The evaluation of isoxsuprine hydrochloride for the treatment of navicular disease: a double blind study

Quantitative comparison of three commonly used treatments for navicular syndrome in horses

OBJECTIVE

To quantitatively compare 3 commonly used treatments for navicular syndrome (NS) in horses: heel-elevation shoeing alone, heel-elevation shoeing and phenylbutazone administration, heel-elevation shoeing and injection of the distal interphalangeal joint (DIPJ) with triamcinolone acetonide (TA), and all 3 treatments in combination.

ANIMALS

12 horses with NS.

PROCEDURE

A force plate was used to measure baseline peak vertical ground reaction force (PVGRF) of the forelimbs. Each horse's forelimbs were shod with 3 degrees heel-elevation horseshoes; PVGRF was measured 24 hours and 14 days after shoeing. Fourteen days after shoeing (following data collection), phenylbutazone (4.4 mg/kg, i.v., q 12 h) was administered (5 treatments). Two hours after the fifth treatment, PVGRF was measured; TA (6 mg) was injected into the DIPJ of the forelimb that generated the lower baseline PVGRF Fourteen days later, PVGRF was measured. Phenylbutazone was administered as before, and PVGRF was measured. Percentage body weight of force (%BWF) was calculated from PVGRF measurements and used for comparisons.

RESULTS

14 days after shoeing, mean %BWF in both forelimbs significantly increased from baseline; additional administration of phenylbutazone significantly increased %BWF applied from the more lame forelimb. Compared with shoeing alone, there was no significant change in %BWF after injection of the DIPJ with TA in shod horses.

CONCLUSIONS AND CLINICAL RELEVANCE

Heel-elevation shoeing alone and in combination with phenylbutazone administration quantitatively decreased lameness in horses with NS. Although not significant, additional DIPJ injection with TA resulted in further quantitative decrease in lameness, compared with that achieved via shoeing alone.

An analgesic evaluation of isoxsuprine in horses

Isoxsuprine is used clinically to treat navicular disease and laminitis in horses. Although it is thought to increase digital and laminar blood flow, isoxsuprine's mechanism of action remains controversial, and analgesia has been suggested recently as such possible mechanism. This research investigated the analgesic potential of isoxsuprine in healthy horses submitted to a mechanical nociceptive test. Isoxsuprine (1.2 mg/kg), xylazine (1.1 mg/kg), distilled water : ethanol 95% (2 : 1, v/v, 20 ml) and saline (0.9%, 20 ml) were injected intravenously, and nociceptive thresholds were measured over 90 min. Only xylazine significantly increased nociceptive thresholds, confirming that alpha(2)-adrenoceptor agonists produce analgesia in horses. Our results do not support an analgesic mechanism of action for isoxsuprine in horses, suggesting that other mechanisms might account for the clinical efficacy of this drug or that mechanical nociceptive testing may not be sufficiently sensitive to demonstrate an analgesic effect for this drug.

Tiludronate as a new therapeutic agent in the treatment of navicular disease: a double-blind placebo-controlled clinical trial

REASONS FOR PERFORMING STUDY

Bisphosphonates, such as tiludronate, are used to normalise bone metabolism via inhibition of bone resorption. Areas of increased bone resorption and formation are typical lesions in a diseased navicular bone.

OBJECTIVES

To determine if bone remodelling changes occurring in navicular disease may be corrected with therapies regulating bone metabolism.

METHODS

We designed a double-blind, placebo-controlled clinical trial to compare 2 doses of tiludronate, 0.5 mg/kg and 1 mg/kg bwt administered via daily i.v. injections over 10 days for the treatment of navicular disease. Seventy-three horses, split into 2 subpopulations of recent and chronic cases, were enrolled to be followed-up over 6 months. Of these, 33 recent and 17 chronic cases meeting the selection criteria were maintained in the final efficacy analyses. Clinical examinations were videorecorded and reviewed blindly by an independent expert.

RESULTS

Horses treated with the higher dose showed optimal improvement of lameness and return to normal level of activity 2-6 months post treatment. The more recent the onset of clinical signs at the time of treatment, the greater the efficacy. The treatment did not modify the response to extension and flexion tests. The lower dose failed to significantly improve the condition.

CONCLUSIONS

Tiludronate efficacy is demonstrated in the treatment of navicular disease at the dose of 1 mg/kg bwt.

POTENTIAL RELEVANCE

Our results support the clinical relevance of bone remodelling changes in the outcome of navicular disease.

Isoxsuprine hydrochloride in the horse: a review

Isoxsuprine hydrochloride has been suggested for use in horses for treatment of navicular syndrome and laminitis. The drug has been shown to be a beta-adrenoreceptor antagonist with beta-adrenoreceptor agonistic properties, with both characteristics contributing to vasodilation and uterine relaxation. In addition, the drug is capable of decreasing blood viscosity and platelet aggregation. Studies have shown i.v. isoxsuprine to have a plasma half-life of <3 h with a large apparent volume of distribution. Cardiovascular effects resolve rapidly following i.v. administration, but are absent with oral dosing. Oral bioavailability is 2.2% with a high first pass effect. Isoxsuprine has an apparent affinity for melanin that may contribute to extended renal excretion. Clinical trials appear to support the use of isoxsuprine for treatment of navicular disease. However, poor bioavailability, lack of cardiovascular effects following oral administration, superficial support in clinical trials, and new evidence regarding the pathogenesis of navicular syndrome indicate that the use of isoxsuprine for treatment of navicular syndrome or laminitis is questionable at best.

Melanin affinity: a possible explanation of isoxsuprine retention in the horse

Isoxsuprine is used in veterinary medicine as a vasodilating agent. The drug has been detected in the urine of horses up to 6 weeks after the cessation of administration. In the present study, the distribution pattern of 3H-isoxsuprine was investigated using whole body autoradiography in mice to find a possible site of retention. Melanin was the only place of retention identified. Additional in vitro studies showed an affinity of isoxsuprine to both melanin and keratin. The K(d) values were 0.02 mmol/l and 1 mmol/l, and the B(max) values were 0.2 micromol/mg and 2 micromol/mg, respectively. A low affinity site with approximately the same K(d) and B(max) as keratin was also detected for melanin. 3H-isoxsuprine was found to have affinity to pigmented horse skin after incubation in vitro and microautoradiography. We believe that affinity to melanin and possibly also to keratin can cause retention of the drug in the body and therefore explain the prolonged excretion of low levels of isoxsuprine in the horse.

Affinity of isoxsuprine for adrenoreceptors in equine digital artery and implications for vasodilatory action

We used isolated equine digital arteries to study the vasodilatory mechanism of isoxsuprine, and fowl caecum preparations to investigate the affinity of the drug for beta-adrenoceptors. Isoxsuprine is a potent vasodilator of arterial smooth muscle that has been precontracted by an alpha-adrenoceptor agonist such as noradrenaline (log EC50 = -6.33 [-5.98; -6.68]). The present study indicates that its effect is due to alpha-adrenoceptor blockade since: (1) after a long lasting exposure to cumulative doses of isoxsuprine the vasoconstricting action of noradrenaline cannot be restored; (2) isoxsuprine does not promote relaxation on preparations precontracted by PGF2alpha; (3) isoxsuprine shifts the dose-response curve of noradrenaline to the right; and (4) its affinity (pK(B) = 6.90 [6.60; 7.20]) in this experiment is comparable to that in noradrenaline-precontracted preparations and is 14 times lower than that of the selective alpha1-adrenergic antagonist prazosin [pK(B) = 8.04 (7.40; 8.68]). The affinity of isoxsuprine for beta-adrenoceptors was 100 times lower than that of isoprenaline when tested on fowl caecum. This preparation has a large beta-adrenoceptor and negligible alpha-adrenoceptor population concerned with the control of smooth muscle motility. Our data suggest that the alpha-mediated effect of isoxsuprine on horse arterial smooth muscle is due to higher affinity of the drug for alpha- than beta-adrenoceptors rather than low concentration or functionality of beta-sites at this site. According to these data, pure beta2-agonists seem to be more profitable tools to determine vasodilation of the arterial bed in horses legs.

Investigations on the stereoselective action of isoxsuprine on alpha- and beta-adrenoceptors in equine common digital artery

The affinity and functional effects of isoxsuprine enantiomers were investigated to determine the enantiospecificity of the beta-agonistic and alpha-blocking effects. Functional assays on isolated smooth muscle preparations from equine common digital artery were performed to determine the apparent affinity (pD(2)) and intrinsic activity (alpha(E)) of (-)erythro-isoxsuprine (alphaS, betaR, gammaR) and (+)erythro-isoxsuprine (alphaR, betaS, gammaS). The affinity of two enantiomers for the different adrenoceptor types was studied by radioligand binding assays on membrane preparations from the same tissue, using (-)[(3)H]CGP12177 and [(3)H]prazosin. On noradrenaline-precontracted artery preparations (-)isoxsuprine was markedly more potent than (+)isoxsuprine in dilating preparations, indicating that the laevorotatory enantiomer has a very high apparent affinity for alpha-adrenoceptors. Binding studies confirmed that (-)isoxsuprine has a higher affinity than (+)isoxsuprine for alpha-adrenoceptors, while the (+) isomer competes for beta-adrenoceptors with an affinity similar to that of propranolol. As described for other beta-phenylethylamines, the two isoxsuprine enantiomers studied have different efficacies for alpha- and beta-adrenoceptors and the effects of the commercially available mixture of stereoisomers therefore depend on the density and functional importance of the adrenoceptor types present in the tissue studied. 1999 Academic Press.

The effect of oral isoxsuprine and pentoxifylline on digital and laminar blood flow in healthy horses

OBJECTIVE

To quantitate blood flow in the palmar digital artery and dorsal laminae of the hoof in standing, unmedicated, nonsedated horses, and in horses treated with oral isoxsuprine, oral pentoxifylline, and intravenous acetylpromazine as a positive control.

STUDY DESIGN

Experimental study; treatments administered in a random cross-over design.

ANIMALS

A total of 6 healthy horses selected with at least one nonpigmented forelimb hoof wall and determined to be free of laminitis.

METHODS

All horses were instrumented with a flow probe placed around one palmar digital artery under general anesthesia and a laser doppler flow probe placed within a hole in the dorsal hoof wall to measure digital blood flow and laminar perfusion respectively. Baseline readings of palmar digital blood flow and laminar perfusion were recorded before and between treatments. Horses were randomly assigned to one of two groups and treated with either isoxsuprine (1.2 mg/kg, orally twice daily for 10 days) or pentoxifylline (4.4 mg/kg, orally every 8 hours for 10 days) in a random cross-over design. Digital blood flow (DBF) and laminar perfusion (LP) were measured on days 2, 5, 7, and 10 of treatment. Horses also received acetylpromazine as a positive control (0.066 mg/kg, intravenously) during the washout period, and measurements were taken every 15 minutes until measurements returned to baseline readings. Data were analyzed by using repeated measures ANOVA.

RESULTS

Digital blood flow (11.2 to 97.7 mL/min) and laminar perfusion (1.0 to 11.1 Capillary Perfusion Units) differed between horses. No statistically significant increases in DBF or LP were detected over the 10 day treatment period with either isoxsuprine or pentoxifylline. Acepromazine resulted in a significant increase (P = .0007) in DBF for approximately 75 minutes beginning 15 minutes after treatment. A mild but insignificant increase in LP was identified after acetylpromazine treatment.

CONCLUSION

Neither isoxsuprine nor pentoxifylline increased blood flow to the digit or dorsal laminae in healthy horses. Acepromazine caused an increased blood flow to the digit. Based on the results of this study acetylpromazine potentially would have a greater effect on improving digital blood flow than oral isoxsuprine or pentoxifylline when treating ischemic conditions of the foot in horses.

Absence of detectable pharmacological effects after oral administration of isoxsuprine

Isoxsuprine is reported to be a peripheral vasodilator used in human and veterinary medicine to treat ischaemic vascular disease. In horses, it is generally administered orally to treat navicular disease and other lower limb problems. To define the scope and duration of its pharmacological responses after oral administration, 6 horses were dosed with isoxsuprine HCl (1.2 mg/kg bwt) q. 12 h for 8 days and then tested to assess the duration and extent of pharmacological actions. There was no significant difference between isoxsuprine and control treatment values for heart rate, spontaneous activity, sweat production, anal muscle tone, core and skin temperatures, and cutaneous blood flow. The lack of pharmacological effect following oral administration was in sharp contrast to the marked response following i.v. dosing reported in earlier experiments.

Scintigraphic and clinical findings in the Standardbred metatarsophalangeal joint: 114 cases (1993-1995)

To correlate scintigraphic and clinical findings of the metatarsophalangeal joint (MTPJ) in Standardbreds, radiographic findings in horses with confirmed MTPJ lameness, and determine if stress reaction and more advanced bone remodelling occurred in the MTPJ, medical records of 114 Standardbreds admitted between September 1993 and April 1995 in which bone scintigraphy included standing lateral and plantar views of the metatarsophalangeal joint (MTPJ) were reviewed. Images obtained using a large field of view gamma camera were evaluated visually for location, definition and intensity of increased radioisotope uptake (IRU), which was graded as mild, moderate, or intense. Clinical history and lameness examination findings were recorded and, in horses with documented MTPJ lameness, radiographic examination included the 30 degree (down-angled) dorsolateral 45 degree plantaromedial view thought to be useful in evaluation of the plantarolateral condyle of the third metatarsal bone (MtIII). The most common abnormality, IRU of the plantarolateral aspect of MtIII, was seen in 67 horses, and horses were further classified according to scintigraphic and clinical findings. In 43 horses in which lameness was not localised to the MTPJ, mild (32 horses), moderate (10 horses), and intense (one horse) IRU of MtHII was found. In 24 horses with lameness localised to the MTPJ, moderate (18 horses) and intense (6 horses) IRU was found. Of 18 horses with moderate IRU of MtIII, 9 had radiographic evidence of abnormal bony remodelling of MtIII, whereas 5 of 6 horses with intense IRU had radiographic changes. In 12 horses with MTPJ lameness and radiographic evidence of bony remodelling without fracture, radiographic changes consisted of plantarolateral subchondral radiolucency and sclerosis (7 horses), radiolucency and osteochondrosis (one horse), and plantar MtIII sclerosis without radiolucency (4 horses). In 2 horses with moderate IRU and MTPJ lameness, radiographic evidence of radiolucency and MtIII fracture was found. Of 19 starters with MTPJ lameness and IRU of MtIII, 18 horses raced after diagnosis, but only 13 remained at the same racing class or improved. The results of this study suggest the most common scintigraphic abnormality of the MTPJ, IRU of the plantarolateral aspect of MtIII, may precede other stress-related changes, and in some horses is associated with a continuum of stress-related subchondral bone remodelling which results in lameness and later radiographic changes. Since 24 of 35 horses with moderate or intense IRU of MtIII had MTPJ lameness, and 5 of 7 horses with intense IRU of MtIII had lameness and radiographic evidence of abnormal remodelling, it was concluded that horses with advanced, scintigraphic findings are more likely to have lameness and radiographic evidence of subchondral bone damage.

Character and duration of pharmacological effects of intravenous isoxsuprine

Isoxsuprine is a therapeutic medication used to treat navicular disease and other lower limb problems in horses and is one of the more frequently detected therapeutic agents in racing horses. In a crossover study, horses were administered isoxsuprine i.v. to determine the character and duration of its pharmacological effects. Isoxsuprine significantly increased heart rate 5-150 min following injection. Unrestrained activity following isoxsuprine treatment was significantly greater than control activity for 105 min after treatment. There was an apparent, although statistically nonsignificant, increased cutaneous blood flow resulting in visible water vapour and sweat production 5-60 min after administration. Initially, there was no difference in skin temperature between control and isoxsuprine treatment values; however, skin temperature decreased below control values 45-120 min after injection. Concurrently, there was a significant decrease in rectal temperature reflecting a decrease in body core temperature. Using infrared thermography, a significant decrease in superficial skin temperature of the front legs occurred 30-240 min after treatment. Isoxsuprine also reduced smooth muscle tone, which was apparent by decreased tone of the internal anal sphincter 10-180 min after treatment. It was concluded that the measurable pharmacological effects of i.v. isoxsuprine are short lived, since none of the above responses were apparent 4 h or more after i.v. administration.