IN-DEPTH: PREVENTATIVE MEDICINE: BEING PROACTIVE IN PRACTICE


joint health are due not to incorporation of the adminis- tered hyaluronan into cartilage and synovial fluid, but rather to anti-inflammatory effects and possibly induc- tion of synthesis of high molecular weight hyaluronan by synoviocytes.17 The most common oral joint health supplements


with some supporting research include glucosamine, chondroitin sulfate, hyaluronic acid (hyaluronan), unsaponified avocado soy, extract of green-lipped mussel (Perna canaliculus), methylsolfonylmethane, and various combinations of those ingredients. More is known about the oral bioavailability and volume of distribution of glucosamine and chondroitin sulfate than other oral joint supplements.18,19 Most literature has focused on management of mild arthritis, and extrapolations to equine treatment are made from human and canine research.Many of the most recent publications exploring in vivo clinical efficacy of nutra- ceuticals usemulti-ingredient formulations with vary- ing amounts of substances, so it is difficult to draw conclusions on specific dosages and ratios (which may have synergistic or additive effects) and to compare to other studies. Because of the possibly slow-acting nature of oral


joint health supplements, it has been recommended that human osteoarthritis patients supplement for at least 3 continuous months before assessing individ- ual effect.1 Extrapolating the same 3-month trial pe- riod for equine patients would be reasonable if clients are to try them.However,Clayton et al. demonstrated a measurable improvement in gait symmetry in horses with degenerative joint disease of the distal tarsal joints after only 2weeks of supplementation with a mixture including manganese, copper, sulphur, vitamin B6, ascorbic acid, glutamine, proline, glutamic acid, glycine, and glucuronic acid.20Many of the ingredients included are surmised to act as free-radical scavengers and anti- inflammatories. In general, adverse effects of nutraceutical supple- mentation have not been reported in studies in which


However, as of yet, there has been no evidence in horses with insulin dysregulation and equine meta- bolic syndrome (and hopefully less so in upper-level athletes) to dissuade use of these supplements at lev- els indicated for joint health.


4. Systemic Parenteral (IV and IM) Products


Parenteral administration of some of the same com- pounds described as oral joint supplements bypasses the effects of digestion and gastrointestinal absorp- tion, potentially increasing bioavailability and effec- tive blood and tissue levels. Incorporation of these compounds into articular cartilage and effects on inflammation and cartilage metabolism in vivo still require more research. However, there are two sys- temic parenteral injectable medications that are Food and Drug Administration (FDA) approved for equine arthritis. This approval requires demonstration of effi- cacy as well as safety and oversight of ongoing good manufacturing processes. Intravenous hyaluronic acid (hyaluronan) and intramuscular polysulfated glycos- aminoglycan are approved for treatment of arthritis in horses, but it should be noted that there are some solu- tions of chondroitin sulfate and pentosan polysulfate that are approved by the FDA as “medical devices” for topical wound care and bladder lavage but not for injection for arthritis. Intramuscular polysulfated glycosaminoglycan has


specific amounts of high-quality ingredients are con- firmed, and beneficial effects are noted in numerous reports. However, quality control and adherence to current goodmanufacturing practices in commercially available formulations can be highly variable and run the risk of contamination with harmful substan- ces.21,22 The 7-step ACCLAIM system devised and presented by Dr. Stacey Oke at the 2008 AAEP con- vention23 remains the most reliable and comprehen- sive assessment tool for commercially available products. It is important to enquire about testing for quality assurance (potency and purity of ingredients and batch-to-batch consistency) as well as how dos- ages are determined and measured. Especially with the risks of inadvertent doping violations in competi- tive horses, contamination of nutraceutical supple- ments could have jurisdictional consequences at best,24 in addition to health risks depending on the compound. Questions have been raised in human medicine about the impact of oral glucosamine and chondroitin sulfate in people with type 2 diabetes.25


398 2022 / Vol. 68 / AAEP PROCEEDINGS


a long history of demonstrated safety and perceived effectiveness in equine arthritis prevention.26–28 Although experimentally the plant-derived pentosan polysulfate compoundwas found to have desirable dis- ease-modifying effects in treating arthritis,29 it is diffi- cult to justify the risk of extra-label use of a device especially for prophylaxis when a similar FDA- approved drug is available. Eighty-six percent of respondents in a recent AAEP survey of practitioners used intramuscular polysulfated glycosaminoglycana “for preventive/prophylactic measures in a high-per- formance horse”28 despite it not being specifically labeled for prevention. Hyaluronate sodiumb was used more for acute disease in the updated survey28 but is also used prophylactically by many practi- tioners.27 The prophylactic use of intravenous hyalur- onan is supported by a study involving 140 racing Quarter Horses. Treatment with intravenous hyal- uronic acid every 2weeks for 9 months resulted in significantly improved racing data compared to intra- venous saline placebo controls.30


5. Regulations


Most of themodalities discussed above are considered relatively safe but still may have medical or regula- tory contraindications, especially if examination and diagnosis have not been completed. For any veteri- nary recommendations, a current veterinary-client- patient relationship should be in effect. A gait analy- sis should be performed to ensure that there is no detectable lameness that could be more specifically diagnosed and treated. In a Journal of the American


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