Active substance (1)

Indications

Identification of alternatives

Explanation of use / specific advantages

Oxybuprocainea

Local topical anaesthesia for use in eyes

None identified

Wide clinical experience

Prilocaineb

Local topical anaesthesia prior to intravenous injection or catheterisation

Lidocaine

In specific preparations (eutectic mixture of local anaesthetics), for topical application to skin; can be used to facilitate intravenous injection or catheterisation

Sevofluraneb

Mask induction of anaesthesia in foals

Isoflurane

Better suited for mask induction as less pungent than the alternative

Active substance (1)

Indications

Identification of alternatives

Explanation of use / specific advantages

Bromfenacb

Treatment of uveitis and ocular inflammation

Systemic nonsteroidal anti-inflammatory drugs (NSAIDs) (e.g. flunixin); topical (ocular) ketorolac

Topical NSAIDs may result in less patient discomfort, reduced postoperative inflammation, prevention of miosis, and improvements in visual acuity in the early postoperative period

Fentanylb

Multimodal approach for moderate to severe acute painful conditions

Butorphanol, morphine

Produces better analgesia than certain other opioids and can be used for very painful conditions; recognised value for use in multi-modal approaches

Ketorolacb

Treatment of eye pain and inflammation

Systemic NSAID therapy (e.g. flunixin)

Formulated for local application

Methocarbamolb

As part of treatment protocols in severe painful muscle spasms or severe muscle inflammation conditions

Systemic NSAIDs (e.g. flunixin)

Potent skeletal muscle relaxation; specific action on the internuncial neurons of the spinal cord to reduce acute skeletal muscle spasms without a concomitant alteration in muscle tone

Morphineb

Analgesia

Butorphanol, fentanyl

More potent than other analgesics

Triamcinolone acetonideb

Treatment of joint inflammation

Methylprednisolone

Less harmful effects on cartilage metabolism

Active substance (1)

Indications

Identification of alternatives

Explanation of use / specific advantages

I. Antibiotics

Amikacinb

Treatment of septicemia in horses and foals

Gentamicin, ceftiofur

Better safety profile in the target animal

Azithromycinb

Treatment of Rhodococcus equi infections susceptible to azithromycin

Clarithromycin, erythromycin, gamithromycin, tulathromycin, doxycycline

Added clinical benefit in cases of Rhodococcus equi infections in foals that can be resolved as monotherapy or in combination with doxycycline

Clarithromycinb

Treatment of Rhodococcus equi infections susceptible to clarithromycin

Azithromycin, erythromycin, gamithromycin, tulathromycin, doxycycline

More active against Rhodococcus equi in vitro than erythromycin or azithromycin; achieves greater concentrations in pulmonary epithelial lining fluid and alveolar macrophages than either erythromycin or azithromycin, though the half-life is shorter

Fusidic acidb

Topical treatment of eye infections caused by gram-positive bacteria susceptible to fusidic acid

Ofloxacin, moxifloxacin

Broad spectrum for treatment of gram-positive infections; primary choice in superficial, uncomplicated corneal ulcers and acute conjunctivitis in horses

Moxifloxacinb

Topical treatment of external eye infections caused by gram-positive cocci, gram-negative, atypical and anaerobic bacteria, such as Pseudomonas aeruginosa, susceptible to moxifloxacin

Ofloxacin

Advantageous pharmacokinetic profile; spectrum of activity includes gram-positive cocci and anaerobic bacteria that may be resistant to other quinolones

Ofloxacinb

Treatment of external eye infections caused by gram-positive and gram-negative micro-organisms susceptible to ofloxacin

Moxifloxacin

Clinical experience; penetrates the entire cornea up to the anterior chamber of the eye

Polymyxin Bb

Treatment of bacterial keratitis, topical use

Ofloxacin, moxifloxacin

Effective alternative to systemic treatments; different mechanism of action to other topical alternatives

II. Antifungals

Amphotericin Ba

Treatment of fungal pneumonia, systemic use

None identified

Treatment of choice

Ketoconazoleb

Adjunctive therapy in the treatment of guttural pouch mycosis, topical use

Enilconazole

Less irritant compared to the alternative; formulated for local application

Miconazoleb

Treatment of fungal infection of the eye

Natamycin, nystatin, voriconazole

Broad spectrum of activity; less irritant compared to other topical antifungals

Nystatinb

Treatment of fungal and yeast infections of the eye and genital tract

Miconazole

Treatment of choice for yeast infections

Voriconazoleb

Treatment of fungal keratitis, topical use

Miconazole

Broad spectrum of activity

III. Antivirals

Aciclovirb

Treatment of cases of equine herpes virus infection associated with complications, topical use only

Ganciclovir

Treatment of choice for ocular ulcers when the implication of a viral pathogen is suspected

Ganciclovirb

Treatment of cases of equine herpes virus infection associated with complications, topical use

Aciclovir, valaciclovir

Wealth of evidence for the treatment of different virus-types causing herpetic infections

Valaciclovirb

Treatment of cases of equine herpes virus infections, oral use

Aciclovir

Better pharmacokinetic profile and a different route of administration

Active substance (1)

Indications

Identification of alternatives

Explanation of use / specific advantages

Ambroxolb

Stimulation of surfactant in premature foals

Steroids, bromhexine, dembrexine, surfactant transfer from healthy donor

Preferred clinical choice for premature foals

Fluticasoneb

Control of allergic pulmonary disease including mild to moderate cases of equine asthma and subtypes via inhalation

Beclomethasone

Inhalation leads to less adreno-cortical suppression, quicker rebound after therapy ends and fewer systemic side effects than systemic corticosteroid therapy because of its limited systemic absorption; especially indicated for control of mild-moderate and refractory severe asthma as well as long-term maintenance therapy

Ipratropium bromideb

As a bronchodilator in horses with mild-moderate asthma

Clenbuterol

Anticholinergic action, as an alternative to beta-agonists

Oxymetazolineb

Treatment of nasal oedema

Phenylephrine

Alpha-adrenoceptor agonist with strong vasoconstrictive properties and longer acting effect

Phenylephrineb

Treatment of nasal oedema

Oxymetazoline

Reduces the need for insertion of nasal tubes during recovery

Active substance (1)

Indications

Identification of alternatives

Explanation of use / specific advantages

Amiodaroneb

Systemic and oral treatment of atrial fibrillation, supraventricular and ventricular tachycardias

Quinidine sulphate/gluconate, sotalol, verapamil

Different mode of action: class III anti-dysrhythmic

Propafenoneb

Treatment of ventricular tachycardia and ventricular tachyarrhythmia

Quinidine sulphate/gluconate

Different mode of action: sodium channel antagonist that decreases heart excitability

Quinaprila

Treatment of heart failure; cardiovascular protection in horses with atrial fibrillation (AF) or mitral regurgitation (MR)

None identified

Different mode of action: angiotensin-converting-enzyme (ACE) inhibitor

Quinidine sulphate/gluconateb

Treatment of cardiac arrhythmias

Amiodarone, sotalol, verapamil

Treatment of choice for atrial fibrillation

Sotalolb

Long-term treatment of cardiac arrhythmias

Amiodarone, quinidine sulphate/gluconate

More suitable in horses requiring long-term anti-arrhythmic therapy; less adverse events than amiodarone

Verapamilb

Treatment of supraventricular arrhythmias

Amiodarone, quinidine sulphate/gluconate, sotalol

Different mode of action: calcium channel blocker

Active substance (1)

Indications

Identification of alternatives

Explanation of use / specific advantages

Barium sulfatea

Enhanced gastrointestinal tract visualisation during radiographic examinations

None identified

No satisfactory alternative treatment for enhanced gastrointestinal tract visualisation during radiographic examinations

Fluoresceinb

Diagnosing corneal keratitis or ulceration, topical use

Rose bengal

Diagnostic tool of choice when a viral culture is needed afterwards

Iohexola

Contrast agent for lower urinary tract radiography, arthrography, myelography, sino- or fistulography and dacryocystography

None identified

Non-ionic, water-soluble contrast agent

Phenylephrinea

Diagnosing grass sickness

None identified

Ancillary diagnostic approach to equine grass sickness polyneuropathy

Rose bengalb

Diagnosing corneal keratitis or ulceration, topical use

Fluorescein

Diagnostic tool of choice for diagnosing eye keratitis/ulcers

Thyrotropin releasing hormonea

Diagnosing pituitary pars intermedia dysfunction

None identified

No satisfactory alternatives for diagnosing pituitary pars intermedia dysfunction

Active substance (1)

Indications

Identification of alternatives

Explanation of use / specific advantages

Metoclopramideb

Treatment of post-operative ileus

Intravenous fluid substitution, painkillers (e.g. flunixin), lidocaine

Prokinetic drug

Misoprostolb

Treatment of gastric glandular disease and colitis

Omeprazole, sucralfate

Superior to omeprazole for the treatment of equine gastric glandular disease

Phenylephrinea

Treatment of nephrosplenic entrapment

None identified

Clinical value in the resolution of nephrosplenic entrapment; causes a dose-dependent splenic contraction

Ranitidineb

Treatment of gastric ulcers in critically ill neonates, intravenous use

Omeprazole

The intravenous route of administration brings added clinical benefit over other oral antiulcer medications

Sucralfateb

Treatment and prevention of gastric ulcers in horses

Omeprazole

Different mode of action than omeprazole (mucosal adherent), which provides physical lesion stabilisation

Active substance (1)

Indications

Identification of alternatives

Explanation of use / specific advantages

Insulinb

As an aid in the treatment of hyperlipidaemia unresponsive to glucose therapy or severe hyperlipidaemia, used in combination with glucose and other therapies

Diagnosing metabolic disorders (e.g. insulin resistance associated with equine metabolic syndrome or pituitary pars intermedia dysfunction)

Low-molecular weight heparin can be used for cases of hyperlipidaemia

Insulin is the preferred clinical choice

Active substance (1)

Indications

Identification of alternatives

Explanation of use / specific advantages

Atracuriumb

Inducing muscle paralysis under general anaesthesia

Cisatracurium, guaifenesin

Brings added clinical benefit in horses under general anaesthesia in cases where increased muscle relaxation is necessary such as ophthalmic surgeries, certain orthopaedic repairs and when deep access to the abdominal cavity is needed.

Cisatracuriumb

Inducing muscle paralysis under general anaesthesia

Atracurium, guaifenesin

Brings added clinical benefit in horses under general anaesthesia in cases where increased muscle relaxation is necessary such as ophthalmic surgeries, certain orthopaedic repairs and when deep access to the abdominal cavity is needed.

Dantrolene sodiumb

Prevention of rhabdomyolysis

Prevention of malignant hyperthermia during anaesthesia

NSAIDs, intravenous fluids, vitamin E/selenium

Efficacious as preventative, inhibiting the release of calcium from the sarcoplasmic reticulum and thus causing dissociation of excitation-contraction coupling

Edrophoniuma

Reversing the effects of atracurium muscle paralysis

None identified

Cholinesterase inhibitor, essential for reversal of neuromuscular blockade; least side effects of the cholinesterase inhibitors in horses

Guaifenesinb

Induction and maintenance of general anaesthesia in field conditions

Atracurium, cisatracurium

Particularly indicated in field (non-hospital) conditions where anaesthesia may be necessary; the reduced cardiopulmonary depressive effects facilitate safe anaesthesia without advanced monitoring equipment or mechanical ventilation

Active substance (1)

Indications

Identification of alternatives

Explanation of use / specific advantages

Diazepama

Short-term anti-convulsant for treatment of seizures

None identified

Second-generation antiseizure

Midazolama

Short-term anti-convulsant for treatment of seizures

None identified

Second-generation antiseizure

Active substance (1)

Indications

Identification of alternatives

Explanation of use / specific advantages

Acetazolamideb

Treatment of glaucoma, oral use

Phenylephrine

Its mechanism of action as carbonic anhydrase inhibitor

Cyclopentolateb

Mydriatic agent

Atropine, phenylephrine

Induces significant mydriasis without affecting tear production, intraocular pressure, digestive function (i.e. gut motility and faeces production), or heart rate

Cyclosporine Ab

Treatment of autoimmune diseases of the eye

Topical steroids

Immunosuppressive effect by inhibiting T-lymphocyte proliferation and reducing cytokine gene expression

Phenylephrineb

Treatment of glaucoma and epiphora

Atropine and tropicamide

It does not (or only slightly) increase intra ocular pressure

Synephrineb

Treatment of the mucous membranes of the eye as a decongestant

Phenylephrine, tetryzoline

Fast local effect; enhances penetration of local therapy, providing synergistic effects with e.g. local antimicrobial therapy

Tetryzolineb

Treatment of the mucous membranes of the eye as a decongestant

Phenylephrine, synephrine

Fast local effect

Timolol maleateb

Treatment of glaucoma, topical use

Acetazolamide

Its specific mode of action as a non-selective beta-adrenergic receptor blocking agent, provides for an important therapeutic choice in the treatment of glaucoma

Triamcinolone acetonideb

Treatment of recurrent uveitis in cases that are refractory to other treatments

Atropine, tropicamide

Effective, low-morbidity treatment in cases that are refractory to other treatments

Tropicamideb

Treatment of recurrent uveitis

Atropine, cyclopentolate, triamcinolone acetonide

Rapid onset of action

Active substance (1)

Indications

Identification of alternatives

Explanation of use / specific advantages

Acepromazineb

For a multimodal approach for tranquilisation and premedication in combination with other sedatives

Detomidine, romifidine, xylazine, diazepam

The mode of action of acepromazine and its unique quality of sedation cannot be produced by alpha-2 agonist sedatives or benzodiazepines

Atipamezolea

Reversing the effects of alpha-2 agonists

None identified

Reverses sedative and analgesic effects and adverse cardiovascular reactions

Dexmedetomidineb

Sedation or general anaesthesia as part of partial or total intravenous anaesthesia protocols

Detomidine, romifidine, xylazine, diazepam

The most selective alpha-2 agonist; short half-life and rapid redistribution, which particularly favour its use as a continuous-rate infusion

Diazepamb

Premedication and induction of anaesthesia, mild tranquilisation with minimal cardiovascular and respiratory side effects

Acepromazine, detomidine, romifidine, xylazine

The mode of action (at gamma-aminobutyric acid (GABA) receptor) provides unique tranquilisation without cardiorespiratory depression that cannot be produced by alpha-2 agonist sedatives (detomidine, romifidine and xylazine) or acepromazine

Midazolamb

Premedication and induction of anaesthesia, mild tranquilisation with minimal cardiovascular and respiratory side effects

Acepromazine, detomidine, romifidine, xylazine

The mode of action (at GABA receptor) provides unique tranquilisation without cardiorespiratory depression that cannot be produced by alpha-2 agonist sedatives (detomidine, romifidine and xylazine) or acepromazine

Flumazenila

Intravenous reversal agent for benzodiazepine effect during recovery from Total Intravenous Anaesthesia (TIVA) techniques

None identified

Antagonist that competitively inhibits the benzodiazepine binding site at the GABA receptor

Naloxonea

Reversal of opioid effects during emergencies

None identified

No alternatives available

Propofolb

Induction of anaesthesia in foals via intravenous administration

Isoflurane

Improvement in cardiovascular stability and quality of recovery over inhalation anaesthesia in foals

Active substance (1)

Indications

Identification of alternatives

Explanation of use / specific advantages

Allopurinolb

Neonatal ischaemia reperfusion injury

Vitamin E

Different mode of action in inhibiting the formation of reactive oxygen species (ROS) than vitamin E

Dalteparinb

Anticoagulant

Heparin

Reduction in molecular size is associated with a loss of thrombin inhibitory activity, but conversely an increase in factor Xa (FXa) inhibition compared to unfractionated heparin

Dobutamineb

Management of hypotension under general anaesthesia

Ephedrine

First-line medication for the treatment of hypotension in adult equines under general anaesthesia

Dopaminea

As part of a treatment protocol for acute kidney injury/renal failure only

None identified

Low doses have been shown to cause renal vasodilation, increased renal blood flow, and increased urine production without systemic cardiovascular effects in conscious healthy horses

Ephedrineb

Treatment of hypotension under general anaesthesia

Dobutamine

Used to treat hypotension in adult equines under general anaesthesia where dobutamine is ineffective. Different mode of action to dobutamine with a more direct effect on cardiac contractility

Gelatinpolysuccinateb

Addressing long-term hypovolaemia resulting from conditions like e.g. low albumin

Crystalloids

Colloids are larger molecules compared to crystalloids, thus stay longer in the intravascular space, which is an advantage for correcting hypovolemia from e.g. hypoalbuminemia

Glycopyrrolateb

Treatment and prevention of bradycardia

Atropine

Minimal central effect; suitable in conscious horses, before and after anaesthesia

Noradrenaline / norepinephrineb

Treatment of early septic shock

Supporting cardiovascular function in critically ill foals

Dobutamine, dopamine

In compromised (sick) foals it is generally the only catecholamine effective in treatment of hypotension

Vasopressinb

Treatment of circulatory collapse in foals and adult horses

Epinephrine, dopamine, dobutamine

Alternative in cases where standard catecholamine therapies like dopamine, dobutamine, epinephrine are ineffective or require potentiation to restore vascular tone in refractory vasodilatory shock states

Active substance (1)

Indications

Identification of alternatives

Explanation of use / specific advantages

Imiquimoda

Treatment of sarcoids

None identified

Current research suggests that equine sarcoids likely result from a complex interaction including host immune system dysfunction

Active substance (1)

Indications

Identification of alternatives

Explanation of use / specific advantages

Cetirizineb

Treatment of conditions where an antihistamine is deemed necessary

Chlorphenamine

Second-generation histamine-1 (H1) receptor inverse agonists are alternatives with fewer central nervous system (CNS) (sedative) side effects

Domperidoneb

Treatment of agalactia/dysgalactia in mares

Sulpiride

Its ability to stimulate prolactin secretion in situations of dopaminergic inhibition

Sulpirideb

Treatment of agalactia/dysgalactia in mares

Domperidone

Its ability to stimulate prolactin secretion in situations of dopaminergic inhibition