Comparison of fasted basal insulin with the combined glucose-insulin test in horses and ponies with suspected insulin dysregulation

Comparison of one novel and four established diagnostic tests for insulin dysregulation in ponies

Several tests have been advocated for diagnosis of insulin dysregulation (ID). Tests using simple sugars may not reflect the response to naturally ingested carbohydrates. This study aimed to evaluate agreement between the oral glucose test (OGT), the oral sugar test (OST), a novel oral test using a proprietary cereal (WEET), the IV combined glucose-insulin tolerance test (CGIT) and fasted basal insulin (FI) for diagnosis of ID. Each of the five tests above was performed on a group of six normal and six insulin dysregulated mixed-breed ponies in a randomised crossover study. Area under the curve (AUC) and maximum concentration of insulin from OGT, OST and WEET showed strong to very strong bivariate correlations (r = 0.85-0.94, and r = 0.87-0.92, respectively; P ≤ 0.001) and were significantly different between tests (associated with dose of carbohydrate) and between CGIT-positive and -negative ponies. Dichotomous results showed substantial agreement between OST and both WEET (κ = 0.65; P = 0.02) and OGT (κ = 0.67; P = 0.01) and between CGIT and both OST (κ = 0.63; P = 0.03) and OGT (κ = 0.67; P = 0.01), and no agreement between FI, which had low sensitivity, and all other tests (κ = 0.15 - 0.31; P > 0. 05). Palatability of WEET was variable, resulting in one pony being excluded for analysis of WEET data. Further work on development of an oral test using a more palatable feedstuff and appropriate cut-offs or diagnostic thresholds for tests of ID is warranted.

Development of a Web App to Convert Blood Insulin Concentrations among Various Immunoassays Used in Horses

The measurement of the blood insulin concentration, and comparison to cut-offs, is essential in diagnosing insulin dysregulation, a common equine endocrinopathy. However, different insulin assays provide disparate results. We aimed to ease comparison between assays by compiling original and published data into a web app to convert insulin measurements from one assay to another. Data were available for ADVIA Centaur insulin chemiluminescent immunoassay (CLIA), Beckman Coulter insulin radioimmunoassay (RIA), Immulite 1000 CLIA, Immulite 2000 CLIA, Immulite 2000 XPi CLIA, Mercodia equine insulin enzyme-linked immunosorbent assay (ELISA), and Millipore porcine insulin RIA. Linear models were fitted for 13 assay pairs using non-decreasing splines, and integrated into this app. Assay comparisons including data from several studies showed a lower performance. This indicates technical variation between laboratories, which has not been described before, but is relevant when diagnostic measurements and cut-offs are provided by different laboratories. Nevertheless, the models' overall high performance (median r2 = 0.94; range 0.57-1.00) supports their use to interpret results from diagnostic insulin measurements when the reference assay is unavailable, and to compare values obtained from different assays.

Evaluation of field-testing protocols to diagnose insulin dysregulation in ponies using a Bayesian approach

Field tests and their association with laminitis have not been evaluated in large cohorts. The objectives of this study were to evaluate the performance of basal insulin (BI), the oral sugar test (OST) and the insulin tolerance test (ITT) to diagnose ID and investigate their association with laminitis. Insulin dysregulation status was determined in 146 ponies using BI (insulin concentration >20 µIU/mL), an OST (insulin concentration >65 µIU/mL at 60 or 90 min after oral administration of 0.45 mL/kg corn syrup) and an ITT (< 50% reduction in glucose concentration 30 min after intravenous administration of 0.1 IU/kg insulin). Laminitis was identified using modified-Obel scores. A Bayesian approach was used to define the characteristics of the tests and receiver operating characteristic curves were used to assess their association with laminitis. All tests were well tolerated and laminitis was diagnosed in 9% of ponies. Insulin dysregulation was diagnosed in 15% of ponies using BI, 38% using the OST and 54% using the ITT with 11% of ponies positive for all three tests. The sensitivities and specificities of BI, the OST and the ITT to diagnose ID were 0.52 (95% confidence interval [CI], 0.35-0.79) and 0.97 (95% CI, 0.91 - 1.00), 0.84 (95% CI, 0.70 - 0.94) and 0.60 (95% CI, 0.49 - 0.71), and 0.85 (95% CI, 0.68-0.96) and 0.88 (95% CI, 0.75 - 0.97), respectively. Only BI and the OST were associated with laminitis (P = 0.003 and 0.015, respectively).

Equine Endocrine Disease: Challenges With Case Definition for Research

Equine endocrine disease is an important area for equine research, requiring an appropriate case definition for inclusion and criteria for exclusion from disease. Defining a case for research may be different from criteria for clinical diagnosis. Further, clinical diagnosis recommendations have been changing regularly, making this area challenging for equine scientists. This review discusses the diagnosis of major equine endocrine diseases, pituitary pars intermedia dysfunction, equine metabolic syndrome and insulin dysregulation, focusing on the most appropriate diagnostic methods for research case definitions. Different diagnostic methods, including use of reference intervals and clinical decision limits, will be discussed with their relative merits for use in case definition for research.

Clinical evaluation of the Immulite® 1000 chemiluminescent immunoassay for measurement of equine serum insulin

Introduction

Accurate quantitative analysis of equine insulin in blood samples is critical for assessing hyperinsulinemia in horses. Although there are various laboratory methods for evaluating equine serum insulin, different immunoassays show significant discrepancies between the determined insulin concentrations and are often not comparable. The aim of this study was to evaluate the Immulite® 1000 chemiluminescent immunoassay (CLIA) to establish independent laboratory and assay-specific cut values to provide an accurate diagnosis of hyperinsulinemia in horses. Thus, the analytical and clinical performance of Immulite® 1000 CLIA in terms of precision (intra- and inter-assay coefficient of variance, CV) and recovery upon dilution were evaluated and compared with radioimmunoassay (RIA), which has been previously validated for use in horses.

Material and methods

Archived serum samples (n = 106) from six Quarter horse mares enrolled in the glucose phase of a Frequently Sampled Insulin and Glucose Test (FSIGT) study were used to measure blood insulin.

Results

The Immulite® 1000 CLIA had good precision with acceptable intra- and inter-assay CVs, adequate recovery on dilution, and a strong correlation with the RIA (r = 0.974, P &lt; 0.0001), with constant bias resulting in consistently lower values.

Discussion

On this basis, the Immulite® 1000 Insulin Assay is valid for measuring equine serum insulin for diagnostic and monitoring purposes when cut values are appropriately adjusted.

A one-health lens offers new perspectives on the importance of endocrine disorders in the equine athlete

Endocrine disorders are associated with joint pain and tendon injury in humans, but the effects in the horse are only starting to be understood. Similar patterns of clinical signs and injury appear to affect horses and humans for both orthopedic and endocrine disorders, supporting the use of a one-health approach to tackle these issues. In this Currents in One Health, we will discuss common equine endocrinopathies, current testing recommendations, dietary management, genetic predispositions, and endocrine disorders' effects on performance. Our aim is to use a one-health lens to describe current comparative research so that veterinarians can employ cutting-edge preventative, diagnostic, and therapeutic recommendations. Identified key gaps in knowledge include whether equine metabolic osteoarthritis exists, if steroid joint injections are safe in horses with endocrine disorders, and if the return to performance percentage improves with concurrent treatment of endocrine and musculoskeletal disorders. Key takeaways include that the relationship between endocrine disorders and musculoskeletal disease in the horse goes beyond laminitis to include lameness, muscle atrophy, suspensory ligament degeneration, osteochondritis dissecans, and potentially metabolic osteoarthritis. Approaches learned from human and equine comparative studies can offer insight into injury recognition and management, thus mitigating the impact of endocrine disorders on performance in both species. Readers interested in an in-depth description of current and future research involving pathophysiology, novel interventions, and multiomic approaches to identify individuals with athletic limitations induced by endocrine disorders are invited to read the companion Currents in One Health by Manfredi et al, AJVR, February 2023.

The Differences in Histoarchitecture of Hoof Lamellae between Obese and Lean Draft Horses

Obesity is a common problem in horses. The associations between obesity and equine metabolic syndrome (EMS) and between EMS and laminitis are known. However, there is a lack of data on whether obesity itself can affect hoof lamellae. Forelimbs and blood from 12 draft horses (six obese and six lean) from a slaughterhouse were acquired. To exclude laminitis and EMS horses, insulin concentration was measured, and hooves were radiographed. Histological evaluation was performed. The shape of the primary and secondary epidermal lamellae (PEL and SEL) was evaluated, and the length of the keratinized and total primary epidermal lamellae was measured (KPEL and TEL). All horses showed pathological changes in lamellae. In the lean group, the changes were longer SELs, more proliferated and separated PDLs, and less standard PDLs. In the obese group, the changes were a lower number of club-shaped and standard SELs and significantly more tapered SELs. No difference in the shape of PELs and the length of KPELs was noticed. The research did not confirm the effects of obesity on lamellar failure. The measurements taken indicate that the lamellae are much longer compared to other research studies; this could indicate that the length of the PEL depends on the hoof size.

Characterisation of the oral glucose and sugar tolerance tests and the enteroinsular axis response in healthy adult donkeys

BACKGROUND

Insulin dysregulation (ID) is diagnosed in horses and ponies using oral glucose (OGTT) and oral sugar (OSTT) tolerance tests. The enteroinsular axis plays a major role in postprandial glucose disposal and insulin response in horses, ponies and foals. The insulin and incretin response to oral carbohydrate challenges has not been characterised in donkeys.

OBJECTIVES

(a) To characterise OGTT and OSTT, and (b) to assess the plasma incretin response to OGTT and OSTT in healthy donkeys.

STUDY DESIGN

In vivo experiments.

METHODS

Six healthy adult female Andalusian donkeys were challenged with OGTT (1 g/kg glucose, 20% solution by nasogastric tube) and OSTT (0.45 mL/kg corn syrup orally by syringe) with a 1-week washout. Blood samples were collected for glucose (spectrophotometry), insulin (radioimmunoassay), glucose-dependent insulinotropic polypeptide (GIP, ELISA) and active glucagon-like peptide-1 (aGLP-1, ELISA) determination over 6 hours. Curves were analysed and proxies calculated.

RESULTS

Glucose and insulin concentrations peaked at 180 minutes in OGTT, but at 300 and 150 minutes in OSTT, respectively. Plasma GIP concentrations increased in the OGTT and OSTT (peaked at 180 and 360 minutes, respectively), but aGLP-1 increased only in OGTT (240 minutes).

MAIN LIMITATIONS

Single breed, narrow age and sample, diet, season and not having donkeys with evidence of ID to provide clinical validation.

CONCLUSIONS

Donkeys have a functional enteroinsular axis that is activated by enteral carbohydrates. Donkeys have evident endocrine differences with horses, supporting the validation of the OSTT and OGTT to assess insulin sensitivity in this species to avoid extrapolation from horses.

Effect of Dose and Fasting on Oral Sugar Test Responses in Insulin Dysregulated Horses

The oral sugar test (OST) is frequently used to identify insulin dysregulated (ID) equines. The effect of fasting and varying sugar dose for the OST has been investigated in the pony but little work has been done in the horse. This study aimed to investigate (1) an OST response with access to forage continued until the time of the OST or prevented for 3 hours prior to the OST and (2) responses of ID and non-insulin dysregulated (NID) horses to two different OST doses. Twenty-one mixed-breed horses (14.8 ± 3.2 years; 574.3 ± 83.3 kg) were used in two randomized crossover studies. Seven ID and seven NID horses were used in study A, and eight ID and eight NID in study B. Study A horses underwent an OST (0.15 mL/kg BW) either after a fast (FA) or directly off pasture (FE). Study B horses received either a low (LD; 0.15 mL/kg BW) or high dose (HD; 0.45 mL/kg BW) OST on one occasion each. Blood was collected at basal (T0), and post-60 minute (T60) for later determination of insulin (RIA). Data were analyzed via ANOVA with repeated measures. ID horses had significantly (P < 0.05) greater insulin responses than NID for all OSTs. There was no statistical difference between LD versus HD mean insulin concentrations (T0, T60, delta insulin) for either ID or NID horses. ID had higher T0 (P < 0.01) for FE compared to FA; however, FE and FA did not significantly affect T60 or delta insulins (DI) concentrations.

Morphometric, metabolic, and inflammatory markers across a cohort of client-owned horses and ponies on the insulin dysregulation spectrum

In human metabolic syndrome and type II diabetes, methylglyoxal (MG), D-lactate, and several cytokines have been recognized as biomarkers of important metabolic and inflammatory processes. Equine metabolic syndrome (EMS) shares many similarities with these human counterparts. The objectives of this cross-sectional study were to compare body condition score (BCS), cresty neck score (CNS), resting insulin, MG, D-lactate, L-lactate, tumor necrosis factor-α (TNF-α), interleukin-6 (IL-6), and monocyte chemoattractant protein-1 (MCP-1) between horses with and without insulin dysregulation, as classified via combined glucose and insulin test (CGIT). 32 client-owned horses were included. History and morphometric data such as BCS and CNS were recorded. Subjects with abnormalities on physical examination or CBC, elevated ACTH or incomplete information were excluded. Baseline serum or plasma concentrations of biomarkers were tested via commercial ELISA or colorimetric assays. Characteristics of insulin dysregulated and insulin sensitive horses were compared by univariate analysis and forward logistic regression. 12 (38%) of the 32 horses were classified as insulin dysregulated. No significant difference between the 2 groups was found for age, BCS, baseline glucose, triglycerides, MG, D-lactate, L-lactate, TNF-α, IL-6, and MCP-1. Baseline insulin was significantly associated with insulin dysregulation in univariate analysis (P = 0.02), but not in the final model. Horses with CNS ≥ 3 had 11.3 times higher odds of having insulin dysregulation (OR 11.3, 95% C.I. 2.04 - 63.08, P = 0.006). In this population, horses with mild-moderate signs of EMS presented similar metabolic and inflammatory profiles to non-insulin dysregulated controls.

Use of palm bran (Nopalea cochenillifera (L.) Salm-Dyck) in partial replacement of concentrate in maintenance equine diets - a pilot study

Forage palm is extremely suitable as animal fodder due to its high tolerance to the climatic rigors of the semiarid region and its ability to withstand the harsh physical–chemical limitations of poor soils. Thus, in this study, the effects of the partial replacement (0 %, 5 %, 10 % and 15 % replacement) of a molasses- or oat-based commercial concentrate with forage palm bran (FPB) on the acceptability, apparent digestibility and glycemic response of horses at maintenance were evaluated. The ratio of concentrate to roughage (Tifton 85 hay) was 30:70, and the dry matter (DM) intake was 2 % of body weight (BW). For the preference test, 10 barren Mangalarga Marchador mares were used. The experimental diets were offered simultaneously to determine the consumption preference and the intake ratio. For the digestibility test, four mixed-breed geldings were used and were distributed in a Latin square experimental design (4×4). For the glycemic response, blood samples were collected 30 min before and 30, 60, 90, 120, 180 and 240 min after supplying the feed. The preference test indicated that feed containing 0 % and 5 % FPB was preferred by the animals. Nutrient digestibility coefficients did not differ among the experimental diets. Blood glucose was lower at 180 min in the 7.42 % FPB inclusion diet (R2=0.97); this was estimated using the following equation: Y=115.05-2.75x+0.19x2. It is concluded that the incorporation of up to 15 % of forage palm bran as a substitute for concentrate in the maintenance diet tested did not negatively influence feed intake, nutrient digestibility or glycemic index; however, inclusion values above 5 % reduced diet acceptability.

Evaluation of the combined glucose-insulin and intravenous glucose tolerance tests for insulin dysregulation diagnosis in donkeys

BACKGROUND

Insulin dysregulation (ID) and donkey metabolic syndrome (DMS) are common in this species. Contrary to horses, diagnostic guidelines compiling insulin cut-offs values and dynamic testing interpretations have not been reported for this species.

OBJECTIVES

To evaluate resting serum insulin concentrations, the combined glucose-insulin test (CGIT) and the glucose intravenous tolerance test (IVGTT) for the diagnosis of DMS with ID suspicion.

STUDY DESIGN

Diagnostic test comparison.

METHODS

Six of 80 mix-breed adult donkeys fulfilled the inclusion criteria for DMS based on history or clinical evidence of recurrent laminitis, body condition >6 and neck score >2 or baseline insulin and leptin concentrations >20 µIU/mL and >12 ng/mL respectively. CGIT and IVGTT were performed in all donkeys within a week and interpreted following guidelines reported for equine metabolic syndrome (EMS). Insulin and glucose curves were analysed, proxies calculated and correlations and multivariate analysis assessed.

RESULTS

Following EMS guidelines, CGIT classified 2 (using glucose-positive phase duration) or 3 (using insulin concentration) and IVGTT classified 5 donkeys as ID. ID donkeys showed a lower glucose/insulin ratio, QUICKI and RISQI, and a higher insulin/glucose ratio, MIRG and HOMA-B%.

MAIN LIMITATIONS

Comparison of these tests with additional dynamic testing including a larger number of ID donkeys is necessary.

CONCLUSIONS

This is the first study evaluating dynamic tests to assess ID/DMS in DMS-suspected donkeys. IVGTT detected more ID donkeys than CGIT. EMS recommendations could also be used for DMS diagnosis, although a baseline insulin cut-off value is needed.

Evaluation of fasting plasma insulin and proxy measurements to assess insulin sensitivity in horses

Background

Proxies are mathematical calculations based on fasting glucose and/or insulin concentrations developed to allow prediction of insulin sensitivity (IS) and β-cell response. These proxies have not been evaluated in horses with insulin dysregulation. The first objective of this study was to evaluate how fasting insulin (FI) and proxies for IS (1/Insulin, reciprocal of the square root of insulin (RISQI) and the quantitative insulin sensitivity check index (QUICKI)) and β-cell response (the modified insulin-to-glucose ratio (MIRG) and the homeostatic model assessment of β-cell function (HOMA-β)) were correlated to measures of IS (M index) using the euglycemic hyperinsulinemic clamp (EHC) in horses with insulin resistance (IR) and normal IS. A second objective was to evaluate the repeatability of FI and proxies in horses based on sampling on consecutive days. The last objective was to investigate the most appropriate cut-off value for the proxies and FI.

Results

Thirty-four horses were categorized as IR and 26 as IS based on the M index. The proxies and FI had coefficients of variation (CVs) ≤ 25.3 % and very good reliability (intraclass correlation coefficients ≥ 0.89). All proxies and FI were good predictors of the M index (r = 0.76–0.85; P < 0.001). The proxies for IS had a positive linear relationship with the M index whereas proxies for β-cell response and FI had an inverse relationship with the M index. Cut-off values to distinguish horses with IR from horses with normal IS based on the M index were established for all proxies and FI using receiver operating characteristic curves, with sensitivity between 79 % and 91 % and specificity between 85 % and 96 %. The cut-off values to predict IR were < 0.32 (RISQI), < 0.33 (QUICKI) and > 9.5 µIU/mL for FI.

Conclusions

All proxies and FI provided repeatable estimates of horses’ IS. However, there is no advantage of using proxies instead of FI to estimate IR in the horse. Due to the heteroscedasticity of the data, proxies and FI in general are more suitable for epidemiological studies and larger clinical studies than as a diagnostic tool for measurement of IR in individual horses.

Pituitary Pars Intermedia Dysfunction and Metabolic Syndrome in Donkeys

Simple Summary

Donkeys are one of the six species of the equid family. Even though they may look similar to horses, there are optical, behavioral, and physiological differences between the two species. The most important endocrine diseases in horses (equine metabolic syndrome and pituitary pars intermedia dysfunction: PPID) also exist in donkeys. The key symptoms of asinine metabolic syndrome (AMS), similar to horses, are obesity, insulin dysregulation, and laminitis. It can be diagnosed with either basal glucose and insulin concentration or dynamic tests. The intravenous glucose tolerance test and the combined glucose insulin tolerance test were evaluated for donkeys. The therapy of AMS is aimed at weight and exercise management. Donkeys suffering from PPID are often laminitic. Other authors have reported on hypertrichosis as a cardinal sign. Donkey-specific differences in shedding compared to horses have to be considered. The PPID can be diagnosed with donkey-specific reference values or dynamic testing. The dexamethasone suppression test, the thyrotropin releasing hormone (TRH) test, and the combined dexamethasone suppression/TRH test were evaluated for donkeys.

Abstract

Appropriate medical care for donkeys is challenging despite being important working animals in non-industrialized countries and pets in first world countries. Although the same principles of diagnosis and therapy as in horses are commonly applied, there are differences in reference values and physiologic reaction to dynamic tests. However, donkeys seem to suffer from typical equine diseases, such as metabolic syndrome and pituitary pars intermedia dysfunction (PPID). Asinine metabolic syndrome (AMS) comprises obesity, insulin dysregulation, and laminitis. The principles of diagnosis are similar to horses. Donkey-specific reference ranges for insulin and glucose have been evaluated previously. Examinations regarding dynamic testing revealed differences in the intravenous glucose tolerance test and the combined insulin tolerance test compared to horses. The therapy of AMS is based mainly on weight loss and exercise. There are conflicting data regarding the incidence of PPID in donkeys. Laminitis and hypertrichosis were described as the main clinical signs. Species-specific and seasonal reference ranges were defined to diagnose PPID in donkeys. Furthermore, the dexamethasone suppression test, the thyrotropin releasing hormone (TRH) test and the combined dexamethasone suppression/TRH test were evaluated. Pergolide is commonly recommended for treatment.

Comparison of Two Diagnostic Methods to Detect Insulin Dysregulation in Horses Under Field Conditions

Straightforward testing procedures to enable the diagnosis of insulin dysregulation (ID) in horses that are suitable for use in daily veterinary practice are needed because of the risk that ID could result in laminitis. In our study (that included 90 horses), we compared the proportion of horses classified as ID-positive, ID-suspect, and ID-not diagnosed according to the basal insulin concentration (BIC) with the proportion of horses classified as ID-positive or ID-negative according to a practical and feasible version of an oral sugar test (OST). Furthermore, BIC, basal glucose concentration, and insulin and glucose concentration after OST were analyzed and compared. In the total study population, the OST detected significantly more ID-positive cases than the BIC, with cutoffs at equivalent specificities. Receiver operating characteristics analysis showed that at a lower cutoff, the sensitivity of the BIC could be increased, but at the cost of a significantly lower specificity. Taking this into account, we found diagnostic performance of the OST to be considerably better than the BIC and therefore considered it more recommendable for use as a screening test for ID in ambulatory practice. Furthermore, we investigated the relationship between body condition score and breed type with glucose and insulin concentration as determined after our version of the OST. For that purpose, the study group was subdivided into lean, moderate, and obese horses and "easy keeper breeds" versus "non-easy keeper breeds". Results supported the general assumption that obese horses and "easy keeper breeds" are more prone to the development of ID.