80 Causes, Predispositions, and Pathways of Laminitis

Sodium-glucose transport protein 2 inhibitor use in the management of insulin dysregulation in ponies and horses

Laminitis is a common and painful condition of the equine foot and approximately 90% of cases are associated with insulin dysregulation (ID) that is a central feature of the common endocrine disorder equine metabolic syndrome (EMS) and occurs in a subset of animals with pituitary pars intermedia dysfunction. Additional features of EMS include obesity, altered circulating concentrations of adipokines (particularly adiponectin and leptin) and hypertriglyceridaemia. Obesity, ID, hypoadiponectinaemia, hyperleptinaemia and an altered plasma lipid profile are also features of human metabolic syndrome (HMS) alongside hyperglycaemia. Sodium-glucose cotransporter 2 inhibitors (SGLT2i) are a novel class of oral hypoglycaemic agents used in combination with lifestyle changes in the management of HMS. SGLT2 receptors are responsible for 90% of the renal glucose reabsorption that occurs in the proximal convoluted tubule. Thus, these drugs increase urinary glucose excretion by suppressing glucose reabsorption from the glomerular filtrate resulting in urinary calorie loss with consequent weight loss and improvements in ID, hyperglycemia, hypoadiponectinaemia and hyperleptinaemia. There are no licenced veterinary drugs available for treating ID and preventing insulin-associated laminitis in horses. Thus, the use of SGLT2i for the control of equine hyperinsulinaemia with the goal of improving recovery from associated active laminitis or preventing future laminitis has recently been advocated. There are a small number of published studies reporting the use of the SGLT2i canagliflozin, ertugliflozin and velagliflozin to aid the management of equine ID. However, the doses used are largely extrapolated from human studies with limited consideration of species-specific variations. In addition, there is limited evaluation of the fundamental differences between ID in horses and humans, particularly the fact that most horses with ID remain hyperinsulinaemic but normoglycaemic such that increased urinary loss of glucose may not explain the beneficial effects of these drugs. Further study of the potential deleterious effects of treatment-associated hypertriglyceridaemia is required together with the effect of SGLT2i therapy on circulating concentrations of adipokines in horses.

Are There Shared Mechanisms in the Pathophysiology of Different Clinical Forms of Laminitis and What Are the Implications for Prevention and Treatment?

Laminitis is a consequence of primary disease processes elsewhere in the body. The key pathophysiologic events are insulin dysregulation in endocrinopathic laminitis, ischemia in supporting limb laminitis, and inflammation in sepsis-related laminitis. These apparently disparate mechanisms converge to cause lamellar attachment failure through epithelial cell adhesion loss and stretch, possibly mediated by common growth factor signaling pathways. Tissue damage through mechanical distraction, inflammation, pain, and a proliferative epithelial healing response are features of acute laminitis regardless of the cause. Preventive and treatment strategies based on knowledge of these unique and common mechanistic events are likely to improve clinical outcomes.

Case-control study of risk factors for pasture-and endocrinopathy-associated laminitis in North American horses

OBJECTIVE To investigate risk factors for the development of pasture- and endocrinopathy-associated laminitis (PEAL) in horses and ponies in North America. DESIGN Case-control study. ANIMALS 199 horses with incident cases of PEAL and 351 horses from 2 control populations (healthy horses [n = 198] and horses with lameness not caused by laminitis [153]) that were evaluated in North America between January 2012 and December 2015 by veterinarian members of the American Association of Equine Practitioners. PROCEDURES North American members of the American Association of Equine Practitioners were contacted to participate in the study, and participating veterinarians provided historical data on incident cases of PEAL, each matched with a healthy control and a lameness control. Conditional logistic regression analysis was used to compare data on PEAL-affected horses with data on horses from each set of controls. RESULTS Horses with an obese body condition (ie, body condition score ≥ 7), generalized or regional adiposity (alone or in combination), preexisting endocrinopathy, or recent (within 30 days) glucocorticoid administration had increased odds of developing PEAL, compared with horses that did not have these findings. CONCLUSIONS AND CLINICAL RELEVANCE The present study identified several risk factors for PEAL that may assist not only in managing and preventing this form of laminitis, but also in guiding future research into its pathogenesis.

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.

Effects of the addition of endotoxin during perfusion of isolated forelimbs of equine cadavers

OBJECTIVE

To examine the effect of endotoxins on metabolism and histopathologic changes of isolated perfused equine forelimbs.

SAMPLE

Forelimbs (comprising the metacarpus and digit) were collected from cadavers of 12 healthy adult horses after slaughter at an abattoir (14 limbs; 1 forelimb of 10 horses and both forelimbs of 2 horses).

PROCEDURES

Forelimbs were perfused for 10 hours with autologous blood, with and without the addition of endotoxin (80 ng of lipopolysaccharide [LPS]/L). Two limbs of the endotoxin exposure group and 2 nonperfused limbs were loaded to failure of the suspensory apparatus of the pedal bone to evaluate the effect of body weight. Metabolic and histologic variables were evaluated.

RESULTS

Blood pressure increased during the first hour and did not differ between groups. Lactate dehydrogenase activity was similar in both groups and increased significantly during the 10-hour period; glucose consumption at 5 hours and lactate concentration at 8 hours were significantly higher in limbs exposed to endotoxin. The width of secondary epidermal lamellae was greater in LPS limbs. In the primary dermal lamellae of LPS limbs, there were significantly more vessels with an open lumen and aggregates of intravascular neutrophils.

CONCLUSIONS AND CLINICAL RELEVANCE

In the blood-perfused isolated forelimbs of equine cadavers, exposure to LPS led to significant changes in the laminar tissue as well as to metabolic changes. Therefore, endotoxin should be considered as a causative factor for laminitis and not merely as a risk factor.

Acupuncture Points of the Horse's Distal Thoracic Limb: A Neuroanatomic Approach to the Transposition of Traditional Points

Veterinary acupuncture charts were developed based on the concept of transpositional points whereby human acupuncture maps were adapted to animal anatomy. Transpositional acupuncture points have traditionally been placed in specific locations around the horse's coronet and distal limb believed to be the closest approximation to the human distal limb points. Because the horse has a single digit and lacks several structures analogous to the human hand and foot, precisely transposing all of the human digital points is not anatomically possible. To date there is no published research on the effect of acupuncture treatment of the equine distal limb points. This paper presents a modified approach to equine distal limb point selection based on what is known from research on other species about the neuroanatomic method of acupuncture. A rationale is presented for modification of traditional equine ting points as well as additional points around the hoof and distal limb that do not appear in the standard textbooks of equine acupuncture. The anatomy and physiology of the equine foot likely to be affected by acupuncture are briefly reviewed. Modified neuroanatomic points are proposed that may be more accurate as transpositional points. As an example of clinical application, a neuroanatomic approach to acupuncture treatment of equine laminitis is presented.