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Learn what veterinarians are taking to improve the way they manage pain in horses.

Posted by Stacey Oke, DVM, Master of Science | September 28, 2021 | Article, Horse Care, Medicine, Musculoskeletal System, Elderly Horse Care Issues, Pain Management, Veterinary Practice, Working with Veterinarians

As a veterinarian and writer, I have researched and written many articles about analgesics over the years, but the true value of these analgesics has recently been running away from home. In early 2016, my son had a spiral fracture of his right femur (thigh bone) and required two surgeries. He spent four months in a wheelchair and underwent painful physical therapy for nearly 50 hours. Fortunately, his doctor prescribed various drugs to help control his discomfort-first intranasal fentanyl on the football field, then other opioids, non-steroidal anti-inflammatory drugs, and hospital nerves. Blockers, to name a few.

My son is very lucky. Many years ago, the patient had to endure extreme pain during the entire rehabilitation process (remember the little house on the prairie or the Quinn woman doctor?). The same applies to horses. The author James Herriot once described that he helped a horse suffer the severe pain of acute laminitis after a grain overload, and he stood with him in an almost icy gurgling creek. Hours.

"There were few other options at the time," said Dr. DVM and Dipl's Chris Sanchez. ACVIM is an assistant professor in the Department of Large Animal Clinical Sciences at the University of Florida School of Veterinary Medicine in Gainesville. "Now, equine veterinarians have prepared a variety of safe, effective and economical analgesics, and several others are in different stages of testing."

A complete description of which drugs are used under which conditions and at which doses and frequency is beyond the scope of this article, but before delving into some of the more novel drugs, we will briefly review the past few years of proven analgesics. Agency and alternative methods introduced in the year. Where possible, we provide research reference materials to guide readers to understand important data and additional information.

The classic understanding of this sentence is that severe punishment is commensurate with the punishment of the crime: an eye for an eye, a tooth for a tooth, a foot for a foot, etc., until the criminal obviously either learns the lesson or runs out of body parts. If pain is the enemy, then perhaps we should embrace this emotion and show that we will retaliate against the pain.

The weapons and equipment we currently use to fight pain rely heavily on the following "big three":

Although these types of drugs have been around for some time, they are still widely accepted as effective first-choice drugs for the treatment of various acute and chronic diseases, including:

In other words, if you have ever experienced severe discomfort, you will know that these drugs are not always sufficient when taken alone, tend to disappear quickly, or only appear in oral form (this takes longer Works because the drug must be absorbed from the gastrointestinal tract before it reaches the blood). Researchers have proposed alternative therapies to improve the way they manage human patients, so it is logical for equine veterinarians to reflect these advances in their quadruped patients.

"Borrowing some drugs and pain control strategies from human medicine has made significant progress and continues to provide better control of various types of pain for horses of all ages and breeds," said Lori Bidwell of DVM, Dipl. ACVAA is a registered veterinary anesthesiologist and certified veterinary acupuncturist, and the co-owner of the East and West Horse Sports Medicine Company in Kentucky.

For example, three newer NSAIDs have been explored in horses recently: felocoxib (Equioxx), topical 1% diclofenac sodium cream (Surpass) and meloxicam.

Firocoxib is a COX-2 inhibitor. The product has been approved by the FDA for use in horses with OA, but the manufacturer's instructions indicate that it can only be administered for 14 consecutive days (for safety reasons and to avoid NSAID-related adverse reactions). Bidwell said that an exciting development in analgesia is that Equioxx is now available as a 57-mg tablet specifically for horses.

"The 57 mg Previcox tablet (labeled as dog) has been used in horses for several years for super-indications and has successfully treated chronic pain management and performance-related pain," Bidwell said.

Veterinarians can also prescribe 1% diclofenac sodium cream for horses with arthritis. Researchers continue to discover more uses for diclofenac, and recently discovered that diclofenac epolamine (rather than sodium) penetrates the skin more deeply than sodium. 1   

Meloxicam also seems promising for controlling postoperative pain and inflammation after musculoskeletal and soft tissue surgery. In 2015, a group of Canadian veterinary researchers reported that the “behavior” of human meloxicam tablets (15 mg) was similar to that of equine liquid preparations (15 mg/ml) approved for treatment (i.e. how the drug is dispersed throughout the body) And metabolism). In Europe, the average dose for horses is 0.6 mg/kg body weight. "It is expected that the use of human meloxicam tablets mixed with molasses will produce clinical effects in horses similar to those of EU-approved oral products," they concluded. 2  

Another team from Germany later discovered that a single intravenous injection of meloxicam and then oral administration once a day for four consecutive days can appropriately relieve the pain of a horse with a partial splint fracture removed. 3  

As for the drug’s ability to fight colic, the authors of a 2014 study assured us that meloxicam is as effective as flunixin meglumine and can control horses with naturally occurring strangulated small bowel disease. Tormenting pain experienced. 4   

"Meloxicam is especially beneficial for foals," said Rachel Hector, an anesthesiologist resident at the Fort Collins Veterinary Teaching Hospital at Colorado State University (CSU). "This is because traditional non-steroidal anti-inflammatory drugs have a longer clearance rate for foals, while meloxicam clears faster, which may benefit foals used for long-term treatment."

In addition to non-steroidal anti-inflammatory drugs, the local anesthetic lidocaine remains a common choice for equine veterinarians who treat painful conditions. Intravenous (IV) use of lidocaine is common in colic surgery and is also useful in treating horses with laminitis. Veterinarians also use intravenous ketamine and dimethyl sulfoxide respectively to treat pain and inflammation.

Lesser known options for treating horse pain are tramadol and gabapentin. Tramadol is an opioid that has been widely used by doctors and small animal veterinarians. Recently, equine veterinarians have explored the advantages of using intravenous tramadol on foals and adult horses. In 2016 alone, several research groups conducted careful studies on the use of tramadol alone or in combination with other painkillers, and the results achieved positive results. However, other papers indicate that tramadol has no analgesic effect in the horse research model; higher doses will only increase excitatory side effects; injections are expensive.

Bidwell said tramadol is not yet a practical choice for horses. Hector added: “Tramadol may function as part of a multimodal analgesia program, but it is unlikely to be effective when used alone.”

Not to be outdone is the "neuralgia" drug gabapentin. According to reports, it attacks pain from a different direction than tramadol, lidocaine and the "Big Three". Horses with chronic diseases such as laminitis seem to benefit from adding this drug to the mixture.

"The role of gabapentin is to calm the excited nerves and make other painkillers more effective," Bidwell said.

"Similar to tramadol, there is very little peer-reviewed evidence on gabapentin," Hector said. "Like human doctors, veterinarians face the challenge of finding the right dosage and treatment plan; however, as part of a multimodal approach, there is good anecdotal evidence of effectiveness and very limited side effects."

Despite these and other options, veterinarians agree that our painkillers are still not used up, which creates opportunities for those interested in exploring other options.

Although much of the discussion surrounding pain often focuses on the acute (short-term) type, there are still dozens of horses suffering from mild chronic pain and pain. Managing a horse that is painful or "uncomfortable" is as important as treating a horse that is convulsing or colic, and it can be challenging. Enter Complementary and Alternative Veterinary Medicine (CAVM).

This is not a synonym for "Hey, I tried all the other methods, so it's okay." In fact, there is a large amount of data to support these therapies in human medicine and veterinary medicine.

Bidwell said: "Five thousand years of evidence, coupled with a large number of studies in the past 10 years, support the use of alternative therapies, including acupuncture. The analgesia produced by the release of systemic endorphins or opioids through acupuncture has anti-inflammatory effects and Causes muscle relaxation."

Another technique, medical massage, involves manually manipulating tight muscles or trigger points until they relax without medication.

Other alternatives include the homeopathic medicine traumeel and Zeel. Bidwell said that both Traumeel and Zeel contain small amounts of arnica and poisonous cuckoo, both of which help relieve pain, inflammation and stiffness associated with muscles and joints. Both products are allowed to be used on horses participating in international competitions.

Even oral joint health products can have an anti-inflammatory effect. The results of the study showed that in laboratory studies, glucosamine, chondroitin sulfate, avocado soy unsaponifiable matter and green tea extract (epigallocatechin gallate) can reduce inflammation of horse chondrocytes.

In a 2014 review article entitled "Horse Pain Control: What Do We Really Know?" Sanchez and colleagues succinctly summarize the challenges of diagnosing pain.

They wrote: "The recognition of obvious painful behaviors, such as rolling, kicking the abdomen, looking on the side, lameness or blepharospasm (squinting), may be obvious." "Small signs of pain may include facial expressions or head position. Changes, location in the compartment, and response to palpation or human interaction."

"As a prey, horses are usually good at hiding signs of pain until the pain becomes so severe that it can no longer be concealed...at the last moment, so to speak," Hector said.

The detailed pain scale allows the owner and veterinarian to recognize more subtle signs of pain more quickly, and helps nurses to objectively evaluate the effect of treatment.

Colorado State University is known for its pain management scales for canines and cats. These scales were developed in the mid-2000s to guide veterinary professionals in identifying discomfort using behavioral and physiological parameters. You can see such scales in veterinary hospitals all over the world.

Researchers at CSU developed a similar scale for horses around the same time. The Equine Pain Scale (available at http://csu-cvmbs.colostate.edu/Documents/anesthesia-pain-management-pain-score-equine.pdf) includes behavioral cues such as head and ear position and irritability , And clinical parameters such as heart rate, eye position, palpation response, and degree of claudication.

Although veterinarians have designed a pain scale to identify acute pain that is common in surgical patients, the descriptors used can be applied to any uncomfortable horse, including horses with OA or equine asthma syndrome.

There are also pain scales for other horses. In 2016, Dutch researchers released the Ma Utrecht University Comprehensive Pain Assessment Scale (EQUUS-COMPASS) and Facial Pain Assessment Scale (EQUUS-FAP). They tested the efficacy of these scales in identifying pain in horses with acute colic and in healthy control horses, and found that EQUUS-COMPASS (use behavior and interaction parameters) and FAP are both for identifying horses with pain and colic. Effective method. In addition, the pain scores using the two scales are significantly different between colic horses that can be treated conservatively and horses that require surgery or euthanasia.

Similarly, researchers at the University of Milan recently tested their horse grimace scale (HGS) on horses with acute laminitis. They suggest that HGS needs further verification, but the pain coding system based on facial expressions seems to be an effective means to assess the pain of acute laminar disease horses, and does not require horses to walk or trot like the currently used Obel limp grading system (TheHorse.com /31062).

"Only when we can recognize physical and even emotional pain, we can begin to treat it," Hector said. "And once we start treatment, can we do better and faster."

1. Vivancos M et al. Pharmacokinetics and bioequivalence of two meloxicam oral preparations in healthy adult horses. Can Vet J. 2015 July; 56(7): 730-736.

2. Walliser U et al. The efficacy of meloxicam in the postoperative management of pain and inflammation in horses after orthopedic surgery was evaluated in a placebo-controlled clinical field trial. BMC veterinary research. 2015; 11:113.

3. Naylor RJ et al. Comparison of flunixin meglumine and meloxicam in the postoperative management of small bowel strangulation in horses. Equine Veterinary J. 2014 July; 46(4): 427-34.

4. Del Rio-Sancho S et al. The topical delivery of diclofenac into and through equine skin from the new liquid diclofenac epolamine formulation. J Vet Pharmacol Ther. December 2016; 39(6): 578-583.

Stacey Oke, Master of Science, DVM, is a practicing veterinarian and freelance medical writer and editor. She is interested in both large and small animals and complementary and alternative medicine. Since 2005, she has been a research consultant for nutritional supplement companies, assisting doctors and veterinarians in publishing research articles and textbooks, and writing articles for many educational magazines and websites.

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