Equine Medication Prices: Why Can’t I Get Something Cheaper?

Probably every horse owner has had the experience of feeling sticker shock when the cost of treating a horse’s malady is revealed by the veterinarian. The cost of pharmaceuticals is high because of development and production expenditures, and horses are really big patients (generally 10 times the size of the average adult human). But often, cheaper alternatives exist, and are often touted as “generic” formulations. Veterinarians may be reluctant to prescribe these less expensive alternatives, which may lead clients to wonder why they have to pay more for name brand medications. There are actually a number of reasons, and they all boil down to providing safe, effective medication to our equine patients.

First, it is important to clarify the terminology. Both name-brand and generic PrascendFDA approved medications are manufactured and labeled according to standards set by the Food and Drug Administration, a government agency charged with, among other things, assuring that medications are safe and effective. Compounded medications are either drugs that are somehow altered from their FDA approved formulation (for example, adding flavoring to children’s antibiotics to make them more palatable), or are formulated from the chemical grade drug or substance in other than FDA approved processes or facilities. The important part of this distinction is that medications with FDA approval are required to adhere to FDA standards for manufacture and labeling. Because compounding pharmacies are not under these requirements, the standards for manufacture are lower and label claims are not under the regular scrutiny of a regulatory body. Why does this matter? Let’s review a few examples.

In April of 2009, 21 polo ponies died as a result of the administration of a selenium product that, because of a clerical error, was 10 times more concentrated that it should have been according to the label. Similarly, this year, 4 horses died and 6 more were sickened when they received a pyrimethamine/toltrazuril combination in which the amount of one of the drugs was inappropriate. (Toltrazuril is not approved for use in the United States, so any complications from the use of these drugs could potentially put the prescribing veterinarians in an awkward spot with the FDA.

Compounding concerns are not limited to veterinary medicine, however. In the fall of 2012, reports began to surface of people suffering from fungal meningitis after having spinal injections with compounded steroids. Sixty four people have died, and 700 more are under long term treatment for persistent infections. The fungus was isolated out of the room in which the drug was prepared.

In addition to safety concerns, the formulation of compounded medications does not always provide the active ingredient in a form that the body can use properly to achieve the desired effect. There are a few important examples of this in equine medicine one of which is omeprazole. The FDA approved omeprazole products (GastroGard® and UlcerGard®) are very expensive to use, driving the desire for a less expensive alternative. Unfortunately, omeprazole is very difficult to formulate in a way that it is useful to horses. In order to be useful, the drug must pass through the stomach to be absorbed in the small intestine, then travel through the blood to the acid-producing cells in the stomach, where it blocks the cellular pumps that produce acid. The challenging part of this is the fact that omeprazole is inactivated by acid, which fills the stomach. GastroGard® is made using a patented process that encapsulates the drug into enteric-coated microspheres that are kept in suspension; the omeprazole is protected from the acid in the stomach so that it can be absorbed in the small intestine. Other formulations of omeprazole which use antacids and buffers in an attempt to protect it through the stomach have consistently failed to achieve blood levels of omeprazole that are sufficient to be effective. (Birkmann et. al, J Vet Int Med 2014) Another related issue is that there is no assurance that the concentration of active ingredient listed on the label is what is actually in the product. Variations from label claims have been documented in numerous compounded medications.

Furthermore, the veterinarian her/himself is bound by law. It is permissible to compound medications, which is good, since it is also necessary in many occasions. However, it is not permissible if an effective FDA alternative is available. Conditions that allow for using compounded products include availability (when pergolide was first off of the human market, only compounded pergolide was available for horses) and patient factors (an infant can’t take a pill, an individual is allergic to a dye or filler in an approved product). The cost of a medication is NOT legal justification for using a compounded product. A doctor or veterinarian who prescribes a compounded medication inappropriately bears all of the legal responsibility for that medication, and is 100% culpable if something goes wrong.

All this is not to say that there is no place for compounding pharmacies in human and veterinary medicine. There are many very reputable pharmacies that have high standards for production and are very concerned about product quality. These pharmacies make available to practitioners medications that, for one reason or another, are not available in an FDA approved form. However, it is important to realize that when a veterinarian prescribes such a drug, he or she is personally taking on the full responsibility of standing behind that product, and there may be a number of very good reasons not to do so in a particular circumstance. If you have a question about a product, the best way to learn more is to open a dialogue with your veterinarian to determine the best, most cost effective product for your horse.

Subcutaneous Emphysema Caused By A Skull Fracture

Recently my horse Mocha fractured a small bone in the sinus region of her face causing subcutaneous emphysema, which means gas or air is trapped beneath the layer of skin. It is not a hot or hard swelling; it feels like it crackles and is crunchy to the touch, a sensation known as crepitus. I had never seen anything like this before, and called Dr. Julia Hecking right away. She asked me to look for a puncture wound that could be leaking air into the skin, however there was not a wound present.

Dr.Hecking thought it was best to take radiographs of her head to look for any fracture that may be causing air leakage. There was indeed a small fracture in her sinus region which explained her head being enlarged. However, we were unsure if that was causing the enlarged throat latch area and neck, or if there could be a secondary problem. We passed a scope through her nostril into her trachea and esophagus to make sure there were no tears or bleeding present. There were no tears or bleeding that she could see, however the scope the doctors use in the field is much shorter than the one we have at the hospital, so it’s hard to see the entire area. This is often the reason a doctor chooses to refer a horse into the hospital for a better look with a longer endoscope.

If you ever encounter this type of swelling in the head or neck region of one of your horses, it is important to call your veterinarian immediately, and keep the horse quiet and in a confined area until the vet arrives. He/she will appreciate knowing if your horse is eating, drinking, breathing normally, and if a fever is present.

After one week, the swelling is decreasing. Mocha continues to eat, drink, breathe and act normally with no indication of fever or discomfort, so we expect it to resolve on its own. Dr. Steve Trostle has seen similar cases and says it may be a few weeks until the swelling completely disappears.

 

What Is An Equine Internal Medicine Specialist?

An Internal Medicine Specialist is a veterinarian who specializes in conditions that affect the general health and well- being of her/his patients, including conditions affecting the GI tract, respiratory system, blood and lymphatics, liver, muscles, kidneys and bladder, neurologic system, infectious diseases, and care of neonates (newborn foals). Specialty training in Internal Medicine emphasizes critical thinking, excellent history taking and physical examination skills, and a problem based approach to reaching a diagnosis and appropriate treatment.

Dr. Abby Sage

Board certification in Internal Medicine requires several years of training with specialists, passing multiple examinations, completing research, and publishing at least one peer-reviewed article. Equine Internal Medicine specialists are employed in many diverse fields, including critical care medicine, cardiology, pulmonology, neurology, sports medicine, neonatology, general practice, industry, and academia, to name a few.

At Blue Ridge Equine Clinic, we are fortunate to have two Internal Medicine Specialists:  Dr. Abby Sage, based in our Earlysville clinic, and Dr. Tracy Norman, in our Valley Division.  They are tremendous resources for our veterinarians, clients and patients, as they are up to date on the very latest research concerning all aspects of equine health.  Having two Internal Medicine Specialists on staff enables us to provide our clients and patients with the most complete, cutting edge treatment and care for your horse.

As always, let us know how we may best serve as a resource for your equine care needs.

 

Equine Lyme Disease

Over one hundred horse owners/ enthusiasts gathered at the Virginia Horse Center on March 19 for dinner and an educational seminar sponsored by Blue Ridge Equine Clinic, Augusta Cooperative Farm Bureau and the Virginia Horse Center. We were delighted to see old friends, clients and to get acquainted with new friends from our horse community.

Dr. Abby Sage, VMD from Blue Ridge Equine Clinic, gave an excellentCE mtg Dr Sage presentation on Equine Lyme Disease: What We Know and What We Still Don’t Know. Although there are been a few studies on the disease, the frustrating reality is that there is still much that has not been proven scientifically about Lyme Disease in horses, which has reached epidemic levels in our region since 2009.

The disease is caused by a bacteria called Borrelia burgdorferi. It is carried by the tiny deer or black legged tick and can be transmitted throughout the year. It is difficult to be certain what the clinical signs of the disease are in the horse. When ponies were experimentally infected with the organism, none of them developed clinical signs even though the organism was recovered from the ponies at necropsy. There have only been six documented cases of Lyme Disease in the horse that have been reported in the scientific literature. However clinical signs that have been attributed to the disease are: stiff, swollen joints, anterior uveitis (moonblindness), neurologic signs, low grade fever, sensitivity to touch, lameness, weight loss, tremors, neck pain, lethargy, laminitis and pseudolymphoma. Unfortunately, these signs may be caused by many other diseases that are commonly seen. Those include anaplasma, EPM, arthritis, typing up, PSSM and many more.

Lyme test results are based on an antibody response. If the horse is infected with the organism, it will develop an antibody response. However, 40-50% of all horses in the mid-atlantic region test positive (75% in New England, where Lyme Disease was first reported) even though they have no clinical signs nor will they develop clinical signs in the future. They have been exposed, develop an antibody response but do not get sick. So a positive test does not mean that the clinical signs the horse is experiencing are definitely caused by the Borrelia organism.

So how do we know if a horse is infected with Lyme Disease? For lack of a better method, veterinarians have adopted the rules for humans the CDC uses:

* the horse must be in an endemic area

* the horse must have compatible clinical signs

* all other potential diseases must be ruled out

* the horse must have a positive test

* if the horse dies, it must have compatible pathology

Results from experiments on treating Lyme Disease have not been definitive. An experiment performed at Cornell University College of Veterinary Medicine divided 16 ponies into 4 groups of four. Horses which were infected with Lyme Disease and treated for 28 days four different ways: Doxycycline (oral form of tetracycline), ceftiofur (antibiotic in Naxcel or Excede), IV Tetracycline or with no medication (control group). The only group that showed a negative antibody test after 28 days of treatment was the IV tetracycline. However another experiment in naturally infected horses did not show a similar effect with IV tetracycline. It is not clear why these horses did not have a negative test after treatment. It may be that they became reinfected or they remain chronically infected.

Considering the results from the first treatment experiment, one may wonder why not just treat all suspected cases with IV Tetracycline? Several reasons: it’s expensive, as it requires a daily visit from the veterinarian for 30 days, horses can collapse if it is giving too quickly, it’s very irritating if it gets outside the vein, it can cause GI upset and renal failure. As you can see, it’s not a treatment decision to be made lightly in a suspected case of Lyme Disease. If you or your veterinarian suspects Lyme’s Disease a discussion about the test and treatment options should follow. Today veterinarians use Monocycline (oral tetracycline) because it is given orally and rises to therapeutic levels in the blood stream of the horse. But there is no clinical evidence confirming if it actually works or how long it should be given.

As you can see, it’s frustrating for all of us that there is so much that is still unknown about Lyme Disease: its prevalence, definitive clinical signs, how to diagnose it and best treatment method. Until more research dollars are invested in further research, the only things we know for sure are the organism that causes it and that tetracycline has some effect on it.

 

Academy Of Equine Veterinary Nursing Technicians

What is the Academy of Equine Veterinary Nursing Technicians (AEVNT)? The AEVNT is recognized as a veterinary technician specialty by the National Association of Veterinary Technicians in America (NAVTA).

In December 2008, the American Association of Equine Veterinary Technicians and Assistants (AAEVT) sent out an inquiry to those members interested in organizing an Academy for Equine Veterinary Technicians. Nine qualified applicants were selected and a committee was formed. The organizing committee researched and drafted an extensive, 88 page proposal, which was presented to the NAVTA Committee on Veterinary Technician Specialists for consideration. The proposal was reviewed, and with a few minor modifications, was accepted by the NAVTA Board at the American Veterinary Medical Association (AVMA) meeting in Seattle.

The AEVNT Mission Statement is to advance the education and professional equine stem cell stem cell therapyrecognition of credentialed equine veterinary technicians who display excellence in, and dedication to, providing superior nursing care to the equine patient.

I have been a member of the AAEVT and employee at Blue Ridge Equine Clinic since 2008. I learned of the AEVNT through being a member of AAEVT and decided that this was a specialty that I wanted to pursue. Between May 2012 and May 2013, I compiled my application, which included my resume, 50 hours of continuing education over the past three years, two recommendation letters (from our amazing surgeons), and 61 brief cases and 5 extensive cases in which I had taken part. I submitted the application and waited to hear back!

In June, I learned that the board had accepted my application and I was eligible to sit for the examination at the American Association of Equine Practitioners (AAEP) Conference in Nashville, Tennessee. In December 2013, I took and passed the examination and was inducted into the Academy of Equine Veterinary Nursing Technicians at AAEVT’s annual luncheon. This designation gives me the opportunity to promote the advancement and standard of excellence of the equine nursing practice by communicating, educating, and mentoring others and utilizing my knowledge in performance of duties as an equine veterinary nursing technician.

I feel truly honored to be one of 17 technicians in the world that have this designation and look forward to using my knowledge in teaching and training externs, interns and other technicians who come through our teaching hospital.

 

Farrier – Owner Relationships

When you find a good farrier, do whatever it takes to keep him or her happy. Farriers, sometimes called blacksmiths, have one of the most challenging and difficult jobs in the equine industry. They constantly deal with difficult owners and horses. It is a very competitive business, so they have to work hard to maintain their clientele. Many people think it’s an easy job and pretty simple, but it is definitely an art that takes a lot of patience and skill.

When you are looking to hire a new farrier, make sure they are knowledgeable about the anatomy of the horse and corrective shoeing techniques. The Journeyman farrier designation requires a good deal of farrier Tyler Golladay2training and experience, and is one indication that a farrier is well equipped to handle most corrective shoeing situations. There are other great certification programs as well. Some farriers choose to do an apprenticeship with another, more experienced, farrier instead; this is another great way to learn the trade. It is important that your farrier listens to what you have to say. If you are questioning your horse’s movement, it could be a shoeing issue that can be corrected with time and skill. This may require collaboration between your farrier and veterinarian, so be sure you choose a farrier who is accepting of a veterinarian’s input and advice.

The best way to keep your farrier happy is to have your horse well trained to stand for him/her, whether you have a yearling or a 20 year old horse. In between shoeing or trims, work with your horse on standing and picking up hooves for a length of time. With young horses, practice hammering lightly on their hooves to get them used to the sound and feeling so they will be dull to it when the farrier comes for the first time. Your farrier will also appreciate a well-lit, dry, uncluttered work space, as well as a clean, dry horse when they arrive.

A competent farrier is an essential part of your horse’s well-being.  Take good care of them, so they can help you take good care of your horses.

Avoiding Conflicts of Interest in Purchase Exams

At the recent American Association of Equine Practitioners Annual Convention in Nashville, several questions regarding potential conflicts of interest when conducting a purchase exam were posed to the Professional Conduct and Ethics Committee, which I chair. I hope a summary of the discussion will be useful to both buyers and sellers, and shed some insight on the veterinarian’s perspective.

The most common potential conflict we encounter in practice is one in which both the buyer and seller are clients of the examiner’s practice. In the past, many have stated that one should not perform such an examination, and this is certainly one option. However, in many cases, neither the buyer nor seller object to such and are comfortable with a veterinarian performing the exam. This requires that there is full disclosure to all parties with whom you have a relationship, and that there is full disclosure of all medical records and history of the animal by the seller. In my opinion, under these circumstances, the potential conflict can be avoided and all parties are served. One should always document such potential conflicts and have all parties sign off on such. When a situation arises in which there is not full disclosure of all medical history, a veterinarians should walk away from the exam and advise the buyer politely that there is a potential conflict of interest and suggest another practice conduct the exam.

images DR footOne question put to the committee concerned basing the fee for the exam on a percentage of the purchase price if the buyer does buy the horse. This is a clear conflict of interest and has great potential to influence the interpretation of the findings in favor of the seller. Many very expensive animals are examined by veterinarians daily and require thorough workups. Veterinarians should be paid a just fee for these exams, but our fee should never be tied to whether a sale goes through.

The following statement from Harry Werner, VMD, effectively sums up these conflicts:

“Potential conflicts of interest, real or perceived, commonly present ethical challenges to performance of prepurchase examinations. Historically, this issue was addressed with a simple and short list of circumstances under which it was recommended that an equine practitioner decline to perform the examination. In reality, while some relationships clearly do represent a conflict, others do not or can be indemnified from such criticism by timely and full disclosure to all parties.

Few would question that the veterinarian should decline performing the examination if he/she owns any equity interest in the horse or stands to gain monetarily from the outcome of the sale. However, an oft-repeated admonition over the years has been to avoid examining any horse when the examiner has a ‘professional relationship’ with the seller or agents of the seller. This, in the opinion of many, is an unrealistic and unnecessary prohibition. In fact, a strong case can be made that the examiner with firsthand knowledge of the horse brings added value to the buyer, providing that the seller authorizes full disclosure of the medical history. Additionally, many times the buyer’s veterinarian also serves the seller in the same form and the buyer clearly expresses that he/she prefers this veterinarians perform the examination. It is my opinion that the answer to the ‘conflict of interest dilemma’ lies in full disclosure of the horse’s medical history and the examiner’s relationship with the seller and the horse to all parties.”

Dr. Werner’s statement is a good working document for all veterinarians conducting prepurchase exams. However, if one suspects that full disclosure is not going to prevent a conflict, then all parties are better served by the practitioner recusing themselves and advising the purchaser on the selection of another veterinarian.

Equine Enteric Coronavirus – A Newly Emerging Disease Of Horses

Cornell University’s School of Veterinary Medicine has provided current information on Equine Enteric Coronavirus, a newly emerging disease most often found in the Northeast during colder seasons.  Good information to keep in mind as you monitor your horse’s health this winter.

As always, please feel free to call us with any questions or concerns about your horse’s health:  (434)973-7947 Earlysville Clinic or (540)460-5702 Valley Division.

Choking In Horses

It can be a very scary thing when a horse chokes, but if you know what to do when it happens, it can make the problem resolve faster with fewer complications.  A horse chokes when grain, hay, or other substances get lodged in the esophagus and will not pass. The esophagus is a muscular tube that takes food, water, and other substances from the mouth to the stomach. Since a choke involves the esophagus and not the trachea (windpipe), the horse can still breathe, but it can cause symptoms such as nasal discharge, stretching of the neck usually in a downward direction, increased salivation, coughing, difficulty swallowing, and/or lack of appetite. Sometimes a choke can also cause aspiration pneumonia, where material passes down the trachea and into the lungs.

Choking can be caused by many things. such as dry feed, horses that eat too fast, a foreign body, and/or dental problems that would cause the horse not to chew its food properly.

If you suspect choke with a horse, the first step is to call your veterinarian and proceed with their directions. While waiting for the veterinarian, you should remove any feed that was offered to keep the blockage from becoming worse and prepare a bucket of lukewarm water. Once the veterinarian arrives, he/she will assess the severity of the choke and proceed with giving a sedative, medication to help the esophagus relax, and/or pass a tube down the esophagus. Sometimes the sedative and other medications will relax the esophagus enough to allow the blocked food to pass on its own, but in many cases, a tube needs to be passed. The veterinarian will pass the tube down the nose and follow the esophagus to the block. With water, they will gently lavage around the blockage to loosen up the material. In most cases, this will dislodge the material and the choke will be resolved. There are some situations where the blockage cannot be fixed this way and more involved procedures need to be used, such as full sedation or surgery, although this is rare.

Round bale feederOnce the choke has resolved and if the horse has been sedated, you should not feed them until they are fully awake. You may be instructed soften the horses feed for a few days to let the esophagus heal. To prevent future chokes you should:

* Make sure your veterinarian has checked the horse’s teeth for any abnormalities on a regular basis (every 6-12 month)

*Always provide clean/fresh water

*If changing feeds, do it gradually

*Cut any apples, carrots or other treats into small pieces

*Soak dry food adequately before feeding

*Slow down a horse that eats too fast by spreading out the food, placing a salt lick or large stone (one that is too big to swallow) in their feed bucket, or feed smaller meals more often

*If sedating a horse. do not give feed until they are fully awake.

As always, call us if you have questions or concerns about any aspect of your horse’s health or care.

Would You Recognize Botulism If You Saw It?

Most of us have probably heard that your horse should have a botulism vaccine if you feed round bales, but if you’re like me, you may have never actually seen or known a horse with the disease.  Just recently, we did have a patient with a confirmed diagnosis of botulism and we hope it will be helpful to detail the symptoms.  Of course, the best scenario is to avoid botulism in your horse, which is easily done by keeping your horse vaccinated against it.

We received a call from a client whose horse was just not himself:  lethargic, depressed, not cleaning up all of his feed, slight fever of 101 degrees, slightly loose stool with an occasional trip/mistep.  The horse had been ridden the day before and seemed fine.  The owner knew the horse well and was convinced something was just not right.  Bute had not seemed to make the horse more comfortable.  He was up to date on his Rabies vaccine only, lived with four other horses who remained well and had access to a round bale in his pasture.

When Dr. Hecking saw the horse, he displayed progressive depression and exhibited weakness, stumbling, and incoordination.  She gave the horse electrolyte paste, Banamine and pulled bloodwork, but was concerned enough about possible neurologic conditions, EHV or enchepalitis that she referred the horse to an equine hospital for evaluation.

Upon presentation at the hospital, temperature/pulse/respiration were normal.   A neurologic exam confirmed that he was very dull, had little to no sensation to the face, eyelid tone was reduced and he would not pull his tongue back into his mouth when it was pulled out.  Likewise, his tail tone was reduced and he had decreased resistance to tail pulls.  His bloodwork showed mild electrolyte abnormalities and increased fibrinogen consistent with inflammation and anorexia.

Based on his access to a round bale and his muscle weakness, a presumptive diagnosis of botulism was made.  Botulism is caused by a toxin produced by the bacteria Clostridium botulism, which can result in stimulated muscle contraction.  This can cause horses to develop a flaccid paralysis, usually starting in the facial muscles, moving to limb muscles and in severe cases, paralysis of the diaphragm.

In adult horses, intoxication usually comes from one or two sources:  contaminated hay or from a toxin produced within a wound infected with the bacteria.  Though this patient had a wound on his left hock, it was reported to be old and was not painful or hot on palpation, so the most likely source of infection was the round bale.

The patient received Botulism antitoxin plasma, IV fluids with electrolytes, DMSO and Banamine.  Within 24 hours, he appeared much brighter and his facial sensation was almost normal, with tongue, eyelid and tail tone significantly improved.  Cerebrospinal fluid was normal, making the botulism intoxication more likely than neurologic diseases like herpes, EEE, WEE or WNV.  A test for EPM was done, although his marked, quick response to treatment made EPM less likely.

Only three days after he was initially seen by Dr. Hecking, our patient was bright, alert, and responsive with a good appetite.  He is expected to make a full recovery, in large part due to his owner’s quick call to us the first day he noticed a departure from normal behavior.

To protect your horse against botulism, we do recommend the vaccine for all equines having access to round bales.  Initially, a series of three vaccines (three to four weeks apart) are necessary for full protection, with only an annual booster required thereafter.  Please call us (434)973-7947 or (540)460-5702 if we may be of help with your vaccine questions.