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Summary of Injectable Agents to Reduce Inflammation and Increase Mobility:Brief Prescribing Information Review 2006Lee Ann Swenson, MS, BSc

Joint Injection Application

Four Joints: tibiotarsal, proximal intertarsal, distal intertarsal,tarsometatarsal

Direct communication of distal joints may be controversial(25%-65%)

1. Gough et al: Diffusion of mepivicaine between adjacent synovialstructures in the horse. Part 2: Tarsus and Stifle. Equine Vet J.2002.2. Serena et al: Concentration of MPA in the centrodistal joint afteradministration into the tarsometatarsal joint. Equine Vet J. 2005

Joint injections can be considered in two separate sections. First, high motion joints,or those that must have full range of movement to allow normal athletic function.Second, low motion joints, or those that may not necessarily be required to move toallow normal athletic function.

An example of a high motion joints would be the ankle or fetlock, similar to theillustration. All of the leg joints in the horse except the pastern joints and the lowertwo joints of the hocks are high motion joints.

The most important, and commonly treated, lower motion joints are the two lowerjoints in the hock. The treatments for these two different types of joints may beradically different....High motion joints require lots of TLC... Conversely, low motion

joints, such as the lower hock joints, may be treated with long term anti-inflammatories without the worries that long term damage to the joint will occur.

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Table: Approved Indications of Available AgentsAgent Administration Effects & Mechanism of Action

Hyaluronic Acid (HA) Intra-articular (IA)

2 mL (20 mg) intra-articularly insmall- and medium-size joints(carpal, fetlock) or 4 mL (40 mg)for larger joints (hock).

May be repeated at weeklyintervals for a total of threetreatments.

HA is a normal component of joint fluid and cartilage and lubricates thejoint and decrease inflammation.

Although the mechanism of action of HA is not entirely understood, it isrecognized that sodium hyaluronate decreases synovial fluidinflammatory mediators.

In addition to the anti-inflammatory actions, HA acts as a lubricatingsubstance within the joint and provides a "protective barrier" over thesynovial membrane.

Depo-Medrol(methylprednisoloneacetate)

Steriods / cortisone

Intra-articular

120 mg IA (range 40 240 mg)

Corticosteroids, often referred to as "steroids" or "cortisone", areactually a large family of drugs with potent anti-inflammatory activities ofvarying strengths and durations. Trimacinolone is one corticosteroid

which has a medium duration of action and is widely used for jointinjection. Methylprednisolone acetate (Depro-Medrol) is a potent, longacting corticosteroid most often used for injection in the lower hock

joints.

Legend (hyaluronatesodium)

IV or IA

IV 4 mL (40 mg) or Intra-articular 2 mL (20 mg)reapeated weekly for a total ofthree treatments

The only HA indicated for IV administration, Legend has been shown todecrease the synovial fluid concentrations of prostaglandins,glycosaminoglycan (GAG), and total protein that are associated withinflammatory joint disease in the horse.

It has been demonstrated that the intravenous administration of Legenddecreases inflammation, products associated with inflammation, and the

degree of lameness in horses with arthritis (joint inflammation).Adequan i.m.(Polysulfatedglycosaminoglycan)(PSGAG)

IM

500 mg q 4 days for 28 days IM

PSGSG is chemically similar to the glycosaminoglycans in articularcartilage and is a potent inhibitor of proteolytic enzymes. PSGAGimproves joint function by reducing synovial fluid protein levels andincreasing synovial fluid viscosity.

Adequan I.A.(Polysulfatedglycosaminoglycan)(PSGAG)

IA

250 mg once per week for fiveweeks intra-articularly.

Same as Adequan IM

Reaction to the IA administration can include inflammatory jointreactions and septic arthritis. Reactions usually appear within 48 hours.

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Cited Package Inserts:HA (Pharmacia Animal Health):http://www.hylartin.com/product_overview.asp?country=US&lang=EN&drug=HY&species=EQ

Depo-Medrol (Pharmacia Animal Health)http://www.pharmaciaah.com/product_overview.asp?drug=DM&country=US&lang=EN&species=EQLegend (Bayer Animal Health): http://www.compasnac.com/cvp/10/1040/1040028.htm

Adequan IM (Luitpold)http://www.luitpold.com/animal_health/equine/pdf/insert_im.pdf

Adequan IA (luitpold)http://www.luitpold.com/animal_health/equine/pdf/insert_ia.pdf

http://www.hylartin.com/product_overview.asp?country=US&lang=EN&drug=HY&species=EQhttp://www.hylartin.com/product_overview.asp?country=US&lang=EN&drug=HY&species=EQhttp://www.hylartin.com/product_overview.asp?country=US&lang=EN&drug=HY&species=EQhttp://www.pharmaciaah.com/product_overview.asp?drug=DM&country=US&lang=EN&species=EQhttp://www.pharmaciaah.com/product_overview.asp?drug=DM&country=US&lang=EN&species=EQhttp://www.pharmaciaah.com/product_overview.asp?drug=DM&country=US&lang=EN&species=EQhttp://www.compasnac.com/cvp/10/1040/1040028.htmhttp://www.compasnac.com/cvp/10/1040/1040028.htmhttp://www.luitpold.com/animal_health/equine/pdf/insert_im.pdfhttp://www.luitpold.com/animal_health/equine/pdf/insert_im.pdfhttp://www.luitpold.com/animal_health/equine/pdf/insert_im.pdfhttp://www.luitpold.com/animal_health/equine/pdf/insert_ia.pdfhttp://www.luitpold.com/animal_health/equine/pdf/insert_ia.pdfhttp://www.luitpold.com/animal_health/equine/pdf/insert_ia.pdfhttp://www.luitpold.com/animal_health/equine/pdf/insert_ia.pdfhttp://www.luitpold.com/animal_health/equine/pdf/insert_im.pdfhttp://www.compasnac.com/cvp/10/1040/1040028.htmhttp://www.pharmaciaah.com/product_overview.asp?drug=DM&country=US&lang=EN&species=EQhttp://www.hylartin.com/product_overview.asp?country=US&lang=EN&drug=HY&species=EQ