Yeah, it was a costly experience, but what isn’t with horses? LOL
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You’re definitely not alone! I just get curious what kind of ulcers there were, because I’ve seen some have either glandular, or both, and then they didn’t understand why this class of drug didn’t work (well).
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I think when using Nexium first came about we were doing 3 capsules as a healing dose? Has that changed? I used the 3 capsules and it worked well for my 1300 lbs Rocky Mountain Mare previously. Now I have an Arab gelding that is a little under 1000 and he is showing classic signs- what should I aim for dosage-wise?
Three is still the research based dose from the beginning. People have been doing different things - I do 6 (3 AM and 3 PM) so that my supp baggies are identical. It’s easier for the barn staff to not miss a dose that way, and that’s the only reason I do 6.
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Nothing has changed. The study that kicked off this thread was seeking a lowest effective dose. Other studies have not explored that particular angle.
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oh good- because taking capsules apart was not something I was wanting to do lol
The problem with the 40/80mg study (where they found no difference, which is why 40mg became the base standard) is that they only have info for stomach pH for up to 6 hours. Note: I can’t access the full study, the best I can access as “full” only has snippets of each section. But I find references to this same study, in this study where they state the doses used “maintained gastric pH > 5 up to 6 hours after administration”
What I don’t know, because I can’t access the full study, is whether they only tested up to 6 hours, or testing showed it only maintained a higher pH for up to 6 hours. If the former, it may maintain higher pH for longer, but I can’t find any reference to that.
EDIT: I got someone to access the full (original) study, and it’s correct that they did not test pH beyond 6 hours after dosing
“The current study did not examine gastric juice pH at 24 hours and was limited to the first 6 hours after drug administration.”
AND, it’s important to note that the original study delivered that 40/80mg via NG tube, so there was no crunching of capsules. I hadn’t caught that until just now.
Subsequent studies had esomeprazole dosed orally, and pH was measured up to 23 hours. I don’t remember if I listed them up above in this thread, or other threads, but here they are again
One looked at a 2mg/kg dose to compare to the omeprazole 4mg/kg dose
This was “per os s.i.d.” so given orally
One looked at .5mg/kg dose to compare to 1mg/kg omeprazole, and found the same pH results
This says “as an oral paste,”, which makes me realize we don’t know the form of the other 3 study drugs
And one looked at .5 and 2mg/kg doses of omeprazole to compare the 2
This says “per os once daily” so also orally
So you can see that doses significantly higher than the original, have also been studied as effective. I definitely wouldn’t bother trying to titrate down 3 capsules for a smaller horse!
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Ok, I got someone to access the full (original) study, and it’s correct that they did not test pH beyond 6 hours after dosing
“The current study did not examine gastric juice pH at 24 hours and was limited to the first 6 hours after drug administration.”
I’ll update my above post to reflect this as well
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Well, eating my words here. Has anyone had Nexium work (multiple times) on the same horse, and then not work? I moved my gelding a month ago and immediately had him on his pills, but I’m starting to see ulcer signs. He’s on 24/7 turnout, the biggest difference between the old place being the pasture isn’t as lush (all the other horses are Cushings/IR retirees, so that’s on purpose).
I’m trying to decide if I’ll up his dose (I did 6am and 6pm in the past, vs the 3 and 3 that’s worked the last few times we moved), or if I should go the ulcergard route for a week and see.
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Different ulcer types respond to meds differently. At this point, scoping to see what you’re dealing with, so you can target therapy appropriately, would be prudent.
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Yes, that’s true. But I need to get my trailer in to replace a window (rock shattered it) and my horse is a freaking nightmare to load at the moment (my fault! I stopped practicing), so I can’t yet make the appointment. I want his back looked at anyways so a trip to the clinic is on the docket ASAP.
In the meantime I’m hoping I can soothe his belly a bit - he can get sharky. Not there yet, but I know him.
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No vet available with a scope that can come to you?
Consider adding sucralfate rather than just more of a PPI. Given the success you’ve had in the past, this appears to be something different.
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No, not out here.
Good idea. I’ll see what I can find.
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Just know that it’s more like 12 pills once a day for the average horse where stomach pH has been tested to 23 hours. Unfortunately the lower dose of 40/80mg was only tested for 6 hours.
So not only might you have different ulcers this time, they could be worse than what a lower dose could affect well enough. And, these are only dosed once a day, especially the higher dose where it’s known to therapeutically raise pH for at least 23 hours
Adding, or using just, sucralfate is another option in case it’s both squamous and glandular, and/or it’s a hind gut issue
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No, we don’t know that. The study you reference wasn’t seeking to identify a lowest effective dose to raise the pH of the stomach to >4 for 24 hours. We don’t know what that dose is, because no one has done that research.
What we do know:
40 and 80 mg were equally effective at raising the pH of the stomach to >4 pH for the duration of the testing period, which was over 6 hours. The last tested pH at hour 6 was >5. By hour 24, it was back to baseline. We don’t know how long it took to return to baseline.
We know that 0.5mg/kg esomeprazole seems to be as effective as 1 mg/kg omeprazole at raising the pH of the stomach (Huxford et al 2017) but this paper did not seek to identify a lowest effective dose.
Sykes et al 2017 found 0.5 mg/kg esomeprazole effective at raising the pH but also saw a diet dependent factor. Interestingly, he states:
“In humans, good healing rates for gastroesophageal reflux disease, which is
analogous to ESGD, are achieved when the %tpH>4 exceeds 66% [9] while %tpH>3 is used as a benchmark for glandular healing in other species with a %tpH>3 of greater than 66% required in humans for healing of glandular disease [9]. Unfortunately, due to limitations in the software of the reporting program, determination of %tpH>3 was not possible. Regardless it has been proposed that %tpH>4 may be a more conservative benchmark until species-specific breakpoints for healing are determined [10].”
So, maintaining the pH at greater than 4 for 24 hours does not seem to be necessary, and pH > 4 may not be required–pH > 3 may be sufficient.
But again, this study did not seek to identify a lowest effective dose.
Additionally, if there’s concern about the duration of effect with the low dose esomeprazole, dosing twice daily is a very reasonable path. We know the pH of the stomach returns to baseline at some point before hour 24, but not when. It is very, very likely looking at the data we DO have that q12h dosing provides (at least) pH >4 for 16 hours in a 24 hour period, which Sykes says is sufficient.
Yes, we do know that. All the other studies I’ve posted above tested pH at the 23 hour mark. The lowest dose/the origina study only tested to 6 hours.
I never said it was
Exactly what I said. We know what happens at hour 6, but not beyond. Even the chart stops at 6 hours.
Totally fine, I didn’t suggest otherwise except to say if you’re dosing at the higher rate where it IS shown to keep pH raised at the 23 hour mark, then I wouldn’t dose more than once a day.
No, JB, we don’t know that the 0.5mg/kg dose is the required dose to raise the pH for a 24 hour period. We know that it does (although Sykes demonstrates that neither the 0.5 mg/kg dose nor the 2 mg/kg dose keep the pH consistently >4 over 24 hours, which is what you’ve been claiming) but we don’t know that a lower dose won’t do the same thing. It hasn’t been studied.
Well I’ve just dropped a week of 6AM 6PM pills, so we may see how that goes for now. Ironically, one time a day dosing is harder at this place than 2 times, but I could give him 12 pills when I go to see him daily. TBD.
And on that note, sucralfate would be a huge pain in the backside with the current setup, if I was to try to dose it correctly. I’ll do it if needed, but it won’t be easy. In the meantime he gets TC Safe Starch or Stress Free forage while I groom, and Outlast cookies are a hit.
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I never said that’s what’s required.
I said - like 80 times now - we know what doses were measured to raise pH for 23 hours, and we know the LOW dose was only measured to 6 hours.
Nothing more, nothing less
Never said otherwise.
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So, just to test and see if it helps, 3 20mg pills AM and 3 20mg pills PM?
