Pain Management

Pain Management

Tuesdays with Tony

     Sometimes, in between cat naps, I pay attention to what medications you humans are picking up at the front desk. Names like ‘Bute’ ‘Banamine’ and ‘Equioxx’ have become pretty familiar to me. So this week I asked the docs what some of these frequently used medications were for. They explained to me that these are all different drugs used to manage pain in horses. Their explanation was fascinating. I never knew how much was involved in choosing the right drugs to control a horse’s pain!
      The ideal pain medication would be one that worked great, lasted all day, had zero side effects, and cost next to nothing. Unfortunately, this medication does not yet exist. So, we have to compromise somewhere. You are either going to have to pay a little more for a medication that has fewer side effects, be willing to administer doses more frequently- up to every few hours, or choose the cheapest option, realizing it has a downside.

NSAIDs

   When you think about managing pain in horses, Bute (generic for phenylbutazone) or Banamine (generic for flunixin meglumine) is probably the first drug to come to mind. These medications both fall into the category of NSAIDs, or non-steroidal anti-inflammatories. As the name implies, they are great at knocking out inflammation anywhere in the body. They also come in an easy-to-administer paste formulation, and they will keep working anywhere from 12 to 24 hours, which is super convenient. These drugs are both relatively inexpensive, with Bute being slightly more affordable than Banamine.
     The downside to Bute and Banamine, however, is the side effects. When given at a full dose for more than a few days, both of these drugs are notorious for causing right dorsal colitis, stomach ulcers, kidney damage, and liver damage. Right dorsal colitis is the most common and arguably the most serious of these side effects. This is an inflammatory condition of the large intestine which results in diarrhea, malabsorption of nutrients, ulceration, and leakage of GI contents. The condition is difficult to treat, can be life threatening, and often leaves the colon permanently damaged.
    NSAIDs cause right dorsal colitis and stomach ulcers because they knock out these little guys called prostaglandins. There are a couple different types. Several of them are inflammatory prostaglandins. When Bute and Banamine block these prostaglandins, it makes horses feel better. Other prostaglandins are involved in keeping the gut happy. When Bute and Banamine block these ‘good’ prostaglandins, you see the GI side effects described above.
     Now there is a newer NSAID which recently became available for horses called Equioxx. Equioxx is a COX-selective NSAID, which means it blocks the inflammatory prostaglandins without blocking the good ones. Equioxx is also super cool because it lasts so long- a good 24 hours- and it’s easy to give in the form of one tiny, tasteless pill. The disadvantage of Equioxx is that it is a fair bit more expensive than Bute, and anecdotally it doesn’t control pain quite as well as the other good old NSAIDs. However, if you have a horse with a history of GI ulcers or colitis, Equioxx is definitely your best bet.
     While NSAIDs will probably always be the first line of pain management in horses, it is important to understand the associated risks and always follow your veterinarian’s instructions when using these potent medications.

Steroids

   As the name non-steroidal anti-inflammatory would imply, another class of anti-inflammatories is steroids, which is short for corticosteroids. The steroids most commonly used in equine medicine are Dexamethasone, Prednisolone, and Depo-Medrol.
    Steroids are the most potent anti-inflammatory medication that exists, but they have effects on just about every organ system in the body. Steroids are actually produced endogenously (that’s a fancy doctor word that means inside the body) all the time. They play a role in several normal day-to-day functions.
    Steroids are very cheap, and the docs prescribe them regularly for primary inflammatory conditions such as equine asthma and skin allergies. Steroids are also used in joint injections to decrease the inflammation caused by arthritis. However, steroids are not the greatest at analgesia (another fancy doctor word which means the reduction of pain).
    Likely the biggest reason vets are hesitant to reach for steroids as a way to control pain is because of their #1 scariest side effect in horses: laminitis, or founder. For many equine practitioners, the risk of laminitis outweighs any potential benefit of reducing pain that steroids may provide.

The Others

   So you know you can’t use Bute or Banamine  for too long, or you risk blowing out your horse’s gut. You know you don’t want to use steroids because your horse could founder. Your horse is on a full dose of Equioxx at $2/day, but he’s still in pain. What else can you use?
    This is the point where vets start thinking outside the box, and using what’s called multi-modal therapy to manage pain in horses. While NSAIDs target inflammatory pathways, there are other pain pathways, such as nerve pathways, that can be targeted as well.
     Gabapentin is a neuro-modulating drug used as an anti-seizure medication in humans. It can be added to a vet’s pain control protocol to target the deep nerve pain associated with certain excruciating conditions in horses. Gabapentin is starting to get into big bucks, however, and it doesn’t seem to work well in some horses. Also, because horses have such a fast metabolism, it needs to be given every 8 hours to stay at therapeutic levels in the body.
     Another option for pain control often used (and abused) in the human world is opioids. Tramadol, an opioid that has been studied and used in horses, has been criticized in the veterinary world as not working well to actually control pain, but primarily causing sedation. It seems that while Tramadol is a miracle drug for some horses with chronic pain conditions, it doesn’t make much of a difference for others. In addition to the obvious drawback that it is a controlled and closely regulated drug in the United States, another disadvantage to Tramadol is that it doesn’t last very long in horses. Studies have shown that the half-life of Tramadol is only about 3 hours, meaning that 3 hours after administration, half of the Tramadol has already been filtered out of the bloodstream, and by 6 hours it is nearly all gone. Who has time to medicate their horses every 6 hours? Not this cat!
   It may seem simple, but a medication that has recently started to be investigated in horses is Tylenol. Yep, the same Tylenol you can buy at your local pharmacy. Since it hasn’t been used much in horses, not much is known about Tylenol’s potential side effects, but early results suggest it is relatively safe. Now, you may think Tylenol is a cheap alternative, but consider that you will be going through about 1 giant bottle of extra-strength Tylenol every 3 days to treat an animal as big as a horse, so the cost does add up. Based on preliminary research, Tylenol doesn’t seem to be potent enough to control pain in horses when used by itself, but it is a promising drug that can be added to your horse’s pain management therapy.
   Well, there you have it: everything you ever wanted to know about pain control in horses.   But don’t take my word for it. If you have any questions about managing your horse’s pain, I can think of 3 excellent humans who also happen to be veterinarians that would be happy to answer them.
     Until next week,
         Tony
P.S. So the humans did a podcast on this topic. If you want to hear it Straight from the Horse Doctor’s Mouth, she does a pretty good job of explaining things. Well, for a human, anyway. You can listen right here on my website, or wherever you get your podcasts.

Tuesdays with Tony is the official blog of Tony the Clinic Cat at Springhill Equine Veterinary Clinic in Newberry, Florida. If you liked this blog, please subscribe below, and share it with your friends on social media! For more information, please call us at (352) 472-1620, visit our website at SpringhillEquine.com, or follow us on Facebook!

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Tuesdays with Tony – Be Patient!

Tuesdays with Tony – Be Patient!

I have patience. OK, I have patience for some things. I will stalk a squirrel for hours, I will watch the birds from the windowsill in the clinic until I have just the right moment to pounce, and I will patiently supervise Shannon from my perch on her desk. Know who isn’t patient? You humans! You want it fixed, and you want it fixed now! This week, let’s explore that impatience.

The latest and greatest (AKA OsPhos)

It seems every time a new drug, or therapy, or gadget comes out, you humans are sure it will fix whatever is going on with your horse. I’m not saying new is bad, but each one of these things has a problem it aims to fix. I’m going to pick on OsPhos, but you guys can use that big ol’ brain to extrapolate.

OsPhos came out, and suddenly every horse needs it. It will fix hock arthritis, bucking under saddle, not riding well, going too slow, going too fast, and being moody. OK, I might be exaggerating, but not by much. OsPhos, and its cousin Tildren, are great drugs for very specific things, but it changes the way bones remodel. There are some very real side effects to changing the way bone remodels. Horses, unlike cats, do actual athletic events. Turning a barrel, landing off a jump, and sitting for a piaffe all require a lot of strength. Use OsPhos incorrectly, and your horse can break a leg. It’s far better to have an actual diagnosis of a problem, good shoeing, proper fitness work, and a plan, than shooting bone altering drugs into your horse!

Mood altering substances

Horses have some crazy personality quirks. I hear training can help you understand and modify many of these quirks. Now, I’m not against a bit of pharmaceutical intervention, when the need arises. You aren’t going to get me on the crazy chestnut mare coming off of 2 weeks of stall rest! There are definite situations where drugs can help your horse manage some PTSD from their previous lives. However, if you find your horse can’t do their job for months at a time without a little help from their friends, maybe it’s time for an intervention.

Expensive stuff

Horses cost a lot of money. Stuff for horses costs a lot of money. Just because that stuff costs a lot of money, however, doesn’t mean it helps. I’m picking on all sorts of things here, but in particular stem cells, and other similar really expensive things to use on your horse when they hurt themselves. Much like OsPhos, there are very good reasons to inject these expensive things into your horse, but they aren’t a magic cure-all. In fact, most research has shown that a good rehab program is more important for tendon and ligament injuries than anything else! Good rehab programs require patience though, and you guys aren’t so good at that.

Moral of the story? Be patient! It’s what horses teach you humans best. Take a cue from a wise cat: go take a nap if things get too uptight.

Until next time…..

Tony

Tuesdays with Tony – Blessed Be The Old Farts

Tuesdays with Tony – Blessed Be The Old Farts

Blessed be the old farts.  Around here there is a kind of reverence for the older horse.  I will admit to jealousy.  It’s not pretty, I know, but it’s real.  I mean, I’m a cat.  I deserve all the reverence around here.  In an effort to explore the causes for this misguided worship I talked with my minions, I mean humans, about the phenomenon.

Turns out all my humans went with something along the lines of enjoying their horses, learning from them, and feeling appreciative of all the horses gave to them during their athletic careers.  The humans said they wanted to make sure their horses had wonderful retirements since they had earned it.  I was a little confused by the “earned it” thing, since I don’t need to earn anything, but I digress.

What messes up a horse’s retirement?

Do they golf? Do they play Canasta and Bridge?  Apparently no.  They wander around a field and eat. This is a typical day for me if you substitute ‘Clinic’ for ‘field’, so not sure if I’m retired already or how that works.  Anyway, dental issues, lameness, and not feeling so hot are the biggies that interfere with retirees’ ability to wander around and eat.

The Teeth

Let’s start with dental issues.  Horses are this really weird thing called an hypsodont.  It means they have a whole lot of tooth when they are young, which they wear down to nothing over their lifetime.  The super cool thing is you humans are doing such a good job taking care of your horses that they now outlive their teeth.  Sure. that sounds scary, but with good nutrition it’s not a problem.  What it does mean is that you may notice your horse not wanting to eat.  You humans do a pretty darn good job knowing your horses.  When Tiny backs off on feed, don’t worry that we are going to think you’re crazy.  We won’t! We do the exact same thing! What we are going to do is schedule an appointment for one of our Docs to come take a look in Tiny’s mouth.  They might find some teeth that need to be adjusted a little bit or potentially extracted.

The Legs

Moving on to lameness.  This one I identify with.  I have jumped down from high places one too many times and I’m starting to develop a bit of arthritis in my right front paw.  Life catches up with us all.  All those daring feats of athleticism we displayed in our younger years show up as aches and pain in our later years.  Laminitis (same as founder) may rear its ugly head as well.  Once again the signs can be subtle, and you, the awesome human, may notice Flicka is in a different corner of the pasture than normal.  Once again, we won’t think you’re crazy when you tell us this.  We do the exact same thing! In this case our Docs are going to evaluate feet, legs, and the musculoskeletal system in general to identify a cause for the lameness.  If it’s arthritis, they will often recommend NSAIDs (horse aspirin) like bute or Equioxx, and movement, even in small amounts.  If it’s laminitis, a test for Cushings is almost always called for.  This is a test even a dog could pass!  It’s just a blood draw.  They also get on the phone with the farrier to make sure your horse’s entire team has the information they need.

When all of it goes wrong

Next there’s the “not feeling so hot”.  Again, when you call to say Mister isn’t right, but you can’t put your finger on it, we will be nodding our heads. We know that feeling!  This one is a little tougher.  Our Docs will put on their detective hats and start the investigation with you.  They won’t start with you because you are the prime suspect, they will start with you because you are the best source of information.  You know your horse.  You know if Mister ate and drank normally, and has he been sleeping normally? Rolling over? Is he in the same place in the herd hierarchy?  Next they will take your information, combine it with a good physical exam, and determine a course of action.  Usually, this involves some blood tests (remember they’re so easy a dog can pass them), along with an ultrasound of the chest and abdomen.  Only thing difficult about an ultrasound is the cold alcohol they put on your skin.  Based on these easy, peasy tests, our Docs will help you map out the best treatment options.  Lots of times these tests turn up Cushings disease.  Cushings is an endocrine disease which messes with every system there is to mess with.  Good news though: one small pink pill daily is the treatment. And if you schedule an appointment by the end of the week, our monthly special is $10 off this blood test!

Horses are like fine wine, they only grow better with age.  Totally patronizing the humans there, they told me to write that.  Anyway, let your horse live long and prosper with a little TLC.  The humans yak on a lot about Super Seniors, so this is the first in a four part Tuesdays with Tony expose.  Tune in next week for part 2

-Tony

Tuesdays with Tony – Cancer Awareness

Tuesdays with Tony – Cancer Awareness

As I look forward to fall, I notice that October is Breast Cancer Awareness month, No-Shave November (Movember) is for Prostate Cancer, but what about the horses? Equine Cancer is a thing too, but I don’t see anybody giving horses their own cancer awareness month! What gives? Well I, the honorable Tony, am officially declaring August to be Equine Cancer Awareness month! And my first act to raise awareness is writing this blog.

 
Like other species, horses are susceptible to many different types of cancer. The most common in horses are melanoma, sarcoids, squamous cell carcinoma, and lymphoma. I’m a cat, so I like to keep things simple. Basically if you are a grey horse, you are going to get melanomas. If you are an Appaloosa or Paint horse with white around your eyes, you are likely to have squamous cell. If you are an unlucky horse of any other color, you could end up with a sarcoid or lymphoma.

 
If you own a grey horse, you probably already know what melanomas look like. They are usually firm, round grey nodules that commonly occur under the tail or around the external genitalia. Luckily I make it a point to spend at least 5 hours a day grooming my external genitalia, so I would be sure to notice a melanoma right away. Small melanomas are usually benign, but as they get bigger and the horse gets older, they are more likely to become malignant. But have no fear- there are new treatments becoming available!

Oncept, a vaccine that has shown promise against canine melanoma, is now being studied in horses. Now, why you would want to prolong a dog’s life is beyond me, but I guess not everyone can be a cat person. Oncept is going to cost you a pretty penny too: about $4,000 for the initial course of treatment. In addition to Oncept there is an autologous vaccine (that’s a vaccine made from the horse’s own cells–aren’t you impressed I knew that?) in clinical trials.

 
Sarcoids come in many forms. They can be flat, bumpy, warty, or a mixture. They can show up anywhere on the body. Depending on their location, they usually don’t pose much of a threat, just more of a nuisance. Kind of like me lying in the doorway so everybody has to step over me when they walk through the door. However, the smaller they are, the easier to treat. One treatment for these pesky tumors is a cream called Aldara (aka Imiquimod- say that 5 times fast!) There is also an herbal cream called Xxterra that has shown success in shrinking sarcoids.

 
Squamous cell carcinoma is not as friendly. As mentioned, it tends to occur on and around the eyes and eyelids of light-skinned horses, and sometimes on their private parts too. This form of cancer is aggressive and difficult to treat. Chemotherapy with 5-Fluorouracil or Cisplatin, radiation, and enucleation (removal of the eye) are the most common treatment modalities. Boy, I can’t wait to play cat Scrabble with Teanie this weekend. Fluorouracil, how many points is that?!

 
Last but not least, horses can get lymphoma too. Just when you thought colic and laminitis were the only things horses could die from. Lymphoma is sneaky. It is usually impossible to diagnose until a large tumor has already grown internally and spread to other parts of the body. Weight loss and lethargy are often the first sign. Bloodwork usually doesn’t show any striking abnormalities. Sometimes a mass is identified by ultrasound or rectal exam, but most often it is a diagnosis made via the process of elimination.

Lymphoma is sad because it is usually fatal within a few weeks to months. Treatment with steroids and chemotherapy is being studied at UC Davis vet school, but it is going to cost you a lot of Meow Mix for that big of an animal. Hence why we need to raise Equine Cancer Awareness to fund new research!
So class, what have we learned from exceedingly wise, supremely intelligent, impressively well-educated Tony today? Cancer in horses does happen! It doesn’t always carry a poor prognosis for a long and happy life, but treatment options are few and very costly. We need to raise awareness of equine cancer in order to further research into new treatments for this malady!

 
Now that I’ve exhausted myself with all this knowledge, I must get back to my nap!

Until next week,
– Tony

Tony in bed

Tuesdays With Tony – The Pharmacy Files

Tuesdays With Tony – The Pharmacy Files

Tony in the equine pharmacy

What better to do on a dreary Monday than help Beth with inventory?  After spending late last week bugging Dr. Vurgason with “Is she here yet? Is she here yet?” (the answer is no) and supervising Dr. Lacher while she performed lameness evaluations at the clinic, I was looking for something a little more low-key to start my week off.

 

Beth is in charge of making sure we have all the stuff the Docs need to do their jobs, and boy is she serious about it! I’m going to warn you not to nap in a box she hasn’t unpacked yet.  She gets a little angry about it.  My supervision on Monday did lead me to a greater understanding of all the stuff we have.  Generally I limit my time in the pharmacy to finding the best sleeping spot.  It is in the VetWrap box, in case you were interested.

 

Let’s start with things that put stuff in horses.  We have 10 different kinds of syringes and another 8 different kinds of needles.  On top of that, we have 4 different sizes and kinds of catheters.  Beth said the Docs have to be able to give different quantities of medications and give them in different way.  For instance, injecting a joint uses a smaller needle than an IV injection, and some horses get so many IV injections we put a catheter in them.   Foals need smaller catheters than big horses, and if the catheter is going to be in longer than 7 days, we use a different kind.  Several different kinds of suture for all those cuts horses get were over in this area as well.  It got very complicated very quickly!

 

Near the sharp stuff we had plastic tubes, which had me baffled.  Turns out that was the breeding equipment area.  Being neutered, this isn’t my area of expertise, but I learned we use different things for frozen semen vs. shipped, cooled semen, vs. live cover.  We also have longer tubes to put fluid and treatments in to the mare’s uterus.  There was also an AV (artificial vagina) for collecting stallions for breeding.  Beth told me some treatments we keep for use in the mares includes antibiotics, treatments for mucous and something rather gross sounding called biofilm, and just plain fluids.

 

Next we moved on to lots of lotions, potions, pills, and pastes.  From this I learned that horses have delicate stomachs, they like pain medication, and their skin gets very funky in this lovely Florida heat and humidity (see my earlier post about why I live indoors).  Oh, and they like to poke their eyes on stuff.  Heck, we keep 4 different kinds of eye ointment in stock, and there are times we can’t order it fast enough! Beth told me horses really, really like to poke their eyes and with all that eye stuff I don’t think I could argue.

 

Last but not least, on the shelves we had all the injectable products.  This covers an array of equine ailments.  Beth told me some of the stuff was also sedation.  Sedation sounded nice…  especially with a catnip chaser!

 

Our pharmacy also has bandaging stuff, hoof stuff, vaccines, more antibiotics, emergency drugs, stuff to make horses sleep, stuff to wake horses up, and drugs that make mares come in heat.  Personally I find the bandaging stuff to be the best part, since napping is great in that area.  Moral of my day with Beth is that we have a lot of things in that room.  Our Docs have to be prepared for just about anything to happen, anytime.  We have foaling, surgery, bandaging, antibioticing, anti-inflamming, bellyache treating, life-saving and more so that our Docs are ready.  And Beth has my admiration for keeping it all in-stock and ready to go!