Laminitis in horses has been proposed to be one of the most common causes of euthanasia in horses next to colic. The condition comes about due to a variety of factors with some horses being more predisposed than others and the condition has varying levels of presentation in terms of severity. Ultimately, we have to ask ourselves why the condition occurs, what is going on at a cellular level and what can we do better to manage the problem and improve the outcome for the patient? In my many years of managing laminitis, I have found that the outcomes are best when we address the needs of the patient through nutritional type of resources, which I believe aid in better long term management and often improved overall health. Here is my approach when it comes to laminitis in horses for optimal outcomes.
Laminitis is a complex condition that although it has been researched for decades, very little changes in therapy have been offered. Today, the same essential approaches are applied to laminitic horses as where utilized when I graduated many years ago. We understand some basics; including the impact of inflammation and changes in blood circulation, but the details are still pretty fuzzy. From my point of view, unfortunately, we still tend to put all laminitic horses into one group instead of looking at them as individuals, understanding that many things play a role.
So, in today's veterinary world, the typical approach includes:
- Radiographs/ foot trim +/- therapeutic shoe or pad application
- Use of non-steroidal anti-inflammatories to control pain
- Usage of blood circulation enhancers including acepromazine, pentoxifylline, isoxsuprine and nitroglycerine
- Stall confinement plus dietary changes
- In severe or non-responsive cases, a dorsal hoof wall resection or deep flexor tenotomy may be performed surgically
Now, I will admit that over the years I have utilized many of these approaches with mixed results. Often, we would gain control of the condition for the short term, only to have the patient relapse or do poorly in the long term. Unfortunately, I have euthanized many horses due to severity of the condition and subsequent pain levels. Although often we have 'cookie cutter' type of approaches for these cases, some simply respond while others show no improvement at all.
When I am presented with a laminitic horse, the first thing we generally do is perform a good physical examination, helping to determine if there is fever/infection present, determine the level of pain present, which feet are involved and to what degree. We can also get a pretty good assessment for the potential need for supportive care such as IV fluids due to dehydration or presence of sepsis. Hoof testers are applied to determine areas of pain and digital pulses are determined which is generally indicative of ongoing inflammation. After the initial exam is completed, blood work is submitted for basic evaluation of white blood cells, red blood cells and organ function. Again, this information may help us to determine if there is concurrent infection, sepsis or organ involvement such as in the case of a severe colic or toxin exposure. Radiographs (x-rays) are also performed of the feet, often all 4 feet, with focus on the front feet as they are the ones most typically involved due to weight distribution. Radiographs are performed to assess the presence of coffin bone rotation, sole depth, presence of abscesses, presence of fractures and various angles within the hoof capsule. The rear feet are less likely to be involved, but have to be evaluated for completeness sake.
We can determine the level of pain involved simply by watching the patient. The higher levels of pain generally correlate with less mobility or willingness to move by the patient. Higher levels of pain are also, in my opinion, often indicative of the severity of the condition and likewise prognosis. It is best to note that pain levels are generally NOT correlated with radiographic (x-ray) findings in terms of degree of rotation. We can have a horse with minimal rotation of the coffin bone present with very high levels of pain, often intractable to traditional pain reducing therapies.
My standard approach to these patients is to evaluate them clinically, assess bloodwork and then radiograph findings. Dependent on what I see and read, this dictates my approach to managing that patient.
Overall Patient Assessment:
As mentioned before, I get concerned that all laminitic horses are grouped into the same bunch and thus approached with the same therapies, feeling that they apply to everyone. Sure, we have similar pathologies taking place including tissue destruction, blood flow alterations and pain, but what else is going on? What else can we do to manage them better?
Utilizing all of the gathered information, I try to determine if the condition is acute or chronic in nature. Acute laminitis essentially just happened recently for various reasons, while chronic laminitis has often been going on for a longer period of time, often for years. Let's consider grain overload or possible retained placenta in mares as a cause of acute laminitis. The laminitis in those cases is a result of an insult to the body that just happened. Next, let's consider metabolic syndrome or insulin resistance as a cause of chronic laminitis. Here, the insult to the body has been present likely for an extended period, often over a year or more. We can determine this based on the level of presentation of the patient, history, examination findings, level of pain, blood work findings and body condition. Often we have to get some details from the owner regarding housing, diet, pasture exposure, past medical problems and even breeding history. It all plays a role in how we manage them most effectively and shows that not every patient is the same.
Acute laminitis cases are generally more serious and can progress very rapidly, especially when associated with severe illnesses such as colic, sepsis or retained placentas. Here we need to keep in mind that the laminitis we are seeing is secondary to a primary event, meaning that both need to be managed aggressively, but each is feeding into the other. In some cases, we can get the primary condition resolved but the degree of tissue damage within the foot is so severe that a vicious cycle develops due to pain, leading to deterioration of the patient. These cases can have severe rotation of the coffin bone but can also have very mild rotation, but significant pain. In those cases of acute laminitis, we approach the patient very aggressively with hopes of gaining the upper hand on the problem. Often these horses are very painful, can barely walk and prefer to lie down to reduce discomfort. If we can determine the underlying problem, then we treat it. In some cases, we can't determine the cause but just know that we have a laminitic and very painful horse. Dependent on the situation, treatment may be aimed at IV fluid therapy, antibiotics and high doses of pain medications to help reduce discomfort. We may also use other medications to enhance blood circulation to the foot and apply pads to help provide overall support to the coffin bone. The prognosis in these cases can generally be dictated within 2-3 days, dependent on the patient's response to therapies.
Chronic laminitic cases are more common in my practice area and often afford the luxury of more time to determine the best course of action. These cases often have mid-range to severe levels of coffin bone rotation, sometimes stunning to the viewer of the x-rays, wondering how the horse is actually walking? The fact is that often the rotation occurs over a long period of time, progressively, allowing the horse to somewhat adapt to the changes, thus demonstrate very mild or subtle signs of lameness in some cases.
Aside from the history and medical testing, I like to 'look' at the patient, trying to get a feel for their temperament, constitution, body condition and overall health. Considering that the majority of the laminitic cases presented to me are more chronic in nature, we can get subtle hints as to other problems. In many of our laminitic patients, they are often overweight with dull hair coats, lacking luster and sometimes with dander. Hoof health is often also compromised with notable dryness, poor growth, cracking and dander to the coronary band region. Blood work may also point out some possible deficiencies such as anemia or protein levels. In these patients, blood work can be further assessed by performing thyroid levels, insulin levels and maybe even testing for Cushing's disease (PPID). The history often points to issues with sugar or carbohydrate metabolism, as they usually flare up when turned out on pasture, especially in the spring. Essentially, we are trying to get a better feel for the patient as whole unit instead of just focusing on the obvious, which is the lameness and laminitis.
Getting a feel for the big picture is paramount to recovery. If we can determine the cause of the laminitic episode, then we approach that and manage it accordingly. The laminitis is approached with four points in mind:
- provide support to the coffin bone
- reduce inflammation/pain
- enhance circulation
- provide nutrients for repair.
- Support to the coffin bone is achieved in my practice after reviewing the radiographs and assessing for rotation. The more painful cases often respond the best to support, while the more chronic cases often fail to show any improvement due to adaptive reasons. For support, I generally try to stay simple by using thick styrofoam padding which is taped to the foot daily or twice daily, providing support to the entire foot. In most cases, proper trimming will be applied to the foot, reducing toe length and restoring balance prior to applying the pad. I have found pads to be just as useful if not more useful in the short term as compared to application of special shoes and radical trimming.
- Inflammation and pain reduction approaches are dependent on the patient. In more severe cases, I will use non-steroidal anti-inflammatories at varying doses to restore patient comfort. The more acute the case, the more likely to use these medications. The more chronic, the less likely I am to implement to be honest. The level of pain dictates my approach. We have to remember that pain is a result of inflammation and that the inflammatory process is very complex, having multiple pathways. Pain medications often only address one pathway or aspect of the inflammatory reaction, thus leading to minimal response in some cases. Personally, I feel that we should be more thorough in our approach to inflammation, as this is not only causing pain in the patient, but contributing to tissue destruction and alterations in blood flow. In those patients with a high level of pain, dictated by a hard time walking or wanting to lie down often, I will use our Cur-OST® Pure EQ formula twice daily and sometimes in combination with prescription pain medications, again dependent on the situation. The Pure EQ formula provides high levels of Curcumin and Boswellia, which have been shown to modulate the inflammatory response more completely, reducing pain and possibly impacting the tissue destruction. Sometimes requirements are higher for some patients, as each is an individual. In the less painful, usually the more chronic type cases, I will use our EQ Plus formula which provides high levels of curcumin and Boswellia, but provides more overall support with alfalfa and mushroom polysaccharides, which give nutrient benefit to the patient. In our chronic laminitic cases, often we can determine that they are also metabolic syndrome or insulin resistant patients. This opens a whole new spectrum of therapy, as the condition is not just in the feet per se, but is systemic, actually impacting many things we cannot physically see. Often those patients are overweight, cresty, dull hair coats and poor hoof condition. I will take one of two approaches with these types of patients, keeping in mind that not only do we have inflammatory problems, but often metabolic issues impacting cellular responsiveness. My first line approach in supporting these metabolic cases is to use our EQ Plus formula in combination with our EQ Meta-Support product; helping to reduce inflammation and also improving insulin responsiveness. If the pain levels are very low and overall the patient seems comfortable, I will use our EQ Green formula in combination with the EQ IR product for management. I have also obtained really good results in management of metabolic type laminitic cases through the use of our EQ Total Support and EQ Nourish formulas. The EQ Total Support reduces inflammation but also supports the GI tract by possibly enhancing digestion, helping the patient to absorb and utilize nutrients in the diet needed for repair. The EQ Nourish provides these nutrients in higher levels, but also supports GI health which is a common problem in these patients in my opinion. One of the key things that I personally look for is signs of poor nourishment such as the dry hoof condition, poor hair coat and possible signs of dander. This points, to me, that we may have nutrient depletion or absorption that may be contributing to the problem.
- Circulation restoration is a key to improving the prognosis in laminitic cases. Research has implied that blood is actually shunted away from digital tissue, resulting in lower oxygen levels and tissue destruction. The process of inflammation is connected strongly with blood circulation through the release of many pro-inflammatory proteins. Considering this, inflammation must be controlled, which if done properly, often restores blood flow to the foot. Pain is also a cyclic type of phenomenon, contributing to poor blood circulation, so again, this must also be controlled if possible. I have not found much clinical value in the use of prescription medications to enhance circulation, especially in chronic cases. What I have found value in is the use of amino acids such as L-glutamine and L-arginine, which have both been found to improve circulation, restore endothelial health and cellular function. We have to remember that blood vessels undergo negative reactions to inflammation, often contributing to 'leakiness' and overall poor circulation. Reducing inflammation and providing antioxidant support can go a long way. For long term management of our laminitic cases, I often rely on our Cur-OST® Immune & Repair formula to help provide these nutrients for repair purposes. The EQ Nourish formula is also used to obtain these effects when combined with our EQ Total Support formula in metabolic type scenarios.
- Nutrients are needed for tissue repair, no question asked. The question is are they being provided and are they being absorbed/utilized properly? I am not one that follows the traditional methodology of putting the metabolic or insulin resistant horses on dry lots and reduced feeds. Although these approaches do help alleviate symptoms, I feel that they are obtaining results only by 'starving' the process and often lead to other clinical problems and loss of overall health. In my experience, with this approach, many of the patients improve in terms of laminitis, but they lose body condition, hair/skin health and even hoof health. I personally feel that if we approach the problem from a cellular perspective, many of these horses can do very well on normal pasture, hays and even grains with minimal issues. That is not the case all of the time, but I overall try not to deprive that patient of nutrients needed not only for tissue repair but for overall health. With many of our patients, especially metabolic cases with evident nutrient depletion, we will use our Nourish EQ formula for long term support in combination with our other formulas.
The approach to laminitis is a complicated one indeed. This is evident by the lack of response of every horse to traditional therapies. Even with our approach of supporting the patient on multiple levels, not every horse responds as we would like. Some problems are more deep rooted and take more time than others to respond. In my non-complicated metabolic patients, the first line approach is to control the inflammation and target blood circulation, which product is used is dependent on the level presented. I will generally choose a formula dictated by the patient, implement it and then reassess in 2 weeks. At that point, hopefully, we have the problem under control and the patient is feeling and moving better. In some cases, we have dramatic improvement in just a few days. If we recheck back with improvement, then I will generally start to tweek the approach, attempting to target the underlying problem. For long term support in a generally healthy metabolic patient, I will often use our EQ Plus or EQ Green formula in combination with the EQ IR product. For long term support in those depleted patients with evident nutrient deficiency, I will use our EQ Total Support in combination with our Nourish EQ. This is of course in addition to proper hoof care, including trimming plus or minus support. Again, not every patient responds as we would like and some do require dietary modifications or prescription medications, but hopefully our goal for the long term is to improve their health and thereby reducing the need for these interventions.
I hope this helps to clarify my approach to laminitis in the horse, with emphasis on metabolic causes. It is a complicated topic and one that is question often by horse owners. We are here to help you, just let us know if you have questions!
All my best,
Tom Schell, D.V.M.
Nouvelle Research, Inc.