/2018
BIOSECURITY MEASURES Can Reduce S. enterica Spread infection risk to their stablemates if precautions are taken once returned to the farm, a recent study found. The findings show that animals with S. enterica infection do shed the bacteria, even if they do not have clinical signs of infection, such as diarrhea. However, those with diarrhea were more likely to shed the organism. They also found that shedding did not appear to increase the risk in stablemates of premature death or gastrointestinal problems such as colic, if biosecurity measures were taken. The retrospective case-control study included 94 horses that had been hospitalized between January 2011 and December 2012 with S. enterica and
Issue 11/2018 | ModernEquineVet.com
A d a m
M a r c u s
Horses hospitalized with Salmonella enterica do not appear to pose an
If you see these signs,
DON’T STALL. Stumbling or tripping Tilted head Asymmetrical muscle loss Lameness or gait abnormality Leaning against walls It could be EPM. As you know, the signs can be subtle, but treatment should be aggressive. Marquis® (15% w/w ponazuril) is a powerful antiprotozoal that works fast to stop the parasite responsible for Equine Protozoal Myeloencephalitis (EPM) – and further damage to the horse’s central nervous system.
IMPORTANT SAFETY INFORMATION: The safe use of MARQUIS in horses used for breeding purposes, during pregnancy, or in lactating mares has not been evaluated. In animal safety studies, loose feces, sporadic inappetence, lost weight, and moderate edema in the uterine epithelium were observed. For use in animals only. Not for human use. Keep out of reach of children. Merial is now part of Boehringer Ingelheim. ‰MARQUIS is a registered trademark of Merial. ©2018 Boehringer Ingelheim Vetmedica, Inc. All rights reserved. EQU-0933-MARQ1118
(15% w/w ponazuril) Antiprotozoal Oral Paste
Caution: Federal (U.S.A.) law restricts this drug to use by or on the order of a licensed veterinarian.
For The Treatment Of Equine Protozoal Myeloencephalitis (EPM) In Horses For Oral Use Only BRIEF SUMMARY Before using MARQUIS, please consult the product insert, a summary of which follows: INDICATIONS MARQUIS (ponazuril) is indicated for the treatment of equine protozoal myeloencephalitis (EPM) caused by Sarcocystis neurona. WARNINGS For use in animals only. Not for use in horses intended for food. Not for human use. Keep out of reach of children. PRECAUTIONS Prior to treatment, a complete neurologic exam should be completed by a veterinarian. In most instances, ataxia due to EPM is asymmetrical and affects the hind limbs. Clinicians should recognize that clearance of the parasite by ponazuril may not completely resolve the clinical signs attributed to the natural progression of the disease. The prognosis for animals treated for EPM may be dependent upon the severity of disease and the duration of the infection prior to treatment. The safe use of MARQUIS (ponazuril) in horses used for breeding purposes, during pregnancy, or in lactating mares, has not been evaluated. The safety of MARQUIS (ponazuril) with concomitant therapies in horses has not been evaluated. ADVERSE REACTIONS In the field study, eight animals were noted to have unusual daily observations. Two horses exhibited blisters on the nose and mouth, three animals showed skin reactions for up to 18 days, one animal had loose stools, one had a mild colic on one day and one animal had a seizure while on medication. The association of these reactions to treatment was not established. ANIMAL SAFETY SUMMARY MARQUIS (ponazuril) was administered to 24 adult horses (12 males and 12 females) in a target animal safety study. Three groups of 8 horses each received 0, 10 or 30 mg/kg (water as control, 2X and 6X for a 5 mg/kg [2.27 mg/lb] dose). Horses were dosed after feeding. One half of each group was treated for 28 days and the other half for 56 days followed by necropsy upon termination of treatment. There were several instances of loose feces in all animals in the study irrespective of treatment, sporadic inappetence and one horse at 10 mg/kg (2X) lost weight while on test. Loose feces were treatment related. Histopathological findings included moderate edema in the uterine epithelium of three of the four females in the 6X group (two treated for 28 days and one for 56 days). For customer care or to obtain product information, including a Material Safety Data Sheet, call 1-888-6374251 Option 2, then press 1.
Roughly 44% of the horses with Salmonella were considered to be shedders of the bacteria based on their first stool sample. That fell to 18% on the second and just 1% by the sixth test. 279 animals without the infection. Of the infected animals, 29 had multidrug resistant (MDR) microbes and 65 had nonresistant strains of the bacteria. All of the horses were treated at the Hagyard Equine Medical Institute in Lexington, Ky., which supported the study. Roughly 44% of the horses with Salmonella were considered to be shedders of the bacteria based on their first stool sample, a figure that fell to 18% on the second test and just 1% on the sixth test. The researchers found that horses with diarrhea were nearly twice as likely to shed Salmonella in stool as those without the condition, but that risk was confined to non–drug-resistant bacteria. “This finding is especially interesting given that receiving antimicrobial therapy during hospitalization was not associated with shedding Salmonella, nor was it associated with shedding of [MDR] strains,” they wrote. “This was unexpected as some research suggests that antimicrobial use during hospitalization creates pressure on the gut microbiome, encouraging a shift to more resistant populations.” On the other hand, horses that ate less during hospitalization were about onethird less likely to shed non-resistant bacteria but nearly six times as likely to shed resistant Salmonella than were animals that maintained normal food intake. The researchers also conducted interviews with stable owners to determine outcomes for both the treated animals and their stablemates. Those interviews were con-
“Generally, we recommend previously positive horses are isolated from others on farm, fed up off the ground, have feces removed from the housing area daily, and have personnel tend to these horses after all others, wearing clothing that can be removed before tending to other animals or going home, and practicing rigorous hand hygiene,” said Dr. Burgess, who is also the director of Infection Control at the Veterinary Teaching Hospital of UGA, in Athens. Ideally, she said, animals would be housed on cleanable surfaces—such as sealed concrete or sealed wood—that can be washed and disinfected before another animal is housed there. “We also should be educating owners that Salmonella is a zoonotic agent and can also cause infections in dogs and cats,” she added. Dr. Burgess and her colleagues are now conducting a prospective study to assess the duration of bacterial shedding and what effect that has on the risk to stablemates. MeV
For more information: Burgess BA, Bauknecht K, Slovis NM, et al. Factors associated with equine shedding of multi-drug-resistant Salmonella enterica and its impact on health outcomes. Equine Vet J. 2018 Sep;50(5):616-623. https://onlinelibrary.wiley.com/doi/full/10.1111/evj.12823
®MARQUIS is a registered trademark of Merial. ©2016 Merial, Inc., Duluth, GA. All rights reserved.
ducted between July and December of 2013. Brandy A. Burgess, DVM, MSc, PhD, DACVIM, DACVPM, an assistant professor of epidemiology and infection control in the College of Veterinary Medicine at the University of Georgia, in Athens, said the message for stables from the new findings is that horses that were infected with Salmonella can safely be returned home— with precautions.
Issue 11/2018 | ModernEquineVet.com
THE BUSINESS OF PRACTICE
g n i t i r W PUT IT IN
Employment contracts can be helpful
the other reason is to detail a non-compete.” While an effective contract could be as short as one page, details are important. Few employment disputes end up in court, but in that event, the interpretation of the employment agreement is what matters, and the contract informs the jury’s understanding. “The reason you get these verbose agreements is because, from an attorney’s standpoint, they have to think of every single way that what you are trying to say could be misconstrued,” Mr. Mortensen said. “I have seen
in running a successful veterinary practice, because a comprehensive contract removes any ambivalence regarding the terms of employment. “There are two main reasons that you have an employment contract for veterinarians,” said Ky Mortensen, JD, MBA, who is the general counsel and director of operations for Inova. “One of them is to describe the agreed-upon compensation package, and you want to make sure that is detailed well. And
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Employment contracts help avoid disputes
a ModernEquineVet.com | Issue 11/2018
THE BUSINESS OF PRACTICE
Employment agreement checklist
• Treating patients and performing the job at the desired locations • Sharing on-call, performing rounds • Keeping appropriate records
contracts where the placement of a comma changed the entire sentence and changed the entire meaning,” he said. The jury does not “know all the things that were said. They don’t know everything you agreed to, all the handshakes, all the ‘Well, we’ll talk about that later,’ all the things that you thought were going to happen. If it’s not within the four corners of that contract, then it does not count.”
What to Leave In
Compensation should be clearly outlined in a contract. A practice owner or manager should keep in mind that those compensation details might be scrutinized closely at some point during a dispute. While many practice management software programs calculate compensation, knowing how those calculations work is important. In case of a dispute that winds up in court, Mr. Mortensen recommended spelling out the mathematics of the compensation package in the contract. “At the end of the day, it is not going to come down to one paycheck,” he said. “It is going to come down to, ‘Hey, I think there is a problem with the way I am getting paid, and I have worked here for 7 years.’ So now we’ve got to go all the 14
Issue 11/2018 | ModernEquineVet.com
• Corresponding with staff and clients • Maintaining skill level • Employer directing activity and control
Compensation should be clearly outlined in a contract. Remember details might be scrutinized closely during a dispute. way back and look at this, and there had better be some way of digging all of this up and making sure we are right or we’ve got a big issue.” Similarly, in case an employee incurs their own debt to the practice—such as treatment of their own horses—a wage deduction authorization form is useful to include in the contract.
What to Leave Out
Conversely, duties and benefits packages are best left out of contracts, Mr. Mortensen said, suggesting that they be outlined in an employee manual, which can be referred to in a contract. Duties, paid time off and other details are very likely to be fluid, and an employment manual can be re-
Source: Ky Mortenson
RECITALS – Describe the veterinary arrangement EMPLOYMENT – Rules, ethics, general duties of the job TERM – Year to year, perpetual, etc. SERVICE – Devotion of full time DUTIES – Detailed description
vised accordingly. “You may decide based on the finances of the practice that you really cannot afford to continually match that 401K the way you have been doing it, or you may not be able to contribute to their health care the way you have been,” he said. “It is not a real morale booster for that to happen … but at the end of the day, the company has to survive, and if you have to make changes to the way your benefits package is structured for the survivability of the company so you do not go bankrupt, well, that is just the way it is. “However, if you have somebody with an employment contract and you tell them right in the contract that for the entire term of the contract you are going to match their 401K at a certain percentage, now you are stuck.” Despite how thorough and comprehensive a contract should be, Mortensen cautions against sticking to it too stringently. Employee morale remains important, and most contracts never will end up in court. “If anything is ever done that is not in that contract that you would have included … do it anyway,” he said, citing mileage reimbursements or housing arrangements as examples. “Always err on the side of good.” MeV
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Regulating Insulin Dysregulation in Ponies: Just as people with diabetes have trouble controlling their disease with just diet, ponies also have problems controlling insulin-dysregulation leading to a host of problems. But an experimental veterinary medication related to one prescribed for diabetics looks promising for preventing laminitis in insulin-dysregulated ponies. “Just like humans, ponies, particularly—and also horses—start to B y
Ponies are at an especially high risk of insulin dysregulation and laminitis, which affects about 20% of ponies.
Issue 11/2018 | ModernEquineVet.com
get fatter around the middle as they age, especially when there is a constant and abundant food supply,” explained Martin Sillence, PhD, a professor in the School of Earth, Environmental and Biological Sciences at the Queensland University of Technology. “We discovered that when some ponies over-eat energy-rich pasture or grains which release a lot of glucose, their pancreas pumps out
M a r i e
even more insulin and this leads to insulin toxicity,” he explained. “The toxic levels of insulin break down the connective tissue in the ponies' feet causing lameness and excruciating pain.” Dr. Sillence and his team wanted to know if velagliflozin, a sodium-glucose cotransport 2 (SGLT2) inhibitor that belongs to a family of drugs developed to treat human metabolic syndrome by Boehring-
R o s e n t h a l ,
Image by Anthony Weate
MORE THAN JUST DIET
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tis pain and oice for treating osteoarthri ch ht rig the is XX UIO EQ d you’ll fin When you do the research, . inflammation for your clients for horses – spares COX-1
NSAID XX – the first and only coxib • First and Only – EQUIO 1 , including while inhibiting COX-2 * ective than phenylbutazone eff 2 re mo or ive ect eff as ed provement scores UIOXX was rat im l EQ ral dy, ove stu a and In e – enc cy fer ca um Effi • , joint circ nipulation, range of motion ;3,4 improvement in pain on ma studies than any other NSAID ety saf in ses hor re mo on n tested • Safety – EQUIOXX has bee ects most horses had no side eff e, dos ed at the recommend o aid in compliance up to 24 hours which can als n pai ls tro con e dos e On – • Convenient been determined. *Clinical relevance has not
D out to pasture. See how Time to put your old NSAI rence for your clients. ffe di a e ak m n ca X OX UI EQ
Available in three formulations to fit in and out of competition needs: Injection, Paste and Tablet. IMPORTANT SAFETY INFORMATION: As with any prescription medication, prior to use, a veterinarian should perform a physical examination and review the horse’s medical history. A veterinarian should advise horse owners to observe for signs of potential drug toxicity. As a class, nonsteroidal anti-inflammatory drugs may be associated with gastrointestinal, hepatic and renal toxicity. Use with other NSAIDs, corticosteroids or nephrotoxic medication should be avoided. EQUIOXX has not been tested in horses less than 1 year of age or in breeding horses, or pregnant or lactating mares. For additional information, please refer to the prescribing information or visit www.equioxx.com. Merial is now part of Boehringer Ingelheim. ®EQUIOXX is a registered trademark of Merial. ©2018 Merial, Inc., Duluth, GA. All rights reserved. EQU-0460-JH0218
Data on file at Merial, Safety Study, PR&D 0144901. Doucet MY, Bertone AL, et al. Comparison of efficacy and safety of paste formulations of firocoxib and phenylbutazone in horses with naturally occurring osteoarthritis. J Am Vet Med Assoc. 2008;232(1):91-97. 3 EQUIOXX product labels and FOI summaries and supplements. 4 Data on file at Merial, Clinical Experience Report PHN 471, PR&D 0030701. 1 2
EQUIOXX® (firocoxib) is indicated for the control of pain and inflammation associated with osteoarthritis in horses. Firocoxib belongs to the coxib class of non-narcotic, nonsteroidal anti-inflammatory drugs (NSAID). CONTRAINDICATIONS: Horses with hypersensitivity to firocoxib should not receive EQUIOXX. WARNINGS: EQUIOXX is for use in horses only. Do not use in horses intended for human consumption. Do not use in humans. Store EQUIOXX Tablets out of the reach of dogs, children, and other pets in a secured location in order to prevent accidental ingestion or overdose. Consult a physician in case of accidental human exposure. Horses should undergo a thorough history and physical examination before initiation of NSAID therapy. Appropriate laboratory tests should be conducted to establish hematological and serum biochemical baseline data before and periodically during administration of any NSAID. NSAIDs may inhibit the prostaglandins that maintain normal homeostatic function. Such anti-prostaglandin effects may result in clinically significant disease in patients with underlying or pre-existing disease that has not been previously diagnosed. Treatment with EQUIOXX should be terminated if signs such as inappetance, colic, abnormal feces, or lethargy are observed. As a class, cyclooxygenase inhibitory NSAIDs may be associated with gastrointestinal, renal, and hepatic toxicity. Sensitivity to drug-associated adverse events varies with the individual patient. Horses that have experienced adverse reactions from one NSAID may experience adverse reactions from another NSAID. Patients at greatest risk for adverse events are those that are dehydrated, on diuretic therapy, or those with existing renal, cardiovascular, and/ or hepatic dysfunction. The majority of patients with drug-related adverse reactions recover when the signs are recognized, drug administration is stopped, and veterinary care is initiated. Concurrent administration of potentially nephrotoxic drugs should be carefully approached or avoided. Since many NSAIDs possess the potential to produce gastrointestinal ulcerations and/or gastrointestinal perforation, concomitant use of EQUIOXX with other anti-inflammatory drugs, such as NSAIDs or corticosteroids, should be avoided. The concomitant use of protein bound drugs with EQUIOXX has not been studied in horses. The influence of concomitant drugs that may inhibit the metabolism of EQUIOXX has not been evaluated. Drug compatibility should be monitored in patients requiring adjunctive therapy. The safe use of EQUIOXX in horses less than one year of age, horses used for breeding, or in pregnant or lactating mares has not been evaluated. Consider appropriate washout times when switching from one NSAID to another NSAID or corticosteroid. The Safety Data Sheet (SDS) contains more detailed occupational safety information. For technical assistance, to request an SDS, or to report suspected adverse events call 1-877-217-3543. For additional information about adverse event reporting for animal drugs, contact FDA at 1-888-FDA-VETS, or http://www.fda.gov/AnimalVeterinary. Rev 10/2016
Survival of the Unfittest The first flush of new grass in spring and autumn pastures are the most dangerous times for susceptible ponies and horses. “Ponies and horses with metabolic syndrome should not feed on pasture that has been fertilized for fattening sheep and cattle, it is too rich, even though healthy horses seem to be able to manage this type of diet,” said Martin Sillence, a professor in the School of Earth, Environmental and Biological Sciences at the Queensland University of Technology. “But it is not just about the quality of the food they eat. It is also about the quantity. If large quantities of unfertilized grass are available they will eat a lot.” Dr. Sillence said laminitis was more common in ponies such as Shetland and Welsh Mountain ponies that had been bred to survive harsh winters when snow on the ground killed the grass. “When the grass appeared in spring they would eat like crazy and absorb as much glucose as possible to store for the winter when they would lose weight by using up these fat stores. “But now most domestic ponies do not experience seasonal food shortage and grow plump because they just keep eating and pack on the weight.”
er Ingelheim, could reduce hyperinsulinemia and prevent the development of laminitis. They screened 75 ponies with an oral glucose test that they adapted for equine use for insulin dysregulation and selected 49 ponies with the highest insulin concentrations for the study. The animals were randomly assigned to a treatment group (12) that received velagliflozin and a control group (37). They were fed a maintenance diet of alfalfa hay for 3 weeks before being fed the challenge diet for up to 18 days. Researchers measured blood glucose and serum insulin concentrations over 4 hours after
eating the challenge diet for 2 days. The researchers found that the maximum glucose concentration was 22% lower in the animals taking velagliflozin than those that were not receiving the drug (P=0.014). In addition, 14 of the 37 untreated animals developed laminitis, but none of the treated animals developed the condition. “It [velagliflozin] works by causing the kidneys to excrete more glucose in the urine to take the pressure off the pancreas and lower insulin levels,” he said. MeV The study was funded by Boehringer Ingelheim Vetmedica, which also provided the study compound.
For more information: Meier A, Reiche D, deLaat M, et al. The sodium-glucose co-transporter 2 inhibitor velagliflozin reduced hypersinulinemia and prevents laminitis in insulin-dysregulated ponies. PLoS One. 2018;13(9): e0203655 DOI: 10.1371/journal.pone.0203655 https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0203655 18
Issue 11/2018 | ModernEquineVet.com
CAUTION: Federal law restricts this drug to use by or on the order of a licensed veterinarian.
For more information: Hagan RW, Didion EM, Rosselot AE, et al. Dehydration prompts increased activity and blood feeding by mosquitoes. Scientific Reports. 2018; 8 (1) DOI: 10.1038/s41598-018-24893-z
This is a vial of mosquitoes. The University of Cincinnati found that mosquitoes seek a blood meal not just for protein to lay eggs but also to quench their thirst.
day after a dry spell – to see what physiological differences they could detect in the two groups, along with random non-feeding mosquitoes they also sampled. They found that dehydrated mosquitoes were more likely to seek a blood meal compared with mosquitoes that were not thirsty. MeV
New Project Looks at Equine Wound Management Image courtesy of the Equine Wound Project
Female mosquitoes bite not only to get the protein they need to lay eggs but also to quench their thirst during a drought, according to biologists with the University of Cincinnati. The students were studying a batch of thirsty, dehydrated mosquitoes when some escaped from a vial. “They noticed the mosquitoes were unusually aggressive,” said UC biology student and study co-author Elise Didion. “They were all trying to bite.” Joshua Benoit, PhD, UC biology professor, and his students study mosquitoes in their biology lab, where adults of six species are sequestered in large mesh boxes in a room kept at a balmy 82°. Each box has a source of water and nectar and a place to lay eggs to create a constant supply of lab specimens. Researchers studied the common house mosquito, Culex pipiens, for the dehydration study. But the lab also is home to the more aggressive Aedes aegypti. Female mosquitoes typically need the protein found in blood to lay eggs. Students warm a capful of chicken blood covered in a thin membrane that mimics animal skin. The researchers were surprised about how infrequently they will seek a blood meal when they have ample water and hydration. “Normally only 5% or 10% of female mosquitoes will feed at any time, depending on the species,” he said. In their study, dehydration prompted as many as 30% of female mosquitoes to seek a blood meal. The researchers theorized that dehydration suppressed metabolism, reduced activity and decreased blood feeding in the northern house mosquito. But surprisingly, they found that conditions of dehydration increased the propensity of mosquitoes to land and feed on a host. Meanwhile, mosquitoes with ready access to water did not seek blood meals at a higher rate when exposed to similar temperature and humidity. The students put their theories to the test in naturalbut-controlled conditions at the UC Center for Field Studies. They released adult mosquitoes in a large mesh enclosure called a mesocosm that mimics natural conditions. After more than a week, researchers introduced a membrane-covered disk of blood that mimics a bird or animal host. Researchers then collected blood-feeding mosquitoes on two occasions – a day after it rained and a
Credit: Andrew Higley/UC Creative Services
Mosquitoes Bite More When They Are Thirsty
Calling all U.K. horse owners. Researchers at the School of Veterinary Medicine and Science, University of Nottingham have teamed up with the equine charity, The British Horse Society, to launch the Equine Wound Project. Owners have no clear guidance about which wounds should be treated by a veterinarian, how long different wounds take to heal, or if the horse will return to normal work. It can be difficult to make an informed decision about what to do, particularly when they may be feeling distressed about their horse’s wellbeing. The project is asking for information, including photos, about their horse’s initial wound, as well as the subsequent assessment, treatment process and outcome. Researchers want to learn about any type of equine wound regardless of size and whether it was treated by a veterinarian, so they can obtain data about a wide range of injuries. MeV For information, go to www.bhs.org.uk/wounds. ModernEquineVet.com | Issue 11/2018
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