NY Lasix Forum: More Questions Than Answers?

A day-long forum in Saratoga Tuesday was designed to shed some light on the policies and practices of furosemide (branded as Lasix or Salix) usage and the management of exercise-induced pulmonary hemorrhaging (EIPH) in racehorses.

But the four in-depth panel discussions–hosted by the New York State Gaming Commission (NYSGC) and comprised of internationally respected veterinarians, horsemen, and regulators–raised far more questions than answers.

“Just like generals who are always fighting the last war, we are always pursuing the drugs of yesterday, and missing the drugs of today,” said New York's former deputy secretary for Racing and Gaming, Bennett Liebman, in opening remarks that set the tone for the wide-ranging discussions. “Racing's policy on raceday medication has always been inconsistent and almost never rational. The initial policy has almost always been driven by whatever seemed to be the popular policy of the moment. And, not surprisingly, initial policy choices, once enacted, have proven most difficult to alter.”

NYSGC Equine Medical Director Dr. Scott Palmer led off the first panel discussion by trying to establish “academic truths” about EIPH and Lasix. But even that proved difficult, as panelists Dr. Paul Morley of Colorado State University and Dr. Corinne Sweeney of the Pennsylvania School of Veterinary Medicine cited the need for better “high quality” evidence to establish baselines and to find out if other treatments might work better than Lasix

“Despite the number of studies that are in the published literature regarding EIPH and regarding different interventions or evaluations of Lasix, the [veterinarians who have studied the topic were] left with the strong impression that most of the available literature in scientific studies did not provide strong evidence about this condition,” said Morley. “And it had to do with the number of very small studies where six or eight horses were enrolled in a study and it was performed on a treadmill. And it's not that those studies don't add to our understanding, but when we're asking questions about whether or not there's efficacy for other preventive measures, we need more data. We need more information.”

Morley said it is well established that EIPH is mitigated with Lasix administration, but that it remains unclear whether a change in racing performance is attributed to fluid weight loss or diminished EIPH.

“The medication has actually been used for 40 years or so in racehorses before our study which provided the strongest evidence with regard to efficacy,” said Morley. “And if we're going to change rules about how that drug is administered and about the efficacy of other medications, it would be our strong urging that we fund and perform studies that truly show [and] demonstrate the presence or lack of presence of efficacy for those drugs.”

There was even debate about whether EIPH should be classified as a disease.

“If it's a disease it might be what we call 'production disease,' a disease that's induced by management practices, by racing,” said Sweeney. “We don't feel the initial onset is due to problems in the heart and the lung, but it does, by repeated episodes of the EIPH, cause problems in the lung that we view as pathologic, as not normal, and probably not in the horse's best interest.”

The panelists touched on other EIPH and Lasix points that were backed up by varying degrees of evidence, such as:

•EIPH appears more related to the frequency and intensity of racing than the age of the horse.

•The more a horse runs, the more likely it is to have an EIPH episode.

•Comparatively few horses bleed on level of grade 3 or 4, which is epistaxis (bleeding through nostrils); most are classified as grade 1 or 2, which can be internal airway and lung bleeding detected through an endoscope.
•Lasix does not appear to be a masking drug.

•There is no scientific evidence to support the notion that the breed is “weakening” (although that doesn't mean it couldn't be happening—it just hasn't been studied in depth).

•Some pedigree analysis shows that there may be “clusters” of bloodlines that seem to relate to epistaxis, yet again, more study is needed.
But still, four decades into the widespread usage of Lasix in the United States racing industry, Morley underscored that more studies with large samples are needed.

“In the medical field, if you were to go to the doctor and ask whether or not a treatment works or whether or not a disease affects your health, they would [try to make conclusions based on] multiple studies of high quality,” Morley explained. “When we draw these [EIPH and Lasix] conclusions around moderate quality [evidence], that's probably the biggest limiting factor, is just the number of well-performed studies to evaluate these things.”

Practicing Vets: Lasix a 'Crutch' but Currently Best Option…

The second panel discussion at Tuesday's NYSGC forum on Lasix and EIPH segued from veterinary research to more of a “view from the trenches” perspective. But again, the practicing vets on the panel kept coming back to the conclusion that while Lasix is an effective treatment for bleeding racehorses, it's tough to give examples of what might work better, because so little research exists on alternative therapies.

“I think Lasix is a very therapeutic drug for EIPH. Unfortunately, I don't think it's probably the best medication out there, but it's the best that we have, and that's part of the problem,” said Dr. Jeff Blea, a California-based vet who is a past president of the American Association of Equine Practitioners (AAEP). “Are there other potential options out there to treat EIPH that we don't know about or that haven't been studied or looked at?…In order to start answering the questions, we have to start asking questions.”

Dr. Scott Hay, chairman of the AAEP Racing Committee, agreed.

“As things circle around over time, we find a lot of things don't help [EIPH] very much, we find a lot of things that anecdotally we think that do help, and Lasix has probably been the one thing that has stood the test of time as far as being our most efficacious tool out there,” Hay said. “Now that being said, I certainly have a lot of trouble controlling horses with EIPH with Lasix alone…We need to look further and deeper…We trying to prod the industry a little bit to find other things…It's easy to say we need to do without Lasix, but we're going to leave a lot of horses behind if we just cold-turkey stop giving horses Lasix on raceday.”

To help shape a game plan for the future, Dr. Gregory Ferraro of the University of California-Davis Veterinary School, offered a “dinosaur's” perspective of the past based on his treatment of Thoroughbreds decades ago, prior to the legalized use of raceday Lasix in the U.S.

Ferraro said that prior to widespread use of the fiber-optic endoscope, a “bleeder” on the racetrack meant a horse that was observed visibly bleeding through the nostrils after a race or workout. He estimated only 2% of Thoroughbreds back then were classified as bleeders, and the problem was managed by rest and training management.

In the 1970s, when endoscoping horses after races became more common (Ferraro was a pioneer in this practice), the estimated rate of bleeding shot up to 40% of all horses, because now even minute traces of airway bleeding could be detected, leading to the phasing-in of EIPH as a veterinary diagnosis.

Ferraro recalled testifying before California racing authorities that Lasix was the only available treatment option. But he also recalled the argument being made that Lasix was to be considered a temporary solution until something better could be developed.

“The problem was that once Lasix was permitted in racing, the money for [EIPH] research just dried up,” Ferraro said. “Essentially, there has been no significant research on EIPH in the last two or three decades, which is a real shame, and that leads us to where we are today in this controversy.”

Ferraro said that mindset about Lasix being a cure-all quickly led to excessive usage.

“I worry that Lasix is a crutch, and that rather helping the situation, it's stymied long-term research and that we're sort of stuck in this quagmire of one medication versus another rather than really delving into quality research that might get us out of this morass,” Ferraro said.

Ferraro gave a specific example of alternative research that isn't being pursued. He believes that since the exact cause of bleeding isn't known, it could be due to a cardiac fatigue problem. Different methods of building cardiac strength could help solve the problem, but this sort of research isn't being attempted.

Blea said he has witnessed the increasing progression over the decades of horses being treated with Lasix in the mornings for training in addition to getting pre-race administrations. “Only a handful” of his clients request no Lasix for their horses until they are certified to have bled.

Dr. Gary Priest, a Kentucky-based vet, said side effects of repeated Lasix usage–such as the drug's effect on electrolyte balance and hydration–are also not well studied. In addition, he said that horses that are considered heavy bleeders might really have a problem with upper airway function that is going undiagnosed.

“I think there are definitely some untoward side effects,” Priest said of the over-reliance on Lasix. “I think the number of horses that are treated on a daily basis at the track with Lasix just seems to be quite excessive when the side effects of that treatment seem to me to be detrimental to the horse's overall health.”

Dr. Foster Northrop, a practicing vet who also sits on the Kentucky Horse Racing Commission board, said economics often play a factor in the treatment of bleeders, particularly if scoping a horse is viewed by owners as an unnecessary veterinary practice.

“I'm not seeing the dire side effects that a lot of people talk about seeing,” said Northrop. “What I do see is the push to use…all of these garbage adjuncts that people want to pull out. I don't want to get into garbage adjuncts and withholding water and hay for 24 hours. This all scares me.”

Ferraro said racetrack vets need to look outside the industry, where other equine sports seem to be outpacing racing in terms of equine athletes' health.

“The rest of the horse world is extremely healthy. It's growing very rapidly; it's doing quite well,” said Ferraro. “It's only Thoroughbred racing that is declining. And from the public's perception, whether we believe in Lasix or we don't believe in Lasix, the public doesn't want it. It's hurting our industry and it's hurting our game. Regardless of our opinion, if we continue down the path that we have chosen, I believe that we'll eventually erode out fan base and have some serious problems in that regard.”

Horsemen, Regulators in Agreement That Lasix by Itself Not the Only Problem…

With its one-day, one-topic forum, the NYSGC tried admirably to isolate the subject of Lasix from other problems that are currently hot-button issues in the sport.

But perhaps more so than any other points that were hammered home at Tuesday's confab, the two final afternoon panel discussions made it clear from multiple perspectives that Lasix, like it or not, is inextricably intertwined with a whole raft of other over-arching issues.

Equine welfare, performance-enhancing drugs, politicized infighting, agenda-pushing, public perception, and how the industry is portrayed in the media all percolated to the surface in separate Tuesday panels comprised first of horsemen, then of regulators and industry executives.

“[Lasix] is not what we should be talking about,” said Thoroughbred owner Maggi Moss. “We should be talking about the protection of these horses in other matters…Lasix is not the issue of the day. It shouldn't be the issue of the day. The reason it's the issue is it's political. It's political for self-interests and people's breeding stallions, and what they perceive. And that does not belong in racing. Not with horses.”

Moss continued, “You've heard it all. You've heard everything. We don't have anything better [for EIPH]…We already have our hands full folks, with lots of unsound horses and shockwaved horses and blocked horses. I don't need to add 100,000 horses to our backlog of finding homes. If you do away with Lasix or change a very good program, you're going to create an onslaught of unwanted horses and more horses going to slaughter.”

Trainer Mark Casse agreed, detailing how he personally tries to adhere to medication regulations even while watching competing horsemen try to beat them.

“I think there are a lot bigger factors than Lasix,” Casse said. “I'm fine with not having Lasix if we have a better alternative, but that's not the case…Don't go after the good guys just because there's a few bad apples.”

Trainer Rick Violette, Jr., who also serves as president of the New York Thoroughbred Horsemen's Association, framed therapeutic Lasix usage as “an obligation to protect” horses.

“There's no science out there that shows it's performance enhancing. Performance enabling? Maybe. If Lasix is doing its job, it's supposed to make the horses run better,” Violette said.

“Everything we do as a trainer is, by its intent, performance enhancing,” Violette said. “We use Lasix in the morning. It's not to get them to breeze faster. It's not to get them to beat another horse that they might be breezing with. It's for the prophylactic treatment so that we can stop them from bleeding before we ask them to perform in the afternoon.”

Trainer Gary Contessa said that his decades as a horseman extend back beyond the advent of legalized Lasix in New York (1995), and that he justifies Lasix by thinking of it in “more humane” terms than previous, medically unproven, methods of trying to keep racehorses from bleeding.

“I've seen just about every product known to man, but in 30 years, no one has ever come up with a product that can stop a horse from bleeding,” Contessa said. “If somebody gives me an all-natural product that will stop a horse from bleeding, I'm the first guy to sign up…I understand the people who are vehemently opposed, and I understand the people who are completely in favor. But I have never seen center ground with an alternative. That's the only thing we haven't had.”

Trainer Jonathan Sheppard said he wished the industry had “never heard of the drug.” But, he continued, “we've dug a very deep hole, and we have to figure out how to get out of it. Banning Lasix overnight is, of course, not going to work.”

Horse owner and breeder Arthur Hancock III, a founding member of the Water Hay Oats Alliance, said he is in favor of banning all raceday medications.

“Our fans don't want drugs and they're gravely concerned about their use,” Hancock said. “So who wants the drugs? It seems to me only those that profit by their use, or who genuinely believe the horses need them. It's my opinion that a great industry has been hijacked by drug money. Let's face it, when you market a product, you sell the sizzle and not the steak.”

Among the regulators who spoke at the final afternoon panel, Ed Martin, the president of the Association of Racing Commissioners International, was the most vocal in speaking out against the potential banning of Lasix and the possibility of federal or third-party oversight replacing the current state-by-state system of regulation in the U.S.

“We need help…But Lasix is not the integrity issue. It isn't even an issue dealing with the breakdown problem that we need to address…This issue has gotten way out of control, and it's a complicated issue on many levels. But at the end of the day, if you don't believe in [Lasix], you don't have to use it.”

Martin followed up by pointing out that numerous owners and breeders continue to use Lasix on their horses even while advocating against it.

Bill Nader, the executive director of the Hong Kong Jockey Club, spoke on the issue from the perspective of being a former New York Racing Association executive who has experienced a different mindset since accepting a job on the other side of the planet nearly a decade ago.

In Hong Kong, Lasix is prohibited in both racing and training, and Nader said it's remarkable how quickly horses are able to bounce back without the diuretic in their systems.

“I'm not a scientist and I'm not drawing any firm conclusions from that, but it's just fact,” said Nader. “It's just very visible and very clear that top horses [or even] ordinary horses, they can come back within two to three weeks and still run at a very peak level of performance.”

Nader concluded, “For me, maybe my view would be different had I not come here and seen a different way of racing and life. In America, it seems that people don't blink that all horses are on Lasix, because that's what they know. But in the rest of the world–you take out North America–horses are free of medication on raceday. That's a basic principle and a basic policy.”