“Developing a solid skill set in the basic fundamentals of a joint health program can be a gateway to practicing cutting-edge medicine,” said Julie Settlage, DVM, MSc Vet Ed, DACVS (LA), and equine professional services veterinarian with Boehringer Ingelheim. “The choices for medications within a joint are growing every year, and new publications are frequent. The basics of utilizing these treatments are the same, however. The combination of utilizing old skills with new knowledge is an exciting place to practice.”
In this article, we look at the science and the business of equine joint health. Preserving and maintaining joint health improves equine welfare and mitigates economic losses and horse attrition. And with approximately 60% of lameness cases attributable to osteoarthritis (OA), the business of bones and joints is booming. Appropriate joint health care—both prophylactic and active management—not only helps your patient but also your practice’s profitability … if you charge appropriately for your time, services and expertise and use the recommended multi-modal treatment approach.
“Joint therapy in the equine world is becoming routine care,” said Ben Espy, DVM, DACT, owner of ProRodeo Equine Sports Medicine in San Antonio, Texas. “I have a thriving lameness practice and look at six or eight horses a day, so 30 to 40 a week. Those horses require comprehensive joint care, including joint injections. I don’t perform joint injections needlessly, but for me those injections are as routine as pulling blood for a Coggins.”
Kate Hodson, DVM, owner of Hodson Veterinary Services LLC located in Hebron, Indiana, also said her joint health profit center is thriving.
“Not only do I offer joint care to show horses but also the back yard horses when owners are looking to keep them comfortable and maximize quality of life in their golden years,” Hodson said. “I offer joint injections when appropriate, injectable medications such as hyaluronic acid (HA) and polysulfated glycosaminoglycans (PSGAG) and advise what oral joint health supplements might be appropriate.”
The Joint Health Basics Aren’t Basic
Are you charging appropriately to look at lame horses? These examinations can be extremely time consuming in some cases. Based on a roundtable discussion held during the 2021 AAEP Annual Convention, this is an area that veterinarians are not charging appropriately for their time. Several recommendations were made during that roundtable, such as charging a flat fee based on the “level” of work-up required. Others preferred charging per procedure.
Espy said, “I charge a baseline lameness exam fee for looking at any horse then another fee for blocking nerves or joints.”
In addition to local blocks, embracing diagnostics such as radiographs and ultrasonography is good medicine to identify underlying pathology that needs to be addressed. We cannot assume joint discomfort always stems from OA. To better pinpoint a lameness for targeted treatment, some regions have nuclear scintigraphy or even magnetic resonance imaging (MRI) available. Increasingly, veterinarians have the benefit of using a standing positron emission tomography (PET) device for imaging lower limbs.
An industry-wide survey of equine practitioners regarding the clinical use of various joint therapies and the role of new or recently developed joint therapies in everyday practice was recently performed. Those results were published in a 2020 edition of the Equine Veterinary Journal by Zanotto and Frisbie.
Following are some of the main concerns, recommendations and popular therapies currently embraced by equine practitioners.
For intra-articular injections, overtreating joints are a reported concern by 66.4% of the survey respondents. About half of the respondents inject joints only once every six months, whereas one-third of respondents are comfortably injecting joints every three months (four times a year).
In addition to corticosteroids (primarily triamcinolone and methylprednisolone), practitioners are commonly mixing amikacin and hyaluronic acid in the same syringe for intra-articular application.
Regenerative therapies are embraced by more than 80% of survey respondents, and practitioners feel their patients benefitted from these therapies when used intra-articularly. Those therapies include interleukin-1 receptor agonist protein/autologous conditioned serum (IRAP), with 83% of survey respondents using this therapy. Seventy-two percent use platelet-rich plasma (PRP), and 53% inject autologous protein solution (APS) and stem cells.
Espy said he uses five different products in varying combinations, but he never mixes corticosteroids with regenerative therapies.
“It is contraindicated to use anti-inflammatories and regenerative therapies concomitantly,” he said. “If the joint is inflamed, I’ll sometimes use a corticosteroid first then a month later come back and use a regenerative therapy, or vice versa. There is no industry standard.”
Hodson added that “you really have to look at what is working and what isn’t. Steroids with HA, HA alone, PRP, stem cells … it all depends on the horse. Some horses do very well with HA.” Hodson added that regenerative therapies have become very easy to use … “they’re a real game changer” in some horses!
Frequency of IA Treatments
In terms of frequency of intra-articular treatments, Espy said it is a balance.
“There is a cost factor and a danger factor,” Espy noted. “First, if you inject a horse four times a year and the owner is spending $400-$500 minimum to inject a horse each time, that’s a $2,000 ‘maintenance bill’ on injections alone per year. An owner’s budget may not be able to bear that. Second, from a medical standpoint, puncturing a joint four times a year increases the odds of infection.”
Overall, both Hodson and Espy felt that it is reasonable to perform intra-articular treatments once every three months if needed, which is a popular opinion based on the industry survey reported above.
That said, Epsy advised other practitioners to not be pressured by owners to over-inject.
“I have never injected a joint that didn’t need it,” he stated. “We don’t need to inject prophylactically to maintain normal joint health. Everything I inject is in response to a problem.”
Nonsteroidal Anti-inflammatory Drugs (NSAIDs)
These medications, particularly phenylbutazone and flunixin meglumine, are a mainstay of maintaining a comfortable horse. With many over-the-counter products, your patients could be receiving these medications without your knowledge or medical input.
“Even though we aren’t going into a joint, we still need to balance risk versus benefit,” Espy advised.
As with any prescription medication, prior to use a veterinarian should perform a physical examination and review the horse’s medical history. A veterinarian should advise horse owners to observe for signs of potential drug toxicity. As a class, non-steroidal anti-inflammatory drugs might be associated with gastrointestinal, hepatic and renal toxicity. Use with other NSAIDs, corticosteroids or nephrotoxic medication should be avoided.
Blood work might be indicated for patients on longer-term NSAIDs, even when using low daily doses. Longer duration of administration is often off-label use of these medications. For example, the label dosage of firocoxib is for 14 days.
“I strongly urge owners to check liver and kidney values [at least] once a year,” Hodson said.
However, to do that, it is imperative that veterinarians know which patients are being given NSAIDs. Some owners, for example, don’t think to mention that they are giving bute, aspirin or firocoxib because they are generally in every horse owner’s medicine kit. Therefore, owners think they are safe to use whenever they want.
“I currently price match NSAIDs because I want an exclusive relationship with my client, and I want them to purchase it from me,” said Espy.
Even with price matching, bulk NSAID sales will benefit your joint health profit center.
Oral Joint Health Products
According to Seabaugh et al. (2022), certain populations of horse owners spend >$60 per month on supplements, and oral joint health supplements are among the most popular. Murray et al. (2018) also reported that joint supplements were commonly offered. Of the 134 individuals that responded to Murray’s survey, 53% sought advice regarding joint supplement selection from merchants, and 46% from their veterinarians.
Given that many joint supplements do not contain the type or amount of product listed on the label (Oke et al. 2006), it behooves practitioners to stock and sell quality products produced using appropriate good manufacturing practices and quality assurance/control.
Even with quality products, Espy said that joint supplements are only about 30% absorbed.
“I’ve actually converted most of my clients to injectable [products] such as HA and polysulfated glycosaminoglycans instead,” he said.
Missed Opportunities, Missed Income
In addition to not charging for lameness exams and working up cases with blocking and imaging, Espy feels some veterinarians are missing opportunities to inject joints.
“I see a population of young vets that are hesitant to inject,” he noted. “The have sensory overload with the options available. They can’t decide between the products, the modalities, and the combinations available. It’s confusing, and they often end up referring the horse instead of managing the case themselves.”
Further, spending money on a regenerative therapy system might seem daunting, but the expenditure could very well be worthwhile.
“Despite having an active joint practice, even I was hesitant to invest in a system,” said Espy. “I agonized over what to buy and whether or not it would be lucrative. I ended up paying for that machine in 90 days. It was an incredible experience as a small business owner.”
Good Medicine is Good Business
Embracing all of the available therapies advocated for robust equine health and being able to directly provide your owners with those products and services will allow your joint health profit center to thrive. Espy and Hodson recommend continuing education for practitioners to improve their joint injection skills.
“If you aren’t utilizing your skills with injections, it’s definitely something to look into CE-wise as it does benefit many horses,” Hodson recommended.
Settlage added, “Developing a comprehensive joint health program can provide early-career equine veterinarians with improved income, deepen their relationship with their clientele, and provide a sense of pride when their patients are able to excel in the work their owners want them to do. All of these elements can be part of helping retain these important members of our profession.”
Final Thoughts: The Whole Horse
When horses are having their joints cared for, Ben Espy, DVM, DACT, owner of ProRodeo Equine Sports Medicine, in San Antonio, Texas, said that owners frequently bring up the fact that they require other routine, preventive health care such as dental work (e.g., floats) and vaccines. This is also a good opportunity to discuss deworming and performing fecal egg counts as recommended by preeminent parasitologist Martin Nielsen, DVM, PhD, DEVPC, the Schlaikjer professor of Equine Infectious Disease at the Gluck Equine Research Center.
These routine preventive care measures are not only important to the overall health of a horse, but they are the meat and potatoes of a financially flourishing practice. To round out a horse’s OA therapeutic plan, don’t forget to recommend weight management, controlled exercise and appropriate shoeing.