Equine pituitary pars intermedia dysfunction: current perspectives on diagnosis and management

Equine Pergolide Toxicity: A Case Series

Veterinary medication exposure may result in human toxicity, with approximately 6,000 exposures to veterinary-only medications reported to poison centers in 2022. There is a paucity of literature on the management of poisoned patients secondary to pharmaceuticals intended for equine use. Pergolide is a dopamine and serotonin receptor agonist and is currently approved to treat equine Cushing's disease. It was previously approved in the United States (US) to treat Parkinson's disease in humans; however, it was withdrawn from the market in 2007 due to its association with valvular heart disease. We report two cases of pergolide toxicity in horse owners following unintentional ingestions. Both patients experienced similar clinical presentations resulting from their unintentional pergolide ingestions. Veterinary medication ingestion presents a unique challenge to clinicians as the drug may have limited human toxicity data and/or recommended animal dosing may differ greatly from human dosing. Case reports of human toxicity may assist with anticipating the clinical course and guiding medical decision-making.

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.

Equine pituitary pars intermedia dysfunction: a spontaneous model of synucleinopathy

Equine pituitary pars intermedia dysfunction (PPID) is a common endocrine disease of aged horses that shows a similar pathophysiology as Parkinson’s Disease (PD) with increased levels of α-synuclein (α-syn). While α-syn is thought to play a pathogenic role in horses with PPID, it is unclear if α-syn is also misfolded in the pars intermedia and could similarly promote self-aggregation and propagation. Consequently, α-syn was isolated from the pars intermedia from groups of healthy young and aged horses, and aged PPID-afflicted horses. Seeding experiments confirmed the prion-like properties of α-syn isolated from PPID-afflicted horses. Next, detection of α-syn fibrils in pars intermedia via transmission electron microscopy (TEM) was exclusive to PPID-afflicted horses. A bank of fragment peptides was designed to further characterize equine α-syn misfolding. Region 62–87 of equine and human α-syn peptides was found to be most prone to aggregation according to Tango bioinformatic program and kinetics of aggregation via a thioflavin T fluorescence assay. In both species, fragment peptide 62–87 is capable of generating mature fibrils as demonstrated by TEM. The combined animal, bioinformatic, and biophysical studies provide evidence that equine α-syn is misfolded in PPID horses.

Influence of endocrine disease on l-lactate concentrations in blood of ponies

Background

Blood l‐lactate concentrations are higher in people with developing or established diabetes mellitus and insulin resistance.

Objectives

To investigate whether blood l‐lactate concentrations are positively correlated with measures of insulin dysregulation (ID) or increased autumnal ACTH concentrations in ponies.

Animals

Systemically healthy client‐owned ponies (n = 101).

Methods

Prospective case‐control study. Blood samples were obtained from 101 clinically healthy ponies. Breed, weight, height, and subjective and objective measures of body condition were recorded. Blood l‐lactate, glucose, triglyceride, total adiponectin, and ACTH concentrations were measured and an oral sugar test (OST) was carried out. Correlations between blood l‐lactate and variables of endocrine health were determined.

Results

Using a seasonal cutoff point of ACTH concentrations ≥47 pg/mL, 55 ponies had increased autumnal ACTH concentrations and 45 did not. Using a basal insulin concentration of >50 μiU/mL, 42 ponies were diagnosed with ID and 58 were not. Using a 60 minutes after OST cutoff point of >45 μiU/mL, 57 ponies had ID and 37 did not. Blood l‐lactate concentrations were significantly lower in obese (average body condition score ≥ 7/9) compared to nonobese ponies (0.6 mmol/L; range, 0.0‐1.9 mmol/L vs 0.8 mmol/L; range, 0.3‐2.7 mmol/L; P = .01). No other significant correlations were detected. No differences were detected between ponies with and without increased autumnal ACTH concentrations (0.7 mmol/L; range, 0.0‐2.7 mmol/L vs 0.7 mmol/L; range, 0.3‐1.8 mmol/L; P = .84) and with and without ID (0.7 mmol/L; range, 0.3‐2.7 mmol/L vs 0.8 mmol/L; range, 0.0‐1.6 mmol/L; P = .63).

Conclusions and Clinical Importance

Results do not support an effect of endocrine status on l‐lactate concentrations in blood of ponies.

Restoring pars intermedia dopamine concentrations and tyrosine hydroxylase expression levels with pergolide: evidence from horses with pituitary pars intermedia dysfunction

Background

Pituitary pars intermedia dysfunction (PPID) develops slowly in aged horses as degeneration of hypothalamic dopaminergic neurons leads to proliferation of pars intermedia (PI) melanotropes through hyperplasia and adenoma formation. Dopamine (DA) concentrations and tyrosine hydroxylase (TH) immunoreactivity are markedly reduced in PI tissue of PPID-affected equids and treatment with the DA receptor agonist pergolide results in notable clinical improvement. Thus, we hypothesized that pergolide treatment of PPID-affected horses would result in greater DA and TH levels in PI tissue collected from PPID-affected horses versus untreated PPID-affected horses.

To test this hypothesis, pituitary glands were removed from 18 horses: four untreated PPID-affected horses, four aged and four young horses without signs of PPID, and six PPID-affected horses that had been treated with pergolide at 2 µg/kg orally once daily for 6 months. DA concentrations and TH expression levels in PI tissues were determined by high performance liquid chromatography with electrochemical detection and Western blot analyses, respectively.

Results

DA and TH levels were lowest in PI collected from untreated PPID-affected horses while levels in the pergolide treated horses were similar to those of aged horses without signs of PPID.

Conclusions

These findings provide evidence of restoration of DA and TH levels following treatment with pergolide. Equine PPID is a potential animal model of dopaminergic neurodegeneration, which could provide insight into human neurodegenerative diseases.

Diagnostic orientation values for ACTH and other parameters for clinically healthy donkeys and mules (insulin, triglycerides, glucose, fructosamines, and ɣ-GT)

Pituitary pars intermedia dysfunction is the most prevalent endocrine disease in horses. Although donkeys and mules may also be affected, only a few data have been published. Reference values for diagnostic parameters, such as adrenocorticotropic hormone (ACTH), are especially scarce or even lacking. Therefore, in the present study, available data from the literature have been verified and completed to facilitate a reliable diagnosis. Clinical inspections and haematological and biochemical examinations were carried out four times in a three-month interval (February to November) in 44 donkeys and 31 mules. Data from clinically healthy animals were used as an orientation. Plasma ACTH concentrations showed seasonal changes in both animal groups. However, it was generally higher in donkeys than mules. Although blood glucose (EDTA plasma) showed no difference between groups, serum insulin concentrations were consistently higher in donkeys. Serum fructosamine levels were slightly higher in mules, whereas, in some cases, serum triglyceride levels were considerably higher in donkeys. Serum gamma-glutamyltransferase showed a striking peak in mules in August, whereas the remaining gamma-glutamyltransferase values were lower compared to donkeys. By comparing donkeys and mules, the present work reveals differences in various blood parameters which should be considered for diagnoses and future studies.

Modelling of oscillatory cortisol response in horses using a Bayesian population approach for evaluation of dexamethasone suppression test protocols

Cortisol is a steroid hormone relevant to immune function in horses and other species and shows a circadian rhythm. The glucocorticoid dexamethasone suppresses cortisol in horses. Pituitary pars intermedia dysfunction (PPID) is a disease in which the cortisol suppression mechanism through dexamethasone is challenged. Overnight dexamethasone suppression test (DST) protocols are used to test the functioning of this mechanism and to establish a diagnosis for PPID. However, existing DST protocols have been recognized to perform poorly in previous experimental studies, often indicating presence of PPID in healthy horses. This study uses a pharmacokinetic/pharmacodynamic (PK/PD) modelling approach to analyse the oscillatory cortisol response and its interaction with dexamethasone. Two existing DST protocols were then scrutinized using model simulations with particular focus on their ability to avoid false positive outcomes. Using a Bayesian population approach allowed for quantification of uncertainty and enabled predictions for a broader population of horses than the underlying sample. Dose selection and sampling time point were both determined to have large influence on the number of false positives. Advice on pitfalls in test protocols and directions for possible improvement of DST protocols were given. The presented methodology is also easily extended to other clinical test protocols.