When an owner is faced with a laminitic horse, their overwhelming concern, understandably, is pain control. However, it is critically important to understand that you cannot get the pain under control unless you eliminate the cause or trigger of the laminitis. That might seem obvious, but it's very easy to lose sight of this and become focused on the pain. If the horse had a gaping wound, you wouldn't just give him bute and hope it would go away. You would control his pain as needed, but also have the wound repaired, update tetanus, give antibiotics if warranted, take measures to protect the wound as much as possible, etc.
There are many possible causes of laminitis, but by far the most common is insulin resistance. Unless there is another clear and obvious cause (e.g. Black walnut shavings, retained placenta, horse broke into the grain bin, systemic infection), it should be assumed that the horse is insulin resistant until proven otherwise, and emergency dietary adjustments made.
If there is any reason to strongly suspect PPID, pergolide should also be started. This does complicate diagnostics a bit, but the horse can always be weaned off and tested after the laminitis is controlled. It is probably best not to do testing for IR until the acute phase of laminitis has been controlled. There's a good chance that an acutely laminitic horse is going to test positive for IR regardless of the cause because of the inflammation and pain/stress.
On the pain and inflammation front, icing or standing the horse in a cold running stream should be part of the treatment plan regardless of whether or not drugs are used. When done within the first 8 hours or so of a possible laminitis trigger, you may be able to completely prevent the laminitis from developing by keeping the feet chilled. Proteolytic enzymes are inactivated by cold. Even if the feet are already controlled and the trigger removed, cold is the best way to control inflammation and give pain relief.
Phenylbutazone (Bute) and flunixin meglumine (Banamine) are the mainstays in anti inflammatory drugs. A newcomer is firocoxib (Equioxx) which carries a lower risk of gastrointestinal ulceration with short term use. These drugs are reasonable to use for the first 3 to 5 days of an acute laminitis bout but should not be used for longer than this. These drugs are in the class called nonsteroidal anti inflammatories. They are well documented to interfere with healing of bone and soft tissue to the point that many human surgeons now instruct their patients not to use this class of drugs after a surgery.
**Remember, the goal of laminitis treatment is not to get rid of the pain, it's to stop ongoing damage and heal the hoof. This takes time. Anti-inflammatories are given to prevent excessive inflammation which can cause even more damage. This does improve pain but that is not their primary benefit. While healing is going on, the tissues are weak. The horse is a large animal and can easily damage fragile laminae, especially if pain is being blocked. With acutely damaged feet, the best place for a horse to be is lying down on a soft comfortable surface. When he feels better, he'll get up.**
Dr. Eleanor Kellon, VMD
Last, but far, far from least, is hoof care in the acute phase. Horses with poor quality hooves or poor hoof care are far more likely to have problems with rotation or sinking than those with healthy, well trimmed feet. We are not suggesting a good trim can prevent rotation or laminitis; we are saying a bad one can greatly increase the effects.
Lateral X-rays of the feet should always be done when the horse has had laminitis. This is the only way to know the position of the coffin bone within the foot. As soon as the X-rays are available, vet and trimmer/farrier should meet to go over the goals of the trim. If you are fortunate enough that the hoof is perfect at the time laminitis strikes, great. If not, it makes no sense to delay the trim. Horses in danger of penetrating can be trimmed when they are down. Otherwise, properly cushion the feet (More DDT - Trim) and proceed with a trim even if it means the horse has to be nerve blocked to get this accomplished. Many suggest delaying the trim during the acute phase of laminitis. However, this just gives improper hoof mechanics more time to contribute to laminar damage.
There is only one proper trim, and no one but God can claim ownership of it;....
...the proper trim is one where the hoof capsule correctly conforms to the bones within it.