International Summit on Race Day Medication: EIPH and the racehorse

On June 13-14, 2011, the New York Racing Association (NYRA) hosted the first International Summit on Race Day Medication at Belmont Park in Elmont, N.Y., which focused on exercise-induced pulmonary hemorrhage (EIPH) and the use of furosemide in racehorses.

The search for a global solution: Whether or not to allow the administration of furosemide on race day was the main point of contention because the United States and other countries have very different policies and regulations. (DAVID JOYNER/GETTY IMAGES)

The event was jointly sponsored by the American Association of Equine Practitioners (AAEP), the National Thoroughbred Racing Association (NTRA) and the Racing Medication and Testing Consortium (RMTC). Veterinarians, trainers and racing officials from the United States and various international racing jurisdictions, including Ireland, Hong Kong, the United Kingdom, South Africa, United Arab Emirates and Australia, participated in the discussions.

Day 1 moderator was Robert Lewis, DVM, a past president of the AAEP and chairman of the RMTC. (See the sidebar for the summit panel veterinarians and discussion topics.)

Summit panel veterinarians and discussion topics

Initiation of the meeting

Scott Palmer, VMD, Dipl. ABVP, New Jersey Equine Clinic and chairman of the AAEP Racing Committee, opened the event stating, "The Race Day Summit concept came about after the Association of Racing Commissioners International (ARCI) meeting in New Orleans in February 2011, where officials issued a press release calling for a ban on all race day medications." Several groups with an agenda to eliminate race day medication, including the Jockey Club, endorsed the press release.

Heart of the matter: The goal of the summit was to address the topic of race day medication in a manner that would allow for the best outcome for horses and for the horse racing industry.(JASON HOSKING/GETTY IMAGES)

In North America, there are 38 different racing jurisdictions with medication rules that generally forbid the use of any race day medication except for the treatment of horses that experience EIPH. Furosemide has been used in racing for about 30 years, and from the beginning it has been controversial. The industry is polarized on this emotional issue.

"If you look at the issue of EIPH with a Salix lens, the discussion takes on a yes or no format; there is no opportunity for consensus," says Palmer. "We felt that the current paradigm for this issue was a dead-end street.

"The RMTC, NTRA and the AAEP convened the summit to refocus the discussion on the medical condition of EIPH and the racehorse rather than furosemide, per se. What do we know about the condition and what is the best way to manage it in the parimutuel environment?" says Palmer. "We felt that if we could address the race day medication issue from that standpoint, we might find some areas of consensus and move the discussion in a positive direction. Since the condition occurs in racing horses around the world and is regulated internationally without the use of furosemide on race day, we wanted to hear from people around the world—how they manage it, how they treat it and how they regulate it. We could get the international perspective and see what we might learn from their experience."

EIPH and the racehorse

EIPH frequently occurs in racehorses at intense speed or exertion and is associated with decreased health and poor performance. It is known to occur in more than 75 percent of Thoroughbreds, with a somewhat less frequent occurrence in racing Standardbreds and Quarter horses. It is also seen in other horses at high performance (barrel racing, cutting, steeplechasing, three-day eventing, polo).

According to Ken Hinchcliff, BVSc, PhD, "EIPH is caused by the rupture of alveolar capillaries, secondary to exercise-induced increased transmural pressure—a pressure difference between the interior of the capillary and the alveolar lumen. If the transmural stress exceeds the tensile strength of the capillary wall, the capillary ruptures, dumping blood into the airways and interstitium. The proximate cause of alveolar capillary rupture is the high transmural pressure generated by positive intracapillary pressure (largely attributable to capillary blood pressure) and the lower intraaveolar pressure (generated by negative pleural pressure associated with inspiration)."

This is shown by blood in the tracheal lavage or bleeding from the nostrils (epistaxis) soon after exercise or blood hemorrhaged into the airways up to one or two hours after exercise. EIPH can recur, with subsequent inflammation of the airways and interstitium and development of fibrosis and alteration of tissue compliance.

Furosemide is a diuretic that decreases plasma volume, cardiac output and, therefore, pulmonary vascular pressures, reducing the incidence of EIPH up to 50 percent in some studies.1 Hinchcliff and colleagues, in a study of 152 Thoroughbreds racing in South Africa, showed that the endoscopic severity of EIPH on a five-point scoring system was less severe after furosemide administration, with no animals having a score of 3 or 4.2 Of the horses scoped after two races, 57 percent of those that had been given furosemide had EIPH with a score = 1, while 79 percent had EIPH scores = 1 after saline (placebo) administration. Results of the study indicate that pre-race administration of furosemide decreases the incidence and severity of EIPH in Thoroughbreds racing under typical conditions in South Africa.

The furosemide paradox

"Here in the U.S. and Canada, we generally allow a single type of anti-bleeder medication on race day known as Salix (furosemide)," says Alex Waldrop, chief executive officer of the NTRA. "Some states in the U.S. also allow adjunct bleeder medications. These medications are administered for the purpose of controlling the incidence and severity of EIPH. Salix is administered in accordance with state regulations that strictly control the amount and timing of administration. Post-race testing is used to confirm compliance with these regulations. In terms of national uniformity across America's 38 racing jurisdictions, we have it when it comes to race day administration of Salix."

"Some in the industry believe that regulators should focus on better testing for designer drugs and harsher penalties for those who use them—and leave Salix alone," says Waldrop. "But that view is countered by those who point out that the public at large is not capable of distinguishing between illegal drugs and permitted race day medications—they are all viewed negatively in today's society."

Some feel that if we could get rid of all the illegal drugs and drugs that are harmful, then furosemide would be less of an issue. It is an appropriate therapeutic medication. To compare furosemide with anabolic steroids in other sports is inappropriate. Furosemide with its known therapeutic benefit is a medication that everyone within the sport, including the wagering public, knows is given. It's even noted on the Racing Form.

But there is current concern, even as raised by the Congressional legislation drafted in May 2011, to ban "performance enhancing" race day medication and to exclude the use of furosemide in Thoroughbred racing in the future.

"According to industry sources, in the U.S. about 95 percent of horses run on Salix and/or some other anti-bleeder medication," says Waldrop. "This is because there are no requirements that horses first bleed before an anti-bleeder medication is administered. Some administer anti-bleeder medication for its diuretic effect that is thought to improve performance because of weight loss and other reasons. Long ago, we determined to end the debate whether Salix and related adjuncts are performance-enhancing by allowing all to have access to the medication, and thereby level the playing field.

"Because of this practice of widely administering prophylactic doses of anti-bleeder medication, the incidents of exterior bleeding are very rare in this country," Waldrop says. "On the other hand, no one knows for sure how many horses would bleed but for the prophylactic dosage. For some, the idea of a race day medication—even one legally administered by a qualified veterinarian under regulatory controls—is unacceptable. For others, administration of Salix is necessary to ensure that we are looking out for the welfare of the horse.

"Many think our policies should be based on science and the best interests of the racehorse," says Waldrop. "Others believe strongly that no horse should run if it needs or is given medication to do so. Still others believe that while science is important, other considerations such as public support for drug-free competition should be factored into the equation when considering race day medication. Some say it enhances performance, while others assert that it merely allows a horse to run to its true form."

Waldrop says that another area of disagreement is in the need for international harmonization. "Some believe that North America needs to be in step with the rest of the world on its medication policies," says Waldrop. "Others believe that we've got it right, and it is foreign jurisdictions that should move toward our policies and treatment programs for horses with EIPH."

The future with or without furosemide

In the 1970s when racing started using furosemide, you had be qualified to give it. The horse was either scoped with a state veterinarian present, or the state veterinarian had to scope the horse and prove that there was bleeding coming from the lungs before furosemide could be administered. Use of furosemide, therefore, had to be justified. Horses that were not bleeding couldn't get it.

After 2001, the RMTC stated that because of the issue of performance enhancement (whether furosemide had performance-enhancing qualities or not), things changed and all horses were allowed access to the furosemide in order to level the playing field and because it was thought that preventing any episode of bleeding and the possible medical consequences was in the best interest of the horse.

"If we do away with furosemide, are we putting horses at risk?" asks Palmer. Most countries around the world do not regulate furosemide based on endoscopic evaluation, but on epistaxis, which is defined as bleeding from the nostrils. In most jurisdictions around the world, if epistaxis takes place, that horse is subjected to forced rest or retirement from racing.

"If you can use furosemide to prevent bleeding from happening during training, as you go along you can minimize the harmful cumulative effects on the lung over time," Palmer says. In the absence of any treatment, older horses bleed more than younger horses, as do those that have more consecutive years in racing compared with those that are early in the process. "One of the real values of furosemide is that we can use it to diminish or modulate the progressive pathologic change in the lung that leads to repetitive bleeding cycles."

The incidence of epistaxis in racehorses after a race before furosemide was used in North America was about two per 1,000 starters. It was subsequently shown that the incidence of epistaxis after the introduction of furosemide was about 0.7 horses per 1,000. Therefore, from an epidemiologic standpoint, horses racing in North America would be about three times more likely to bleed without furosemide treatment than with it. Although the numbers of horses that do bleed from the nose are low (0.15 to 1 percent), as many as 600 animals in about 60,000 horses may be at risk of epistaxis without furosemide treatment.

"Although that's a relatively low number, it certainly hits home if it's your horse and/or it's a million-dollar horse," says Palmer. "Particularly if you have to retire it from racing if you cannot use furosemide. Veterinarians understand and appreciate the public relations concerns, politics and global business implications of the medication issues in racing, but our own bottom line is that we do believe we must do what is in the best interest of the racing horse."

The current AAEP policy states that the only appropriate medication to give on race day is furosemide. It's the only therapeutic medication scientifically proven to work.

"When you ask the AAEP to support the elimination of furosemide for treating horses that experience EIPH, you're asking us to turn our back on the science and extensive medical experience of veterinarians and put this horse at risk, and we're not going to do that unless we have an alternative," Palmer says. "If we can develop an alternative treatment and management program for EIPH that we can use prior to race day, then we can support no medication on race day, and I do think that there's value in that. The strategic goal that we should be aiming for is to send healthy horses to the gate free of the pharmacologic influence of any medication."

"The good news is that we do have some new therapeutic options in the pipeline, things that we can do that have nothing to do with the diuretic—furosemide," Palmer says. "But those treatments are much more expensive and largely unproven at this time. The current economic pressures also are relevant. We have a difficult time finding treatments that are as effective and as cheap as furosemide."

The AAEP and NTRA can make recommendations, along with the RMTC, which can propose model rules. But none of these organizations have the ability to effect change—to make a rule that will influence this process. That responsibility rests largely with the ARCI and individual state racing commissions.

"The role of the equine practitioner in this process is to provide solid information and make recommendations that will hopefully enable the regulators to make an informed decision that is good for the horse and good for the business of racing," says Palmer.

One of the concerns with a proposed furosemide ban in North America is how many horses will be unable to race here without furosemide? We don't know the answer to that. The business model of North American racing is unique in the world. If this medication is eliminated here, the challenge will be how to make what amounts to a profound cultural change in North American racing with the least impact on the horses' health, as well as that of an industry stressed by a down economy and intense competition for the gaming dollar.

The medication summit tries to reach consensus

Palmer says that the core question for the medication summit was how to address the issue of race day medication in a way that's both good for the horse and good for the business of racing.

At the end of the second day of the summit, the participants tried to identify areas of consensus. Since many international participants were part of the discussion, the straw votes were biased to some degree by their views that were supportive of a ban on any race day medication.

"Nevertheless, there were broad areas of interest identified by the group that focused on a need for improved security and surveillance at the track, support for a pilot study to investigate the effect of a furosemide ban in 2-year-old horses, changing the way we administer furosemide, restructuring the model rules to create more severe penalties for medication violations, public education on medication issues and creation of a central racing authority to address medication issues in racing," says Palmer.

At the end of the summit, Lewis formed committees to gather further information on these areas of interest to be presented at a RMTC board meeting to be held on Aug. 4, 2011. The objective of the August meeting is to have these ad hoc committees report to the RMTC Board to facilitate board discussion and formulation of possible recommendations to the ARCI.

Ed Kane, PhD, is a researcher and consultant in animal nutrition. He is an author and editor on nutrition, physiology and veterinary medicine with a background in horses, pets and livestock. Kane is based in Seattle.

References

1. Kindig CA, McDonough P, Fenton G, et al. Efficacy of nasal strip and furosemide in mitigating EIPH in Thoroughbred horses. J Appl Physiol 2001;91(3):1396-400.

2. Hinchcliff, KW, Morley PS, Guthrie AJ. Efficacy of furosemide for prevention of exercise-induced pulmonary hemorrhage in Thoroughbred racehorses. J Am Vet Med Assoc 2009;235(1):76-82.

Suggest Reading

• Hinchcliff, KW. Exercise-induced pulmonary hemorrhage, in Proceedings. Equine Nutrition Conference, Kentucky Equine Research, Lexington, Ky., 2004.

n Hinchcliff KW, Morley PS, Jackson MA, et al. Risk factors for exercise-induced pulmonary haemorrhage in Thoroughbred racehorses.

Equine Vet J

2010;42 Suppl 38:228-234.