Medications Articles

Lameness & Joint Medications

How Much Bute is Too Much?
Steroids

Lameness & Joint Medications
by Benjamin Espy, DVM
General Information
As horse owners you have een omarded with numerous articles and advertisements that deal
with the !revention and treatment of "oint disease in horses# Althou$h "oint thera!y has een
!rimarily tar$eted at thorou$hred and %uarter horses& there are even miniature horses that deal
with the same sorts of !rolems# Breedin$ stallions and drivin$ horses are es!ecially !rone to
"oint soreness#
Traumatic "oint disease in horses includes synovitis 'inflammation of the fluid(!roducin$
memrane)& ca!sulitis 'inflammation of the firous "oint ca!sule)& articular cartila$e and one
fra$mentation& li$amentous tearin$& and eventually arthritis# In most cases the disease !rocess
!rimarily involves soft tissue overuse and in"ury and cannot e dia$nostically confirmed e*ce!t for
arthrosco!y+,ou have to trust your veterinarian to decide when "oint in"ections may e eneficial
for your horse# There is no -$old standard. for the dia$noses of !reliminary "oint disease in the
horse as radio$ra!hic chan$es are usually indicative of irre!arale harm# A$$ressive treatment in
"oint disease is indicated to decrease immediately soft tissue swellin$ and inflammation as well as
to !ost!one the onset of !ermanent osteoarthritic chan$es#
There is inherent difficulty in identifyin$ "oint !atholo$y y any other means than su"ective
e*amination and lameness or -shortness of stride. re!orts from trainers# The $oal of any
intraarticular 'medications !ut directly into the "oint) thera!y is to sto! !rolems efore they occur
rather than wait for anormal radio$ra!hs and then start a$$ressive thera!y#
Inflammatory and de$radative en/ymes that destroy normal "oint environments can e altered y
use of hyaluronic acid 'HA) and corticosteroids in"ected into the "oint# The comination of the two
has een scientifically !roven to have a more thorou$h and lastin$ effect than HA alone or
corticosteroids alone# Medications introduced into "oints y human !hysicians that s!eciali/e in
s!orts medicine are ecomin$ more common!lace#
0revious $enerali/ations and !er!etuation of myths aout dama$e to "oint environments caused
y corticosteroids are !rimarily unfounded# The elief that corticosteroids cause dama$e or
!er!etuate cartila$e destruction can only e e*!erimentally re!eated y multi!le "oint in"ections
over days to wee1s# Ty!ically& when there is mild soreness '"oint ca!sulitis or synovitis) in a "oint&
and "oint thera!y is instituted 2(3 times !er year& the environment inside the "oint ecomes more
hos!itale to cartila$e& not destructive# 4ama$e may occur from corticosteroid in"ection alone
when there is cartila$e fra$mentation and one alterations in a "oint& usually associated with
lameness# This is why your veterinarian may re%uire a radio$ra!h efore institutin$ "oint thera!y#
Interestin$ly& even in "oints that have documented one fra$ments cartila$e dama$e does not
occur until "oints are re!eatedly in"ected with corticosteroids routinely over many days and wee1s#
The metaolism of the e%uine "oint is different than in other s!ecies# They are not afflicted with
-5harcot(Li1e. arthro!athy that occurs in humans with the develo!ment of arthritis from
corticosteroid in"ections# It has een !roven that corticosteroids and HA to$ether allows the
natural synovial linin$ of a "oint to ma1e a more viscous and luricatin$ environment#
Intraarticular Hyaluronic Acid 'HA)
0roaly the most commonly used HA !roducts are Hylartin(6& Hy6isc& Le$end& or Hyalovet# All
of these !roducts are laeled for intraarticular use insurin$ !urity and consistency with each
individual manufacturer# MA0(7 is hyaluronic acid used in s!erm e*tender and is not laeled for&
ut has een used in "oint thera!y# HA is normally synthesi/ed y the synovial memrane# HA is
res!onsile for the oundary lurication of articular cartila$e# 8*!erimental evidence comined
with anecdotal re!orts from e%uine !ractitioners that do s!orts medicine s!ecialties re!ort that
usin$ the hi$hest molecular wei$ht 'thic1ness) of HA !rovides the most enefit#
0olysulfated Glycosamino$lycans '0SGAG9s)
The most common e*am!le of this ty!e of !roduct is Ade%uan# This !roduct is used only y
intramuscular in"ection and will cause "oint inflammation if used intraarticularly# These !roducts
are !rimarily used as the uildin$ loc1s for successful cartila$e re!aration# This !roduct is also
usually used when cartila$e dama$e is already !resent rather than in acute "oint inflammation#
Arte!aron is the human e%uivalent to Ade%uan and the chemical structure of the two !roducts is
identical# 5hondroitin sulfate is the most commonly used GAG in these !roducts and is harvested
from ovine lun$ and trachea#
:ral Joint Su!!lementation
5hondroitin sulfate and various other GAG9s can e found in oral su!!lements# 0ure chondroitin
can e found in ;le*(;ree and with a comination of nutrients from the sea mussel in Syno(;le*#
Most recently $lucosamine& chondroitin& and various other GAG9s have een comined in the
!roduct 5ose%uin# Benefits of these oral thera!ies alone are difficult to !rove e*!erimentally& so
usually we treat a$$ressively with intraarticular medication and then su!!lement the horse with
oral !roducts# <ecently there has een much deate aout whether horses can even asor oral
forms of "oint su!!lementation# ;or years we have used data e*tra!olated from human research
studies& and since horses are herivores and have different GI asor!tion characteristics& efficacy
of oral su!!lementation is in %uestion until further studies can e done#
Glucosamine y itself has een associated with decreased !ain& inflammation& and ran$e of
motion when com!ared with a !laceo in human trials# It has een shown in one study to e as
effective as iu!rofin 'Motrin) in !eo!le with arthritic chan$es# La studies have shown increased
"oint !roduction of !rotective GAG9s in tissues treated with $lucosamine# It is li1ely that this
!roduct !rovides the most enefit in the concoction of oral "oint su!!lementation since there is
confusion over how well GAG9s y themselves are asored throu$h intestinal linin$s#
Intraarticular 5orticosteroids
This class of dru$ $ained much fame& or infamy& as it is commonly used in racehorses with
arthritis and has een lamed for many in"uries !ost(in"ection# <esearch has !roven that used
correctly& these are necessary medications in the !atho$enesis of "oint disease# As we mentioned
earlier& en/ymes that are !roduced y diseased or inflamed "oints are very destructive to normal
cartila$e# Joints that are inflamed must e treated with anti(inflammatory medication& as well as
HA in some instances& to allow them to secrete normal "oint fluid# Intraarticular corticosteroids
allow the "oint to start !roducin$ luricatin$ HA as inflamed "oint tissues =ILL >:T ma1e thic1&
luricatin$ HA# It was once said that a -human on corticosteroids can wal1 to the auto!sy room.
ut now most ortho!edic sur$eons use these !roducts in the most famous athletes in the world#
Horses are& y far& much harder on their "oints than any human athlete# It only ma1es sense#
Sustantiation for a direct lin1 etween corticosteroid administration and arthritis has !ersistently
een unale to !rove y do/ens of investi$ators+Most of the !rolems associated are attriuted
to !oor techni%ue 'infection)& and !oor selection of corticosteroid !roducts#
>onsteroidal Medication '>SAI49s)
0henyluta/one 'Bute)& fluni*in me$lamine 'Banamine)& and 1eto!rofen '?etofen) are the most
common >SAI49s used in horses while as!irin and iu!rofen are the most commonly used
>SAI49s in humans# These are very effective in eliminatin$ discomfort and are usually the first
line of thera!y in minor musculos1eletal !ain# There is little evidence on how they affect actual
"oint environments and have as their most common and severe side(effect $astrointestinal
ulceration and reductions in 1idney !erfusion+@lcer formation is ecomin$ more reco$ni/ed as a
common occurrence in all reeds of horses#
5onclusion
My desire throu$h all of these articles has een to ta1e a lot of the mystery out of veterinary
medicine in a well(informed(owner a!!roach# ,our veterinarian will encoura$e intelli$ent
%uestions# 4o your own research# Ta1e res!onsiility for the care of your athletic horse# =e as
humans have a lot to offer the athletic e%uine with thera!y and medication that has een
orrowed from the human medicine field and that which has een desi$ned s!ecifically for use on
the horse+
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How Much Bute is oo Much!
by A"#" Asbury, DVM

My $eterinarian recently prescribed %Bute% when my &eldin& came up sore
a'ter an endurance ride" He ad$ised a speci'ic dosa&e, but ( wonder i' (
could be helpin& my horse more by increasin& the amount o' Bute or
&i$in& it to him more o'ten" #an ( &i$e him more without ma)in& him sic)!
0henyluta/one& or FButeF as it commonly is 1nown& is a !otent com!ound that is classified as a
non(steroidal anti(inflammatory dru$# It wor1s y inhiitin$ the formation of a class of com!ounds
called !rosta$landins& which are amon$ the 1ey elements of the inflammatory !rocess# The
reduction of !rosta$landins moderates inflammation& reducin$ !ain& swellin$& and heat& and
restorin$ function as a result#
There are side effects of the dru$ which can e very harmful to the horse# The most im!ortant
ones affect the $astrointestinal tract and occasionally the urinary tract# @lcers of the
$astrointestinal tract are the most common result of these side effects# The dama$e is clearly
related to dose and duration of treatment& so the answer to the %uestion is fairly strai$htforward#
,esG
The official recommended dose of !henyluta/one is two to four $rams !er day for a H&DDD(!ound
horse& y either the in"ectale or oral route# Intravenous dosa$e should e limited to five days&
then continued dosa$e should e y the oral route# That is the manufacturerIs recommendation
ased on the studies done to otain a!!roval of the dru$# Interestin$ly& the lowest dose
associated with $astrointestinal !rolems is sli$htly elow four $rams a day& when the dru$ is
administered for seven to HE days# As a result& most !ractitioners are comfortale usin$ the
hi$her dose level 'four $rams !er day) for no more than five to si* days& then reducin$ the dose to
two $rams a day#
Sometimes horses will have troule even with this lower dosa$e scheme& so any horse on Bute
thera!y should e watched carefully for early si$ns of troule# The early si$ns are fairly non(
s!ecific and include colic& fever& $rindin$ of teeth& and sometimes diarrhea# Those si$ns easily
could e the result of some other $astrointestinal !rolem& such as 0otomac horse fever& or
infectious colitis# To confirm that the si$ns oserved are related to !henyluta/one to*icity& some
laoratory tests are indicated# A com!lete lood count '5B5) and a serum electrolyte !anel will
!rovide the est clues# Lower than normal lood alumen levels are seen first& followed y a dro!
in white lood counts and lowered serum levels of sodium and chlorine# ,our veterinarian mi$ht
su$$est other means of evaluation#
In acute in"ury or une*!lained inflammation of sudden onset& a course of treatment will hardly
ever e*ceed HE days duration& so !henyluta/one to*icity should not e a !rolem# If an initial
dose schedule of four $rams is indicated& reducin$ that to two $rams as soon as !ossile is a
$ood idea# The i$ !rolem comes with chronic inflammation& such as in laminitis or chronic
arthritic !rolems# In those situations& anti(inflammatory thera!y mi$ht e indicated over a lon$er
!eriod of time# In fact& !henyluta/one mi$ht e the est dru$ to use in these situations# ;aced
with that scenario& a dose of two $rams a day should not e e*ceeded& and that dose should e
in the oral form# In addition& the animal should e monitored carefully for the duration of the
treatment#
I have had roodmares with laminitis who would not stay on their feet without daily treatment with
Bute& which were maintained on this sort of dosa$e re$imen all throu$h !re$nancy# ;oals from
these mares were ty!ically normal and showed no ill effects from their damsI treatment# The
mares usually im!roved somewhat after delivery#
,oun$ horses a!!ear to e more susce!tile to the !rolems of !henyluta/one to*icity# ;oals
and yearlin$s with inflammatory disorders should e mana$ed very carefully with re$ard to anti(
inflammatory medication# :ther dru$s that reduce inflammation y the same means
'!rosta$landin su!!ression)& !articularly fluni*in me$lumine 'Banamine)& are ca!ale of causin$
similar to*icity in horses and are also es!ecially ha/ardous to youn$ foals#
In summary& !henyluta/one and other non(steroidal anti(inflammatory com!ounds are very
effective at reducin$ inflammation& and can e valuale assets in the mana$ement of many
e%uine !rolems# But& there is always the !otential for troule when too much of a $ood thin$ is
used for too lon$# Horse owners should wor1 closely with their veterinarians in the mana$ement
of these !rolems#
A.C. Asbury, DVM, retired to Versailles, Ky., after a practice and academic career devoted to
equine reproduction.
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*teroids
by Michael A Ball, DVM

My horse had a so't tissue injury and my $eterinarian &a$e him steroids"
*ome o' the people in my barn say ( need to be care'ul that he doesn+t &et
too a&&ressi$e or &et 'oundered" (+m con'used" How can steroids do all o'
that!
The steroids, an extremely broad category of drugs and natural hormones, have a wide
variety of effects on the body. All drugs when used for the wrong reasons or at an
inappropriate dose or frequency of treatment can be toxicthe steroids are no exception.
The two main classifications of steroids are the anabolics and the corticosteroids (the
reproductive hormones such as estrogen, progesterone, and others are also classified as
"steroids". The anabolic steroids function to increase protein synthesis by the body and
build muscle mass. The drugs are designed to be used in the treatment and rehabilitation
of chronic debilitating disease processes. The drugs often are used in attempting to ma!e
a gelding act more li!e a stallion and to promote the development of muscle mass and
therefore strength, stamina, and endurance. The drugs allow for a better conversion of the
protein ingested through feed into body proteins (and more particularly muscle tissue.
The anabolic steroids should be used with caution and within ethical boundaries. There
can be severe side effects that include ma!ing a horse so hyped"up that he actually
becomes dangerous to humans. There also is the development of liver disease with
chronic use. The anabolic steroids have pharmaceutical actions on the body that are very
different from the corticosteroids.
#ome corticosteroids only have an effect for $%"&% minutes after administration, whereas
others can have an effect for wee!s. The individual potency also varies greatly, with some
being '%% to ',%%% times more powerful than others.
(ne of the ma)or mechanisms of action of the corticosteroids is to decrease inflammation.
The corticosteroids also reduce inflammation associated with allergic reactionsone
important use is for the treatment of allergic airway disease (allergic bronchitis or chronic
obstructive pulmonary disease*(+, or heaves.
The corticosteroids are extremely potent anti"inflammatory agents that also are useful in
the treatment of numerous disease processes. The most common usage is for the
treatment of arthritic conditions and certain types of )oint problems.
As with all drugs, there are a good side and a bad side. The good side is that the
corticosteroids are very effective in reducing the inflammation associated with )oint
in)ury and arthritis. The bad side is that they potentially can have a seriously negative
impact on cartilage health. *orticosteroids, if used inappropriately, can destroy the
cartilage and potentially contribute to chronic arthritis.
The corticosteroids have a well"documented negative impact on normal healing with
respect to soft tissue (tendon and ligament in)ury. #o, essentially any in)ury where
corticosteroids are used will have a delay in the healing process. The corticosteroids often
are in)ected locally or applied topically with "carrier" agents such as ,-#( to the areas
of soft"tissue in)ury. Again, this has a good and a bad side. The decrease of inflammation
in soft tissue in)uries is very important for the overall outcome. .ut in some cases, if the
horse continues wor!ing in the face of that in)ury, more serious tendon or ligament
damage can occur. The horse is wor!ing on an in)ury that feels better due to the steroids,
so not only is he placing normal strains on in)ured tissue, that tissue/s healing responses
have been decreased.
0t has been well demonstrated that long"term chronic use of systemic steroids (especially
at higher doses suppresses the immune system. 0n competition horses already
experiencing stresses that can supress the immune system (e.g., trailering, these effects
might be compounded. 1orses given corticosteroids on a regular basis might be
predisposed to chronic infectionlung and sinus most commonly.
Another side effect of corticosteroids in the horse is laminitis or founder. The specific
reason why corticosteroids predispose to founder is un!nown, but it is thought to be
related to an effect on the blood supply to the deep layers of the foot. The occurrence of
this phenomenon is variable and is more li!ely to occur when more potent types of
corticosteroids are used or very high doses of the less potent ones are used for long
periods of time.
The exception to this is the individual horse, which for un!nown reasons, is more
sensitive to corticosteroids with respect to founder. 0t has been observed that even a few
low doses of less"potent corticosteroids will cause sore feet in some horses.
0n addition, if systemic corticosteroids are used, an effort should be made to ' use as low
a dose as possible to achieve the desired therapeutic effect2 3 use them for as short a time
period as possible2 $ monitor the horse for any signs of development of infection, e.g.,
daily temperature ta!en while on the drug2 and & monitor the horse for any signs of
laminitis or founder (sore feet4lameness, warm feet, etc.. Also, it should be remembered
that if the corticosteroids are being given for a musculos!eletal problem, a significant
mas!ing of pain can occur. *ontinued exercise of in)ured tissue might not be in the best
interest of the horse.
The use of either corticosteroids or anabolic steroids should only be under the advice and
prescription of a veterinarian.
Michael A Ball, DVM, currently is a staff member in the Department of Pharmacology at
Cornell University
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