We will be having a meeting February 27 at 6:30 pm at the Howard Johnson in Lexington, VA. The topic is on Cushing's disease and the new FDA approved drug Prascend. Boehringer-Ingelheim will provide their technical veterinarian to answer questions on the disease and drug. Food and drink are provided and it is FREE to all. Please RSVP to MVEH at 1-540-377-5700 by February 22, 2013 if interested so we can get a number count for food. Look forward to seeing you there!

We have also hired a new licensed veterinary technician, Christina "Tina" Wilson.Tina graduated from BRCC with a degree in Veterinary Technology in 2008 and has worked for Westwood Animal Hospital.  Tina has grown up with horses and will spend her time here assisting the doctors in day to day activities and will specialize in the area of reproduction and stallion care. Tina will be a welcome addition to help our other two licensed veterinary technicians Erin and Ashley.

WHAT'S NEW? 
BREEDING SEASON! 

It is that time of year, BREEDING SEASON!!! We have several great new stallions in our line-up this year.
Go to our website at www.mveh.com/stallions.html 
to see what we have to offer.

Welcome to our first electronic quartlery newsletter! We are excited to start offering an electronic newsletter to our clients to keep you informed and reduce our paper wastage. We hope you enjoy our articles and information. If there is something specific you would like us to discuss, message us on Facebook or email us at mtviewequinehospital@gmail.com. We look forward to your comments and suggestions.

We will plan to have quarterly newsletters that you can feel free to share with your other horse friends that may not be clients of MVEH. We welcome all! Please do not forget to "LIKE" us on Facebook and visit our website at www.mveh.com for more information. Our door is always open, so please share how we can better serve our community and you, our clients.

Pentaussie (pentosan polysulfate sodium) is a new compound that was FDA approved about 11/2 years ago for wound lavage prior to closure. This was the fastest way to get it into the US but in Australia and Europe it has been used for years as a joint therapy. Pentaussie is made from hemicellulose of the beechwood tree and its chemical composition is not the same as Adequan. However, Pentaussie works similarly in that it helps to decrease inflammation and pain in a joint just in different ways.

Pentaussie helps to increase joint and bone blood flow by making the cells "more slippery" so it is easier to flow to the smaller vessels. It also stimulates cartilage cells to increase development through proteoglycans. It has been noted that this product stimulates hylauronic acid production by the joint synovial cells and inhibits the inflammatory cascade of events to help reduce pain and swelling.

We have currently been prescribing this medication for chronic lameness due to joint pain or osteoarthritic conditions. We have seen good results using this as an additional therapy to prolong duration between the other joint therapies we use. We have seen really good results in older horses with multiple joint problems.

Pentaussie comes as an injectable to be given mainly in the muscle or in the vein. There are no great guidelines as to dosing but in Europe it has been used similar to Adequan. We give a loading dose of 4-5 shots 4 days apart and then give the drug once to twice a month depending on the severity of joint disease and pain.

IRAP stands for Interleukin-1 Receptor Antagonist Protein. IRAP is a biologic therapeutic agent used for treatment of joint inflammation and other inflammatory conditions. IRAP blocks the receptors from interleukin-1. By blocking the interleukin-1 inflammation is slowed or even stopped.

 

Interleukin-1 and Tumor Necrosis Factor are cytokines that are found in many different cells such as white blood cells, synoviocytes (joint capsule cells), and others. The cytokines are released with trauma or other factors affecting the cells. Once they are released, they go to receptors on other cells that start a cascade of events that lead to inflammation, cartilage degeneration, collagen destruction, increase of bad prostaglandins and more. In other words these cytokines are some of the main players in starting inflammation. The inflammation triggered by the cytokines can lead to destruction of the joint and soft tissue structures. They are both involved in many other things in the body but the main job is inflammation.

 

Inflammation in the body is both good and bad. The bad part is the destruction of good structures such as cartilage and tendons. The good part is the signaling of cells to come in and clean up things such as bacteria and dead cells. Inflammation in normal structures in not good.  

The cells in the body not only make a way to start inflammation but they also can stop inflammation. IRAP comes from the activation of monocytes which are white blood cells. IRAP is made from the animals own blood.

IRAP is produced by taking blood from the animal (horse, dog, or human). The blood is drawn up in a specially developed syringe that contains 235 little glass beads. These glass beads look like little glass golf balls. The beads have divots in them to increase surface area and have a special coating to help attract the monocytes. Once the monocytes attach, they get stimulated and start dumping out their contents. In the contents, there is a high level of interleukin-1 receptor antagonists proteins. The syringe is incubated for 24 hours. The syringe is then centrifuged and the serum is removed. The serum contains high levels of interleukin-1 receptor antagonists proteins. The serum is the substance that we inject.

IRAP is most notably used for the treatment of arthritic joints. IRAP will reduce inflammation and thus reducing the pain and destruction caused by inflammation. IRAP is also used for other treatments which we will discuss later.

The big question has been when to use IRAP. Other products are available to treat arthritis and inflammation. The most common anti-inflammatories used in joints are corticosteroids alone or in combination with hyaluronic acid (HA) or polysulfated glycoaminoglycans (PSGAG). Sometime IRAP is also used in combination with HA so the biggest debate is do we use IRAP or corticosteroids. Certain corticosteroids can cause cartilage degeneration with improper use. Corticosteroids can also cause the onset of laminitis and increase the chance of bacterial proliferation which could increase the chance of joint infections. Corticosteroids levels are also tested for at many horse shows so they have to be used about a week before show time. Corticosteroids are very effective at reducing inflammation and are relatively inexpensive. IRAP can increase the chance of bacterial proliferation much like corticosteroids but other then that, I know of no detrimental side effects. Often IRAP is used alone without HA so the cost of use is comparable to corticosteroid/HA injections when injecting multiple joints. Long term use of IRAP does not appear to be a detriment. Usually one IRAP kit will produce about eight to twelve doses. The remaining IRAP can be frozen and used at a later date. 

  
When choosing between corticosteroids or IRAP therapy, I look at several things:

Response to corticosteroid injections or combinations- Did the effects last longer then a few months and were the effects satisfactory.

1. Is there injury to the cartilage or structures in the joint?
2. When is the horse going to show?
3. Is there an increased possibility of laminitis such as in, ponies or older horses?
4. What combinations are affordable?
5. Did IRAP work well on the horse before?

If the response of the corticosteroid injections only lasted a few months then the next time, I like to use IRAP. Many times when there is less then satisfactory response with corticosteroids, I will use IRAP and get a good response.

If there are joint structures that are injured, I prefer to use IRAP because of the increased healing time that can be seen with some corticosteroid use.

If the horse has to show in a few days or is at a show, then it is best to use IRAP. Using IRAP will let you avoid any chance of testing positive for steroids which is a controlled substance. Horses can also show quickly after IRAP injections, unlike corticosteroids, which there is a recommended three to five day rest period.

If the horse has an increased possibility of laminitis, I do not like to use any corticosteroids. Corticosteroids injections are well known to be associated the onset of laminitis. Ponies and older horses appear to have an increase possibility of the onset of laminitis so I like to use IRAP on those horses.

Corticosteroid combinations with a HA or PSGAG can get relatively expensive especially when injecting multiple joints. IRAP initial cost is from the kit and processing but you can get several doses. When injecting multiple joints, the injection product costs are about the same if IRAP is used alone. If just one joint that needs to be treated, then corticosteroid combinations will be the most inexpensive. IRAP is often used in a three injection series if treating a specific problem. If IRAP worked well the last time it was injected in to that animal, I like to continue to use it.
 

IRAP is not just used for joint treatment. Soft tissue injuries can be treated with IRAP. It reduces the length of the inflammatory stage of healing, thus reducing the possibility of scar tissue formation. We have used IRAP for treatment of inflamed tendon sheaths and bursae much like a joint is treated. We have treated laminitis with regional perfusion of IRAP with many successes in reducing pain in the early onset of founder.
 

Owners of horses diagnosed with Equine Cushings or Metabolic Syndrome are given the difficult job of determining when it is appropriate to allow their horse to graze. The answer is not always straightforward and can vary between different horses and pastures. There are some important strategies that can help these owners manage their horses in the best way possible to help avoid debilitating laminitis.

Equine Cushings and Metabolic Syndrome are two separate syndromes that have similar effects on how horses handle the fructans or sugars in the grass. Quite often, horses with these syndromes have insulin resistance.   This is similar to what happens in humans with type II diabetes.   The job of insulin is to help the sugar horses eat go into the cells to generate energy for the body to function.   Unfortunately, the cells of horses with insulin resistance cannot use the insulin properly, so the result is that the sugar levels continue to rise in the horse's blood causing insulin levels to rise as it tries harder to get the sugar into the cell.   The high sugar and insulin levels cause many negative changes in the horse's body and can ultimately lead to the dreaded laminitis or founder. Owners that have been through repeated or even one battle with laminitis can attest to the fact that it should be avoided at all cost.

On the flip side of avoiding grass to avoid laminitis, most owners want their horse to have a good quality of life. For most horses, this involves regular turnout. Since these horses do not deal well with uncontrolled turnout, a few guidelines should be followed. First, I strongly recommend making a dry lot. This can be a small paddock for one horse or a larger pasture area for multiple horses with little to no grass. This will allow the horse to go out as long as you wish while you stay in complete control of his diet. If you are at a boarding facility and this cannot be done, a grazing muzzle is the next best option for turnout on grass. The grazing muzzle will reduce the grass intake by about 50%, but this still may not be enough regulation for some horses.   Horses handle the grazing muzzle fine and learn to eat and drink through it, but I do not think it is the best option for 24 hour control. Turnout with a grazing muzzle for a portion of the day usually works best.

When can the horse actually go out on pasture with grass? The grass typically has the highest amounts of sugars during dynamic periods. Examples of these times are: rapidly growing spring pastures, rapid growth after a heavy summer rain and in the fall when the grass is starting to become dormant after the first few cold snaps. More rigid grazing control should be employed during these times.    

A typical recommendation for a horse with insulin resistance, especially if they currently have laminitis, is to work with your vet to get the laminitis and insulin levels under control prior to any exposure to grass. Once the insulin levels have decreased, the horse can start being allowed on grass for short increments gradually building up to more time spent grazing. Monitor the horse's weight often while building up time. If weight gain starts to occur, reduce grazing to a time increment where the weight can be maintained. Usually, I start turnout with a grazing muzzle. Remember that a grass deprived horse can eat its entire daily caloric requirement in grass in just 6 hours! Horses allowed full turnout take breaks and naps during the day, but those kept in on hay will eat nonstop.

Working with your vet or equine nutritionist can be a great way to determine a good, complete feeding regimen for your horse with Equine Cushings or Metabolic Syndrome. Institute forms of grazing control such as dry lots and grazing muzzles to better regulate appropriate caloric intake.   Being aware of changes in your pasture can help you determine appropriate times for turnout and will make you and your horse happier!