Treatment strategies sharpen for equine gastric disease

Treatment approaches for equine gastric disease are evolving as the field draws a sharper line between equine squamous gastric disease and equine glandular gastric disease. That distinction matters because the two conditions differ in pathophysiology, risk factors, and treatment response. In its recent sponsored educational coverage, The Horse underscored a now-familiar but still important message for practice: horses with suspected gastric disease need an accurate diagnosis, then pharmacologic therapy combined with management change. (thehorse.com)

That message reflects a broader shift in equine internal medicine over the past decade. Consensus and review literature have described ESGD as more directly linked to acid exposure, especially in performance horses, while EGGD appears more complex, with impaired mucosal defense, inflammation, exercise intensity, stress, and NSAID exposure all implicated. This helps explain why ESGD often responds well to acid suppression, while glandular disease can be slower to heal and more frustrating for both clinicians and pet parents. (pmc.ncbi.nlm.nih.gov)

In the U.S., omeprazole remains the only FDA-approved drug class option for treatment of equine gastric ulcers, marketed as GastroGard, with preventive labeling on UlcerGard. Educational and manufacturer materials continue to position omeprazole as the standard first-line therapy, particularly for squamous disease. Reviews cited in the current literature report strong healing rates for ESGD after about 28 days of treatment, while management changes, including forage access and lower-starch feeding strategies, are important to reduce rebound or recurrence after treatment ends. (animalhealth.boehringer-ingelheim.com)

For glandular disease, the picture is less straightforward. Reviews and conference-linked reports indicate that clinicians frequently add sucralfate to omeprazole, but evidence for superior outcomes is mixed. A study highlighted in Journal of Veterinary Internal Medicine reported that misoprostol was superior to combined omeprazole and sucralfate for healing glandular gastric lesions in horses with clinical disease, helping explain why misoprostol has become part of the treatment conversation for refractory or selected EGGD cases. Separate work from the University of Illinois also found omeprazole outperformed sucralfate in a feed-fast/NSAID model, reinforcing that not all gastroprotectants perform equally across lesion types or clinical settings. (ovid.com)

Newer adjunct strategies are also being tested, though the evidence is still early. A 2025 blinded, randomized, placebo-controlled trial published in Equine Veterinary Journal evaluated a nutraceutical containing lecithin, pectin, and meadowsweet after omeprazole treatment in 30 horses. The product did not significantly prevent recurrence of ESGD or EGGD on gastroscopy, although investigators reported changes in salivary biomarkers that could indicate effects on mucosal health. That makes the study useful, but not practice-changing, at least yet. (pubmed.ncbi.nlm.nih.gov)

Expert and industry commentary broadly aligns on one point: diagnosis first. University and continuing education sources consistently stress gastroscopy as the diagnostic standard because clinical signs are nonspecific, and recent retrospective work has reinforced that behavioral and physical signs do not reliably map to lesion location. That means empirical treatment without scoping may still happen in the field, but it carries the risk of missing lesion type, concurrent disease, or a case that needs a different protocol and different expectations for response. (vmc.usask.ca)

Why it matters: For veterinary professionals, this is less about a brand-new drug than about a more disciplined treatment framework. ESGD and EGGD shouldn’t be managed as interchangeable problems. Cases that don’t respond to omeprazole alone may need reevaluation of diagnosis, compliance, formulation, feeding schedule, NSAID exposure, exercise intensity, and comorbid pain or stressors. The practical takeaway is that better outcomes likely come from matching therapy to lesion type and building management plans that support mucosal healing after the prescription ends. (pmc.ncbi.nlm.nih.gov)

What to watch: The next area to watch is whether better recurrence-prevention strategies emerge for horses coming off omeprazole, especially for glandular disease, and whether newer protocols, including misoprostol-based regimens, alternative omeprazole formulations, or validated adjunct nutraceuticals, can show consistent benefit in larger controlled studies. (pubmed.ncbi.nlm.nih.gov)