I’ve mentioned in a few previous posts that when I’m not thinking about horses and how to keep them healthy and fit, I spend a lot of time thinking about (and sometimes doing some things about) my own health and fitness. This summer I indulged the fitness enthusiast (and super nerd) in me by attending first ever The Radiance Retreat in the beautiful mountains of Ashville, NC. Hosted by fitness experts (and seriously kick-a$$ chicas) Jen Sinkler, Neghar Fonooni and Jill Coleman, this 3 day women’s only fitness and mindset retreat covered everything from perfecting your snatch (a tough but awesome Olympic Weightlifting technique) to eating to fuel your body and soul and learning to recognize and radiate your inner awesomeness. If fitness and being the best version of yourself is something you’re into, I highly recommend this event (which will be held again in Santa Monica in January, so sign up now cause spots are going fast!).
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On of the nutritional techniques we briefly talked about was intermittent fasting (aka IF), something I’ve been dabbling in since May of this year. The idea behind intermittent fasting is that you have set windows of “feeding time” followed by prolonged periods of fasting. I won’t go into the details of how and why because I’m sure I wouldn’t do it justice but if you’re interested in learning more check out LeanGains or EatStopEat. It's certainly not for everyone, but for me it works because I am not a breakfast eater, I’m just not hungry in the mornings and eating a meal before 8am guarantees that I’ll be gnawing off my own arm off by 10:30am and will seriously blow my daily caloric intake by lunchtime. Also, I like to feel full after I eat, and not just “not hungry” or sated but really truly “food baby” full. And eating 3-5 small meals a day (and not consuming enough calories to rival Michael Phelps or a sumo wrestler) for me means never being really full. So I’ve been happy with my venture into IF, it’s helping me make smarter food choices (knowing I’m going to be fasting has helped me lay off the sugar spike/crash foods that I normally abuse), my body composition is improving without feeling like I’m “dieting” and I still get to feel full.

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   But I always worry when there is a hot new trend in human medicine/fitness that equestrians will grab onto it and try applying it to our equine athletes. Remember those neon strips on every Olympic athlete last summer? I’m not even sure I believe that Kinesio Tape helps humans (the MDs aren't sure either) but now we’re strapping up our horses in neon strips? So while I’ve been pleased with IF and think you should give it a try if you’re looking for a new way to structure your meals, I don’t want anyone thinking I would be a proponent of intermittent fasting in horses. Horses and fasting are two words that should never be used in the same sentence (unless you’re prepping for a veterinary procedure like a gastroscopy, insulin testing or surgery). In the wild horses were designed to live on the open plains, constantly on the move, covering up to 25 miles a day in search of food and water supplies. Because they mainly live in grassland regions they have to constantly graze for up to 18 hours a day to meet their caloric needs. And because they are prey animals and designed to flee at first sign of a predator they can’t have a heavy meal weighing them down, they have small stomachs and a streamlined GI tract.

PictureGrade 3/3 Bleeding Gastric Ulcer in a Horse
    So what would happen if a horse was placed on an IF program? If we fed them one to two very large meals a day with nothing in between? (sadly the way many stabled horses are fed) Well the number one thing that would develop would be gastric ulcers. When a horse constantly grazes they are constantly producing saliva with each bite that coats the lining of the stomach, buffering the gastric acids and helping to prevent ulcers. When we feed very large meal, especially grain meals, horses produce even more stomach acids than when eating a small hay or grass meal and they produce much LESS saliva per bite of grain compared to per bite of hay. So we’re doing double damage by increasing the acid and decreasing the buffer. And what happens between meals, when they’re in a fasted state? Well they continue to have acidic fluid in their stomachs but because they are not chewing, there is no saliva production. Fasting is so effective and reliable at producing gastric ulcers that that’s how researchers induce ulcers in their experimental horses in order to study how they heal!

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    So while I prefer an eating pattern that involves 8 hours of munching followed by 16 hours of fasting (most of which are spent sleeping), this is the exact opposite of what our horses should be doing. In this case what's good for the goose is NOT good for the gander!
   We should strive to feed our horses multiple small meals throughout the day while always having some kind of forage (grass or hay) in front of them all day long to help buffer their stomach acids and prevent painful gastric ulcers.


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This past Saturday night was the 35th Anniversary Gala for the Philadelphia Women’s Rugby Club, a team I was proudly a member of from 2002-2006 while living in Philly during vet school. Rugby is a rough sport (yes girls can play too, and yes we play by the same rules as the boys, no helmets, no pads, just knee socks and a mouth guard) and during my time with the Philly Women, in addition to making it to Nationals twice and being named to a few all-star teams, I also dislocated my right shoulder, broke my nose (for the 3rd and 4th time) and had more than one black eye that made my boyfriend afraid to be seen in public with me.  Ruggers know about pain, and pain management. And the one thing I was thinking about on Sunday morning, after a long night of reminiscing with old friends, dancing in 4” BCBG metallic blue stilettoes (a far cry from my old brown clogs) and one too many Yeungling lagers (you can’t get it in Indiana) was pain management.

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When you look at the Pain Relief aisle of your local Walgreens or CVS, for pills containing the anti-inflammatory drug ibuprofen there are a million and one choices: joint & muscle pain, back pain, childrens’ pain, arthritis pain, menstrual pain, migraine pain and oral pain. And I’ve always wondered; How do the drugs in this ibuprofen pill treat just my back pain? What makes that ibuprofen pill just go to my headache? But when you read the fine print on the label, many of these pill contain the same concentration of the same drug, no magic road map to your pain, its just that they are marketed for certain ailments (and usually the arthritis pills have an easy to open cap and the childrens’ pills have a child-saftey cap).  And while we tend to use them interchangeably, most of us understand that ibuprofen is not the same as aspirin, which is not the same as naproxen (Aleve®), making the choice even more confusing. Luckily in the horse world we don’t have so many choice. Pretty much just two dominate the field: phenylbutazone (Bute) and flunixin meglumine (Banamine®).

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Their innovative marketing techniques aside, the most misleading part of the previous paragraph is how the section in the pharmacy is labeled: Pain Relief. I think that it is very important to understand how these drugs work and why we prescribe them. Yes, they do relieve pain, but that is a secondary benefit of their main focus: control of inflammation. This is why we call them Non-Steroidal Anti-Inflammatory drugs, or NSAIDs, which include phenylbuazone, flunixin meglumine, firocoxib (Equioxx®), ketoprofen and carprofen (Rimadyl® for our dogs). They are “non-steroidal” because this group does not contain corticosteroids (dexamethasone) which also stop inflammation but also affect the immune system. They are anti-inflammatory because they stop the affects of inflammation by blocking the production of prostaglandins, one of the final products of the inflammatory pathway. Prostaglandins are produced by many tissues in the body as part of normal functions like blood flow to the stomach and colon lining and the kidneys (remember this point, it’ll come up again later). 

So are Bute and Banamine® the same? Not exactly… Banamine® has been shown to be more effective in relieving gastrointestinal, soft tissue and systemic inflammation and pain. Think colic, eye pain, sepsis. Bute on the other hand is more commonly used for musculoskeletal inflammation and pain (muscle pain, arthritis, tendon/ligament injury).

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So now that you have an idea of which drug to give when, the next questions are: How do I give it? How much? and How often? 

Both Bute and Banamine® are prescription medications and should be obtained from your veterinarian to treat a specific problem on a specific horse. That being said, we all know it lives in every medicine chest of every farm out there. Bute comes in an injectable solution that should only be given intravenously (IV) by an experienced person, namely your veterinarian. It is very irritating and if it gets outside of the vein or in the muscle it can cause severe inflammation, necrosis and sloughing of the tissue.

The safer formulations for laypeople to use are the oral forms, powder or paste. Make sure you read the label to know how many grams are in one scoop of powder or one turn of the dial on the paste tubes (its usually 1g). Banamine® also comes in injectable and oral formulations. The injectable form can be given IV (again make sure you have an experienced hand giving the injection) or intramuscularly (IM). I tend to discourage people from giving Banamine® IM because it has been closely associated with Clostridial myositis, a severe and often life threatening bacterial infection in the muscle. You can also give the injectable formulation orally! Yes, draw the same amount from the bottle that you would have giving IV or IM and squirt it in their mouth! It has similar oral bioavailability, which means its absorbed just as well. NB Injectable Banamine® is VERY bitter (trust me, I’ve accidentally gotten some sprayed in my face) and your horses will appreciate it if you mix it with applesauce or molasses before giving it orally. Banamine® also comes in a paste and granules to be given orally.

The label dose of Banamine® is 1.1mg/kg BID which is a fancy way of saying that a 1000lbs horse should get ~500mg (10cc or a 1000bls dose of paste) no more than once, every 12 hours. Bute’s label dose is 4.4-8.8mg/kg BID. Translation: a 1000lbs horse should get between 2 and 4 grams no more than once every 12 hours. It is very important to note that these volumes are based on body weight and are for a ONE THOUSAND POUND horse!!! If your horse weighs more or less than 1,000lbs, then these doses are not right for you! Example, a 500lbs pony is half the weight of a 1,000lbs horse (get out your calculator and check if you don’t believe me, but my mother will tell you I did very well in math as a child), therefore a 500lbs pony should receive HALF the dose of a full sized horse. I know, I know “But human medicine gives every adult the same amount of pills whether you’re a 90lbs gymnast or a 300lbs sumo-wrestler.” This doesn’t make sense to me, and I hope someday an MD will give me a good explanation as to why. And notice how I say “no more than once every 12 hours?” I didn’t say “twice in a day” because to some people that means, once, and then if it doesn’t work, another dose 20min later. And giving your 1000lbs horse 10cc of Banamine® and then another 10cc an hour later is the same as giving them 20cc at once, and you have overdosed your horse.

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So why is it that I’m so crazed with appropriate dosing? Because, being an internist, I get to deal with the sickest, most critical cases and I hate seeing ones that could have been prevented. While Bute and Banamine® are wonderful drugs that help us keep our horses comfortable and inflammation free, they are not without side effects. Remember how I said that there were “normal” functions of prostaglandins and how that fact would be important later? Well the time is now. Prostaglandins regulate blood flow to the kidneys and to the lining of the stomach and colon (specifically the Right Dorsal Colon). When NSAIDs are given, they block all prostaglandins, both normal and inflammatory, so you get decreased heat, swelling and pain but you also get decreased blood flow to your kidneys and gut lining. Now in a well-hydrated horse that is getting an appropriate dose for a short period of time, this usually won’t be a problem. If your horse is dehydrated, getting excessive doses or even normal doses but for long periods of time, you will see the harmful side effects. Gastric ulcers, colonic ulcers and renal failure. These can lead to colic, diarrhea, excessive drinking/urination and many other signs associated with NSAID-toxicity. This is a treatable condition but it can become so severe that no amount of treatment can repair the damage.

It’s not that we should never use these medications; we just need to know the appropriate doses and dosing intervals to make their use as safe and effective as possible.

Believe me, Sunday will not be the last time I reach for the ibuprofen (only at the labeled dose and I’ll keep hydrated with plenty of water) but I do so cautiously (and swear to myself I will never run down Walnut St in 4” heels in freezing temperatures again!). And the safest, most cautious way to administer NSAIDs to your horses is to do so under the direction of your veterinarian. Only he or she knows the right type and the right dose of NSAID for your horse based on the specific problem at the time.

 

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