The Horse

JAN 2019

The Horse:Your Guide To Equine Health Care provides monthly equine health care information to horse owners, breeders, veterinarians, barn/farm managers, trainer/riding instructors, and others involved in the hands-on care of the horse.

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36 January 2019 The Horse | TheHorse.com therapy in his clinic in 2013 after consult- ing with sports medicine physicians that treat muscle and tendon injuries in elite human athletes with lasers. He chose a 15W diode laser that emits four wave- lengths of light simultaneously and was immediately impressed by its results in horses with tendon injuries. "We could return horses to low-level and ultimately full performance much faster than with other treatment modali- ties," said Drumm. Tierklinik Lüsche practitioners studied 150 Warmblood sport horses treated for acute or chronic superficial digital flexor tendinitis or suspensory desmitis using high-power laser therapy daily for two weeks. Each limb was clipped and degreased before treatment. The team did follow-up exams four weeks later, finding: ■ All improved in lameness score; 80% were sound four weeks post-treatment. ■ On ultrasound, 76% showed only mild or no abnormalities after treatment. ■ The median time to return to low-level exercise was six weeks. ■ 55.8% had returned to their previous level of performance within six months. ■ Reinjury rate after one year was 21%— comparable to other treatments, he said. ■ There were no complications. "We concluded that high-power laser with this device is safe, results in fairly low reinjury rates, and has a fairly quick return to performance," he said. "We have now treated 1,070 horses with it." He added that while therapy with this device (Therapy Laser X's FP4 System) appears to be safe and efficient for treat- ing equine soft tissue lesions, we can't extrapolate results between machines. Bisphosphonates for Navicular Since hitting the commercial equine market four years ago, bisphosphonates have been used primarily to manage podotrochlosis (navicular disease). But what effect do they have on navicular region pain and lameness? Drumm re- viewed existing research on this topic. Bisphosphonates are believed to be the most potent inhibitors of bone resorption, said Drumm; they counter bone loss by killing osteoclasts (cells that absorb bone tissue during growth and healing). Stud- ies in humans and animals also suggest they might also be anti-inflammatory, chondroprotective, pain-relieving, and anti-angiogenic (preventing new blood vessel growth). Two bisphosphonate types, tiludronate and clodronate, are currently licensed for use in horses in several countries. In a 2003 study Denoix et al. found im- proved lameness in horses with navicular issues two to six months after tiludronate treatment. In a 2007 study on that drug's effect in horses with back pain due to spinal OA, Coudry et al. saw relief four months post-treatment. And in a 2010 study of horses with bone spavin (OA of the lower hock joint), Gough et al. found that tiludronate use resulted in improved lameness 120 days post-treatment. While fewer studies have been done on clodronate, the drug's 2010 Freedom of Information Act summary showed a 74.7% improvement in navicular lame- ness two months post-treatment, drop- ping to 67.4% six months post-treatment, which is comparable to tiludronate, said Drumm. Among all bisphosphonate stud- ies, he said scientists saw the best results two to six months after treatment, with no follow-up longer than six months. He said to remember that degenerative changes can affect all parts of the podo- trochlear apparatus: bone, tendon, bursa, and ligaments. "Many more structures … can cause palmar heel pain," he said. "And DISCOVERY AND DISCUSSION Tildren ® (tiludronate disodium) BISPHOSPHONATE DRUG FOR INTRAVENOUS INFUSION. For use in horses only WARNINGS Do not use in horses intended for human consumption. NSAIDs should not be used concurrently with Tildren ® . Concurrent use of NSAIDs with Tildren ® may increase the risk of renal toxicity and acute renal failure. HUMAN WARNINGS Not for human use. Keep this and all drugs out of the reach of children. Consult a physician in case of accidental human exposure. CAUTION Federal law restricts this drug to use by or on the order of a licensed veterinarian. INDICATION Tildren ® is indicated for the control of clinical signs associated with navicular syndrome in horses. CONTRAINDICATIONS Do not use in horses with known hypersensitivity to tiludronate disodium or to mannitol. Do not use in horses with impaired renal function or with a history of renal disease. Bisphosphonates are excreted by the kidney; therefore, conditions causing renal impairment may increase plasma bisphosphonate concentrations resulting in an increased risk for adverse reactions. PRECAUTIONS Approximately 30-45% of horses administered Tildren ® will demonstrate transient signs consistent with abdominal pain (colic). Horses should be observed closely for 4 hours post-infusion for the development of clinical signs consistent with colic or other adverse reactions. Colic signs can last approximately 90 minutes and may be intermittent in nature. Hand walking the horse may improve or resolve the colic signs in many cases. If a horse requires medical therapy, non-NSAID treatments should be administered due to the risk for renal toxicity. Avoid NSAID use. Horses should be well hydrated prior to administration of Tildren ® due to the potential nephrotoxic effects of Tildren ® . Tildren ® should be used with caution in horses receiving concurrent administration of other drugs that may reduce serum calcium (such as tetracyclines) or whose toxicity may exacerbate a reduction in serum calcium (such as aminoglycosides). Horses with HYPP (heterozygous or homozygous) may be at an increased risk for adverse reactions, including colic signs, hyperkalemic episodes, and death. The safe use of Tildren ® has not been evaluated in horses less than 4 years of age. Bisphosphonates should not be used in pregnant or lactating mares, or mares intended for breeding. Bisphosphonates have been shown to cause fetal developmental abnormalities in laboratory animals. DOSAGE AND ADMINISTRATION A single dose of Tildren ® should be administered as an intravenous infusion at a dose of 1 mg/kg (0.45 mg/ lb). The infusion should be administered slowly and evenly over 90 minutes to minimize the risk of adverse reactions. Maximum effect may not occur until 2 months post-treatment. For ADMINISTRATION INSTRUCTIONS (preparation of the reconstituted solution (20mg/mL) and preparation of the solution for infusion) and for complete product information, please read the insert contained within the product packaging. STORAGE Sterile powder (not reconstituted): Store at controlled room temperature 68°F-77°F (20°C-25°C). After preparation, the infusion should be administered either within 2 hours of preparation, or it can be stored for up to 24 hours under refrigeration at 36°F-46° F (2°C-8°C) and protected from light. HOW SUPPLIED Tildren ® is supplied in a 30mL glass vial as a white, sterile lyophilized powder containing 500mg tiludronic acid (as tiludronate disodium) packaged in a folding carton. For technical assistance or to report suspected adverse reactions, call 1-888-524-6332. INFORMATION FOR OWNERS Prior to Tildren ® administration, owners should be advised of the potential for adverse reactions in the hours or days following treatment. Adverse reactions within 4 hours post dosing may include signs of colic (manifested as pawing, stretching, getting up and down, sweating, rolling, looking at flanks, kicking at belly, frequent gas, and pacing). Owners should be instructed to contact their veterinarian immediately if any adverse reactions are observed. Owners should be advised to consult with their veterinarian prior to the administration of an NSAID following Tildren ® administration. Made in Canada Patent information: U.S. patent 6,057,306 Drumm tested one laser, finding it offered quick return to performance, among other benefits. COURTESY DR. NIKLAS DRUMM

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