Veterinarians should not rely on a horses appearance alone to determine his metabolic status. | Adobe StockAs horses live longer and remain active well into their senior years, veterinarians face the increased challenge of managing joint disease in patients that dont fit the traditional athlete profile. One of the most important, yet previously overlooked factors influencing treatment decisions is a horses metabolic status. Common metabolic disorders in horses include equine metabolic syndrome, pituitary pars intermedia dysfunction (PPID, formerly called equine Cushings), or insulin dysregulation.Regardless of the therapy, the goals of equine joint treatment remain the same: Decrease inflammation, repair or protect the articular surface, lubricate the joint, restore homeostasis, and prevent further injury, said Kyla Ortved, DVM, PhD, Dipl. ACVS, ACVSMR, associate professor of large animal surgery at the University of Pennsylvanias New Bolton Center, in Kennett Square. Ortved discussed joint therapy options for treating endocrine horses with Lauren Schnabel, DVM, PhD, Dipl. ACVS, ACVSMR, professor of equine orthopedic surgery at North Carolina State Universitys College of Veterinary Medicine, in Raleigh, during their table topic at the 2025 American Association of Equine Practitioners Convention, held Dec. 6-10, in Denver, Colorado.Corticosteroid Use in Endocrine HorsesIntra-articular corticosteroidsthose injected into the jointremain a common choice for veterinarians when the goal is controlling joint inflammation, said Ortved. However, their use requires careful consideration of total dose, cumulative exposure, withdrawal times, and long-term effects on joint tissues.The presenters said laminitis risk continues to be a central concern for veterinarians when addressing joint issues in the metabolic horse. Laminitis is a painful inflammatory condition of the tissues that connect the hoof wall to the underlying coffin bone and can lead to lasting structural damage within the foot. In a review of approximately 2,000 horses, only a small number developed laminitis following steroid administration; however, some surveys report nearly 75% of veterinarians consider the corticosteroid triamcinolone likely or very likely to contribute to laminitis, particularly in at-risk horses.Researchers have shown that even in metabolically normal horses, certain corticosteroids can increase insulin concentrations, said Ortved. In horses with elevated baseline insulin due to insulin dysregulation, that response can be exaggerated, with insulin levels rising dramatically after joint injection. Betamethasone and methylprednisolone acetate appear to have a less pronounced effect on insulin than triamcinolone in a small number of studies. Schnabel and Ortved advised practitioners to use steroids with caution in horses at risk of laminitis and that more studies need to be performed.These concerns remain especially relevant given the prevalence of metabolic disease in the sport horse population, said Schnabel. Researchers in the Schnabel Laboratory using oral sugar testing have identified insulin dysregulation in nearly 25% of sport horses, though only a fraction were diagnosed based on baseline fasted insulin levels. The Schnabel Laboratory also identified radiographic evidence of laminitis in more than 40% of sport horses, regardless of known metabolic status, underscoring the need for routine radiographic monitoring of horses feet in addition to testing a horses insulin levels regardless of appearance.Alternative Joint Therapies for Metabolic HorsesFor horses with known or suspected metabolic disease, veterinarians often look beyond corticosteroids. Hyaluronic acid and polysulfated glycosaminoglycans continue to be common components of joint therapy protocols.Veterinarians are exploring the use of polyacrylamide hydrogels (PAAGs) in metabolic horses. Ortved said the 2.5% PAAG has been associated with integration into synovial tissue and modification of the synovial membrane.Schnabel added that the 4% PAAG functions primarily as a viscoelastic to reduce friction within the joint and can bind to sites of damaged cartilage. The presenters described on-label intra-articular PAAG use as safe, particularly in cases where corticosteroids might be less desirable.Orthobiologics in Endocrine HorsesOrthobiologic therapies such as platelet-rich plasma (PRP), autologous conditioned serum (ACS), autologous protein solution (APS), alpha-2-macroglobulin (A2M), and mesenchymal stem cells (MSCs) offer treatment options for managing horses with joint disease, said Ortved. However, because some of these products are produced using the individuals blood or stem cells, a horses metabolic status might influence how they perform.Certain medications used to manage PPID can affect platelet function, raising questions about the consistency and efficacy of platelet-based therapies.Finally, the presenters noted that little research exists into the use of orthobiologics for equine axial skeletal painthat of the neck, back, and pelvisbut research in humans leads veterinarians to believe they are an effective option in horses, said Schnabel.Take-Home MessageManaging joint disease in metabolic horses requires a nuanced approach. Insulin testing, rather than reliance on appearance, plays a critical role in identifying at-risk patients, said Schnabel. From there, therapy selection should prioritize safety while addressing pain, inflammation, and long-term joint health.