Esomeprazole (Nexium) for equine ulcers

[ToTheNines]

This is of course, purely anectodal. But I have an ulcer horse. He is fat, laid back, out most of the time at my farm – you would never think of him as the ulcer type. But about a year ago, he was acting colicy. Took him to wonderful vet, who said “that looks like ulcers to me”. Scoped him and sure enough, pretty bad case of ulcers. Did the GG routine to the letter, tapering etc. Put him on mainly alfalfa per vet recommendations. Scoped again four weeks later, and ulcers gone. However, he had same symptoms about four months later.

I had taken him off Triple Crown Senior because my feed store quit carrying it. I put him back on TC Senior, and added one Clear Mini Nexium to his am feed each day. Just drop it in his feed. Also, about 2/3 scoop of KER’s EquiSure, in am. He gets about 2 quarts TC Senior am and the same pm.

Knock on wood, but he is fat and happy. No acting uncomfortable. Justt one Clear Mini Nexium and a bit of EquSure seems to be the trick. I will probably keep him on this all his life.

[Peggy]

I talked to my vet about using Nexium. He said that based on the experience in his practice, Nexium often resolves the symptoms but that, when the horse is re-scoped, the ulcers are still there. I think that he said his associate does something like 100 gastroscopies (!) a month. Maybe even more.

But based on reading things like ToTheNines’ post just above I wonder if there is always a 100% correlation between symptoms and observable ulcers, if that makes any sense.

[IPEsq]

I picked up some tablets today. I’m thinking of trying them in a bit of carrot.

After going in for neck and SI injections a week ago, and subsequently turning into a terror for trailer loading, horse has gone off his grain all week. He eats some. Will eat more dry than wet or with beet pulp. He tries, eating maybe half, then sniffs then gives up. He doesn’t get much–mostly a carrier for supplements to support his gastric and neuromuscular health. He had his teeth done a month ago and is still eating hay and alfalfa relatively well. And mugging me for treats.

Starting him back to work has been awful. In hand, he is super. But grooming, he’s kicking out at me for brushing his belly, is harder to girth, and while he goes fine under tack on the longe, he has started rearing at the walk under saddle. Alllll the way up. Then will start pawing like he’s digging to China. If I lean forward when I feel a bit of a pop up coming, it only escalates the rear faster.

It is very disappointing, but his only rearing history has been ulcer related, so that plus the food thing makes me want to give this a shot. I don’t really have the budget for a month of GG at the moment given the injections and an associated Rx for Adequan.

I may also check his mouth again because he is being weird about the bit. Just a simple lozenge snaffle, and I am riding on a loose rein right now (per vet) unless things start to go sideways where I will try to turn him. I don’t think I pull him into the rear, and thankfully I know how not to pull when we are up there.

I’m starting to wonder if my nice fun horse isn’t gone for good, but he had a flare about this time last year, so I’m not panicking yet.

I’ll report back if I can get him to eat the tablets.

[knic13]

@Peggy

I talked to my vet about using Nexium. He said that based on the experience in his practice, Nexium often resolves the symptoms but that, when the horse is re-scoped, the ulcers are still there. I think that he said his associate does something like 100 gastroscopies (!) a month. Maybe even more.

But based on reading things like ToTheNines’ post just above I wonder if there is always a 100% correlation between symptoms and observable ulcers, if that makes any sense.

This observation is consistent with my nexium experience so far. When I tapered from 3 down to 2 tablets ulcer symtoms show up the next day.

I havent done a before and after scope with nexium, but this horse has been treated and scoped before and after gg and his symptoms are consistent.

It may be that I haven’t treated long enough with nexium to completely resolve existing ulcers? At 45 days of treatment thus far.

[scruffy_the_cat]

@knic13

This observation is consistent with my nexium experience so far. When I tapered from 3 down to 2 tablets ulcer symtoms show up the next day.

I havent done a before and after scope with nexium, but this horse has been treated and scoped before and after gg and his symptoms are consistent.

It may be that I haven’t treated long enough with nexium to completely resolve existing ulcers? At 45 days of treatment thus far.

I believe I am seeing the same thing. I’m “stuck” on Nexium and keep having to up the dose. That being said, I had the same experience on 2 months of GastroGard so who the heck knows what’s going on? Will be trying something else soon.

[IPEsq]

I told my vet about my horse’s behavior, and she said no riding for 5 days, work in hand only and give GG if I have it. I said I only have one tube but was going to try Nexium at 60mg/day. She said…have you done your math right? Usually that’s cost prohibitive. (Um, what?) I get that message right after I post the above.

If you feed .5mg/kg for a 1300lb horse (the low end of the above), then that’s like 14-15 Nexium pills a day. Versus 3. I responded back saying I was trying 3 pills per study #1…Although if I fed 15 pills a day, that’s still cheaper than UG at closer to $8/day.

SIGH.

I had already fed the three Nexium this morning. He ate them right up in a carrot. Buying Ulcergard at the local stores (or GG from vet) is OMG expensive. I told the vet I could order some more Ulcergard…

[Simkie]

I don’t know, IPEsq. The paper I linked in the OP demonstrates 40 mg works just as well as 80 mg at raising the pH of the stomach.

I’ve had horses on 60 mg/day, felt like there was a good result with that, tapered, have not seen symptoms returned. I’ve had horses on and off antibiotics this spring/summer, and have used it there, and have also had a few longish stressful events, and have used it following those.

Overall I find it cheap and easy and effective.

Why don’t you send the original paper off to your vet and see what she says?

[IPEsq]

K…I can email it to her. She said she only knew about the more recent study at 0.5mg/kg dose. She really wants him on a full tube of UG for at least 5 days to see if we get a behavior change. She said I could do 15 pills of Nexium in the meantime or could try less…helpful, huh?

I did see the original paper found 80mg as effective as 40mg. But now we’re talking 300mg…

I’m not sure he will eat 15 pills right now since he’s not much interested in his feed, so 3 may be it. I got him willing to eat close to 1lb TC Senior last night, no water or beet pulp added, a splash of flax oil (maybe 1/4 cup) and his Platinum Pak…if I hand fed it to him one small handful at a time. Bucket had been thoroughly scrubbed. I’d just like him to not kill me while we figure out what kind of bee is up his britches THIS time.

How many days has it taken everyone to see a symptom change with Nexium at 60mg? In the past, my horse has needed 7-10 days of GG/UG before behavior improved, and he’s only ever scoped at grade 1 ulcers.

[Simkie]

@IPEsq

How many days has it taken everyone to see a symptom change with Nexium at 60mg? In the past, my horse has needed 7-10 days of GG/UG before behavior improved, and he’s only ever scoped at grade 1 ulcers.

I have Blush going through it now–she’s about 10 days in, I think?–and I saw an improvement in her grain manners in 2-3 days. I think the others have been similar, but it’s been awhile.

[EventerAJ]

After reading this thread, I decided to try the Nexium minis for a fresh off the track 5yo. A little thin, disinterested in (new, unfamiliar) feed. Ate alfalfa ok, picked at grass. No scope but pretty good bet he had ulcers.

Because of his size (17.1, very big bodied) I started him on 5 pills daily. By day 2 he was eating better, and licking the tub clean by day 4. Grazing with determination in turnout. Tapered to 3 pills now after 9 days. He’s already gaining weight and filling out, and nickering for food. Not sure how long to keep him on the Nexium, but I’m pleased with the results so far.

For dosing, I’ve been reusing an old, clean ivermectin wormer syringe. Put pills in, add a tiny bit of oil, and dose before he gets any morning feed (clean mouth). I make sure the pills get far back in his mouth and he hasn’t spit any out. I probably don’t even need the oil as a carrier, but it’s working.

[theresak]

I used Pill Camo treats and Nexium mini capsules. I can hide 3-4 pills in a single small Pill Camo. He ate every single one for 28 days + 2 week taper. And this is a super picky eater.

[IPEsq]

Can a science person explain the difference in testing the pH serially over a course of 5 days versus testing pH for a continuous 23 hr period?

The second study (with the higher dose) tested pH for a continuous 23 hour period and then looked at the percentage of time the gastric pH was at the desired level.

So, if serial testing looks at more of a snapshot in time (first study), then I wonder if there would be a tapering off of the pH over part of the day?

The second study also found a cumulative effect of the dose.

Where I’m going is…is one dose better for maintenance/prevention and one better for healing (healing occurring where the pH that supports healing is maintained until healing is completed)?

My horse appears so far to be eating a bottle full (0.5mg/kg) dose of tablets with some TC Senior and a coating of oil. Ate that up with the most enthusiasm than he’s eaten any grain in a week.

[Peggy]

@IPEsq

Can a science person explain the difference in testing the pH serially over a course of 5 days versus testing pH for a continuous 23 hr period?

The second study (with the higher dose) tested pH for a continuous 23 hour period and then looked at the percentage of time the gastric pH was at the desired level.

So, if serial testing looks at more of a snapshot in time (first study), then I wonder if there would be a tapering off of the pH over part of the day?

The second study also found a cumulative effect of the dose.

Where I’m going is…is one dose better for maintenance/prevention and one better for healing (healing occurring where the pH that supports healing is maintained until healing is completed)?

My horse appears so far to be eating a bottle full (0.5mg/kg) dose of tablets with some TC Senior and a coating of oil. Ate that up with the most enthusiasm than he’s eaten any grain in a week.

I’m a chemist science person not a physiology science person, but testing once a day wouldn’t give you an idea of if/how the pH varied over the course of the day. Did it say when the pH testing was done relative to the time of medicating?

[IPEsq]

@Peggy I was hoping you’d chime in! The first study says:

“During the 5 days of experimentation, before the morning meal, the animals were fitted with an 8-mm NGT, and a small quantity of gastric secretion was drawn by suction for pH measurement (T0) with a laboratory pH meter (PH-TECH). Subsequently, esomeprazole magnesium or saline was administered individually according to the experimental group. After dosing, the NGT was removed. Thirty minutes after the administration of esomeprazole or saline, the animals were fed. Sixty minutes after feeding, the NGT was again inserted and fixed, and the pH of the gastric content was measured at intervals of 30 minutes for a total of 10 measurements. The gastric content was aspirated and stored in a disposable plastic container. The gastric content that was still in the NGT from prior pH measurements was always discarded.”
…

“The current study did not examine gastric juice pH at 24 hours and was limited to the first 6 hours after drug administration. However, even considering this limitation, the results are significant considering that the doses used (40/80 mg) were less than half the current omeprazole dosage (4 mg/kg) routinely used.”

So, it looks like measurements were taken every 30 minutes until the 6 hour mark. Based on previous omeprazole studies (showing results lasting 27hrs), it was hypothesized that the effects of the Nexium would last for a longer period. Though, I’m not sure why they went there given the relatively small dose and the note on the following limitation in the method:

“In addition, it is important to note that, at T0, which reflects the gastric juice pH of the first measurement before the administration of esomeprazole magnesium for all 5 days of experimentation, the pH was between 2 and 3. Such a pattern leads us to consider the works of some authors who emphasized the need for a wider evaluation of gastric pH fluctuation (24 hours), the time interval in which acidity would be capable of supplanting the action of the proton-pump inhibitors. They indicate an especially harmful behavior of gastric pH during the night, when there is strong tendency for a decrease in pH 5 hours after the last meal of the individuals of the groups studied.”

I can’t access the full text of the second study to see why they selected the doses they did, but they did appear to monitor for a longer period of time per day.

[scruffy_the_cat]

@IPEsq

I read this thread in a hurry yesterday. Didn’t see if this article has already been posted.

One interesting observation for those having trouble healing ulcers is that the PPIs seem to be less effective over time when the horse is on a forage-only diet. Which is what many of us feed for the most part with ulcer prone horses, right?

@scruffy the cat , maybe this is why you find you have to keep upping the dose? It appears that with grain diets, the therapeutic pH hangs around but not so much on the hay-only diets. So, it would seem you may have to give more of the drug to get back to the same acid suppression level?

In the very brief discussion of Nexium, it sounded like that worked a little better on the longer term than omeprazole. But they calculate a dose of .5-2 mg/kg. That seems like a lot higher than 60mg (???)

The once a week injection also sounds promising.

In my case, my horse gets a lot of hay but also grain (Nutrena Pro Force Fuel) since he’s a hard keeper. We had to increase his dose yet again this week (started at 3 capsules/day, now at 5/day). I’m going to have him scoped in a couple of weeks to see if we can determine what’s going on. It doesn’t seem right that he has to keep upping the dose.

[Peggy]

So they did the pH before treatment/feeding (t=o) and then treated, then fed at t=30 minutes and then starting monitoring at t=60 minutes using 30-minute intervals for five hours. So total of 6 hours. And then no sampling for18 hours.

The other study monitored for 23 hours.

So you might be able to compare the first study to the first six hours of the second one.

Does it anywhere address the pH increase that you’d expect with treatment? Or were they just looking for less variation. And then I wonder what’s normal and that’s where my lack of physiology rears its ugly head.

As you probably know the pH scale is logarithmic so a +1 change in pH corresponds to a ten-fold decrease in hydrogen ion concentration.

[IPEsq]

It doesn’t really discuss in detail but the studies seem to both target pH >4. It’s mentioned somewhere that that level was associated with healing. It seemed in both studies that they were happy with most responding at >4 (I think median was 5?) and then maintaining that.

The second study found that by day 5, the horses maintained desired pH for at least 80% of the time. …I have to look back at the first study’s chart to see what the T0 readings were on later days.

[IPEsq]

T0 day one showed pH of 2-3. I guess that’s normal?

[Peggy]

@IPEsq

T0 day one showed pH of 2-3. I guess that’s normal?

Normal apparently depends on what part of the stomach you’re measuring and the individual horse… Yet another variable. Assuming we trust Wikipedia (which I find generally OK for chemistry stuff), “The pH of the stomach contents varies by location. The most dorsal part of the stomach has the highest pH, usually close to 7, dropping to a pH of 3.0–6.0 near the margo plicatus, and reaching as low as 1.5–4.0 in the glandular regions.” (ref - https://en.wikipedia.org/wiki/Equine_gastric_ulcer_syndrome). Later in the article they cite the need to get the pH>4 to get healing–presumably that’s as measured in the lower portion since that’s the most acidic.

The Australian study measured the lower portion, so the glandular region.

[Peggy]

Possibly random fact regarding dosing of Gastr/Ulcergard. (but I just remembered it)

One thing I learned from the vet who does all the scoping is that you want to make sure that you give each dose of Gastrogard/Ulcergard within 24 hours of the previous day’s dose. It only is designed to work for 24 hours so after that acid production starts up. She said about 30 minutes later was OK, but nothing beyond that.