Emergency Treatment for Laminitis
Identify and remove/treat the cause, and support and realign the feet
Follow these emergency procedures if your horse is showing any signs of laminitis, or if you suspect your horse may develop laminitis, for example if a previously laminitic horse has escaped into long grass.
More information about recognising and treating laminitis: www.thelaminitissite.org/Laminitis
Follow these emergency procedures if your horse is showing any signs of laminitis, or if you suspect your horse may develop laminitis, for example if a previously laminitic horse has escaped into long grass.
- CALL YOUR VET (and farrier/trimmer). Ask for x-rays to be taken. Establish the cause of the laminitis and remove/manage it.
- Remove horse from grass but SUPPORT FEET BEFORE MOVING & MOVE AS LITTLE AS POSSIBLE. If the horse cannot move, make a temporary small stable sized enclosure around him/her and put down some bedding and/or pad feet.
- Confine on deep conforming bedding, ideally sawdust (soaked wood pellets) or sand (but guard against sand colic), otherwise shavings.
- Support the feet if the bedding isn’t sufficient to do this, e.g. with EVA foam, boots and thick soft pads, styrofoam, padding the whole bottom of the foot (not just the frog) to maximize weight bearing and support the pedal bone.
- Feed a low sugar/starch diet based on soaked hay plus a mineral supplement/balancer and salt. The combined sugar and starch content of the diet should be below 10%, with each feed also below 10% if possible (apart from balancers).
- Medication - your vet may advise NSAIDS e.g. Bute, Danilon, Equioxx to reduce pain. Check Prascend dose is adequate if PPID diagnosed. Metformin?
- Have feet trimmed to (start to) restore the palmar angle to 3-5 degrees, bevel breakover at the toe to the outer edge of the true white line and bevel the outer wall to reduce separating forces on the laminae.
More information about recognising and treating laminitis: www.thelaminitissite.org/Laminitis
These suggestions relate primarily to endocrinopathic laminitis. Horses with sepsis-related or supporting limb laminitis are likely to already be receiving intensive veterinary treatment and/or be in a clinic.
1. CALL YOUR VET and farrier/trimmer
If this is the first time the horse has had laminitis the vet should be called as an emergency. Because correct foot balance/alignment and support are so important, your farrier/trimmer should also be called or at least alerted.
If the horse is at risk of, but hasn't actually developed, laminitis, you may not need to call the vet as an emergency, but both vet and farrier should be kept informed of the situation. However, be aware that research has shown that many owners do not recognise laminitis, and it is always best to ask your vet to come out.
X-rays should always be taken at the first signs of laminitis. By the time clinical signs of laminitis are seen, abnormal changes have taken place in the laminae. It is not uncommon to find rotation when x-rays are taken of the feet of horses with insulin dysregulation that have not been obviously lame. The sooner rotation, or more accurately the misalignment of the hoof capsule with the pedal bone, is recognised and corrected, the quicker the horse is likely to recover, and very often the less serious the laminitis will be. Probably the most common mistake we see is waiting to take x-rays, thereby keeping a horse in pain and potentially increasing the risk of further damage to the feet, rather than having x-rays taken and realigning the feet in the first couple of days after signs of laminitis are seen.
The type of /cause of the laminitis must be established, as this affects treatment. The 3 types of laminitis are:
- endocrinopathic - by far the most common form of laminitis, due to above normal insulin (insulin dysregulation), often triggered by the sugars in grass (also called pasture associated laminitis). Horses should be tested for (and assumed to have) EMS, and tested for PPID if they are >10 years old and/or showing any clinical signs of PPID. Having recently had corticosteroids treatment can also cause insulin dysregulation and increase the risk of endocrinopathic laminitis.
- sepsis related - where the horse is already very sick and develops laminitis as a result. The horse will often be under the care of a vet before laminitis is seen.
- supporting limb laminitis - where the horse is already seriously lame on another leg and develops laminitis as a result of not being able to weight the lame leg, usually due to a fracture or septic joint (an abscess wouldn't cause this). The horse will almost certainly be under the care of a vet before laminitis is seen.
For more information about the 3 types of laminitis, see What causes laminitis?
Horses suspected of having endocrinopathic laminitis should have insulin tested (always), ACTH (if PPID is suspected or if aged 10 or more), glucose (not diagnostic but can add information to an EMS or PPID diagnosis), and perhaps adiponectin.
If PPID is suspected or diagnosed, treatment with Prascend/pergolide may be necessary to reduce insulin, but all cases of endocrinopathic laminitis will benefit from a low sugar/starch diet and gradual weight loss if necessary.
2. Remove the horse from grass.
Grass can contain high (and unknown) levels of sugar and is often the trigger for endocrinopathic laminitis. During active laminitis the horse should be completely removed from grass, or if this is not possible, restricted in a very small (stable sized) area of the field with as little grass as possible.
If you have just discovered a horse with laminitis and need to remove him from the grass, ensure his feet are fully supported and walk him as little as possible to do this - consult vet and farrier first if necessary. This may involve using a trailer with supportive bedding to move him from field to stable, and/or fitting thick pads (see EVA foam pads and Sole support). Ensure stress and pain are kept to a minimum. Be aware that if the horse is in pain from laminitis, this is likely to mean that the connection between hoof and bone is compromised and therefore there is a considerable risk of rotation/sinking, likely to be made worse by movement - take every step possible to reduce movement. If walking is unavoidable, ensure the feet are well padded to allow weight bearing on the structures in the less-painful back of the foot, and keep to soft ground, if necessary making a path of sand/sawdust/mud/rugs/carpet/rubber mats for the horse to walk on.
3. Confine the horse on deep conforming/supportive bedding.
The bedding must pack right into the feet to spread weight bearing as much as possible. Sawdust (wood pellets that are soaked to make a sawdust bed) and sand are very good - if using sand, be aware of the risks of sand colic and avoid feeding on sand. If using sawdust, be aware that this can become quite hard - ensure it remains soft and conforming by raking frequently. Shavings are less supportive but may be acceptable if deep, and/or if pads are used. Straw is not good bedding for laminitis, it is not supportive enough and horses may eat it - if it contains seed heads it can be quite high in starch. Pea gravel can be good but often later in the rehabilitation, and may not be suitable for horses with thin soles.
The horse should be encouraged to lie down and get the weight off his feet as much as possible.
If he is stressed by being alone, ensure he has company nearby but not close enough to make or encourage him to move.
Keep food (e.g. soaked low sugar/starch hay or low sugar chaff) and water near by and ideally above ground level to reduce pressure on the front feet.
4. Support the feet.
With laminitis the laminar connections between the hoof wall and the pedal bone stretch and weaken, so the walls, usually particularly at the front of the foot, are no longer fully connected to the pedal bone and therefore skeleton, and cannot hold up the horse's weight - asking the walls to bear weight is likely to increase separating forces on the laminae and increase the risk of rotation and sinking of the pedal bone. The horse should be encouraged to bear most of his/her weight on the structures in the back of the foot - the frog, heels, bars and sole. Supporting the feet aims to spread and maximize weight bearing at the back of the foot and support the pedal bone in the front of the foot.
Support the feet with padding if the bedding isn’t sufficient to do this - it's always worth trying pads even with good bedding, many horses are more comfortable with correctly applied pads. EVA foam, boots with thick soft pads, styrofoam, impression material are all possible materials - see EVA foam pads and Sole support. The full solar surface of the foot should be supported, not just the frog.
On p 351 of Care and Rehabilitation of the Equine Foot Pete Ramey says “at the first signs of laminitis, restore P3 to a more natural ground plane” (e.g. a 3-5 degree palmar angle), “relieve pressure on the walls and pad the sole with foam rubber – vertical sinking and destructive pressure to the solar corium can be prevented”. Where sole depth is <7 mm, hollowing out an air space directly beneath the rim of P3 in the pad next to the foot may increase comfort.
5. Feed a low sugar/starch diet based on soaked hay plus minerals and salt.
The diet should:
contain less than 10% combined sugar and starch;
provide all essential protein, minerals, vitamins and essential fatty acids (feeding a balancer e.g. Spillers Lite + Lean plus salt will usually be adequate);
be based on forage, e.g. soaked or analysed hay, analysed haylage, low sugar/starch chaffs or feeds like unmolassed sugar beet or soya hull mash;
be fed at the rate of between 1.5 and 2% of the horse's bodyweight, depending on the energy content of the feed and the need for weight loss.
Assess the horse's body condition and adapt the diet according to whether weight needs to be lost or maintained. If weight needs to be gained - usually because a horse has PPID - aim for weight maintenance until the laminitis is controlled (pain controlled and insulin normal or reduced) before increasing calories (and consider the reason why weight needs to be gained, e.g. undiagnosed PPID).
Never feed below 1.5% of the horse's bodyweight without supervision from an expert vet/nutritionist, and use slow feeder methods if doing so to minimize the length of time the horse has nothing to eat, and therefore reduce the risk of gastric ulcers.
The sugars that increase insulin and that should total less than 10% of the diet are simple sugars, also called ESC (ethanol soluble sugars - glucose, fructose and sucrose) and starch. Fructans do not increase insulin. WSC and NSC are measures of carbohydrates that include fructans, and are not accurate. Ask feed manufacturers to analyse and report simple sugars/ESC and starch.
Please read Feeding horses with laminitis/EMS/PPID.
6. Medication - NSAIDS, pergolide/Prascend, Metformin?
NSAIDS (non-steroidal anti-inflammatory drugs) e.g. Bute, Danilon, Metacam have historically been the mainstay of laminitis treatment. However, it is now known that, unlike sepsis related laminitis, endocrinopathic laminitis involves little or no inflammation, therefore "anti-inflammatory medications may only be useful for their analgesic properties in this form of laminitis, and may not alter progression of the disease" (de Laat et al. 2011). Your vet may prescribe NSAIDs for a few days to reduce your horse's pain, but if pain is not significantly reduced within a week, check whether the cause of the laminitis has truly been found and treated/removed/managed, and/or that the feet have been/are being correctly realigned and supported. Very often correctly realigning and supporting the feet, and reducing separating forces on the less-than-well connected laminae, will bring an immediate reduction in pain.
Pergolide/Prascend - if a horse has been diagnosed with PPID, check that the current level of treatment with pergolide/Prascend is fully controlling the PPID (note that treatment with pergolide alone may not control insulin dysregulation in horses with PPID, and that management for EMS - a low sugar/starch diet and weight loss if necessary - is also likely to be essential). Note that many horses with PPID benefit from an increased dose of pergolide during the seasonal rise (approximately mid July to mid November in the northern hemisphere). Horses with clinical signs of PPID may benefit from a trial of pergolide/Prascend if the PPID could be driving the insulin dysregulation and laminitis. Ideally blood should be taken and tested for ACTH and insulin before starting treatment, but pain will increase both ACTH and insulin, and it is most important to bring the laminitis under control. If necessary the horse can be weaned off the pergolide and tested for PPID once the laminitis is fully controlled.
Metformin - for a while Metformin was considered a possible treatment for reducing blood glucose and therefore insulin levels. However, recent research has suggested that "the potential benefit of these effects [giving Metformin] in horses fed appropriate forage that is low in nonstructural carbohydrates versus more glycaemic diets, such as grass, forage with a high nonstructural carbohydrate concentration and cereals, may be questionable". So compliance with a low sugar/starch diet, and weight loss if necessary, are likely to be the most important factors in controlling insulin dysregulation. If this is not possible, then short-term treatment with Metformin may help reduce glucose and therefore insulin levels, but aim to make changes to diet and management long-term, and be aware that Metformin is not licensed for horses, therefore side effects are not recorded, and owners have reported seeing mouth ulcers when Metformin is given by syringe.
7. Trim to realign the feet (if necessary) at the earliest opportunity.
Do not wait - it is having the hoof capsule out of correct alignment with the pedal bone that is likely to cause/increase pain.
Restore the palmar angle to around 3 to 5 degrees (guided by the live sole plane and collateral groove depths), bevel breakover at the toe to the outer edge of the true white line, and bevel the outer wall at least from quarter to quarter to reduce separating forces on the laminae. Where the sole is thin, the heels must be beveled by floating the rasp above the front of the foot, leaving the foot in 2 planes while sole depth in the front of the foot develops. The feet should continue to be supported as in 4. above, with weight bearing maximized in the back of the foot and minimized in the front of the foot.
See: Realigning trim
Recognizing and Treating Rotated Hoof Capsules
Laminitis and the Feet.
8. Apply cold therapy
Icing the feet/applying cold therapy (cryotherapy) has been shown to prevent or reduce the progress of sepsis related laminitis. It is not yet known whether applying cold therapy in cases of endocrinopathic laminitis is helpful. The problem is likely to be that by the time signs of laminitis are seen, the damage has taken place and the time when cold treatment may have been useful may have passed.
References
de Laat M, Sillence M, McGowan C, Pollitt C
Insulin-Induced Laminitis - An investigation of the disease mechanism in horses
RIRDC Dec 2011
1. CALL YOUR VET and farrier/trimmer
If this is the first time the horse has had laminitis the vet should be called as an emergency. Because correct foot balance/alignment and support are so important, your farrier/trimmer should also be called or at least alerted.
If the horse is at risk of, but hasn't actually developed, laminitis, you may not need to call the vet as an emergency, but both vet and farrier should be kept informed of the situation. However, be aware that research has shown that many owners do not recognise laminitis, and it is always best to ask your vet to come out.
X-rays should always be taken at the first signs of laminitis. By the time clinical signs of laminitis are seen, abnormal changes have taken place in the laminae. It is not uncommon to find rotation when x-rays are taken of the feet of horses with insulin dysregulation that have not been obviously lame. The sooner rotation, or more accurately the misalignment of the hoof capsule with the pedal bone, is recognised and corrected, the quicker the horse is likely to recover, and very often the less serious the laminitis will be. Probably the most common mistake we see is waiting to take x-rays, thereby keeping a horse in pain and potentially increasing the risk of further damage to the feet, rather than having x-rays taken and realigning the feet in the first couple of days after signs of laminitis are seen.
The type of /cause of the laminitis must be established, as this affects treatment. The 3 types of laminitis are:
- endocrinopathic - by far the most common form of laminitis, due to above normal insulin (insulin dysregulation), often triggered by the sugars in grass (also called pasture associated laminitis). Horses should be tested for (and assumed to have) EMS, and tested for PPID if they are >10 years old and/or showing any clinical signs of PPID. Having recently had corticosteroids treatment can also cause insulin dysregulation and increase the risk of endocrinopathic laminitis.
- sepsis related - where the horse is already very sick and develops laminitis as a result. The horse will often be under the care of a vet before laminitis is seen.
- supporting limb laminitis - where the horse is already seriously lame on another leg and develops laminitis as a result of not being able to weight the lame leg, usually due to a fracture or septic joint (an abscess wouldn't cause this). The horse will almost certainly be under the care of a vet before laminitis is seen.
For more information about the 3 types of laminitis, see What causes laminitis?
Horses suspected of having endocrinopathic laminitis should have insulin tested (always), ACTH (if PPID is suspected or if aged 10 or more), glucose (not diagnostic but can add information to an EMS or PPID diagnosis), and perhaps adiponectin.
If PPID is suspected or diagnosed, treatment with Prascend/pergolide may be necessary to reduce insulin, but all cases of endocrinopathic laminitis will benefit from a low sugar/starch diet and gradual weight loss if necessary.
2. Remove the horse from grass.
Grass can contain high (and unknown) levels of sugar and is often the trigger for endocrinopathic laminitis. During active laminitis the horse should be completely removed from grass, or if this is not possible, restricted in a very small (stable sized) area of the field with as little grass as possible.
If you have just discovered a horse with laminitis and need to remove him from the grass, ensure his feet are fully supported and walk him as little as possible to do this - consult vet and farrier first if necessary. This may involve using a trailer with supportive bedding to move him from field to stable, and/or fitting thick pads (see EVA foam pads and Sole support). Ensure stress and pain are kept to a minimum. Be aware that if the horse is in pain from laminitis, this is likely to mean that the connection between hoof and bone is compromised and therefore there is a considerable risk of rotation/sinking, likely to be made worse by movement - take every step possible to reduce movement. If walking is unavoidable, ensure the feet are well padded to allow weight bearing on the structures in the less-painful back of the foot, and keep to soft ground, if necessary making a path of sand/sawdust/mud/rugs/carpet/rubber mats for the horse to walk on.
3. Confine the horse on deep conforming/supportive bedding.
The bedding must pack right into the feet to spread weight bearing as much as possible. Sawdust (wood pellets that are soaked to make a sawdust bed) and sand are very good - if using sand, be aware of the risks of sand colic and avoid feeding on sand. If using sawdust, be aware that this can become quite hard - ensure it remains soft and conforming by raking frequently. Shavings are less supportive but may be acceptable if deep, and/or if pads are used. Straw is not good bedding for laminitis, it is not supportive enough and horses may eat it - if it contains seed heads it can be quite high in starch. Pea gravel can be good but often later in the rehabilitation, and may not be suitable for horses with thin soles.
The horse should be encouraged to lie down and get the weight off his feet as much as possible.
If he is stressed by being alone, ensure he has company nearby but not close enough to make or encourage him to move.
Keep food (e.g. soaked low sugar/starch hay or low sugar chaff) and water near by and ideally above ground level to reduce pressure on the front feet.
4. Support the feet.
With laminitis the laminar connections between the hoof wall and the pedal bone stretch and weaken, so the walls, usually particularly at the front of the foot, are no longer fully connected to the pedal bone and therefore skeleton, and cannot hold up the horse's weight - asking the walls to bear weight is likely to increase separating forces on the laminae and increase the risk of rotation and sinking of the pedal bone. The horse should be encouraged to bear most of his/her weight on the structures in the back of the foot - the frog, heels, bars and sole. Supporting the feet aims to spread and maximize weight bearing at the back of the foot and support the pedal bone in the front of the foot.
Support the feet with padding if the bedding isn’t sufficient to do this - it's always worth trying pads even with good bedding, many horses are more comfortable with correctly applied pads. EVA foam, boots with thick soft pads, styrofoam, impression material are all possible materials - see EVA foam pads and Sole support. The full solar surface of the foot should be supported, not just the frog.
On p 351 of Care and Rehabilitation of the Equine Foot Pete Ramey says “at the first signs of laminitis, restore P3 to a more natural ground plane” (e.g. a 3-5 degree palmar angle), “relieve pressure on the walls and pad the sole with foam rubber – vertical sinking and destructive pressure to the solar corium can be prevented”. Where sole depth is <7 mm, hollowing out an air space directly beneath the rim of P3 in the pad next to the foot may increase comfort.
5. Feed a low sugar/starch diet based on soaked hay plus minerals and salt.
The diet should:
contain less than 10% combined sugar and starch;
provide all essential protein, minerals, vitamins and essential fatty acids (feeding a balancer e.g. Spillers Lite + Lean plus salt will usually be adequate);
be based on forage, e.g. soaked or analysed hay, analysed haylage, low sugar/starch chaffs or feeds like unmolassed sugar beet or soya hull mash;
be fed at the rate of between 1.5 and 2% of the horse's bodyweight, depending on the energy content of the feed and the need for weight loss.
Assess the horse's body condition and adapt the diet according to whether weight needs to be lost or maintained. If weight needs to be gained - usually because a horse has PPID - aim for weight maintenance until the laminitis is controlled (pain controlled and insulin normal or reduced) before increasing calories (and consider the reason why weight needs to be gained, e.g. undiagnosed PPID).
Never feed below 1.5% of the horse's bodyweight without supervision from an expert vet/nutritionist, and use slow feeder methods if doing so to minimize the length of time the horse has nothing to eat, and therefore reduce the risk of gastric ulcers.
The sugars that increase insulin and that should total less than 10% of the diet are simple sugars, also called ESC (ethanol soluble sugars - glucose, fructose and sucrose) and starch. Fructans do not increase insulin. WSC and NSC are measures of carbohydrates that include fructans, and are not accurate. Ask feed manufacturers to analyse and report simple sugars/ESC and starch.
Please read Feeding horses with laminitis/EMS/PPID.
6. Medication - NSAIDS, pergolide/Prascend, Metformin?
NSAIDS (non-steroidal anti-inflammatory drugs) e.g. Bute, Danilon, Metacam have historically been the mainstay of laminitis treatment. However, it is now known that, unlike sepsis related laminitis, endocrinopathic laminitis involves little or no inflammation, therefore "anti-inflammatory medications may only be useful for their analgesic properties in this form of laminitis, and may not alter progression of the disease" (de Laat et al. 2011). Your vet may prescribe NSAIDs for a few days to reduce your horse's pain, but if pain is not significantly reduced within a week, check whether the cause of the laminitis has truly been found and treated/removed/managed, and/or that the feet have been/are being correctly realigned and supported. Very often correctly realigning and supporting the feet, and reducing separating forces on the less-than-well connected laminae, will bring an immediate reduction in pain.
Pergolide/Prascend - if a horse has been diagnosed with PPID, check that the current level of treatment with pergolide/Prascend is fully controlling the PPID (note that treatment with pergolide alone may not control insulin dysregulation in horses with PPID, and that management for EMS - a low sugar/starch diet and weight loss if necessary - is also likely to be essential). Note that many horses with PPID benefit from an increased dose of pergolide during the seasonal rise (approximately mid July to mid November in the northern hemisphere). Horses with clinical signs of PPID may benefit from a trial of pergolide/Prascend if the PPID could be driving the insulin dysregulation and laminitis. Ideally blood should be taken and tested for ACTH and insulin before starting treatment, but pain will increase both ACTH and insulin, and it is most important to bring the laminitis under control. If necessary the horse can be weaned off the pergolide and tested for PPID once the laminitis is fully controlled.
Metformin - for a while Metformin was considered a possible treatment for reducing blood glucose and therefore insulin levels. However, recent research has suggested that "the potential benefit of these effects [giving Metformin] in horses fed appropriate forage that is low in nonstructural carbohydrates versus more glycaemic diets, such as grass, forage with a high nonstructural carbohydrate concentration and cereals, may be questionable". So compliance with a low sugar/starch diet, and weight loss if necessary, are likely to be the most important factors in controlling insulin dysregulation. If this is not possible, then short-term treatment with Metformin may help reduce glucose and therefore insulin levels, but aim to make changes to diet and management long-term, and be aware that Metformin is not licensed for horses, therefore side effects are not recorded, and owners have reported seeing mouth ulcers when Metformin is given by syringe.
7. Trim to realign the feet (if necessary) at the earliest opportunity.
Do not wait - it is having the hoof capsule out of correct alignment with the pedal bone that is likely to cause/increase pain.
Restore the palmar angle to around 3 to 5 degrees (guided by the live sole plane and collateral groove depths), bevel breakover at the toe to the outer edge of the true white line, and bevel the outer wall at least from quarter to quarter to reduce separating forces on the laminae. Where the sole is thin, the heels must be beveled by floating the rasp above the front of the foot, leaving the foot in 2 planes while sole depth in the front of the foot develops. The feet should continue to be supported as in 4. above, with weight bearing maximized in the back of the foot and minimized in the front of the foot.
See: Realigning trim
Recognizing and Treating Rotated Hoof Capsules
Laminitis and the Feet.
8. Apply cold therapy
Icing the feet/applying cold therapy (cryotherapy) has been shown to prevent or reduce the progress of sepsis related laminitis. It is not yet known whether applying cold therapy in cases of endocrinopathic laminitis is helpful. The problem is likely to be that by the time signs of laminitis are seen, the damage has taken place and the time when cold treatment may have been useful may have passed.
References
de Laat M, Sillence M, McGowan C, Pollitt C
Insulin-Induced Laminitis - An investigation of the disease mechanism in horses
RIRDC Dec 2011