Vet refusing to prescribe antibiotics without ulcer scope?

[soloudinhere]

I have a horse who, this time of year, for the last 3 consecutive years, has presented with muscle stiffness, grumpy behavior, general disagreeableness and discomfort.

Every time, the lyme titer has come back elevated, we’ve treated for 30 days, and he’s turned right around within a week. We are in northern CT, in a lyme endemic area.

This time, the vet is categorically refusing to prescribe antibiotics until the lyme assay is back AND he has been ruled negative for ulcers. She is insisting that any ulcers be treated first before antibiotics are considered. Even if we waited for the lyme titer to come back, she is insisting that she would have to come back to scope before confirming the lyme treatment.

Is this some new thing the vets have all discussed? I’m completely aghasted (to use an old COTH term) at the refusal to start antibiotics when in the past that was the first response to any suspected lyme or related illness. This is going to cost my horse another week or more without treatment since the assay won’t be back for 5 days, then the drugs have to ship, plus the stress of the scoping.

Scoping is going to cost me about $600. I have zero reason to believe this horse has ulcers. Even if he did, he would have suddenly developed them out of nowhere despite no significant changes to his diet, workload, or anything else at this time of year, which is the same time of year that he’s had this issue, and also coincidentally peak tick season. He is on high quality, low sugar grain + ration balancer, free choice hay, gets 9+ hours a day of turnout, and is generally a calm, tractable, very relaxed horse. He is eating normally and is an absolute food hound.

WWYD?

[Posting_Trot]

Is this a vet who has treated the horse before? Does the vet know that the horse has a history of Lyme disease?

Truthfully, in your shoes, I’d find another vet. My previous horse had Lyme three or four separate times, and the first time, basically the vet simply didn’t believe that Lyme was a problem for horses and refused to test. I (eventually) changed vets and one of the first things the new vet did was a test for Lyme. My horse’s numbers weren’t crazy high, but she definitely responded to treatment. Unfortunately, that was about 7 months after the initial problems, plus over a thousand in vet bills chasing other possible causes.

Good luck.

[supershorty628]

On the other hand… antibiotic resistance is a problem that has been exacerbated by overprescribing antibiotics when they might not be indicated. More judicious use of antibiotics (like confirming that they’re actually indicated) is one way to slow that problem.

I’m not saying that’s the case with your horse here given that you pulled blood for a titer too, but I wouldn’t say it’s necessarily bad medicine either without more information.

[Heinz_57]

I have zero experience with lyme - but that seems a little odd to me. Did the vet offer an explanation as to why ulcers are suspected or need to be ruled out before starting?

Only thing I can think of is she suspects he may have them and that it may somehow interfere with treatment, OR that the abx might possibly make the ulcers worse or bleed?

”‹”‹”‹”‹”‹”‹”‹I would at least consult another vet to see if it’s reasonable.

[joiedevie99]

Nope. My vet will generally wait for the test to come back, but not necessarily so in the case of a repeat offender.

[soloudinhere]

@Posting Trot

Is this a vet who has treated the horse before? Does the vet know that the horse has a history of Lyme disease?

Truthfully, in your shoes, I’d find another vet. My previous horse had Lyme three or four separate times, and the first time, basically the vet simply didn’t believe that Lyme was a problem for horses and refused to test. I (eventually) changed vets and one of the first things the new vet did was a test for Lyme. My horse’s numbers weren’t crazy high, but she definitely responded to treatment. Unfortunately, that was about 7 months after the initial problems, plus over a thousand in vet bills chasing other possible causes.

Good luck.

I have used the same vet for the 3 years I have had the horse. She has been involved in both previous lyme episodes.

I did decide to cancel his appointment and move on to another vet. After some thought, I felt the diagnostic approach was unnecessarily aggressive, risky to the horse, and expensive when he could easily be treated for ulcers if there is a suspicion.

I’d be fine waiting for the titer to come back but I was pretty surprised by the vet’s abject refusal to just wait for the titer results and the absolute insistence that a horse who is presenting as classic lyme and identically to the previous two years, absolutely must have ulcers. There was some other content in her emails that made me raise my eyebrow, but it’s basically irrelevant to the root of the situation.

[beowulf]

I’m sorry to hear that, and think I’d swap as well.

A scope is not exactly a stress-free or cheap request! And in that scenario I am not sure it would be covered by insurance since it would seem extraneous to the insurance company… I wouldn’t put my horse through it either.

I do understand the reticence in prescribing ABXs “willy-nilly” – but in this case it sounds as if this is a horse who has a “routine flareup” every fall. Sounds like all involved are familiar with this horse.

Did the vet explain why? Was she worried the ABXs would cause ulcers? What ABXs?

My vet always gives the warning any time doxy (or other lyme treatments) are used that it is very hard on the stomach. His practice won’t require you scope, but his vets do push you put the horse on an ulcer treatment program while treating for lyme. Maybe your vet is of a similar thought but wants to see evidence on paper first.

Either way, I wouldn’t find that request reasonable either. And I am generally someone who trusts my vets judgment and will A-OK most all procedures if they feel it is necessary.

As a slight tangent, you are in an area that is neighboring me, and there is one practice here I will not use because I find their diagnostic approach unnecessarily expensive and a “throw everything at the wall to see what sticks”. They cater to a certain clientele that is well beyond my wallet’s depth, so that does color both the prices and the diagnostics they are willing to use. It’s a big practice, with lots of very nice barns in my area using them – but I was shocked to learn this practice requires every Adequan/Legend/Whatever script to be accompanied by fresh set of x-rays every time you buy the Adequan. For joint injections, I totally understand a vet wanting to see how the joint is doing on film first… but for an Adequan script…? Wow. Some vet practices do upsell when they have a certain class of clientele.

[Equibrit]

You may find this an interesting read;
https://aaep.org/sites/default/files/Guidelines/Borrelia_burgdorferi_and_Lyme_disease_Guidelines_2020.pdf

[soloudinhere]

@beowulf

I’m sorry to hear that, and think I’d swap as well.

A scope is not exactly a stress-free or cheap request! And in that scenario I am not sure it would be covered by insurance since it would seem extraneous to the insurance company… I wouldn’t put my horse through it either.

I do understand the reticence in prescribing ABXs “willy-nilly” – but in this case it sounds as if this is a horse who has a “routine flareup” every fall. Sounds like all involved are familiar with this horse.

Did the vet explain why? Was she worried the ABXs would cause ulcers? What ABXs?

My vet always gives the warning any time doxy (or other lyme treatments) are used that it is very hard on the stomach. His practice won’t require you scope, but his vets do push you put the horse on an ulcer treatment program while treating for lyme. Maybe your vet is of a similar thought but wants to see evidence on paper first.

Either way, I wouldn’t find that request reasonable either. And I am generally someone who trusts my vets judgment and will A-OK most all procedures if they feel it is necessary.

As a slight tangent, you are in an area that is neighboring me, and there is one practice here I will not use because I find their diagnostic approach unnecessarily expensive and a “throw everything at the wall to see what sticks”. They cater to a certain clientele that is well beyond my wallet’s depth, so that does color both the prices and the diagnostics they are willing to use. It’s a big practice, with lots of very nice barns in my area using them – but I was shocked to learn this practice requires every Adequan/Legend/Whatever script to be accompanied by fresh set of x-rays every time you buy the Adequan. For joint injections, I totally understand a vet wanting to see how the joint is doing on film first… but for an Adequan script…? Wow. Some vet practices do upsell when they have a certain class of clientele.

The proposal was minocycline.

My feeling on it was if ulcers were suspect, it would cost the same amount to do a full course of ulcergard + sucralfate as it would the scope, with a much better end result for the horse for the same $600.

Basically her reasoning was if he’s not positive for Lyme, the abx weren’t required and I would have her back out to scope so she was saving me money. If he is positive for both then you have to treat both. In her mind there is no possibility that ulcers are not involved.

When asked about hindgut (since she wouldn’t see that on the scope) the response was ambiguous. I saw the only outcome of this that I scope for $600 and it doesn’t actually tell us anything, so she tells me we need to treat for hindgut anyway, which we could have done with a $129 bottle of sucralfate and less stress on the horse.

I appreciate the idea of not medicating unnecessarily but I thought waiting for the titer was a fair response - and when she said that insurance would cover it I got a little suspicious.

I had a lengthy conversation with the vet at another nearby practice and explained the situation - she said she would have zero issue starting him on even IV oxytet right away if the owner said there was a history of seasonal flare. Oral doxy absolutely no issue.

Not that I pick my vets by drug shopping but I’ve had horses for 25+ years and I know this horse inside and out. I like a vet that works with me, not throws my checkbook at the horse.

[Posting_Trot]

I’m glad you’ve gone with another vet.

I wanted to add to my story above that I’ve always felt (without hard evidence) that the delay in getting that first bout of Lyme disease treated had some long-term impacts on my horse’s health. She continued to experience some body-soreness, became more cold-backed, and perhaps also made it easier for her to be re-infected (or else it’s possible that she never truly cleared the disease).

(Just to be clear: as part of “chasing the other possible causes” that I mentioned in the first post, she had an extensive work-up at a vet clinic including a bone-scan that showed nothing aside from, in the soft-tissue stage, some inflammation/soreness. So, we were reasonably confident that bone-chips, kissing spine, significant arthritic changes, etc. were not the cause).

[soloudinhere]

@Posting Trot

I’m glad you’ve gone with another vet.

I wanted to add to my story above that I’ve always felt (without hard evidence) that the delay in getting that first bout of Lyme disease treated had some long-term impacts on my horse’s health. She continued to experience some body-soreness, became more cold-backed, and perhaps also made it easier for her to be re-infected (or else it’s possible that she never truly cleared the disease).

(Just to be clear: as part of “chasing the other possible causes” that I mentioned in the first post, she had an extensive work-up at a vet clinic including a bone-scan that showed nothing aside from, in the soft-tissue stage, some inflammation/soreness. So, we were reasonably confident that bone-chips, kissing spine, significant arthritic changes, etc. were not the cause).

With the exception of this issue, this horse is incredibly sound, healthy, not sore at all, and there’s nothing to indicate another cause. Even right now he’s still working pretty willingly it’s just because he’s usually SO happy go lucky that we thought something was wrong. If he had a flaw, it’s that his immune system is not great and he has skin allergies that make him very susceptible to…bug related illnesses and infections.

Last year when this happened we x rayed everything, treated for ulcers, had the hocks done, ironically the same vet never suggested a scope for him last year but about $3500 of other work was done. The only thing that turned him around was the first 3 days of abx.

The delay caused me some serious concern because it’s been about 3 weeks since this started creeping up and then it would be another month to start treatment. That is a long time in a spirochete infection.
”‹”‹”‹”‹

[Simkie]

That’s bizarre. I’m also in CT and just treated a horse with a dose of oxytet and then 30 days of mino without even having the vet OUT, based 100% on symptoms. I’m glad to hear you’re going with someone new–what your current vet is proposing is…crazy.

Hope your horse has a speedy improvement!

[soloudinhere]

@Simkie

That’s bizarre. I’m also in CT and just treated a horse with a dose of oxytet and then 30 days of mino without even having the vet OUT, based 100% on symptoms. I’m glad to hear you’re going with someone new–what your current vet is proposing is…crazy.

Hope your horse has a speedy improvement!

That was really what I was expecting and was surprised to go the complete opposite direction.

I’ve switched him over to a major practice in our area - pluses and minuses, but the cost is about the same.

[Ghazzu]

That’s just plain bizarre.
The DVM is free to recommend gastroscopy to r/o ulcers, but to refuse to treat the Lyme if the client declines the scoping is a bit beyond the pale.
Especially if you were willing to treat for ulcers empirically.

[LuvEquines]

Get a new vet. I worked for vets and as a surgeon. “Stacking the bill” has become too common. Both my horse and dog vets don’t do it because I won’t allow it. They know I’ll just go around them or get another vet. I’m way too smart to have useless procedures pushed on me.

[soloudinhere]

For anyone following this saga, the horse in question turned around within a week of doxycycline treatment and has shown no indication of ulcer behavior - but we did give him a month’s worth of esomeprazole just in case.

He is back to 100% normal, and we have a new vet.

[WildLittleWren]

It sounds like you made the right call. I, too, find it bizarre that the vet refused to treat with the history she has on the horse. Glad you were able to get him some relief.

[Posting_Trot]

That’s good news. It sounds like you made the right call.