Bute Vs. Equioxx: Tradeoffs

Because it's a good time to learn about things, right?

I recently had the unfortunate but useful opportunity to compare the results of the two most commonly used equine NSAIDs (Non-Steroidal Anti-Inflammatory Drugs; bute & Equioxx) on the same injury -- Echo's shoulder.  There are pros & cons to each.  Because I firmly believe in making the most informed decisions possible, let me share with you what I learned.

Background

Heat, pain, & swelling are the result of the body's inflammatory cycle.  One of the primary mediators of this cycle is a group of prostaglandins created by cyclooxygenase (COX) enzymes, which convert a substance interestingly named arachidonic acid (does it have spiders in it?).  There are different varieties in this group, referred to by number:  horses have COX-1 & COX-2, while humans have additional variants.  NSAIDs aim to break the inflammatory cycle by inhibiting the production of these enzymes, during which the body can break down harmful prostaglandins which have already formed (which takes about 12 hrs).

As you might suspect, COX-1 & COX-2 have different functions.  COX-1 plays important roles in things like maintaining stomach mucous coatings, keeping blood flowing through kidneys, & coagulating blood.  COX-2 is only found at low levels in normal tissues, but levels surge when that inflammatory process begins & COX-2 feeds that cycle. 

A simplified illustration from previcox.com; click to embiggen

Drugs

Bute refers to phenylbutazone, our old friend which has been around for decades.  It's cheap & fairly effective for pain management.  Given orally, it takes about 2-3 hrs to absorb from the belly & peaks in 3-5 hrs.  Persisting about 12 hrs, bute blocks both COX-1 & 2 production.

Equioxx is a brand name of firocoxib, a newer drug that is known in the canine world as Previcox.  It was developed for the treatment of osteoarthritis.  It's also given orally by owners, but is much slower to take effect.  It takes at least 24 hrs for levels to begin to peak & does not reach steady state for 4-6 days.  It also has a half-life of 44-46 hrs, so it takes an additional two days minimum to disappear after you stop giving it.  Firocoxib is a selective COX-2 inhibitor, which means it preferentially blocks COX-2 but still has a minor effect on COX-1.

Choices & My Observations

It just so happened that I was able to directly compare the two as Echo was on bute for the first week of his shoulder pain, then on Equioxx for a second week.  Pros & cons:

Bute Pros:

• Much more effective pain control (side note: I've heard the same from others)
• Significantly more rapid action - both to start & finish.  The latter can be especially important if you need to take a lame horse to the vet the next morning & you need the pain unmasked for an exam.
• Relatively cheap
• Easy to give -- even picky Solo will usually eat it on his food.  If they start refusing it after multiple days, I just dump it in a syringe with a little water & shoot it in their mouth.

Bute Cons:

• Blocking both COX-1 & 2 is what brings about the higher incidence of GI issues with bute.  This is why I switched to Equioxx, as Echo had already been on bute a lot for his foot bruise & I was beginning to see ulcer signs.

Equioxx Pros:

• Primary benefit is its selective COX-2 action:  this spares the GI tract some abuse, as well as protecting other COX-1 processes (cartilage maintenance is another one not mentioned above).
• Also pretty easy to give as a tablet -- Echo snarfed it up when I put it in my hand with a little grain.  I've also heard of people stuffing them in cookies or gumdrops.  Just don't let other humans eat the gumdrops.  I've also heard of that happening once, LOL.

Equioxx Cons:

• I saw significantly less pain control that definitely seemed better suited to something milder like arthritis.
• Slow action, both to kick in & withdraw.  
• Not cheap -- I did find (too late for me) that it was significantly cheaper online than through my vet.  Vet also did say that he did the math & it was actually cheaper per hour of pain control than bute was.  I believe him, but almost $2 a pill still hurts me.

Related note:  Equioxx & Previcox are both firocoxib.  Because Previcox can be cheaper, many people use it for their horses & just divide pills themselves.  However, be aware, it is now illegal, through the FDA, for a vet to give Previcox for a horse.  This is because accurate dosage for firocoxib is important to avoid adverse effects & it's very easy to over- or under-dose when manually dividing dog tablets.  This legal change occurred around 2016, when the tablet form of Equioxx became available; here is a good explanation.  I'm not going to call the drug police on you, just informing. 

One more note:  I learned from the Equioxx package insert that all NSAIDs have the potential to also block the prostaglandins which control body temperature.  This isn't common, but is something to keep an eye on if something goes awry.

Take Homes

Just like pretty much all of life, there are tradeoffs with each option, but I hope this will help you better understand which might work best for you.  I still consider bute my first line tool in acute pain control due to its strength & speed.  However, if you need to give an NSAID for a long period of time or are treating a horse who already has ulcers, Equioxx may be a more appropriate choice to protect GI tracts.

If you really want to dig in, here is a really nice paper from the Journal of the American Vet Med Association from 2017 on the COX enzymes & use of selective COX-2 inhibitors.

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Disaster Horse Votes No To Boring

Without doubt, we are in tumultuous times.  Echo the Disaster Horse did not want to be left out of this & had no interest in my plea to be boring.  Not that I thought he actually would.

Right after my last post, he galloped around the pasture like an idiot & re-aggravated whatever he did to his shoulder.  Two weeks later, he still has some lingering soreness.  Vet says it's possible he bruised a nerve, which will take a little longer to heal.  I wish that was our biggest concern.

About 9 days ago, last Sunday morning, Echo was just looking kinda sorry for himself at breakfast.  I took his pulse on a whim & it was a bit elevated, so I took his temp & discovered he had a fever of 101.8 F.  He was already on Equioxx, so I consulted vet & he said go ahead & give bute if the fever gets higher.  At 102.1 F, I went ahead. 

The bute did control the fever well & Echo perked up, but then Monday night, I went out to give the horses their midnight snack of alfalfa cubes only to find the poor kid was completely covered in hives.  As in, his whole body looked like furry cottage cheese & his neck felt hard as a rock, I have never seen anything like it -- even his butthole had hives on it.  He was extremely tolerant of me shoving my shaking hands up his nose to make sure he still had an airway while I dialed the vet emergency line yet again. 

Gee, mom, you didn't actually want to sleep ever, did you??

A few doses of dex took care of that & we never did determine exactly what he reacted too.  It wasn't fire ants (no bites), he had no changes in food (not even a new bag) -- the best guess is maybe a wasp sting but invisible aliens are equally plausible.  At this point, I had no idea what was going on & took him in to the clinic to figure out what the heck to do before I had an aneurysm.

Long story short, blood work came back showing a possible bacterial infection (origin unknown).  Even though the fever had quit by Wednesday, vet prescribed a course of SMZs, which we've just finished.  In addition, & completely unsurprisingly, he also has some acute ulcers from the on-and-off bute over the last few months for his foot bruise.

Baby Monster, you be killin' me.

I have UlcerGuard on order & will be stalking the tracking number, since Echo is now off his feed & he doesn't have weight to spare.  After the last 10 days, I'm off my feed too!  Until it gets here, I'm offering him soaked alfalfa cubes & anything else he will pick at -- at least I have grass coming in & he is grazing some. 

Alfalfa slurpies

I have been itching to get him back into work, as he has lost all that muscle & weight I put on him last fall & he just does better overall when he is doing SOMEthing.  But I don't have the heart to ask him to do anything extra with a sore belly sloshing around, especially when I can't even give him any painkillers.  I'm even afraid of the Equioxx now, which will take a whole 'nother post to get into.

I am absolutely grateful they are at home with me right now & that Echo can at least keep himself mobile since they live out.  I think Solo is also grateful Baby Monster is wayyyyy less annoying right now.  And at least I can keep a close eye on him since I am working from home most of the time right now.

I hope you all are staying safe out there & I hope all your horses stay very very boring! 

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Update On Disaster Horse

Maybe that should be his new name...

Echo's shoulder has improved some this week.  I'm leaning heavily towards it being a kick & have absolutely no doubt that he was asking for it (he basically always is).  Reason being, he has shown no protest to me extending the leg & he did a big "downward dog" stretch himself this morning, which I don't think he'd be that in to if he had pulled those muscles.

He still has a lump there, although it's reduced a bit, which I'll continue to SoreNoMore, but plan on tapering back the bute & seeing what happens.  He's moving much better, I don't see any more tightness in his walk & he trotted up for his late-night snack last night.

I briefly got on him bareback this morning, just to walk him around & get a feel for things, as that can often give me a lot of information.  I didn't feel anything from that bruised foot (granted, he was still on bute, but that doesn't hide everything), which is good, & got no real resistance from the shoulder.

On Thursday, farrier removed the glue-on boots & put him back in the flip flop pads.  So far, he's looking pretty comfortable in them, which confirms that his initial discomfort with them last time was in fact that it was a suddenly firm surface under that bruise.  He's made enough healing progress now that it no longer bothers him.  We did use race nails (thinner/lighter) in the shoes this time, just for cautious bet-hedging. 

They're back (altho this weird-angle pic is from the first round)

Thanks to the commenter on that post who gave us a perfectly timed tip:  the EasyCare flip flop boots CAN be reused!  We pried them off intact with a screwdriver (by the way, the Adhere glue worked perfectly for 5 weeks).  The adhesive stayed stuck to the hoof, so the boots came off clean & ready to go if I ever want to use them again.  If adhesive does stick to the boot, it can be easily dremel-ed off.  This at least made the price slightly less painful -- if you get two cycles out of them, that's $30 a cycle, which is still a bit high, but much closer with other plastic/rubber/polyurethane footwear.

I am happy with the boots' performance overall:  they stayed on (always critical), tread still looks good, horse moved normally (you know, for a creature with 3 functional legs).  I would definitely add the pour-in material in the toe in the future, as there is just no way to get gunk out of there & there was some moisture trapped in there when we pulled them (we've been in a rainy period).  Echo's feet were healthy when they went on, so no harm done, but pad material would help prevent that buildup.  Alternatively, you could probably cut out some sole "windows," the way we've done with the pads, because the material is pretty sturdy (caveat, I haven't tried this, but I bet someone has).  

Please, Echo, can we just be boring for a while?

Discovering spring grass a couple weeks ago

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Unlucky People Shouldn't Own Unlucky Horses

Echo insists on continuing to demonstrate his talent...for misfortune.  Combined with my own terrible luck, I feel like we are stuck on a moebius strip of exasperation.

You know his left front leg, the one with the bruised coffin bone at the end of it?  Well, it had been showing some improvement...until yesterday.

I came home from work to find him limping anew.  I initially thought we had somehow aggravated the foot on the short, walking trail ride I ponied him along on Sunday.  Oh no -- now he has done something to the shoulder ON THE SAME LEG!

I found a big, hard lump just behind his scapula that foamed up white as soon as I put SoreNoMore on it (which can be an indication of elevated temperatures which go along with inflammation/spasm in the muscles, which arnica reacts to).  At this point, my hypotheses are either:

1. Solo kicked him.  Which I have absolutely no doubt Echo deserved, so I couldn't even be irritated at Solo.  If you get kicked by Solo, it's only after you have ignored countless warnings, which are not subtle.  Echo is not one to take warnings seriously if he feels entertained.  There wasn't a mark, but Solo is barefoot. 
2. Echo torqued the shoulder playing Wild Rearing Plunging Mustang games.  Equally possible.

He didn't react at all when I poked it.  I've seen him roll & get up just fine & he's weight-bearing.  He had no problem with me lifting the leg, extending it in front of him, rolling the shoulder around in its joint.  Which is a little baffling, but at least tells me he didn't break a rib (or anything else) & he didn't dislocate the shoulder.

At least one piece of my tack is getting some use

I'll give him a few days with bute & rest -- oh wait, he was already resting, gahhhh.  If he doesn't improve much with that, then I'll call my poor, harassed vet again.  I'm cautiously hopeful it looks like nothing too major right now, as the lump had softened when I got home from work today.  I put some ice on it this afternoon, although I'm not sure it can penetrate much in an area with so much body mass.

Hopefully he will decide to quit all this nonsense before I forget how to ride a horse.  The key to preventing this kind of stuff is strengthening soft tissues through fitness -- which is a little hard to do when you can't work them.  That hollow, thumping sound you hear is just my skull hitting the table repeatedly.  I'm thinking it would be smarter to trade him in for a pet turtle -- it takes some serious effort to break a turtle. 

Can someone just pat my head & possibly pour some libations down my throat??

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Two Suppling Exercises For Any Gait

Echo & I are just doing sporadic walking with occasional short trot spurts (less than 10-15 steps) currently, as I wait oh-so-impatiently for his foot to heal.  It bores both of us, but there are endless opportunities to work on important basics.  Things like lateral cues, contact & balance in transitions, responsiveness to aids.  We learned some new simple schooling exercises from Trainer Neighbour last fall -- here are two of them that I have been using very frequently.  Both can be done at any gait.

Exercise 1:  Stretchy Turn On Haunches

I just made up that name for it.  This one has been excellent for Echo's devotion to curling behind the bit.  Prerequisites:  you need control of your horse's shoulders such that you can move them sideways.

Walk on a long or loose rein.  When you are ready to turn on the haunches (TOH), shorten your reins up.  Then ask the horse to move his shoulders around to reverse direction.  I'm calling it TOH, but it doesn't have to be a perfect, hind feet immobile, thing.  The important part is mobilizing the shoulders & feeling them step around.

When direction is reversed, immediately slip your reins back out & if the horse has actually used himself, he should stretch over his topline, reaching down & out.  I was amazed that this worked immediately with Echo.  I had never done or tried to do TOH with him before, just taught him to move his shoulders around at the walk.

The words aren't exactly in the right place, but you get the idea

Repeat the exercise as desired.  You are looking for the shoulder motion in the turn & then for the stretch when you slip the rein.  I find this very effective in warm up.

At the trot or canter, I use an abbreviated version, without the rein slipping, if Echo starts to curl again. Just bring the shoulders sideways for a step or two, which shifts his balance & uncurls him.  You could probably also encourage a stretch this way, but I haven't had a chance to try it yet.

Exercise 2:  Spiral Circles

This is a variant on the classic spiral that I find helps keep the horse moving better so they don't get "stuck" in a circle.  Simply incorporate small circles (whatever is appropriate for your horse) all around your work area.  But as you get to the last 1/3 of the circle, cut in a little, then leg yield back out to your track.  Diagram, because words are confusing:

Arrows are where you leg-yield out, I just failed to angle them enough

I also like to incorporate transitions within a gait in these.  For example, if posting the trot, compress the horse into a sitting trot for the circle.  Or just half the circle.  Or just the leg yield.  Alternate.  You get lateral & longitudinal suppling this way, along with balance & strength work.

You can also add in shoulder mobilization to these circles, a couple steps here & there.  Keep them separate from the leg yields, so your aids are distinct (unless your horse is wayyyy more advanced than mine, in which case you probably don't need this post, ha).

Tell me about your favourite exercises -- especially if you have uncurling tricks!

Evidence from last fall: uncurling after some spirals

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