@JB nailed it. At the time I treated this horse in 2018, I had found three different papers testing esomeprazole in horses. I decided to go with the 0.5 mg/kg, which was the lowest dose that had the most reliable results (in my layman’s opinion). There are studies with dosing up to 2.0 mg/kg, but at the time that was approaching/exceeding the cost of Ulcerguard. I hedged my bets, really wanted to resolve the ulcers for this horse. YMMV
Might have been this study?
Thanks for the reply!
Where and what grade were the ulcers? Did you treat with any other meds? And how did you taper?
I’ve noticed a difference in 2 days with just 4 pills but I am thinking of just doing the full 14 since generic Nexium is $10 for 42 pills currently on Amazon.
I’ve read some of the study’s on the different dosing and it does seem that everyone latches into the 3-4 pill dose.
I’m also noticing a lot of people are struggling with getting them off the meds without symptoms returning. So I am wondering if the 14 pills a day is more reliable and the 3-4 pills is just making their tummy’s feel better but not actually healing them.
Something to keep in mind is that horses need something in their stomach, so care is important. That is possibly what “diet” meant in the referenced study above.
My responses at the time were post #378 Dec ‘18 and #398 Jan ‘19 on the big Nexium thread. Those posts say I treated for 5-wks at 14/d. I did taper on that horse, but I don’t remember the exact regimen and I believe more recent research suggests tapering isn’t as necessary/important as originally believed.
Ulcers are complicated. I believe there is so much more to keeping horses ulcer free than a round of treatment, such as feeding routine, living situation, stress, chronic pain, etc.
These days I focus on low stress lifestyle for my horses - 24/7 turnout, constant hay buffet, low key riding. If I’m trailering I feed a bunch of alfalfa, peppermint tums and a dose of ranitidine or famotidine.
Edited for grammar.
IME, most people aren’t scoping, they’re assuming 1) ulcers, and 2) squamous ulcers, so reach for UG/GG or Nexium. Yes, those proton pump inhibitors can make glandular ulcers feel better while the pH is higher (lower acidity), which fools them into thinking they’ve found the issue and fix. Then either they don’t treat long enough because they didn’t scope at 30 days to make sure things were healed but they really need 60 days, or they weren’t using the right medication (eso/omeprazole doesn’t really facilitate healing of glandular ulcers), or there weren’t even ulcers to begin with.
On the tapering - this is worth watching
Yes, he suggests it’s not useful as a whole, yes he looked at omeprazole not eso, though some horses may benefit, so it doesn’t hurt to try.
Some things of note from the esomeprazole research:
The 0.5 mg/kg dose was ONLY found effective at consistently raising the pH of the stomach when used with a low forage/high concentrate diet. It was NOT found effective when used with a high forage diet, which is how most of us feed our ulcer horses. The 2.0 mg/kg study dose was shown to be effective on the high forage diet. Reference Sykes et al doi: 10.1111/evj.12670
(eta: 0.5 mg/kg is about 14 20 mg esomeprazole pills for a 1200# horse. 2.0 mg/kg is 54.)
While Sykes says “you don’t need to taper” he has also not published that for peer review, and is making assumptions about tapering based on his “no dimmer switch” research which found that varying the dose does not vary the response in a reliable way. I wrote up a response to this before here:
Sykes has also demonstrated a massive recurrence rate of 83% in three days for horses that have sudden discontinuation of a PPI. These were horses that had healing confirmed via endoscopy, medication was discontinued and they were shown to have ulcers again in three days. Reference Sykes et al doi: 10.1111/jvim.16795
I wrote about this paper and it’s companion which describes the gastroscopy portion of the study here:
Clearly sudden discontinuation is not advised. Sykes has some recommendations which include no hauling, no work, OTC buffers, through the d/c period, but afaik has not run a study to see if that’s effective. He has also not actually studied what happens when horses are tapered.
What I take from all of this is:
Dose on as empty a stomach as you can. Whatever dose you’re using will be more effective with less in the stomach. I don’t purposely fast mine, but I do target the dose for when they’re most likely to be empty, which for mine is at evening turn in.
If you cannot find a time when they’re likely to be empty, you will probably have to use more drug.
We don’t really HAVE answers on how best to discontinue at the end of treatment. I still taper. When I have not (not on purpose, but once or twice life has provided enough of a distraction…) I have had a quick return of the symptoms that led me to treat, while I have never seen that with a taper. There is likely very little harm in tapering.
General question, but for people that have done 14 pills how are you feeding them? Just straight on the grain? When I did 3 or 4 I put them in a cookie, but obviously that is less feasible for 14.
All I have is one datapoint on one horse, one lifestyle management, for a one-time treatment regimen at 0.5 mg/kg for 5wks with before and after scope. Post treatment scope was completed prior to tapering so not relavent to the scoping results. I agree with Simkie, probably very little harm in tapering. Wish there was more data on whether OTC buffer or alternate drug class (ranitidine/famotidine) helped in that scenario or also incur acid rebound effect.
Maybe 40-80mg/day would have been enough? Maybe he crunched 10 of the 14 capsules and only 4 reached his stomach intact? Maybe how my horse was choosing to eat or not eat his free choice hay and 2x/day TC Sr was considered “low forage/high concentrate” (I certainly wasn’t able to measure how much hay he actually consumed, especially in group turnout)? Who knows? …as usual in my personal and professional life…WE NEED MORE DATA! 
I just put the capsules on his grain. He ate them.
Kind of.
I had my late mare on 3 - 5 pills a day for an extended period of time. She was a MEGA anxious type - totally should have had ulcers. She lived life redlining whatever gear she was in.
I had to have her euthed for the cancer. I did a necropsy, and they found no evidence of ulcers, which was a shock to me.
To be clear, I am not at all in the least little bit disputing your results! I think it’s super fab that you did the work to scope pre and post. I would love to do the same. And I totally agree we need more data!
What I have above is some of what HAS been published on this topic, though. The 0.5 mg/kg dose has been shown to “work”…with caveats. That study certainly indicates that dose is a lot less likely to be effective if given on a belly full of hay. Sykes has research showing the same is true with omeprazole, and this concept almost certainly contributes to success or failure with the popular lower dose of esomeprazole as well. With ANY of the PPIs, at any dose, it will be more effective on an emptier belly.
And wrt to tapering, there’s just sooo much we don’t know. Representing it as settled, as it often is, (“Sykes says you don’t have to taper!” sure gets tossed around a lot) is just incorrect. 83% recurrence in 3 days sucks. We still need to figure out how best to discontinue.
So much we still don’t know :-/
Even when feeding 14 pills, I just put them in their grain. Even my super picky guy ate them.
FWIW - I put my guy on the 4 Nexium treatment for a bit to see if I noticed a difference. I noticed no difference whatsoever but did scope later (wanted to scope his airways so we just did gastric at the same time) and he had pretty bad ulcers. Treated and his symptoms did go away, so for him in particular the Nexium didn’t do anything even as just a symptom treater vs an ulcer treater.
@NaturalSelection Ulcergard. He’s about 1000lb so he got a 500lb dose every morning 30 min before eating for I think 14 days.
What’s particularly interesting about this is it’s 1 mg/kg of esomeprazole. Half of omeprazole is esomeprazole.
Just out of curiosity, did you dose the nexium the same way on an empty belly?
Horses in general can absolutely respond differently horse to horse and med to med, which just adds to the frustration trying to solve this problem. It’s tough to know how any particular horse will respond to any particular med, which also means failure in one horse doesn’t mean the exact same approach won’t work in another.
And even though our “gold standard” is 30 days of Gastrogard, digging into the patent data shows that success was only “improvement,” not resolution, of ulcers, and more recent research is showing a pretty significant amount of treatment failure, which is frustrating and disappointing.
There’s a new ulcer drug type on the market for people called vonoprazan. It’s eye wateringly expensive right now, but it’ll be so interesting to see what happens when the price comes down and it gets trialed in equines. It’s a potassium-competitive acid blocker, the first in it’s class.
Bumping this thread back up hoping for some advice. My primary question is whether it is OK to give esomeprazole with grain? The vet told the barn owner it was fine, but I haven’t been able to reach him to confirm and I can’t find any specific instructions about esomeprazole, but lots about how omeprazole must be on an empty stomach. My horse is also getting sucralfate twice/day, but they’ve been putting it in his grain with the esomeprazole and hot water so it may be that neither drug is working very well.
Would it be beneficial to bring him in at lunch (he is out 24/7), fast him for 30 minutes, give the esomeprazole, fast him in for another 30-60 minutes and then turn him back out? I could ask the barn manager to give him the sucralfate about 30 minutes before before breakfast and dinner?
It’s not ideal, but I don’t think I can swing 2 barn trips every day and I think it would be hard for the barn manager to incorporate much more fasting time into their feeding/turnout routine. I would really appreciate any advice, I’ve never dealt with ulcers before.
Dosing concurrent with sucralfate is not ideal.
Esomeprazole and omeprazole are the same re: dosing guidelines. Half of omeprazole IS esomeprazole. The closer you can get it to an empty belly the better. 30 minutes of fasting, however, is probably not significant.
Giving it with a handful of grain on as empty belly as you can manage is (probably) fine. I personally wouldn’t sweat a 30 minute pre and post fast. Targeting very first thing in the AM when they’re most likely to be empty is probably more useful, or whenever the natural breaks in their consumption are.
When I was treating my horse the vet had me do an hour fast, dose Gastroguard, fast for another 30 min, dose misoprostal (sp?), fast another 30 min, dose Sucralfate, fast 30 min, then feed his grain. Sucralfate can block absorption of other drugs and was given last.
My horse did live outside with hay available at all times so we didn’t get the “free” likely to have self fasted before the breakfast grain arrives period that stalled horses have. I must say my BO was fantastic about dealing with the hassle of ulcer meds for the two months of Gastroguard.
We went with this sort of drug spacing because this was a recurrence of ulcers after I’d had a difficult time clearing them the first time.
I appreciate the responses. I think we worked out something better, but definitely not ideal. He will stay in at night (we are still on day), get his esomeprazole first thing in the AM, wait 30 mins and feed alfalfa/grain/sucralfate and 2 PM and 8PM fast/sucralfate, grain around 6 PM.
He gets Uekele Gut, but the amount in the maintenance dose Smartpak is probably too low for his body weight. Do I need to get something to keep his stomach calm when he tapers off the esomeprazole? I’ve been looking at Succeed, Alimend, Ritetrac. Would any of those help? Or upping the Uekele? I think the ulcers are driven by recent stress/dietary changes from moving to a new barn. I’ve added 3 flakes alfalfa/day and he has 21/7 access to a roundbale. V. little grass 
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