Pituitarypars intermediadysfunction: Diagnosis and treatment

Effect of pergolide treatment on insulin dysregulation in horses and ponies with pituitary pars intermedia dysfunction

BACKGROUND

Due to the high frequency of laminitis reported for both conditions, the relationship between pituitary pars intermedia dysfunction (PPID) and insulin dysregulation (ID), and the potential role of dopamine in modifying insulin secretion, requires further investigation.

OBJECTIVES

To evaluate the effect of pergolide mesylate on insulin sensitivity and postprandial insulin and glucose responses in horses and ponies with ID, both with or without concurrent PPID.

STUDY DESIGN

Randomised crossover study.

METHODS

Sixteen horses and ponies, comprising eight matched pairs (PPID+ID or ID-only), were given pergolide mesylate at a dose of 2 μg/kg bwt orally once daily for 4 weeks (plus a 4-week non-treatment control period, with a 4-week washout between phases). A combined glucose and insulin tolerance test (CGIT) and a standard meal test (SMT; containing 1.1 g/kg bwt of starch and 0.1 g/kg bwt of free sugars), were performed before and after each treatment period to determine insulin sensitivity and postprandial insulin and glucose responses, respectively. Variables derived from the CGIT and SMT were analysed using linear mixed models.

RESULTS

Pergolide treatment did not alter any of the variables derived from the CGIT in either the PPID+ID or ID-only groups (all p > 0.05). For the SMT, insulin responses were reduced by pergolide treatment for the PPID+ID group, with Δ change values for the total area under the curve for insulin over 300 mins (estimated marginal mean [95% confidence interval]) being -25.4 (-39.9 to -7.3) min∙mIU/mL (p = 0.03) and Δ change values for peak insulin concentration being -100 (-167 to -29) μIU/mL (p = 0.04). No effect of pergolide treatment was detected for the ID-only group.

MAIN LIMITATIONS

Number of animals and heterogeneity among groups.

CONCLUSIONS

Pergolide had no effect on tissue insulin sensitivity. However, the results suggest that postprandial hyperinsulinaemia may be limited by this dopamine receptor agonist in animals with PPID plus ID.

Distribution and sequence analysis of the melanocortin 2 receptor in horses and ponies

The melanocortin 2 receptor (MC2R) has relevance to equine pituitary pars intermedia dysfunction (PPID), as it is the primary binding site for ACTH, which circulates at elevated concentrations in animals affected by PPID. Despite this, little is known about MC2R in equine species. The overall aim of this investigation was to determine MC2R mRNA expression in tissues relevant to PPID in healthy horses and to examine the MC2R gene sequence in a cohort of horses and ponies with and without PPID. The study found that the MC2R gene was expressed in both adrenal and pituitary gland tissues as reported in other mammalian species. However, no expression was seen in adipose or skin tissue. An investigation of the tissue distribution and functionality of the MC2R in individuals with PPID is now recommended. Then, we investigated the coding regions (exons) of the equine MC2R gene for variations associated with PPID in a limited number of animals. This was performed using a hybridised gene capture and next generation sequencing method which found a 100% pairwise identity between all 28 individuals in the study, and with the reference genome sequence. This preliminary study found no evidence of major genetic variations in the coding region of the MC2R gene associated with PPID, though variants affecting expression may occur in the introns or remain unidentified within the exons of the gene and studies on a larger scale are required.

Effect of short-term dopamine reduction on insulin sensitivity and post-prandial insulin and glucose responses in Standardbred horses

The role of dopamine in the regulation of insulin secretion in horses is poorly understood and requires further investigation. Pituitary pars intermedia dysfunction (PPID) is associated with decreased activity of dopaminergic neurons which normally suppress peptide hormone secretion from the pituitary pars intermedia. A high proportion of horses with PPID also have insulin dysregulation (ID), characterised by post-prandial hyperinsulinaemia and/or tissue insulin resistance, which are risk factors for the development of laminitis. The aim of this study was to investigate the effects of alpha-methyl-para-tyrosine (AMPT), a tyrosine hydroxylase inhibitor that reduces dopamine production, on insulin sensitivity and the post-prandial insulin response to a glucose-containing meal. Six healthy Standardbred horses were enrolled in a placebo-controlled randomised crossover study, in which one dose of AMPT (40 mg/kg BW) or placebo was administered orally, prior to performing an in-feed oral glucose test (OGT) and a frequently sampled intravenous glucose tolerance test (FSIGTT). Dopamine reduction by AMPT was confirmed by an increase in plasma prolactin concentration and the lack of post-prandial increase in plasma dopamine concentration compared to placebo. Post-prandial insulin responses, both peak and AUCi, were increased after AMPT compared to placebo (P=0.048 and P=0.005, respectively), without affecting blood glucose concentrations. However, one dose of AMPT did not appear to affect tissue sensitivity as assessed by the FSIGTT. This study confirmed that dopamine plays a role in the regulation of insulin secretion in horses, as it does in other species, whereby the post-prandial release of dopamine into the circulation may inhibit pancreatic insulin secretion. Further studies are required to evaluate different dosing protocols for AMPT, and to further investigate the links between PPID, ID and laminitis risk in horses.

Retrospective assessment of the use of extended-release cabergoline in the management of equine pituitary pars intermedia dysfunction

Introduction

Dopaminergic agonists are accepted as the most effective treatment for pituitary pars intermedia dysfunction. However, some horses are refractory to daily oral pergolide, the recommended registered treatment. Extended-release cabergoline (ERC) injection may offer an alternative. The objective of this retrospective case series was to describe clinical and endocrinological responses to ERC.

Methods

Medical records of horses treated with weekly intramuscular injections of ERC (5 mg/mL, BOVA Aus) at either 0.01 mg/kg (high dose, HD) (n = 10) or 0.005 mg/kg (low dose, LD) (n = 30) were reviewed. Short-term ACTH responses were assessed at 5-8 days using a Wilcoxon signed ranked test. Longer-term ACTH responses (30 to 365 days) were assessed using generalised estimating equations.

Results

Five to eight days after the first dose of LDERC, median adrenocorticotropic hormone (ACTH) concentration was lower (p = 0.001), changing from 153 pg/mL (IQR: 78, 331) to 57 pg/mL (IQR: 30, 102). With HDERC, median ACTH concentration was also 153 pg/mL (IQR: 96, 185) before and then 56 pg/mL (IQR: 29, 86) after 5-8 days of treatment (p = 0.047). Over 12 months of treatment, ACTH concentration ranged from 14 to >1,250 pg/mL (median: 51 pg/mL) in horses treated with LDERC and 20 to 472 pg/mL (median: 50 pg/mL) in horses treated with HDERC. Measurements remained above the seasonal reference range in 39.3 and 52.3% of horses treated with LDERC and HDERC, respectively. Clinical improvement was reported by owners in 78.3 and 100% of horses treated with LDERC and HDERC, respectively. Partial, self-limiting inappetence was reported in 30.0% of LDERC and 60% HDERC cases. Seven horses exhibited lethargy (5 LDERC, 2 HDERC). Insulin concentrations measured 30 days post-ERC treatment were no different from baseline.

Discussion

Clinical and endocrinological responses were consistent with results of previous reports of oral pergolide treatment. Weekly injection of ERC may be an effective alternative to pergolide; the 0.005 mg/kg dose appeared to be as effective, with less risk of inappetence, than the 0.01 mg/kg dose that has been reported previously.

Diagnosis of equine pituitary pars intermedia dysfunction

Equine pituitary pars intermedia dysfunction (PPID) is common in aged horses. The majority of horses respond well to treatment, but treatment is lifelong, meaning accurate diagnosis of PPID is important. Similar to any condition, there is no perfect laboratory test to diagnose PPID and accuracy is affected by the characteristics of the population in which the test is being evaluated. This review details the importance of consideration of clinical factors and diagnostic test accuracy. Basal adrenocorticotrophic hormone (ACTH) concentration is used most frequently in practice and has very good diagnostic accuracy when used in combination with clinical judgement and the correct application of diagnostic thresholds. The thyrotropin-releasing hormone stimulation test can be used in horses with equivocal test results following basal ACTH testing, or to evaluate subtle cases due to its improved accuracy.

Management of pituitary pars intermedia dysfunction in practice: A clinical audit

In horses/ponies with pituitary pars intermedia dysfunction (PPID), pergolide mesylate treatment, with monitoring of therapeutic response, is recommended by contemporaneous literature and equine endocrinologists. However, it is unknown whether these recommendations are adhered to in private practice. This clinical audit aimed to compare treatment and monitoring of PPID cases in veterinary practice against available recommendations. Case data and basal plasma adrenocorticotropic hormone (ACTH) concentrations from all equids tested for PPID between 2012 and 2016 from a single veterinary practice in the UK were obtained. Records were reviewed and information on treatment and monitoring over the subsequent 2-6 years was extracted and compared with published recommendations. After exclusions, the audit population was 480 animals (median age, 20 years). The most common presenting signs were laminitis and/or historical laminitis (51.2%) and hypertrichosis and/or delayed coat shedding (24.5%). Based on seasonally adjusted reference intervals for basal ACTH concentration, 51.7% (n = 248) of animals were classified as positive, 37.1% (n = 178) as negative and 11.3% (n = 54) as equivocal for PPID. Records were available for 459 animals; of which pergolide treatment was initiated in 78.7% (n = 185/235) of positive cases, 19.2% (n = 10/52) of equivocal cases and 6.4% (n = 11/172) of cases classified as negative. Overall, 87.2% (n = 129/148) of cases commenced treatment as per recommendations. Only 77.7% (n = 160/206) of pergolide-treated animals had documented PPID monitoring and of these, only 48.1% (n = 77/160) had follow-up basal ACTH testing in the first 1-3 months following diagnosis. The findings confirm that management of PPID in veterinary practice fell below contemporaneous recommendations, especially for monitoring.

Prospective Case Series of Clinical Signs and Adrenocorticotrophin (ACTH) Concentrations in Seven Horses Transitioning to Pituitary Pars Intermedia Dysfunction (PPID)

Simple Summary

Pituitary pars intermedia dysfunction (PPID) is a common disease of the geriatric horse population. The most common clinical sign of PPID is hypertrichosis, or a long hair-coat with delayed shedding. Hypertrichosis is the most easily recognized clinical sign of PPID. However, the presence of hypertrichosis is often associated with severe end-stage disease. There is little research investigating sub-clinical or early PPID and the clinical signs associated with these stages of disease. The benefit of being able to recognize early PPID, is that we are able to begin treatment earlier on in disease process, potentially reducing the deleterious consequences of PPID and improving survival. Laboratory tests are available to more accurately diagnose PPID, and these tests include the basal ACTH and TRH-stimulated ACTH tests. Basal ACTH is easy to perform and is recommended in cases where clinical disease is suspected. The TRH-stimulation test improves diagnostic accuracy in early PPID cases. This study documents both test results and clinical signs associated with the transition from subclinical to clinical PPID, so that we are better able to recognize potential early PPID, as well as interpret results in these horses.

Abstract

Poor recognition of subtle clinical abnormalities and equivocal ACTH concentrations make early diagnosis of PPID difficult. Progressive clinical findings and corresponding ACTH concentrations in horses transitioning to PPID over time have not been documented. Seven horses with ACTH concentrations equivocal for PPID (utilizing locally derived, seasonally adjusted diagnostic-cut off values (DCOV)) and no clinical signs of PPID were selected. Sequential measurement of basal and thyrotropin-releasing hormone (TRH)-stimulated ACTH concentrations and recording of clinical findings occurred from October 2017 to November 2021 in a prospective case series. In two horses, marked hypertrichosis developed. Although 1/11 basal ACTH concentrations were below DCOV in 2018, subsequently all basal ACTH concentrations in these two horses without treatment were greater than DCOV. One horse was treated with pergolide which normalized basal ACTH concentrations. Four horses developed intermittent, mild hypertrichosis, and one horse never developed hypertrichosis. Basal ACTH concentrations in these five horses were greater than DCOV in 63/133 (47.4%) of testing points. TRH-stimulated ACTH concentrations in these five horses were greater than DCOV in 77/133 (57.9%) of testing points, sometimes markedly increased and greater than the assay upper limit of detection (LoD) of 1250pg/mL. TRH-stimulated ACTH concentrations were most frequently positive in late summer and early autumn, with 24/37 (64.9%) of TRH-stimulated ACTH concentrations greater than the DCOV in February and March. Horses transitioning to PPID can have subtle clinical signs and equivocal ACTH concentrations. However, TRH-stimulated ACTH concentrations can be markedly greater than DCOV, especially in late summer and early autumn (February and March) allowing for identification of subclinical and transitional cases.

Pituitary Pars Intermedia Dysfunction (PPID) in Horses

Substantial morbidity results from pituitary pars intermedia dysfunction (PPID) which is often underestimated by owners and veterinarians. Clinical signs, pathophysiology, diagnostic tests, and treatment protocols of this condition are reviewed. The importance of improved recognition of early clinical signs and diagnosis are highlighted, as initiation of treatment will result in improved quality of life. Future research should be targeted at improving the accuracy of the diagnosis of PPID, as basal adrenocorticotropic hormone (ACTH) concentration can lack sensitivity and thyrotropin releasing hormone (TRH) used to assess ACTH response to TRH stimulation is not commercially available as a sterile registered product in many countries. The relationship between PPID and insulin dysregulation and its association with laminitis, as well as additional management practices and long-term responses to treatment with pergolide also require further investigation.

The effect of pergolide mesylate on adrenocorticotrophic hormone responses to exogenous thyrotropin releasing hormone in horses

Thyrotropin releasing hormone (TRH) stimulation testing is often used to support a diagnosis of pituitary pars intermedia dysfunction (PPID) in horses although it is unclear whether or not repeat TRH stimulation testing post-treatment is a valid means of assessing response to medical therapy. Laboratory submissions from 64 suspected equine PPID cases were examined including the initial pre-treatment TRH stimulation test and a follow up test within 100 days of starting medical therapy with pergolide. In a subset of cases, further follow-up tests were examined beyond 100 days of starting treatment. Results from tests conducted between 1 July and 30 November 30 were excluded. Significant improvements were seen in both the baseline and TRH-stimulated adrenocorticotrophic hormone (ACTH) concentrations within 100 days with no further improvements seen in the subset of cases examined thereafter. Although 88% (n=56/64) of all cases showed a decreased response to TRH post-treatment, only 24% (n=9/38) of horses with positive pre-treatment TRH stimulation tests normalised following treatment, with a further 34% (n=13/38) improving into an equivocal test outcome category. Most commonly (42%; n=16/38), horses with positive pre-treatment TRH stimulation tests remained positive following treatment, although 75% (n=12/16) of these showed a numerically lower post-treatment response to TRH. These results will help inform practitioners of expected changes in TRH stimulation test results when assessing response of horses with PPID to medical therapy with pergolide.

Short-Term Effects of Temperature and Thyrotropin-Releasing Hormone Stimulation on Adrenocorticotropin Stability in Horses

Pituitary pars intermedia dysfunction (PPID) is diagnosed by increased basal or post thyrotropin-releasing hormone (TRH) stimulation ACTH concentrations. ACTH is known to be unstable; however, the effect of different temperatures and TRH stimulation on equine ACTH stability is poorly described. In total, 15 horses, including 8 PPID positive (ACTH > 35 pg/mL at baseline or >65 pg/mL 30 min after TRH stimulation), were divided into 2 groups: 9, including 5 PPID positive, with basal ACTH concentrations and 6, including 3 PPID positive, with post TRH stimulation ACTH concentrations. Whole blood was stored for 1 h at 4, 20, 30, 40, or 70 °C. After centrifugation, immunoreactive ACTH concentrations were determined using a chemiluminescent assay. Linear mixed effect models were used to detect the effects of temperature, PPID status, and TRH stimulation on the immunoreactive ACTH concentration. Temperature had a significant effect (p = 0.003) on immunoreactive ACTH concentrations, and this effect was greater in PPID-negative horses (p = 0.01), with the changes in immunoreactive ACTH concentrations being slightly unpredictably higher or lower than samples stored at 4 °C. Even at 20 °C, mean immunoreactive ACTH concentrations minimally changed by 5% in PPID horses and 12% in non-PPID horses after 1 h. No significant effect of TRH stimulation was identified. Although ACTH concentrations should ideally be determined from samples kept at 4 °C, samples inadvertently left at temperatures of up to 40 °C can provide valid results if analyzed within 1 h; however, this increases the risks of altered ACTH concentrations, occasionally influencing the diagnosis of PPID.

The Gingiva of Horses With Pituitary Pars Intermedia Dysfunction: A Macroscopic Anatomical Evaluation

Pituitary pars intermedia dysfunction (PPID) is a common neurodegenerative disease mainly in horses older than 15 years. The domestic equine population is following the same demographic change as that seen in humans; it is aging and veterinarians are asked to attend to geriatric horses more frequently. Common problems seen regularly in older equines are dental disorders and especially periodontal disease. As a systemic and endocrine disease, associated with delayed wound healing and impaired immune function, PPID should be considered before major dental treatment in aged equines is started. Possible negative effects of PPID on epithelial tissues could also affect the periodontium. Therefore, the aim of the present study was to identify gross changes in the gingiva associated with PPID. Fourteen horses with clinical signs of PPID and adenoma in the pituitary pars intermedia and 13 controls showing neither clinical signs nor PPID-associated histological changes in the pituitary gland were included. PPID-affected horses (26.9 ± 0.73 years) were significantly older than controls (20.0 ± 1.24 years). In the PPID-affected group, significantly more often an irregular and bulky appearance of the gingival texture was observed, as well as an irregular shape of the gingival margin. Furthermore, the sulcus gingivalis of cheek teeth frequently was deeper than 1 mm. These findings indicate a possible association between age, soft tissue alterations, and PPID and suggest a potential predisposition of PPID-affected horses for periodontal diseases.

Evaluation of the sensitivity and specificity of basal plasma adrenocorticotrophic hormone concentration for diagnosing pituitary pars intermedia dysfunction in horses: A systematic review

Measurement of basal adrenocorticotrophic hormone (ACTH) is currently used to diagnose pituitary pars intermedia dysfunction (PPID) in horses, yet a systematic review of the evidence for its use has not been undertaken. This study aimed to systematically review evidence regarding the sensitivity and specificity of the basal ACTH diagnostic test. Electronic databases were systematically searched in January 2019, September 2020 and January 2021, for English language publications published prior to these dates. Screening, data extraction and quality assessment of publications was undertaken by the authors using predefined criteria. Study design, methodology and information reported in included studies were assessed using Standards for Reporting of Diagnostic Accuracy (STARD) checklists. Risk of bias and applicability were appraised using the Quality Assessment tool for Diagnostic Accuracy Studies (QUADAS-2) quality assessment tool. Due to identified biases and marked between-study variations, meta-analysis was not undertaken. After removal of duplicates, 415 publications were identified, of which 25 were evaluated in full, with 11 of these meeting inclusion criteria. In most studies, basal ACTH was reported to have good sensitivity (overall median 75.5%; interquartile range [IQR], 64.0-86.5%; range, 36.0-100%) and excellent specificity (overall median, 95.2%; IQR, 84.2-98.9%; range, 63.3-100%). However, QUADAS-2 and STARD assessment highlighted that studies did not utilise optimal study design and/or study populations for the evaluation of a diagnostic test and the majority were subject to bias, or provided insufficient information to fully assess possible biases. Based on this review, basal ACTH performed better at ruling out PPID than detecting it.

Translating research into practice: Adoption of endocrine diagnostic testing in cases of equine laminitis

Research demonstrating insulin's causal role in endocrinopathic laminitis has greatly advanced understanding of equine laminitis. However, the degree to which this knowledge has been translated into clinical practice has not been assessed. This two-part study aimed to investigate veterinary surgeons' current diagnostic approach to laminitis, whether this had changed over time, and the impact of diagnosing an endocrinopathy on laminitis case management and outcome. Two cross-sectional online surveys of equine veterinary surgeons working within the UK were undertaken. The first study population comprised 141 veterinary surgeons, who had graduated a median of 8 years previously. Overall, 83.6% of respondents (n = 117/140) had changed their diagnostic approach to laminitis since graduating, primarily through increasing use of endocrine testing (88.7%; n = 86/97). Ninety-nine percent (n = 140/141) performed endocrine diagnostic test(s) for some or all laminitis cases at initial and/or subsequent examinations. The second study had 120 participating veterinary surgeons, ≥76% of whom considered diagnosing underlying endocrine diseases greatly influenced their laminitis case management. Where an endocrinopathy was identified, 75.0% (n = 90/120) considered that client communication regarding laminitis was facilitated, and ≥67% considered that treating the endocrinopathy was effective in reducing laminitis recurrence. This study demonstrates successful translation of research knowledge into equine practice, with the vast majority of veterinary surgeons adopting endocrine diagnostic testing within their routine approach to laminitis cases. Respondents perceived that this change in diagnostic approach has resulted in improvements in several non-clinical and clinical healthcare outcomes, including client communication and reduction in recurrent laminitis episodes.

Efficacy of pergolide for the management of equine pituitary pars intermedia dysfunction: A systematic review

Pergolide, a dopamine agonist, is commonly administered to manage pituitary pars intermedia dysfunction (PPID), a progressive neurodegenerative disease prevalent in aged horses. However, available evidence regarding pergolide's efficacy in improving clinical and endocrine parameters is limited. The aim of this systematic review was to assess published literature and evaluate evidence regarding whether pergolide treatment results in improvement of clinical signs and/or adrenocorticotrophic hormone (ACTH) concentration compared to no treatment or other unlicensed treatments. Systematic searches of electronic databases were undertaken in April 2019, repeated in August and October 2019, and updated in July 2020. English language publications published prior to these dates were included. Screening, data extraction and quality assessment of publications was undertaken individually by the authors using predefined criteria and subsequently cross-checked. Modified critically appraised topic data collection forms were used to extract data. Due to marked between-study variations, meta-analysis was not undertaken. After removal of duplicate records; 612 publications were identified, of which 129 abstracts were screened for eligibility and 28 publications met criteria for inclusion in the review. Most studies were descriptive case series, cohort studies or non-randomised, uncontrolled field trials. Despite marked variation in study populations, case selection, diagnostic protocols, pergolide dose, follow-up period and outcome measures, in the vast majority of the included studies, pergolide was reported to provide overall clinical improvement in >75% of cases. However, reported improvements in individual clinical signs varied widely. A reduction in plasma ACTH concentrations was reported in 44-74% of cases, while normalisation to within reported reference intervals occurred in 28-74% of cases.

Circannual variation in plasma adrenocorticotropic hormone concentrations and dexamethasone suppression test results in Standardbred horses, Andalusian horses and mixed-breed ponies

OBJECTIVE

To compare circannual plasma concentrations of adrenocorticotropic hormone (ACTH) and seasonal dexamethasone suppression test (DST) results between three different equine breed groups.

METHODS

Six Standardbred horses, six Andalusian horses and six mixed-breed ponies were followed over a 1-year period, during which time groups were managed identically. Blood samples were collected monthly (around the autumn equinox) or in every second month (other times of the year) for the determination of plasma ACTH concentrations using a chemiluminescent immunoassay. Overnight DSTs were performed quarterly, with suppression of plasma cortisol to below 27 nmol/L at 19 h considered a normal result.

RESULTS

Seasonal variation in plasma ACTH concentrations was present among all breed groups with, as expected, higher levels detected around the autumn equinox, from February to April (P < 0.001). Plasma ACTH concentrations were different between breed groups in March, with higher levels in Andalusians compared with Standardbreds (P = 0.048) and in ponies compared with Standardbreds (P = 0.010). Suppression of cortisol during the DST was normal for all animals in winter, spring and summer, but five Andalusians and three ponies returned abnormally high results in autumn, compared with zero Standardbreds.

CONCLUSION

Higher plasma ACTH concentrations and more false-positive DST results were obtained during autumn in ponies and Andalusian horses when compared with Standardbred horses. Potential differences between breeds should be considered when interpreting test results for horses and ponies that are evaluated for pituitary pars intermedia dysfunction. Further work is recommended to establish population-based reference intervals and clinical cut-off values for ACTH in different equine breeds.

Can Endocrine Dysfunction Be Reliably Tested in Aged Horses That Are Experiencing Pain?

Simple Summary

Pituitary pars intermedia dysfunction (PPID) is an endocrine (secreting internally) disease of aged horses and ponies. An enlargement (hyperplasia) of the pars intermedia of the pituitary gland leads to an increased secretion of hormones, including adrenocorticotropic hormone (ACTH). The main tests for a diagnosis of PPID are the measurement of basal ACTH and the thyrotropin-releasing hormone (TRH) stimulation test, where TRH stimulates the secretion of ACTH. Since pain can also lead to elevated concentrations of ACTH, it is unclear whether horses with pain can be tested for PPID correctly. The aim of the present study was to find out whether pain caused a marked increase of ACTH can lead to a false positive result in the diagnosis of PPID. Therefore, we examined fifteen horses treated for different pain conditions, which also served as their own controls as soon as they were pain-free again. The ACTH and cortisol were measured before and after the TRH stimulation test. There was no significant difference in the ACTH concentration in horses with pain and the controls, between different pain intensities or between disease groups. Thus, measuring the basal ACTH concentration and performing the TRH stimulation test for the diagnosis of PPID seem to be possible in horses with a treated low to moderate pain condition.

Abstract

The aim of the present study was to evaluate (i) the effects of different intensities and types of treated pain on the basal concentrations of adrenocorticotropic hormone (ACTH) and cortisol, and (ii) the thyrotropin-releasing hormone (TRH) stimulation test, to determine whether treated pain caused a marked increase of ACTH, which would lead to a false positive result in the diagnosis of pituitary pars intermedia dysfunction (PPID). Methods: Fifteen horses with treated low to moderate pain intensities were part of the study. They served as their own controls as soon as they were pain-free again. The horses were divided into three disease groups, depending on their underlying disease (disease group 1 = colic, disease group 2 = laminitis, disease group 3 = orthopedic problems). A composite pain scale was used to evaluate the intensity of the pain. This pain scale contained a general part and specific criteria for every disease. Subsequently, ACTH and cortisol were measured before and after the intravenous application of 1 mg of TRH. Results: There was no significant difference in the basal or stimulated ACTH concentration in horses with pain and controls, between different pain intensities or between disease groups. Descriptive statistics, however, revealed that pain might decrease the effect of TRH on the secretion of ACTH. There was an increase of ACTH 30 min after TRH application (p = 0.007) in the treated pain group, but this difference could not be statistically confirmed. Measuring the basal ACTH concentration and performing the TRH stimulation test for the diagnosis of PPID seem to be possible in horses with low to moderate pain.

Clinically and temporally specific diagnostic thresholds for plasma ACTH in the horse

BACKGROUND

Pituitary pars intermedia dysfunction (PPID) is commonly investigated using plasma ACTH concentrations but problems exist with currently available diagnostic thresholds.

OBJECTIVES

To derive temporally specific diagnostic thresholds for equine plasma ACTH concentration to be used alongside clinical judgement in each individual week of the year and appropriate for the degree of clinical suspicion in any given case. Furthermore, to apply these thresholds to compare the prevalence of high and low ACTH in two subgroups of animals with high and low clinical suspicion of PPID.

STUDY DESIGN

A retrospective population study examining a large laboratory database of equine plasma ACTH concentrations using an indirect approach to calculate diagnostic thresholds.

METHODS

Logs of plasma ACTH concentrations from 75 892 individual horses were examined using robust L₂ estimation of mixtures of two normal distributions in categories of each week and month of the year. Thresholds dividing the two populations of high-ACTH and low-ACTH horses were then established at different levels of sensitivity and specificity and compared with clinical subgroups of horses divided based on reported clinical signs, as having high (n = 4036) or low (n = 3022) clinical suspicion of PPID.

RESULTS

For most of the year there were small interweek differences in diagnostic thresholds. However, from mid-June to early-December diagnostic thresholds showed greater interweek variability, reaching a maximum in late September and early October. Grouping of high- and low-ACTH compared favourably with grouping based on clinical signs.

MAIN LIMITATIONS

Given the multiple sources of diagnostic samples, pre-analytical data could not be fully verified.

CONCLUSIONS

Diagnostic thresholds for equine plasma ACTH vary through the year. It is especially important to consider the temporally specific threshold between June and December. Different clinical thresholds can be used depending on the case circumstances and whether a false-positive or false-negative diagnosis is deemed least desirable.

The effect of freeze-thaw cycles on determination of immunoreactive plasma adrenocorticotrophic hormone concentrations in horses

Background

Determination of plasma adrenocotrophic hormone (ACTH) concentration (endogenous or thyrotropin‐releasing hormone [TRH] stimulation test) is the most commonly used diagnostic test for pituitary pars intermedia dysfunction (PPID) in horses. Because ACTH is unstable, samples often are frozen to be shipped to laboratories or to allow for batch analysis of research samples. However, the effect of multiple freeze‐thaw cycles on equine ACTH is unknown.

Objective

To determine the effects of multiple freeze‐thaw cycles on immunoreactive ACTH concentration.

Animals

Twenty‐eight horses ranging from 10 to 27 years of age were used.

Methods

Prospective study. Horses were divided into 4 groups: group 1, PPID‐negative, without TRH stimulation; group 2, PPID‐negative, with TRH stimulation; group 3, PPID‐positive, without TRH stimulation; and group 4, PPID‐positive, with TRH stimulation. Whole blood was collected from each horse at baseline or 30 minutes after TRH stimulation. Immunoreactive plasma ACTH concentration was determined using a chemiluminescence assay. Plasma samples then were frozen at −80°C >24 hours, thawed at 4°C and reanalyzed for 5 freeze‐thaw cycles. Changes in plasma ACTH concentration were analyzed using a linear mixed‐effect model.

Results

Significant effects of freeze‐thaw cycles (P = .001) and PPID status (P = .04) on plasma ACTH concentration were observed, but no significant effect of TRH stimulation was identified.

Conclusions and Clinical Importance

The plasma ACTH concentration is altered by freeze‐thaw cycles, and the effect is observed sooner in horses with PPID. To diagnose PPID, multiple freeze‐thaw cycles should be avoided when measuring plasma ACTH concentration.

Pharmacokinetics and pharmacodynamics of pergolide mesylate after oral administration in horses with pituitary pars intermedia dysfunction

Published information on the pharmacokinetic and pharmacodynamic properties of pergolide is limited. The aim of this study was to investigate the pharmacokinetic and pharmacodynamic properties of oral pergolide in horses with pituitary pars intermedia dysfunction (PPID). The study design was a nonrandomized clinical trial. Six horses with PPID diagnosed by thyrotropin-releasing hormone (TRH) stimulation tests received pergolide at 4 μg/kg for 18 d. Plasma samples for determination of pergolide and ACTH concentration were collected 0.5 h before and 2 and 12 h after each administration of pergolide. Maximum plasma concentrations after the first oral dose of pergolide (0.104-0.684 ng/mL; median 0.261 ng/mL; interquartile range [IQR] 0.184-0.416 ng/mL) were not significantly different to the maximum steady-state concentration at day 18 (0.197-0.628 ng/mL; median 0.274; IQR 0.232-0.458 ng/mL). Chronic administration was not associated with drug accumulation (R = 1.09) and pergolide concentration reached steady state within 3 d. Throughout, concentrations of pergolide fluctuated considerably, with median plasma peak concentrations more than four times higher than median trough concentrations. Plasma ACTH concentration reduced significantly within 12 h of administration with further reductions occurring up to 10 d after the initiation of treatment. Although there were parallel fluctuations in the concentrations of pergolide and ACTH, timing of ACTH measurement in relation to the administration of pergolide did not have a significant effect. Alterations in the response to TRH were identified at 8 d with no further change being identified at 18 d. A small number of horses were studied. Oral pergolide results in significant suppression of pars intermedia activity within hours. Pergolide and ACTH concentrations fluctuated in tandem although correlation was poor. Fluctuations in pergolide concentration were consistent with a terminal elimination half-life of less than 12 h. To reduce the level of fluctuation of ACTH, twice-daily dosing of pergolide may be more appropriate.

ECEIM consensus statement on equine metabolic syndrome

Equine metabolic syndrome (EMS) is a widely recognized collection of risk factors for endocrinopathic laminitis. The most important of these risk factors is insulin dysregulation (ID). Clinicians and horse owners must recognize the presence of these risk factors so that they can be targeted and controlled to reduce the risk of laminitis attacks. Diagnosis of EMS is based partly on the horse's history and clinical examination findings, and partly on laboratory testing. Several choices of test exist which examine different facets of ID and other related metabolic disturbances. EMS is controlled mainly by dietary strategies and exercise programs that aim to improve insulin regulation and decrease obesity where present. In some cases, pharmacologic aids might be useful. Management of an EMS case is a long‐term strategy requiring diligence and discipline by the horse's carer and support and guidance from their veterinarians.

Pharmacokinetics of Metformin in Combination With Sitagliptin in Adult Horses After Enteral Administration

Insulin dysregulation (ID) is a common metabolic disorder in horses. Recently, incretin hormone release has been suggested to be involved in ID in horses. In human medicine, metformin and sitagliptin are commonly used in combination for metabolic syndrome. This combination could be useful in treating ID in horses. However, no pharmacokinetics data have been reported in this species. The objective of the present study was to establish the plasma concentration-time profile and to derive pharmacokinetics data for a combination of metformin and sitagliptin in horses after enteral administration. Six healthy adult Purebred Spanish horses were used. A metformin (15 mg/kg) plus sitagliptin (1.5 mg/kg) preparation was administered by intragastric route (IG) as an enteral solution. Blood samples were collected from 0 to 48 hours after IG drug administration. Plasma concentrations of metformin and sitagliptin were measured using high performance liquid chromatography methods. The t_½λz for metformin was 2.9 hours and for sitagliptin 21 hours. The C_max was 442 ± 84 mg/L within 0.9 hours for metformin and 94 ± 14 mg/L within 1.3 hours for sitagliptin. No adverse effects were observed, and the combination of metformin and sitagliptin was well tolerated. Therefore, these results suggest that metformin plus sitagliptin might be a combination to consider in horses with ID. Additional studies are needed to establish the effectiveness and tolerance in equids affected by endocrine disorders.

PITUITARY PARS INTERMEDIA DYSFUNCTION (EQUINE CUSHING'S DISEASE) IN NONDOMESTIC EQUIDS AT MARWELL WILDLIFE: A CASE SERIES. ONE CHAPMAN'S ZEBRA ( EQUUS QUAGGA CHAPMANI) AND FIVE PRZEWALSKI's HORSES ( EQUUS FERUS PRZEWALSKII)

  Pituitary pars intermedia dysfunction (PPID), also known as equine Cushing's disease, is widely reported in middle-aged to older domestic equids but to date reported in only one nondomestic equid, the onager ( Equus hemionus onager). This case series reports clinical, hematological, and pathological findings consistent with PPID in two further equid species: one Chapman's zebra ( Equus quagga chapmani) and five Przewalski's horses ( Equus ferus przewalskii). The case series reports basal adrenocorticotropic hormone (ACTH) testing as a method to diagnose and monitor PPID in zoological equids and the use of pergolide mesylate to reduce basal ACTH concentration and reduce clinical signs associated with PPID. Gross and histopathological examinations of the pituitary gland in four of these cases revealed either pars intermedia adenomas or adenomatous hyperplasia, similar to pathological findings in domestic equids affected by PPID. These findings suggest that clinicians working with nondomestic equids should be aware of this condition and consider screening for it routinely, particularly given that improvements in management and veterinary care for exotic animals are resulting in a more aged captive population. Early diagnosis and treatment of PPID may prevent the development of painful clinical sequelae and therefore improve the welfare of zoo equids.

Comparison of two methods for measurement of equine adrenocorticotropin

Accurate measurement of equine adrenocorticotropin (ACTH) is important for the diagnosis of equine pituitary pars intermedia dysfunction (PPID). Several radioimmunoassays (RIAs) and chemiluminescent immunoassays (CIAs) are used for measurement of ACTH concentration in horses; whether these methods yield similar results across a range of concentrations is not determined. We evaluated agreement between a commercial RIA and CIA. Archived plasma samples ( n = 633) were measured with both assays. Correlation between the 2 methods was moderate ( r = 0.49, p < 0.001). Bland-Altman analysis revealed poor agreement, with a proportional bias and widening limits of agreement with increasing values. Poor agreement between assays was also observed when evaluating plasma samples with concentrations at or below the recommended diagnostic cutoff value for PPID testing. The lack of agreement suggests that measurements obtained should not be considered interchangeable between methods.

Paradigm shifts in understanding equine laminitis

Laminitis, one of the most debilitating conditions of all equids, is now known to be the result of several systemic disease entities. This finding, together with other recent developments in the field of laminitis research, have provoked a rethink of our clinical and research strategies for this condition. First, laminitis is now considered to be a clinical syndrome associated with systemic disease (endocrine disease, sepsis or systemic inflammatory response syndrome, SIRS) or altered weight bearing rather than being a discrete disease entity. Next, laminitis associated with endocrine disease (endocrinopathic laminitis) is now believed to be the predominant form in animals presenting (primarily) for lameness. Third, the designation of laminitis as a primary and severe basement membrane pathology now requires revision. Instead, current data now proposes a variable subclinical phase associated with gross changes in the hoof capsule, with stretching and elongation of the lamellar cells an early and key event in the pathophysiology. These findings have fuelled new mechanistic hypotheses and research directions that will be discussed, together with their implications for future clinical management.

Therapeutics for Equine Endocrine Disorders

Equine endocrine disease is commonly encountered by equine practitioners. Pituitary pars intermedia dysfunction (PPID) and equine metabolic syndrome (EMS) predominate. The most logical therapeutic approach in PPID uses dopamine agonists; pergolide mesylate is the most common. Bromocryptine and cabergoline are alternative drugs with similar actions. Drugs from other classes have a poor evidence basis, although cyproheptadine and trilostane might be considered. EMS requires management changes as the primary approach; reasonable justification for use of drugs such as levothyroxine and metformin may apply. Therapeutic options exist in rare cases of diabetes mellitus, diabetes insipidus, hyperthyroidism, and critical illness-related corticosteroid insufficiency.

Neural modulators of temperament: A multivariate approach to personality trait identification in the horse

A relationship between dopamine and temperament has previously been described in human cases of dopaminergic dysfunction. Adjustment in temperament prior to disease manifestation can enable the early identification of individuals at risk of such conditions, and scope exists to extend this application of temperament alterations to cases of dopaminergic dysfunction in horses. A multivariate and mixed-methods approach utilising a questionnaire along with two inferred measurements of dopamine activity (Spontaneous Blink Rate [SBR] and behavioral initiation rate [BIR]) were recorded from direct observation of animals (n=99) to identify the potential relationship between dopamine and temperament in horses. Principal components analysis (PCA) of 36 temperament variables revealed nine principal components, including 'Anxiety' and 'Docility', which accounted for 72.4% of the total variance. Component scores were calculated and correlated with SBR and BIR utilising Spearman rank correlation coefficient analysis. The component 'Anxiety' was found to have a significant positive relationship with SBR, whereas 'Docility' was observed to have a significant negative relationship with SBR. These results indicate a relationship between dopamine and temperament within the horse that is certainly worthy of further study. Potential mechanisms involving neural dopaminergic and GABAergic systems are presented, in addition to how such alterations could be utilised to probe for equine dopamine dysfunction pending future research.

Serum insulin concentration in horses: Effect of storage and handling

Serum insulin concentration is commonly measured during investigation of suspected endocrinopathic disease in horses, but immediate analysis is frequently unavailable. The aim of this study was to examine the effect of storing samples at room temperature for 72 h as serum and as whole blood, compared to immediate separation and freezing. Samples from 14 horses were evaluated. Correlation was excellent for all comparisons (≥0.992). Bland-Altman plots revealed a negative bias (mean difference 2.16 µIU/mL) in samples stored as whole blood compared to serum, but this difference was not considered clinically significant. At two commonly used diagnostic cut-offs, there was no effect of storage on result. This study indicates that storage at room temperature for 72 h, either as serum or whole blood, has minimal effect on measured serum insulin concentration in horses.

Equine metabolic syndrome

Laminitis is one of the most common and frustrating clinical presentations in equine practice. While the principles of treatment for laminitis have not changed for several decades, there have been some important paradigm shifts in our understanding of laminitis. Most importantly, it is essential to consider laminitis as a clinical sign of disease and not as a disease in its own right. Once this shift in thinking has occurred, it is logical to then question what disease caused the laminitis. More than 90 per cent of horses presented with laminitis as their primary clinical sign will have developed it as a consequence of endocrine disease; most commonly equine metabolic syndrome (EMS). Given the fact that many horses will have painful protracted and/or chronic recurrent disease, a good understanding of the predisposing factors and how to diagnose and manage them is crucial. Current evidence suggests that early diagnosis and effective management of EMS should be a key aim for practising veterinary surgeons to prevent the devastating consequences of laminitis. This review will focus on EMS, its diagnosis and management.

Pharmacokinetics of pergolide after intravenous administration to horses

OBJECTIVE

To determine the pharmacokinetics of pergolide after IV administration to horses.

ANIMALS

8 healthy adult horses.

PROCEDURES

Pergolide mesylate was administered IV at a dose of 20 μg/kg (equivalent to 15.2 μg of pergolide/kg) to each horse, and blood samples were collected over 48 hours. Pergolide concentrations in plasma were determined by means of high-performance liquid chromatography-tandem mass spectrometry, and pharmacokinetic parameters were determined on the basis of noncompartmental methods.

RESULTS

After IV administration of pergolide, mean ± SD clearance, elimination half-life, and initial volume of distribution were 959 ± 492 mL/h/kg, 5.64 ± 2.36 hours, and 0.79 ± 0.32 L/kg, respectively.

CONCLUSIONS AND CLINICAL RELEVANCE

With an elimination half-life of approximately 6 hours, twice-daily dosing may be more appropriate than once-daily dosing to reduce peak-trough fluctuation in pergolide concentrations. Further pharmacodynamic and pharmacokinetic studies of pergolide and its metabolites will be necessary to determine plasma concentrations that correlate with clinical effectiveness to determine the therapeutic range for the treatment of pituitary pars intermedia dysfunction.

Investigation of single and paired measurements of adrenocorticotropic hormone for the diagnosis of pituitary pars intermedia dysfunction in horses

Background

Paired measurement of ACTH concentration may be more reliable than a single measurement.

Hypothesis/Objectives

To determine whether the mean of 2 measurements of ACTH concentration is more reliable in assessing pituitary pars intermedia dysfunction (PPID) than a single measurement.

Animals

Paired ACTH measurements were performed on (1) 148 occasions from 124 horses being investigated for PPID, (2) 90 occasions from 76 horses with PPID that were receiving treatment with pergolide, and (3) 63 occasions from 50 horses in which there was no clinical suspicion of PPID. Histologic examination of the pars intermedia was performed in 67 of the untreated horses.

Methods

Outcome of testing using single and the mean of paired samples was compared directly and both methods were compared against histology, which was considered the gold standard.

Results

Paired ACTH measurement altered binary classification as healthy or diseased in 6 of 211 cases, all off which had equivocal initial ACTH concentrations between 20 and 39 pg/mL. Using histology as the gold standard, optimal sensitivity and specificity for diagnosing PPID were 69.4 and 80.9%, respectively, for a single measurement and 72.2 and 76.2%, respectively, for paired measurements. The area under the receiver operating characteristic curve was 0.72 and 0.73 for single and paired measurements compared with histopathologic diagnosis, respectively.

Conclusions and Clinical Importance

Paired measurement of ACTH concentration offers no advantage over a single measurement.