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.

Go Back

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.

Go Back

Colic

Alpacas Common Treatments

Signs of colic

There can be a wide range of symptoms of colic, and these don’t always correlate with the severity of the disease. The signs can include any individual or combination of the following:

Not wanting food
Being quiet and subdued
Pained expression on face (tension around eyes, wrinkled nostrils, ears back)
Lip curling (flehmen response)
Flank watching (turning head around to look backwards towards their belly)
Pawing the ground with a front leg
Tail swishing
Lying down and getting back up
Lying down flat out
Heavy breathing
Rolling
Sweating

If you suspect colic at all veterinary attention is required as soon as possible. The severity of the colic can only be determined following a thorough clinical examination including an internal rectal examination. Sometimes the less dramatic looking cases have more serious disease and likewise the opposite can happen, so it is never worth the risk of leaving it.

Causes and treatments of colic

The causes of colic can be largely categorized into two groups – medical or surgical. Medical colic refers to colic which can be treated with medication and treatments without any need for an operation, this could happen at home or at a hospital. Surgical colic refers to problems which can only be treated with an operation at a hospital and are life threatening. The veterinary surgeon will use a range of their findings from clinical assessment to determine whether a colic is medical or surgical and offer the relevant treatment options to you.

Medical colic types

Spasmodic colic

The most common type of colic. This is when the intestines go into spasm. This is treated with drugs such as anti-spasm medication and pain killers. If a horse has spasmodic colic recurrently it may be worth investigating for an underlying cause such as worms, gastric ulceration, sand, liver disease or inflammatory bowel disease.

Sand colic

This can present as spasmodic, impaction or diarrhoea. This can be tested for by a faecal test or x-ray of the abdomen and is treated with pain killers, stomach tubing, Epsom salts and psyllium. Please tell the vet if your horse has colic and lives on sandy soil.

Impaction

A blockage of dried-up foodstuff usually in the part of the large intestine called the pelvic flexure. This is treated with medication, starving (to prevent further blockage build up), exercise and regular stomach tubing (to hydrate and flush through the blockage).

Displacement

The large intestine has altered motility causing one part to fill with gas and flip over on itself up to 180 degrees. The displacement can be left or right sided. This is treated with medication, starving (to reduce blockage risk and gas production), exercise and regular stomach tubing. The displacement will often self-correct within 1-5 days but these can be labour intensive cases.

Colitis

Severe diarrhoea with inflammation of the large intestine. This is treated with medications and may require fluid therapy and possibly hospitalization and a drip in severe cases.

Enteritis

Inflammation or infection of the small intestine. Treated with anti-inflammatories and antibiotics if indicated.

Surgical colic types

Severe displacement or impaction not correcting medically

Sometimes these don’t respond to medical management and require an operation to empty the gas and food from the intestines and untwist the intestine if twisted.

Small intestine strangulation

This can be a twist on itself, the small intestine being trapped or being strangulated by a lipoma on a stalk. The operation will unravel any twists and remove intestine which has been irreversibly damaged.

Colon torsion

A 360-degree twist of the large intestine which can only be untwisted by surgery.

Caecal impaction

A serious blockage of the caecum which requires emptying in an operation.

To operate or not to operate?

If you are faced with the unfortunate situation of a horse having a surgical colic it is a big decision whether to have surgery done or not. In these situations, the alternative is to have the horse put to sleep as there is no other treatment and we must prevent unnecessary suffering. Either option is perfectly reasonable, and the right decision is different for everyone. Some important points to consider include the age and general health of the horse, the ability to box rest the horse for a prolonged period and manage the wound after surgery and finances (colic surgery costs range from £5,000 to in excess of £10,000 with most costing around £8,000). There is of course no guarantee of a positive outcome with short term survival rates reported at approximately 80% and longer-term survival rates up to one year post surgery reported at approximately 60%. It is sensible to consider how you feel about colic surgery for your horses in advance of being in the situation so that you can make quick educated decisions if ever required.

Prevention

A lot of colic cases are random and can not be prevented, however some routine considerations can help prevent cases which could be, including:

Worming

Worm burdens will predispose to colic so a worming programme is essential.

Dentistry

If the teeth are poor the food won’t be chewed properly therefore hits the intestines in a non-digestible state and can cause colic. Routine dentistry is advised every 6-12 months with a vet or BAEDT.

Routine

Changes to routine and management are a risk factor for colic in particular changing fields, feeds, hay, stabling, yards, competing etc. Always make feed and grass changes as gradually as possible and do your best to minimize stress caused by major changes in management.

Feeding

Horses are trickle feeders and so require a constant source of fibre. Most horses require a high fibre low sugar and starch diet to have enough energy for their workload and maintain optimal gut health. It is also important to consider the microbiome by feeding high fibre diets and considering a probiotic particularly for sensitive horses.

Hydration

To prevent blockages the horse needs to drink plenty of water. Always provide constant access to clean fresh water and consider using mash-based feeds to further increase water intake.

Movement

A risk factor for impaction colic is box rest due to lack of movement. Where possible provide horses with turnout and exercise to keep their guts moving. If your horse requires box rest for a medical reason, then increase the water intake of the horse by soaking hay and feeding mash-based high fibre feeds. As soon as the horse is able to walk out to hand graze and in-hand walk then start this under vet advice.

Sand management

If you keep your horse on sandy soil it is recommended to treat with psyllium (1 gram per kilo so up to 500g for a horse!) preventatively for one week every month to clear the sand out of the system. There is also evidence that sugar beet is a super-fibre which helps clear sand so consider using this as part of the normal feed ration.

Go Back

Arthritis

Horses Common Treatments

What is arthritis?

Arthritis literally means inflammation of a joint. It can be traumatic in origin affecting one joint or most commonly develops slowly over time due to wear and tear and affects multiple joints. There is a scale of disease from inflammation of the synovial fluid and joint capsule only known as synovitis, through to involving cartilage damage and then progressing to involving the bone then termed osteoarthritis. Arthritis is most commonly bilateral and symmetrical e.g. involving both hocks. There is a condition in young horses called juvenile arthritis which may have an inherited genetic component, but the most common form is in adult horses and is due to wear and tear. Arthritis is one of the most common conditions seen in equine veterinary practice and is responsible for a large amount of loss of use in ridden horses.

Symptoms

Horses may demonstrate one or more of the following symptoms:

Lameness
Poor performance
Back and/or neck pain
Difficulty in canter – disunited, incorrect strike off
Swollen joints
Fidgety or struggling for the farrier when limbs flexed or when nailing on
Stiff coming out of the stable
Limb filling when stabled
Takes time to warm up when ridden

Diagnosis

A thorough history taking and physical examination is a key starting point. The vet will then observe the horse in walk and trot in a straight line and perform flexion tests to test various joints further. Observing the horse on the lunge on both hard and soft surfaces also reveals more information. If there is a suspicion of joint pain then further diagnostics will likely be indicated. This can involve nerve blocks where different regions of the limb are made numb to localise the source of discomfort and will also include x-rays with or without ultrasound scans. In some circumstances referral for higher level diagnostics is needed such as for MRI scans or nuclear scintigraphy scans.

Treatment Options

There is a wealth of treatment options available for arthritis in horses and the right choice is individual for each owner and horse.

Joint injections

Injecting medication directly into the affected joints provides targeted pain relief and positive effects on the joints themselves and is often the most reliable way of achieving soundness. We have options of what product to inject as follows:

Steroids

Steroids are potent anti-inflammatory drugs which reduce pain and inflammation due to joint disease. When injected directly where they are needed, they have maximum effect and there is minimal systemic absorption reducing side effects around the body. Steroids start acting very quickly (within days) however their duration of action is variable. On average a horse who responds well would remain sound for 3-6 months.

Side effects with steroid joint injections include infection and laminitis. Infection is uncommon and the risk of this is reduced by the strict sterile approach to the procedure and careful aftercare. Laminitis from steroid joint injections is very rare and is usually only seen in high-risk horses. A risk assessment can be made prior to this treatment involving a physical assessment and possibly blood tests for cushings and/or equine metabolic syndrome.

Steroids are prohibited under FEI competition rules therefore please discuss if this is applicable to you and your horse and we can advise on appropriate withdrawal periods prior to future competition.

Hyaluronic acid (HA)

HA can be injected into joints alongside steroid or on its own. It provides anti-inflammatory effects and lubricates the joints whilst topping up the body’s natural HA levels which are used to support healthy synovial fluid, cartilage and joint capsule. There can be a joint flare reaction if used without steroid so it is common for a short course of anti-inflammatories to be given at the time of injection.

Arthramid

Arthramid is a polyacrylamide hydrogel which when injected into a joint adheres to the synovial lining reducing the effects of inflammation and forming a cushion in the joint. It forms its cushion and begins to take its effects over the 14 days following injection and the full effect is seen within 4 weeks after injection in most cases. Due to its nature of action it shows potential as a long-term solution to joint disease and is thought to elicit positive effects for multiple years in the joint.

As with any joint injection there is a risk of infection which is minimised by strict sterile injection technique and careful aftercare. There have been no reports of systemic side effects or allergic reaction however mild self-resolving swelling or joint flare at injection site is occasionally reported.

Stem Cells

A mesenchymal stem cell product made from umbilical cord tissue is now available as a ready to inject preparation making stem cells more readily available. Stem cells elicit positive effects in the joint via a natural anti-inflammatory effect, inhibition of cartilage breakdown and providing a basis for repair of damage. The clinical effect is seen approximately 4 -5 weeks post injection, and it has potential to have longstanding benefits.

Systemic Treatments

Anti-inflammatory Medications

Either a course or long-term use of systemic pain relief medications can be highly effective in managing arthritic horses. The benefits include effective reduction in pain and inflammation, a horse-wide effect which is helpful if multiple joints and multiple limbs are affected, and it is non-invasive as the medication is given in feed. Examples of drugs used for this include phenylbutazone (Equipalazone/Chanazone), suxibuzone (Danilon), meloxicam (Metacam/Inflacam/Rheumocam) and firocoxib (EquiOxx).

Cartrophen/Osteopen

A course of intramuscular injections containing pentosan polysulphate which provides pain relief and supports repair of damaged cartilage.

Tildren/Osphos

A type of medication called bisphosphonate administered via a drip in the case of tildren or intramuscular injection if using osphos. This drug slows down resorption of bone and is particularly useful in the long-term treatment of hock arthritis and navicular disease as bone resorption is a feature of these conditions.

Rehabilitation

A whole horse approach is essential in managing arthritis.

Farriery

Make sure your farrier is always kept updated if a diagnosis of arthritis is made (your vet can do this). Optimal foot balance is essential for ensuring the forces through the joints are kept equal and do not predispose to further joint inflammation and your farrier may choose to alter the shoeing cycle or use a different shoe for supporting certain conditions.

Physiotherapy

Regular physiotherapy will keep the secondary muscular compensation maintained, relieve any muscular discomfort and provide targeted exercises to help support the horse moving forward.

Acupuncture

An additional therapy which can provide pain relief and relieve secondary muscle tension.

Exercise

Arthritic horses often benefit from regular low intensity exercise to keep them supple, improve synovial fluid quality and prevent stiffness. Often after treatment we aim to return horses to their previous level of work although sometimes in more severe cases the workload may need to be altered. For example, a horse may be better to only be jumped on a surface opposed to firm ground or may happily hack for years without medication but would struggle to do more. In the short-term post treatment rehabilitation, there should also be a focus on building muscular strength to support the inflamed joints and reduce recurrence of lameness. This will often involve pole work, hacking, hill work and possibly water treadmill.

Saddle fitting

Optimal saddle fit is essential and regular checks are required to accommodate for any changes through the horse’s body which may be more likely in arthritic horses.

Turnout

Horses with arthritis tend to do better with more turnout opposed to more stabling. Offering as much turnout as possible and considering 24/7 turnout can be helpful in managing these horses.