What are the current treatment recommendations for equine gastric ulcer syndrome grades 1-4?

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Omeprazole is the first-line treatment for equine gastric ulcer syndrome (EGUS) regardless of grade, with the standard treatment dose of 4.0 mg/kg PO q24h for a minimum of 28 days. A dose-response relationship exists for both squamous and glandular ulcers, and the higher dose of 4.0 mg/kg outperforms 1.6 mg/kg for squamous ulcer improvement.6 Both gastro-enteric resistant granule and powder paste omeprazole formulations show equivalent efficacy over 28 days.9 Equine squamous gastric disease (ESGD) responds more completely to omeprazole than equine glandular gastric disease (EGGD). The percentage of glandular ulcers that improve with acid suppression is significantly lower than for squamous ulcers, and glandular ulcer improvement is not dose-dependent between 1.6 mg/kg and 4.0 mg/kg.6 The glandular mucosa responds poorly to omeprazole monotherapy.9 For EGGD, treatment duration is longer than for ESGD, and sucralfate may be added or alternatives such as misoprostol, a prostaglandin analogue, may be necessary.1 Gastroscopy is the only current method to confirm treatment efficacy and monitor healing progress, and a control gastroscopy is recommended after the treatment course to assess ulcer resolution.311 Lesions are graded on a 0–4 ordinal scale as established by the Equine Gastric Ulcer Council (EGUC); this grading system is recommended for squamous mucosa assessment and has higher interobserver reliability than alternative systems.2 Grade ≥2/4 is the threshold used in treatment trials to define clinically significant ulceration requiring therapy.6 Dietary and environmental management are required alongside pharmacotherapy to prevent recurrence. Known risk factors — high concentrate diets, intense exercise, prolonged fasting exceeding 6 hours, stress, and nonsteroidal anti-inflammatory drug use — should be minimized or eliminated.111 Continuous pasture access is considered protective against EGUS, though pastured horses are not entirely free of risk.14 Approximately