Chronic laminitis: current treatment strategies

Soluble epoxide hydrolase activity and pharmacologic inhibition in horses with chronic severe laminitis

BACKGROUND

The roles of soluble epoxide hydrolase and lipid mediators in inflammatory and neuropathic pain could be relevant in laminitis pain management.

OBJECTIVES

To determine soluble epoxide hydrolase (sEH) activity in the digital laminae, sEH inhibitor potency in vitro, and efficacy of a sEH inhibitor as an adjunct analgesic therapy in chronic laminitic horses.

STUDY DESIGN

In vitro experiments and clinical case series.

METHODS

sEH activity was measured in digital laminae from euthanised healthy and laminitic horses (n = 5-6/group). Potency of 7 synthetic sEH inhibitors was determined in vitro using equine liver cytosol. One of them (t-TUCB; 0.1 mg/kg bwt i.v. every 24 h) was selected based on potency and stability, and used as adjunct therapy in 10 horses with severe chronic laminitis (Obel grades 2, one horse; 3-4, nine horses). Daily assessments of forelimb lifts, pain scores, physiologic and laboratory examinations were performed before (baseline) and during t-TUCB treatment. Data are presented as mean ± s.d. and 95% confidence intervals (CI).

RESULTS

sEH activity in the digital laminae from laminitic horses (0.9±0.6 nmol/min/mg; 95% CI 0.16-1.55 nmol/min/mg) was significantly greater (P = 0.01) than in healthy horses (0.17±0.09 nmol/min/mg; CI 0.07-0.26 nmol/min/mg). t-TUCB as an adjunct analgesic up to 10 days (4.3±3 days) in laminitic horses was associated with significant reduction in forelimb lifts (36±22%; 95% CI 9-64%) and in pain scores (18±23%; 95% CI 2-35%) compared with baseline (P = 0.04). One horse developed gas colic and another corneal vascularisation in a blind eye during treatment. No other significant changes were observed.

MAIN LIMITATIONS

Absence of control group and evaluator blinding in case series.

CONCLUSIONS

sEH activity is significantly higher in the digital laminae of actively laminitic compared with healthy horses, and use of a potent inhibitor of equine sEH as adjunct analgesic therapy appears to decrease signs of pathologic pain in laminitic horses.

Treating laminitis: beyond the mechanics of trimming and shoeing

Laminitis is typically classified into developmental or prodromal, acute, subacute, and chronic phases. Scientific evidence regarding the pathophysiology of laminitis does exist, but it is often conflicting and dependent on the clinician's interpretation/understanding of the study or the model used for inducing laminitis. The diagnosis of laminitis consists of obtaining an accurate history, performing a thorough physical examination, and taking good-quality radiographs. The use of radiographs for diagnosis and interpretation of laminitis is an absolute necessity for the clinician. Laminitis is one disease that requires the assembly of a team consisting of the veterinarian, the farrier, and the owner to be successfully treated.

Use of a soluble epoxide hydrolase inhibitor as an adjunctive analgesic in a horse with laminitis

HISTORY

A 4-year old, 500 kg Thoroughbred female horse diagnosed with bilateral forelimb laminitis and cellulitis on the left forelimb became severely painful and refractory to non-steroidal anti-inflammatory therapy (flunixin meglumine on days 1, 2, 3 and 4; and phenylbutazone on days 5, 6 and 7) alone or in combination with gabapentin (days 6 and 7).

PHYSICAL EXAMINATION

Pain scores assessed independently by three individuals with a visual analog scale (VAS; 0 = no pain and 10 = worst possible pain) were 8.5 on day 6, and it increased to 9.5 on day 7. Non-invasive blood pressure monitoring revealed severe hypertension.

MANAGEMENT

As euthanasia was being considered for humane reasons, a decision was made to add an experimental new drug, trans-4-{4-[3-(4-Trifluoromethoxy-phenyl)-ureido]-cyclohexyloxy}-benzoic acid (t-TUCB), which is a soluble epoxide hydrolase (sEH) inhibitor, to the treatment protocol. Dose and frequency of administration were selected based on the drug potency against equine sEH to produce plasma concentrations within the range of 30 nmol L(-1) and 2.5 μmol L(-1) . Pain scores decreased sharply and remarkably following t-TUCB administration and blood pressure progressively decreased to physiologic normal values. Plasma concentrations of t-TUCB, measured daily, were within the expected range, whereas phenylbutazone and gabapentin plasma levels were below the suggested efficacious concentrations.

FOLLOW UP

No adverse effects were detected on clinical and laboratory examinations during and after t-TUCB administration. No new episodes of laminitis have been noted up to the time of writing (120 days following treatment).

CONCLUSIONS

Inhibition of sEH with t-TUCB was associated with a significant improvement in pain scores in one horse with laminitis whose pain was refractory to the standard of care therapy. No adverse effects were noticed. Future studies evaluating the analgesic and protective effects of these compounds in painful inflammatory diseases in animals are warranted.

Effect of ketamine hydrochloride on the analgesic effects of tramadol hydrochloride in horses with signs of chronic laminitis-associated pain

OBJECTIVE

To investigate the effects of ketamine hydrochloride on the analgesic effects of tramadol hydrochloride in horses with signs of pain associated with naturally occurring chronic laminitis.

ANIMALS

15 client-owned adult horses with chronic laminitis.

PROCEDURES

Each horse received tramadol alone or tramadol and ketamine in a randomized, crossover study (≥ 2 months between treatments). Tramadol (5 mg/kg) was administered orally every 12 hours for 1 week. When appropriate, ketamine (0.6 mg/kg/h) was administered IV for 6 hours on each of the first 3 days of tramadol administration. Noninvasive systemic blood pressure values, heart and respiratory rates, intestinal sounds, forelimb load and off-loading frequency (determined via force plate system), and plasma tumor necrosis factor-α and thromboxane B(2) concentrations were assessed before (baseline) during (7 days) and after (3 days) each treatment.

RESULTS

Compared with baseline data, arterial blood pressure decreased significantly both during and after tramadol-ketamine treatment but not with tramadol alone. Forelimb off-loading frequency significantly decreased during the first 3 days of treatment with tramadol only, returning to baseline frequency thereafter. The addition of ketamine to tramadol treatment reduced off-loading frequency both during and after treatment. Forelimb load did not change with tramadol alone but increased with tramadol-ketamine treatment. Plasma concentrations of tumor necrosis factor-α and thromboxane B(2) were significantly reduced with tramadol-ketamine treatment but not with tramadol alone.

CONCLUSIONS AND CLINICAL RELEVANCE

In horses with chronic laminitis, tramadol administration induced limited analgesia, but this effect was significantly enhanced by administration of subanesthetic doses of ketamine.

Chronic laminitis is associated with potential bacterial pathogens in the laminae

A common sequella of chronic laminitis in horses is repeated abscesses with variable lameness and drainage. It is unclear whether the exudate represents the debridement phase of a non-septic inflammatory process involving clearance of laminar tissue damaged during the acute episode of laminitis, or a response to a microbial infection developed by ascent of microbes from the environment to the tissue via the white line. The objective of this study was to evaluate the possibility that an undiagnosed microbial infection in laminar tissue is present in laminar tissue collected from chronically laminitic horses without an active hoof abscess. Methods to collect laminar tissue, aseptically, from control (non-laminitic) horses and those with chronic/recurrent laminitis are described. Laminae homogenates were evaluated for the presence of bacteria. Bacteria were identified using biochemical tests and sequencing of 16S rRNA and virulence genes. Laminae from chronically laminitic horses revealed 100-fold higher levels (P=0.002) of bacteria compared to control, non-laminitic horses. Although environmental organisms were identified, potential pathogens were identified. Included were Gram positive bacteria, Brevibacterium luteolum, coagulase-negative Staphylococcus spp. as well as Gram negative bacteria, enterohemorrhagic Escherichia coli and Alcaligenes faecalis. Further research is warranted to evaluate the role of bacteria in equine chronic laminitis.

The effect of hoof angle variations on dorsal lamellar load in the equine hoof

REASONS FOR PERFORMING STUDY

In the treatment of laminitis it is believed that reducing tension in the deep digital flexor tendon by raising the palmar angle of the hoof can reduce the load on the dorsal lamellae, allowing them to heal or prevent further damage.

OBJECTIVE

To determine the effect of alterations in hoof angle on the load in the dorsal laminar junction.

METHODS

Biomechanical finite element models of equine hooves were created with palmar angles of the distal phalanx varying from 0-15°. Tissue material relations accounting for anisotropy and the effect of moisture were used. Loading conditions simulating the stages in the stance where the vertical ground reaction force, midstance joint moment and breakover joint moment were maximal, were applied to the models. The loads were adjusted to account for the reduction in joint moment caused by increasing the palmar angle. Models were compared using the stored elastic energy, an indication of load, which was sampled in the dorsal laminar junction.

RESULTS

For all loading cases, increasing the palmar angle increased the stored elastic energy in the dorsal laminar junction. The stored elastic energy near the proximal laminar junction border for a palmar angle of 15° was between 1.3 and 3.8 times that for a palmar angle of 0°. Stored elastic energy at the distal laminar junction border was small in all cases. For the breakover case, stored elastic energy at the proximal border also increased with increasing palmar angle.

CONCLUSIONS AND POTENTIAL RELEVANCE

The models in this study predict that raising the palmar angle increases the load on the dorsal laminar junction. Therefore, hoof care interventions that raise the palmar angle in order to reduce the dorsal lamellae load may not achieve this outcome.

Laminitic pain: parallels with pain states in humans and other species

Laminitis poses a threat to all horses, and is widely considered as being one of the most important diseases of horses and a global equine welfare problem. The effects of laminitis lead to debilitation, development of pronounced digital pain, and great suffering in the afflicted animal. The precise pathophysiological processes that result in laminitic pain are poorly defined, and hence the delivery of effective palliative care is clinically challenging. Knowledge and understanding of pain states in other animal species may further aid the elucidation of equine laminitic pain mechanisms, guide the search for treatable causes of this multifactorial problem, and thereby help achieve enhanced therapeutic and palliative care. However, parallels drawn from pain states in other animals must consider species differences in both anatomy and physiology, and the specific nature of the laminitic disease process.

Neuropathic pain management in chronic laminitis

Managing pain in horses afflicted by chronic laminitis is one of the greatest challenges in equine clinical practice because it is the dreadful suffering of the animals that most often forces the veterinarian to end the battle with this disease. The purpose of this review is to summarize our current understanding of the complex mechanisms involved in generating and amplifying pain in animals with laminitis and, based on this information, to propose a modified approach to pain therapy. Furthermore, a recently developed pain scoring technique is presented that may help better quantify pain and the monitoring of responses to analgesic treatment in horses with laminitis.