Diagnosis and management of thyroid disorders and thyroid hormone supplementation in adult horses and foals

Equine thyroid disorders pose a diagnostic challenge in clinical practice because of the effects of nonthyroidal factors on the hypothalamic-pituitary-thyroid axis, and the horse's ability to tolerate wide fluctuations in thyroid hormone concentrations and survive without a thyroid gland. While benign thyroid tumours are common in older horses, other disorders like primary hypothyroidism or hyperthyroidism in adult horses and congenital hypothyroidism in foals are rare. There is a common misunderstanding regarding hypothyroidism in adult horses, especially when associated with the clinical profile of obesity, lethargy, and poor performance observed in dogs and humans. Low blood thyroid hormone concentrations are often detected in horses as a secondary response to metabolic and disease states, including with the nonthyroidal illness syndrome; however, it is important to note that low thyroid hormone concentrations in these cases do not necessarily indicate hypothyroidism. Assessing equine thyroid function involves measuring thyroid hormone concentrations, including total and free fractions of thyroxine (T4) and triiodothyronine (T3); however, interpreting these results can be challenging due to the pulsatile secretion of thyroid hormones and the many factors that can affect their concentrations. Dynamic testing, such as the thyrotropin-releasing hormone stimulation test, can help assess the thyroid gland response to stimulation. Although true hypothyroidism is extremely rare, thyroid hormone supplementation is commonly used in equine practice to help manage obesity and poor performance. This review focuses on thyroid gland pathophysiology in adult horses and foals, interpretation of blood thyroid hormone concentrations, and evaluation of horses with thyroid disorders. It also discusses the use of T4 supplementation in equine practice.

A randomised, controlled trial to determine the effect of levothyroxine on Standardbred racehorses

BACKGROUND

The use of thyroid supplement is pervasive in athletic horses although its effects on measures of performance are not known.

OBJECTIVES

One purpose of this study was to determine whether supra-physiologic doses of levothyroxine affect the velocities at which blood lactate was greater than 4 mmol/L (V_La4 ) and heart rate was over 150 (V₁₅₀ ) and 200 (V₂₀₀ ) beats per minute respectively. Additionally, a survey of post-race blood samples was also conducted to determine whether high thyroxine concentrations were common in racehorses.

STUDY DESIGN

A randomised, crossover, trial was performed in six healthy Standardbred racehorses.

METHODS

Study 1: T4 was determined in 50 post-race samples from a single Standardbred meet. Study 2: Research horses were trained to fitness and then randomised to one of three treatments: carrier, 0.1 mg/kg thyroxine or 0.25 mg/kg thyroxine for 2 weeks. Horses completed a standardised exercise treadmill test (SET) to fatigue on the last day of treatment. Serum free and total thyroxine and triiodothyronine were determined on the day of SET testing. Blood lactate and ECG data were collected during the SET at 6, 8, 10, 11, and 12 m/s and during recovery. The effect of treatment and SET on heart rate and blood lactate was examined using generalised linear mixed models. Post hoc analysis was adjusted for multiple comparisons using Tukey's Test. Data were expressed as mean ± standard deviation and P < .05 was considered significant.

RESULTS

Study 1: The median T4 value in this population of horses was 2.00 µg/dL (laboratory's normal range 1.5-4.5 µg/dL) and 3 of 50 racehorses had values above the laboratory reference range. Study 2: Levothyroxine at 0.25 mg/kg resulted in higher heart rates during SET (199 ± 30, 223 ± 17 and 239 ± 9 bpm at 6, 8 and 10 m/s respectively) and recovery (144 ± 20 and 119 ± 15 at 5 and 15 min) as compared to placebo (176 ± 18, 203 ± 10 and 219 ± 6 bpm at 6, 8, and10 m/s and 126 ± 5, 102 ± 11 at 5-15 minutes respectively). Three of six horses developed cardiac arrhythmias including atrial fibrillation.

MAIN LIMITATIONS

A relatively small number of animals were used and a SET is not identical to actual racing conditions.

CONCLUSIONS

Supra-physiologic thyroxine supplementation caused a decreased V₂₀₀ during a standard exercise test and may result in cardiac arrhythmias.

Genomewide association study reveals a risk locus for equine metabolic syndrome in the Arabian horse

Equine obesity can cause life-threatening secondary chronic conditions, similar to those in humans and other animal species. Equine metabolic syndrome (EMS), primarily characterized by hyperinsulinemia, is often present in obese horses and ponies. Due to clinical similarities to conditions such as pituitary pars intermedia dysfunction (formerly equine Cushing's disease), conclusive diagnosis of EMS often proves challenging. Aside from changes in diet and exercise, few targeted treatments are available for EMS, emphasizing the need for early identification of at-risk individuals to enable implementation of preventative measures. A genomewide association study (GWAS) using Arabian horses with a history of severe laminitis secondary to EMS revealed significant genetic markers near a single candidate gene () that may play a role in cholesterol homeostasis. The best marker, BIEC2-263524 (chr14:69276814 T > C), was correlated with elevated insulin values and increased frequency of laminitis ( = 0.0024 and = 9.663 × 10, respectively). In a second population of Arabian horses, the BIEC2-263524 marker maintained its associations with higher modified insulin-to-glucose ratio (MIRG) values ( = 0.0056) and BCS ( = 0.0063). Screening of the predicted coding regions by sequencing identified a polymorphic guanine homopolymer and 5 haplotypes in the 3' untranslated region (UTR). An 11 guanine (11-G) allele at was correlated with elevated insulin values in the GWAS population ( = 0.0008) and, in the second population, elevated MIRG and increased BCS > 6.5 ( = 0.0055 and = 0.0162, respectively). The BIEC2-263524-C and the 3' UTR -11(G) polymorphisms were correlated at a 98% frequency, indicating strong linkage disequilibrium across this 150-kb haplotype. Assays for these markers could diagnose horses with a genetic predisposition to develop obesity. Additionally, discovery of FAM174A function may improve our understanding of the etiology of this troubling illness in the horse and warrants investigation of this locus for a role in metabolic- and obesity-related disorders of other species.

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.

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.

Persistent Hypercalcemia and Hyperparathyroidism in a Horse

A 27-year-old, American Quarter Horse gelding was evaluated for anorexia, lethargy, a swelling on the right, cranial aspect of the neck, and signs of esophageal obstruction. Serum biochemical analyses revealed hypophosphatemia, total and ionized hypercalcemia, and hemoconcentration. Sonographic examination of the neck revealed a 1.7 cm diameter mass within the right lobe of the thyroid. The serum concentration of intact parathyroid hormone (iPTH) was increased. The right lobe of the thyroid was excised with the horse sedated. The mass within that lobe was determined, by histological examination, to be a parathyroid adenoma. Despite excision of the mass, serial blood analyses revealed persistent hypercalcemia, hypophosphatemia, and increased iPTH. Anorexia and lethargy resolved, and follow-up communication with the owner and referring veterinarian one year later indicated that the horse was clinically stable.

Thyroid hormone concentrations differ between donkeys and horses

REASONS FOR PERFORMING STUDY

Reference intervals for thyroid hormones (TH) concentrations have not been previously established for donkeys, leading to potential misdiagnosis of thyroid disease.

OBJECTIVES

To determine the normal values of TH in healthy adult donkeys and compare them to TH values from healthy adult horses.

METHODS

Thirty-eight healthy Andalusian donkeys and 19 healthy Andalusian horses from 2 different farms were used. Donkeys were divided into 3 age groups: <5, 5-10 and >11 years and into 2 gender groups. Serum concentrations of fT3, tT3, rT3, fT4 and tT4 were quantified by radioimmunoassay. All blood samples were collected the same day in the morning. None of the animals had received any treatment for 30 days prior to sampling or had any history of disease. Both farms were in close proximity and under similar management. Differences between groups were determined using a one-way ANOVA analysis followed by Fisher's LSD test. P<0.05 was considered significant.

RESULTS

Serum TH concentrations were higher in donkeys than in horses (P<0.01). Donkeys <5 years had higher serum rT3, fT4 and tT4 concentrations than donkeys >5 years (P<0.05). Furthermore, older donkeys (>11 years) had lower serum fT3 and tT3 concentrations than younger donkeys' groups (<5 and 5-10 years, P<0.05). TH concentrations were not different between genders (fT3: P = 0.06; tT3: P = 0.08; rT3: P = 0.15; fT4: P = 0.89; and tT4: P = 0.19).

CONCLUSIONS

Thyroid hormone concentrations are different between healthy adult donkeys and horses.

POTENTIAL RELEVANCE

Establishing species-specific TH reference ranges is important when evaluating clinicopathologic data in equids in order to avoid the misdiagnosis of thyroid gland dysfunction. Further studies to elucidate the physiological mechanisms leading to these differences are warranted.

Equine metabolic syndrome

The concept of an equine metabolic syndrome (EMS) was first proposed in 2002. This concept has developed over time, and EMS was recently described in a consensus statement released by the American College of Veterinary Internal Medicine. In human medicine, metabolic syndrome (MetS) refers to a set of risk factors that predict the risk of cardiovascular disease, including obesity, glucose intolerance and insulin resistance (IR), dyslipidemia, microalbuminuria, and hypertension. EMS shares some of the features of MetS, including increased adiposity, hyperinsulinemia, IR, but differs in that laminitis is the primary disease of interest.

Laminitis and the equine metabolic syndrome

Although much has been written about laminitis in the context of its association with inflammatory processes, recognition is growing that most cases of laminitis examined by veterinarians in private practice are those associated with pasture grazing, obesity, and insulin resistance (IR). The term 'endocrinopathic laminitis' has been adopted to classify the instances of laminitis in which the origin seems to be more strongly associated with an underlying endocrinopathy, such as either IR or the influence of corticosteroids. Results of a recent study suggest that obesity and IR represent the most common metabolic and endocrinopathic predispositions for laminitis in horses. IR also plays an important role in the pathogenesis of laminitis that develops when some horses or ponies are allowed to graze pastures at certain times of the year. The term equine metabolic syndrome (EMS) has been proposed as a label for horses whose clinical examination results (including both physical examination and laboratory testing) suggest heightened risk for developing laminitis as a result of underlying IR.

Effects of long-term oral administration of levothyroxine sodium on glucose dynamics in healthy adult horses

OBJECTIVE

To determine the effects of long-term oral administration of levothyroxine sodium (L-T(4)) on glucose dynamics in adult euthyroid horses.

ANIMALS

6 healthy adult mares.

PROCEDURES

Horses received L-T(4) (48 mg/d) orally for 48 weeks. Frequently sampled IV glucose tolerance test procedures were performed on 3 occasions (24-hour intervals) before and at 16, 32, and 48 weeks during the treatment period. Data were assessed via minimal model analysis. The repeatability of measurements was evaluated.

RESULTS

During treatment, body weight decreased significantly from the pretreatment value; mean +/- SD weight was 49 +/- 14 kg, 43 +/- 7 kg, and 25 +/- 18 kg less than the pretreatment value at weeks 16, 32, and 48, respectively. Compared with pretreatment findings, 1.8-, 2.4-, and 1.9-fold increases in mean insulin sensitivity (SI) were detected at weeks 16, 32, and 48, respectively; SI was negatively correlated with body weight (r = -0.42; P < 0.001). During treatment, glucose effectiveness increased and the acute insulin response to glucose decreased. Overall mean within-horse coefficients of variation were 5% and 29% for plasma glucose and serum insulin concentrations, respectively, and 33%, 26%, and 23% for SI, glucose effectiveness, and the acute insulin response to glucose, respectively.

CONCLUSIONS AND CLINICAL RELEVANCE

Long-term administration of L-T(4) was associated with weight loss and increased SI in adult euthyroid horses, although other factors may have confounded results. Levothyroxine sodium may be useful for the treatment of obesity and insulin resistance in horses, but further studies are required.