Low Albumin (Hypoalbuminaemia)

Horses Alpacas Guides Advice

Causes

The most common cause of low blood albumin in horses is intestinal disease. If there is diarrhoea then the loss is likely from the large intestine, if there is no diarrhoea then the loss is most likely from the small intestine. The causes of intestinal disease include worms particularly encysted redworm, sand, inflammatory bowel disease, some medications, infection, or neoplasia. It may also be caused by kidney or liver disease in rarer cases.

Symptoms

Weight loss
Fluid swelling under belly and/or lower legs
Lethargy
Not quite right
Diarrhoea
No outward symptoms in mild cases

Diagnosis

The low albumin is shown on a blood test. The cause can be investigated with:

an ultrasound scan on the abdomen to assess the small intestine, large intestine, kidneys and liver.
Faecal testing for worm burden, sand and infections.
Further blood testing looking for concurrent disease or inflammation.
Biopsy of the small intestine or rectum.
Gastroscopy.

Treatment

The specific treatment depends on the underlying cause but may include:

Wormer – encysted red worm is a common cause of low albumin so an equest wormer is usually recommended.
Steroids – the albumin is leaked through inflamed intestine walls therefore steroids are often indicated to treat the inflammation.
Misoprostal – a medication which improves the blood supply to the intestine to aid healing.
Psyllium – if sand is suspected and for large intestine support.
Probiotic supplement.
Fluids – if dehydrated.
Stopping any medications which could be the cause.
Treating any concurrent disease.
Plasma transfusion may be required in severely affected horses.

Prognosis

Mild cases which respond well to treatment quickly have a good prognosis, particularly if the underlying cause is identified and treated. However, some cases may require long-term treatment such as inflammatory bowel disease. Severely affected hypoalbuminaemic horses particularly with a heavy encysted redworm burden can have a poor prognosis and the condition may lead to euthanasia.

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Gastric Ulcers

Horses Common Treatments

Gastric ulceration refers to a scale of disease from inflammation to erosions of the lining of the stomach. The disease can also be called Equine Gastric Ulcer Syndrome (EGUS) or stomach ulcers. There are two types of ulcerative disease in the equine stomach which depends on where in the stomach they occur.

Squamous ulceration refers to ulceration of the squamous portion or top half of the stomach. This portion of the stomach is not designed to tolerate high acid levels as under normal circumstances the pool of acid should not sit this high up and with a natural diet there should be a matt of fibre sat on top of the acid keeping it low down and neutralised at this level. These ulcers can be considered acid splash ulcers and may be predisposed to by low fibre intake, exercise without a fibre matt or insufficient acid suppression caused by stress or a malfunction of this mechanism.

Glandular ulceration refers to a condition affecting the glandular portion or bottom half and exit of the stomach. This portion of the stomach is designed to tolerate high acid levels as this is where the acid pool sits, therefore the mechanism of disease in these cases is thought to be different. The barrier to acid must be breached to allow the acid to then cause ulceration, this is most likely due to a reduction in the mucosal blood flow which may be caused by stress, certain medications, or a malfunction of this mechanism.

Symptoms

There is a wide range of symptoms associated with gastric ulceration including any individual or combination of the following:

Weight loss
‘Girthy’ or ‘saddle shy’ behaviour or resenting rugs being done up
Resistance to the leg when ridden including tail swish or high head carriage
Loss of performance in the absence of or alongside an orthopaedic cause
Grumpy stable behaviour particularly around food
Signs of discomfort after eating a hard feed which self resolves or preferring grass and hay to hard feeds
Loss of condition of coat or just not looking as well as usual
Colic
Windsucking or weaving may have a relationship with ulcers
Stressy or nervous behaviour or over-reacting to stimuli

Diagnosis

The only way to know whether a horse has gastric ulcers is via gastroscopy. This is a diagnostic test where a camera is passed up the nose, down the throat and into the stomach to visualise the inside of the stomach. The horse has to be starved overnight and is sedated for the procedure.

Treatment

There are a few different treatments available and the decision of which to use will depend on the location, type and severity of the ulcers as well as some practical considerations around the individual case and will be discussed between the vet and the owner in each case.

The potential treatments include:

Omeprazole

This suppresses acid which quickly improves comfort and allows the ulcers to heal. There are options to use oral paste syringes or injections.

Sucralfate

This also suppresses acid and also binds to the surface of the ulcers providing a barrier whilst they heal. This is a powder which can be mixed with water and syringed orally or mixed with food.

Misoprostal

This increases mucosal blood flow to promote healing and function of the mucosal barrier. This is a tablet given in food. There are human safety considerations with this medication so careful consideration must be given to its use.

Steroids

These are potent anti-inflammatory medications and may be used in some cases of severe glandular disease. These are tablets given in food.

A high specification supplement is often used alongside or immediately after medical treatment. These contain ingredients shown to keep acid levels suppressed, improve mucus production and improve the mucosal barrier to help treat and prevent recurrence of ulcers.

Identify and address any predisposing factors such as orthopaedic pain, feed issues or environmental stress. Without dealing with these the success of treatment is limited.

Treatment is required for a prolonged period of time and may range from 4 to 12 weeks in most cases.

Monitoring

A repeat gastroscope at the end of treatment is required to assess the response to treatment. Often the treatments will make the horse feel better so the outward signs improve but the healing may not be complete so stopping too soon could cause relapse.

Prognosis

In the majority of cases a good outcome is expected with full resolution of ulcers seen and a management strategy in place prevents recurrence. However, in some cases the ulcers do not fully respond to treatment, these are most likely to be glandular ulcers. It is thought that some horses have a fundamental issue with their stomach lining and it will need ongoing low doses or treatment or repeat course of treatment over time to manage but not cure the condition. Likewise if a horse has an underlying predisposition such as stress, orthopaedic pain or management factors which don’t suit him/her then the ulcers will not resolve. In the most part treating ulcers is straightforward but it can be complex and drawn out at times, as well as financially expensive.

Prevention

Some horses appear to get gastric ulcers regardless of what we do however there are some things well associated with ulcers that we can learn from. Prevention strategies include:

Ad lib forage

A constant source of good quality fibre forage is important to keep the acid levels normal in the stomach. This looks like ad-lib hay/haylage and turnout to grass.

Turnout

There is good evidence that being turned out is both mentally beneficial reducing environmental stress and provides ad lib forage. Ideally the horse should be able to interact with other horses too to promote natural behaviour and release happy hormones.

Hard feed

High fibre, low in sugar and starch is the aim. Most horses which are fed grass and hay are completely fine with this based diet. If a horse is underweight and therefore requires more calories it is advised that this is achieved via increased fat and protein levels as opposed to sugar and starch. For example, use linseed or oils in the feed to increase fat and replace a plain chaff with an alfalfa based chaff for increased protein. There is a range of mainstream feeds which do this for you which advertise that they are ulcer friendly and advice can always be sought by a nutritionist.

Corn Oil

There is evidence that 1ml corn oil per kg of horse’s bodyweight can support a healthy mucosal lining and help prevent stomach ulcers.

Shavings vs straw

You may come across advice regarding this. There is a study showing that horses which ate their straw bedding had higher rates of stomach ulcers and this is though to be due to the physical abrasiveness of the straw. This could be something to consider if your horse is on straw and has a stomach ulcer issue.

Alfalfa

There is conflicting advice regarding alfalfa. One study showed that it made ulcers worse and one showed that it makes them better. It turns out that it depends on the abrasiveness of the chop itself – the study where they got worse was using a harsh firm alfalfa chop and where it was seen to help stomach health used a soft alfalfa chop. So similar to the straw study this harshness of the chaff seems to make a difference and it may be worth using a soft alfalfa chop in an ulcer prone horse particularly if you want some extra calories.

Dentistry

If the teeth are ineffective or painful then food will be swallowed before it has been chewed properly, this may have an impact on stomach health. Routine dental checks are recommended every 6-12 months with a vet or BAEDT.

Comfort

It is well recognised that horses in physical discomfort are predisposed to gastric ulcers. Routine physiotherapy checks, farriery and saddle/bridle/bit fit checks are essential if you are riding your horse to prevent ridden discomfort.

Routine

Horses thrive on routine and this is thought the help prevent low grade stress.

Feeding before travel and exercise

Contrary to historic belief we now know that riding or travelling on an empty stomach is a big risk factor for stomach ulcers. It is recommended that a horse is fed a small chaff feed 20 mins prior to ridden work. This chaff forms a matt on top of the acid pool and prevents splashing and over-acidified stomachs during the exercise or travel session. Consider this also when at a show all day and may be riding multiple times, always offer the horse grass, hay or feed and water between rides and before and/or during travel home.

Supplements

There may be some merit in feeding a good quality gastric ulcer supplement including antacids and pro-barrier components if your horse has had ulcers before or is predisposed.

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Equine Metabolic Syndrome (EMS)

Horses Common Treatments Advice

EMS is a syndrome involving insulin resistance and unusual fat distribution around the body causing an increased risk of laminitis. Although it is not technically the same it is often likened to diabetes in humans, and this can be helpful when thinking about the condition. Some horses will be temporarily affected by EMS due to management and circumstances. This is because insulin resistance can be caused by obesity and lack of exercise (for example a horse who is out of work and on increased grass would be at risk), in these cases adjustments to the management system with or without short term medications can result in a resolution of both the clinical aspects of the disease and evidence on blood tests. Some horses however are genetically predisposed to EMS and these horses require lifelong management changes with or without medication and they may not ever test negative on blood tests despite best efforts.

Symptoms

Regional Adiposity

This refers to fat pad development typically on the crest of the neck, behind the shoulders and at the top of the tail. The horse may not have any excess fat in the abdomen region and can even have good rib exposure and so may not typically be thought of as overweight but still holds a cresty neck for example.

General obesity which is difficult to manage

In some cases the horse is just generally overweight all over.

Laminitis

Horses with EMS are significantly at risk of laminitis.

Exercise intolerance or mild demeanour alterations such as lethargy

Some horses with EMS feel groggy and be less keen for exercise.

Diagnosis

A clinical assessment is likely to cause high suspicion. Confirmation of the condition is obtained via blood tests, either resting or dynamic.

Resting blood test

This will measure (one or all of the following): insulin, glucose, triglycerides and adiponectin at rest. The most significant measurement is insulin as this is the driver of laminitis. A high level of insulin at rest is very significant. Glucose measures the free sugar in the blood and triglycerides is a measure of fat in the blood. Adiponectin is a hormone which is suppressed by metabolically unhealthy fat (bad fat), if the level is low then the horse has too much bad fat in the body.

Dynamic blood test

This measures the response of insulin to a sugar challenge (usually karolyte syrup) and is the most accurate insulin function test. The sugar syrup represents normal grass, hay or hard feed and so is a way for us to see how the body copes with a challenge which it should normally cope fine with. A horse with insulin dysregulation would have an overly high insulin result on this test.

Treatment

Management

Diet

A high fibre low sugar and starch diet is essential. This is because the body has insulin which is not working therefore it cannot process sugar normally, therefore keeping triggers low helps the body out. This usually means no grass, soaked hay and a high fibre, low starch and sugar hard feed.

Exercise

As long as the horse is sound, they should be exercised every day for at least 20 minutes. This has been shown to reduce insulin levels significantly and can be as simple as walking or lunging in-hand. If physical exercise is not an option then clever turnout solutions can be helpful such as track systems.

Don’t over-rug in winter

Allowing horses to regulate their own body temperature gives them the opportunity to use their fat supplies and increase their own insulin sensitivity.

Medication

‘Flozin’ drugs are highly effective. Examples are canagliflozin and ertugliflozin. These work by encouraging glucose to be excreted via urine and this causes weight loss and increased insulin sensitivity very quickly – insulin levels are regularly seen to drop dramatically within 7 days of starting this medication. These drugs can be used short term to rescue a case if for example the horse has laminitis (insulin directly damages the laminae so getting it down quickly helps get the horse better quicker) and then management can continue to manage the horse long term or can be used in an ongoing fashion for genetically affected horses. Side effects include urinary tract infections due to the sugar in the urine and high fat mobilisation in the blood which can be monitored with regular blood tests.

Prevention

Maintaining a healthy weight, providing regular exercise and keeping sugar and starch intake low are all vital parts of prevention of this condition.

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Cushings

Horses Health Problems Common Treatments

Cushings disease is also known as pituitary pars intermedia dysfunction (PPID). It is a condition affecting part of the brain called the pituitary gland. This part of the brain makes hormones including one called ACTH and this disease causes excessive amounts of this hormone to be in the blood. It is a condition mostly associated with ageing horses with the average age of diagnosis being 19 years, although it can be diagnosed in horses 7-10 years of age plus.

Symptoms

There is a wide range of symptoms relating to excessive ACTH levels which may include one or a few of the following, or in some cases there are no obvious outward symptoms, and it is found on screening blood tests:

Lethargy

Not quite themselves.

Drinking and urinating more

Infections

Which either don’t resolve as we expect or are recurrent – this is due to a suppression of immunity.

Increase in faecal worm egg count

Again due to immune suppression.

Long haircoat which may be curly and delayed shedding of winter fur

Sometimes the coat just loses quality and becomes stary and they may be more prone to catching lice.

Increased sweating

Laminitis

Cushings can cause laminitis.

Loss of topline

Due to muscle mass breaking down.

Pot belly

Due to the loss of muscle strength and topline cushingoid horses can appear potbellied. This is typically associated with old age but is most likely due to cushings.

Diagnosis

A blood test can be taken to measure the ACTH hormone levels. A horse’s ACTH levels naturally fluctuate throughout the year with a natural elevation in the autumn and the laboratory now have accurate adjusted reference ranges to be able to interpret these levels accurately.

In some cases, a resting ACTH blood test is not accurate and may produce a false negative result. If there is a high clinical suspicion of cushings but a negative resting ACTH result, we may perform a TRH stimulation test. This is a dynamic test where the ACTH level is measured before and again 10 minutes after an injection of a hormone called TRH which stimulates the ACTH pathway. This is the most accurate cushings test.

Treatment

Treatment is with a medication which will be required for the rest of the horse’s life. There are a few available treatments with the most common being daily pergolide tablets (Prascend) or weekly cabergoline injections.

The pergolide tablets are given once or twice daily depending on the individual response. These are mostly well tolerated but some horses go off their food. If this happens a dose adjustment may be indicated or if this does not work either, then alternative treatment should be considered.

The cabergoline injections are once weekly under the skin injections which can be given by the owner. These are particularly useful in horses who do not tolerate pergolide, require high doses of pergolide to maintain control of the cushings or when owners prefer the convenience.

Management

Managing the consequences of cushings can help to keep the risk of complications to a minimum and keep the horse more comfortable. This can include clipping of the hair coat to prevent overheating, keeping up with regular worm control and maintaining excellent farriery and dental care. Diet is also important – with the increased risk of laminitis the aim should be to keep sugar and starch levels low but with the loss of topline some nutritional support is helpful for maintaining condition. This is best achieved with protein and fats as opposed to sugar and starch, it is best to seek nutritional advice for feeding cushingoid horses to provide optimal benefits and minimise risks.

Regular blood tests are invaluable in helping to monitor the disease levels and to see if the current treatment dose is correct or whether it needs to be adjusted. Cushings disease may progress despite the treatment and so dose increases are fairly common over time.

Prognosis

Although it is a lifelong condition which cannot be reversed, most horses with cushings can live a normal and long life with medication and management. The key is reducing the side effects of the disease such as infections and laminitis which may have more serious implications.

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Atypical Myopathy

Horses Health Problems

A myopathy is a condition affecting the muscles where damage to the muscle cells releases enzymes into the blood, causes significant pain and limits the horse’s ability to move. Typical myopathies are related to exercise such as ‘tying up’ or rhabdomyolysis as it is technically known and conditions such as PSSM. Atypical myopathy refers to a myopathy which is not related to exercise and appears to come from nowhere. It is caused by ingestion of sycamore leaves, seeds or seedlings which contain a toxin called hypoglycin A. It is therefore also known as sycamore poisoning. There appears to be variability in the susceptibility of individual horses and also in how badly affected horses are in different years and seasons. The disease is seen in autumn and winter when the sycamore seeds are on the ground and again in spring when the seedlings are growing, and young horses are most at risk although it can affect any age.

Symptoms

Horses may demonstrate one or more of the following symptoms:

Weakness or walking oddly
Low head carriage
Muscle tremors
Sweating
Laboured breathing
Looking like they have colic but they usually still have an appetite
Dark coloured urine – brown or red
Down and unable to stand

Diagnosis

Clinical examination will raise suspicion including recognising the above symptoms as well as the horse having an elevated heart rate but normal temperature and gut sounds usually so it can be a rather confusing clinical picture. A blood test will confirm a significant myopathy by elevations in blood enzymes called CK and AST. In severely affected horses the kidneys will be damaged too which will also show on the blood test. A confirmation of the disease can be achieved via a muscle biopsy being sent to a laboratory which can also be used to prove cause of death via a postmortem examination.

Treatment

Stopping any further ingestion of toxin by removing the horse from the pasture. Stomach tubing with activated charcoal may be used to reduce further absorption of toxins from sycamore in the horse’s digestive system.
Aggressive fluid therapy via a drip to support the kidneys, maintain hydration and flush the enzymes and toxins through the system.
Pain relief.
Vitamin E for muscle support and antioxidant properties.
Nursing – meeting the horse’s care needs such as support in feeding or comfort if recumbent.

Due to the intensity of care required in these cases referral to an equine hospital may be required.

Prognosis

Unfortunately, atypical myopathy carries a very poor prognosis, and it leads to death in 75% of affected horses. Poor prognostic indicators include kidney failure showing on the bloods, horses which are down and unable to stand and horses which are not clinically improving within the first few days of treatment. Due to the grave prognosis it is reasonable to consider early euthanasia in severely affected horses or if financial and practical situations preclude an attempt at the intensive treatment required.

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Asthma

Horses Health Problems

What is asthma?

Asthma is an inflammatory disease affecting the lungs which is triggered by environmental factors including dust and pollen. It was historically known as COPD and RAO and can also be referred to as heaves or broken wind. It is not contagious and often life long to a degree requiring ongoing management to prevent flares.

Symptoms

There is a scale of symptoms which correlates with severity of disease fairly well.

Mild disease:

No signs at rest, only signs when exercised
A cough or a few coughs at the start of a ride particularly when go into trot but then nothing more once gets going
A slight runny nose after exercise – clear or white

Moderate disease:

Some mild signs at rest, worse signs when ridden
Snotty nose at rest, usually found on the floor over the stable door in the morning. The snot can be thick white or creamy coloured
Coughing occasionally at rest particularly after eating, coughing more consistently when ridden not just at the start
Some reduced athletic performance or exercise intolerance such as seeming to tire quicker, clearing nose more, breathing heavier or having flared nostrils at exercise
Heave line seen during or after exercise. This refers to a visible line at the back of the abdomen between the tummy muscles and becomes obvious because the horse is having to use these muscles more to breathe

Severe disease:

Marked signs at rest
Coughing frequently at rest particularly after eating
Snotty nose frequently at rest – seen on stable floor and at nostrils. The snot is creamy or white or may be yellow or green if a secondary infection is present
Heave line at rest
Visible increased laboured breathing and flared nostrils at rest
May appear dull or not right and not want to eat like normal
Acute asthma attack – panting, visibly struggling to breathe, noisy breathing

If a horse demonstrates signs of severe disease and you suspect they may be experiencing an acute asthma attach an emergency vet visit is required.

Diagnosis

Asthma can be diagnosed or at least suspected based on clinical assessment alone sometimes. Ruling out an infection may be required via a blood test or nasal swab. Accurate definitive diagnosis requires a tracheal wash or bronchioalveolar lavage test done via endoscopy under sedation. The samples taken during the endoscopy are sent to a laboratory for analysis of the cells and high levels of particular inflammatory cells (neutrophils) in the absence of infection determines asthma.

Treatment

Initial stabilisation and treatment of the episode:

Steroids

the underlying driver of asthma is inflammation and so treating this is key and often requires steroids. This may be a one-off injection, a course of oral tablets and/or inhaled medications via a nebuliser, aservo inhaler or human inhalers via spacer.

Buscopan

Most commonly associated with colic this drug is useful in the emergency asthma attack scenario as it relaxes smooth muscle – whereas in colic this is useful to stop stomach spasms, in asthma it reduces bronchial spasms and relieves symptoms quickly. This is a one-off injection.

Ventipulmin

An airway opener relieving bronchial spasms which can be given orally in food for up to 2 weeks as a course of treatment.

Sputulosin

This breaks down mucus making it easier to cough up and clear the airway and may be indicated if your horse is producing a lot of mucus. It is a powder which goes in feed for a course of treatment.

Remove any obvious triggers

See management measures

Preventing Recurrence

Controlling the environmental triggers

See management measures.

If environmental control is not sufficiently preventing symptoms (i.e. flare ups happen frequently) then a low dose of ongoing medication may be required. This is most commonly done now using a nebuliser to deliver steroids, saline or ventipulmin directly to the lungs. The alternative is pulse therapy with oral or inhaled steroids and/or ventipulmin when the symptoms are worse.

Management Measures

Horses suffering from asthma are usually triggered by one of two things – dust or pollen. Generally, these will then either be seen in the winter or summer. Of course, horses can be sensitive to both and there can be some cross over but it is worth monitoring timing of any patterns to help pinpoint the trigger.

Dust and mould

The biggest source of dust is straw, next is hay, then soaked hay, then steamed hay and haylage. The first thing to address with an asthmatic horse is the stable environment. Firstly, if possible, these horses may do better living out 24/7 – there is no better airflow than being outside. If stabling is required, then optimal airflow needs to be considered – this can be as simple as opening windows and doors or making some if they don’t exist. A deep clean and de-cobweb is required and switching to a dust free bedding will play a big role. A huge trigger is the forage they eat, dry hay is likely to be a problem for an asthmatic horse and if you watch a horse eat you will see the spores released from hay as they eat it and inhale it immediately. Likewise keeping feeds soaked can reduce the physical irritation at the back of the throat which may trigger a cough. Haylage or steamed hay is optimal, soaked hay may be sufficient for a less severely affected horse. Regardless of the type of forage the quality and cleanliness of it is imperative and no mouldy forage should be fed to an asthmatic horse.

Pollen

This is trickier to manage as pollen is everywhere and you can’t prevent it. All you can do is reduce exposure and manage symptoms meaning that summer affected horses tend to be harder to manage. It may help to stable the horse (in a well-managed dust free stable) during high pollen times of the day, there are apps which are useful at helping to see when the pollen count is high to help guide this. Sometimes it can be clear which pollens trigger a horse more, for example earlier in the season tends to be tree pollens and some are particularly affected when nearby rapeseed is harvested. Learning these triggers can help you prevent recurrence the following year by being prepared – e.g. move to a field away from many trees or stable during the harvest. Other simple things which may help include using Vaseline around the nostrils to capture pollen reducing inhaled amounts and using a pollen specific nose net. Exercise will always increase the risk of an asthma attack so if you know your horse is pollen sensitive it may be sensible not to ride during these periods or peak times of the day. In some cases, systemic anti-histamines are helpful such as piriton 4mg tablets, although the dose rates are high with an average 500kg horse usually needing around 20 tablets twice a day to see some effect and this will work better in a preventative way opposed to once symptoms have started.

An area of interest in these cases is immunotherapy

Which is essentially vaccinating the horse against the allergens that he/she is allergic to. The immunotherapy we use via injections for allergic skin diseases in horses is thought to not be effective against asthma although some people try it. In the last few years there has been research into inhaled immunotherapy which shows some promise in asthma cases (in humans and horses) so this may play a role in treating these horses in the future.

Prognosis

Mostly asthmatic horses can be well managed and live with a good quality of life. However, it can be labour intensive and expensive as it is a condition that the horse will have for the rest of its life, and it may worsen with age. It may also have an impact on the athletic use of a horse during periods of time where the horse’s trigger is bad and if the horse is rendered exercise intolerant they cannot perform in their intended way. In some scenarios despite the most committed management and best treatments horses can become too severely affected or unresponsive to treatment and require euthanasia sadly. Thankfully this is the minority of cases and a worst-case scenario with most horses doing well.