Primum non nocere – Robyn Louw

First Do No Harm

Primum non nocere / First Do No Harm. This phrase is commonly quoted as part of the Hippocratic oath, although it is more likely to have been derived from the Hippocratic Corpus which states that “The physician must be able to tell the antecedents, know the present, and foretell the future – must mediate these things, and have two special objects in view with regard to disease, namely, to do good or to do no harm.”

There has been some debate following the recent suspension imposed on a Vaal trainer for the use of banned substances.  I don’t wish to wade in on the extenuating circumstances or whether the suspension is warranted or not.  What I am interested in are the opinions regarding the use of the banned substances in question, Flunixin (an NSAID or non steroidal anti-inflammatory drug) and Furosemide or Lasix (a diuretic commonly used in racing to treat ‘bleeders’).

The local debate seems to be concerned that the NHA are being obstructive by banning the use of these substances in horses competing on the track.  A large number of trainers, vets, owners and members of the public allegedly feel that certain medicines should be allowed under veterinary prescription and control for pain relief as part of the recovery programme for treating injured horses.

It is interesting that the FEI hosted a recent congress to debate the use of NSAIDs on equine athletes.  The debate centred around whether to maintain the status quo banning the administration of NSAIDs to sport horses during FEI competitions;  or alternatively changing the legislature to permit the use of NSAIDs at “appropriate levels”.

Lynn Hillyer of the British Horse Racing Authority stated that the Racing Authorities of Europe, Hong Kong, North and South Africa, Australasia, Asia and the Middle East (except Saudi Arabia) dictate that horses must not race under the effects of any drugs.  However, they do acknowledge that medication is necessary off the racetrack to ensure a horse’s physical well-being. “In other words, medication should be an aid to recovery, not a tool to enable a horse that should be resting and recuperating to race or train.”

To start with, the words ‘substance’, ‘medication’ and ‘drug’ seem to be used interchangeably to mean one and the same thing.  For the purpose of this article I am going to assume that we are discussing the two medically approved substances mentioned above.

Now, before we go getting all hot under the collar about ‘substance abuse’, let’s have a look at what these substances do.

The reason tissues become inflamed is usually in response to injury or infection (like the swelling you get after a bee sting).  Anti-inflammatories do more or less what they say on the tin – they inhibit certain enzymes and therefore reduce the body’s inflammatory response.  They also reduce pain and fever.  Roughly the same as the common aspirin.  In horses, NSAIDs are commonly used to treat a wide variety of muscle, colic and joint pain and to reduce fever.  One of the side effects of NSAIDs is that they can decrease blood platelets, resulting in “thinner” blood (hence people at risk of thrombosis take aspirin as a preventative measure before a long haul flight).

Furosemide or Lasix, is a diuretic used on thoroughbreds to prevent bleeding from the nose.  In simple terms, diuretics increase the excretion of water from the body.  To understand why they work, we first need to understand why horses bleed in the first place.  Simply put, the respiratory and circulatory systems are intimately linked.  The lungs are made up of thousands of tiny air sacs called alveoli and contain thousands of tiny blood vessels called capillaries.  These capillaries and alveoli are so fine and interconnected that oxygen inhaled into the lungs passes across the cellular membranes of the alveoli into the capillaries and into the bloodstream (by the same token, carbon dioxide also passes across this membrane from the capillaries to the alveoli to be exhaled out of the body).  As horses can only breathe through their nostrils, any bleeding will present in the nose.

The term ‘bleeding’ or (for you science vultures), Exercise-Induced Pulmonary Haemorrhage (EIPH) is a condition where the tiny capillaries in the lungs rupture due to physical exertion.  There are 3 different ‘versions’ of EIPH.  Simple EIPH is an acute version resulting from exercise strain.  In Patent Pulmonary Haemorrhage (PPH) the bleeding may occur as a reaction to an allergen, infection, or hypertension.  The third version is composite bleeding, which is a combination of simple EIPH and PPH.  Although simple EIPH will heal over the course of a few days, PPH is a chronic or recurring condition which requires medical intervention.

In essence, all horses that are expected to gallop at high speeds for extended periods are susceptible to some form of EIPH.  However, some horses are more vulnerable and will exhibit more dramatic symptoms than others.  Obviously, any significant episode of EIPH will cause a buildup of fluid in the horse’s air passages, causing difficulty in breathing and a rather obvious subsequent decline in performance.  A diuretic such as Lasix will cause the body to eliminate fluids, lowering the blood pressure in the body and in the lungs and relieving the symptoms of EIPH.

The length of time it takes a substance to half its concentration in the body is called the elimination half life.  The standard for calculating the time to eliminate a substance from the body completely is generally accepted as being 5 times the elimination half life.  One of the main reasons that diuretics are banned in sport is that they can be used to mask other agents or used to make the body eliminate other, possibly illegal substances.

A list of substances banned in human sport is issued by an organization called WADA (the World Anti-Doping Agency) who are accredited by the IOC.  This list is an International Standard identifying substances and methods prohibited in-competition, out-of-competition and in particular sports, and it is reviewed and updated on an annual basis.

Because professional athletes will occasionally sustain injuries or contract conditions necessitating the use of medication on the prohibited list, an athlete may apply for a ‘Therapeutic Use Exemption’ (TUE).  There are obviously formal channels and protocols that need to be followed, but essentially, as long as the medication is not deemed to enhance performance significantly, is prescribed by a doctor and permission is applied for and granted by the correct authorities, an athlete is allowed to use a substance on the list.  However, it goes without saying that TUE’s are granted for specific medications, with defined dosages and also for specific and limited periods of time.

Pain is part of the body’s natural protective and healing mechanism.  If you are injured, you experience pain and instinctively protect the vulnerable part of your body until the injury has healed.  If the pain is removed, it is all too easy to forget the extent of the injury and revert to exerting yourself as normal.

Humans are rational, logical beings, who are able to make objective decisions regarding injury treatment.  We can take pain killers and make an informed decision to use the medication purely for pain relief and not engage in further physical exertion where we might risk further injury.  Horses do not have this choice.  They simply know that they are pain free.  Their protective mechanisms therefore do not kick in and they are likely to re-injure themselves if not managed / protected appropriately.

In an ideal world, rehabilitation and the return to training should conform to the healing and remodeling processes of the horse.  However, it is easy to see that it might be tempting to use substances to hurry things along, or even keep an animal competing when it is not 100% sound.  Professional sport is tough and athletes inevitably pick up a variety of small injuries, aches and pains along the way.  The danger is when small injuries go undetected, or are deemed too insignificant to merit serious attention.  These have the potential to accumulate, eventually resulting in what is referred to as a ‘catastrophic breakdown’.

No one can say for sure why so many horses break down on the racetrack.  The theories vary from improper shoeing to undetected stress fractures, from the proverbial “bad step” to the escalating use of painkillers.  There are also those among our ranks who strongly suggest that horses are being inbred too closely or raised too softly.

Either way, half-ton racehorses travel at speeds of up to 36 miles per hour and strike the ground with incredible force.  Considering that a galloping horse exerts a 12,000-pound load on the cannon bone alone, one starts to appreciate the value of good conformation, straight limbs and correct movement.  You also start to appreciate what a remarkable piece of biomechanical machinery a horse’s leg really is.

Now imagine that same piece of machinery with an ever so slight defect such as, oh I don’t know, perhaps an undetected microfracture which doesn’t show up on standard X-rays.  Let’s say the owner of this mechanism (the horse we all so readily forget about), has been presenting with an ever-so-slight ‘mystery’ lameness.  The vet has examined it, but it’s a young and not particularly valuable animal, so we don’t go for the big, expensive scintigraphy machines.  We decide to follow a conservative course of treatment, administer some anti-inflammatories and see what happens.  After a few days, we stop the anti-inflammatories, the horse remains sound and we resume work.

The tricky thing is that the healing process consists of 3 phases – the inflammatory phase (which can last up to 5 days), the proliferative phase (2 days – 3 weeks) and finally the remodeling phase (3 weeks – 2 years).  And we have resumed work after phase 1.

Now imagine that same horse a few weeks later, exerting all that pressure on that ever so slightly unsound skeletal structure.  In the middle of a group of other horses all travelling at speed.  All with vulnerable human beings on board.  Not a comfortable thought, is it?

Because this is not just about horses.  Jockeys (and work riders for that matter) are out there every day risking their necks on these animals and a lot of jockeys have been seriously injured as a result of catastrophic breakdowns (Lester Piggott, our own Bartie Leisher and just recently, 24 YO Michael Martinez).

A 1992 study by the University of Minnesota showed that approximately 0.1% of the horses on American tracks suffered fatal racing breakdowns.  Because of some fairly high profile cases of catastrophic breakdowns, our American friends began conducting extensive research into the subject.  California has an extensive necropsy program and any horse that dies in a CHRB racing enclosure is autopsied by pathologists associated with the UC-Davis School of Veterinary Medicine.  And what in excess of 20 years of research has shown is that 90% of horses suffering fatal musculoskeletal injuries had a pre-existing pathology at the site of the fatal injury.

At the end of the day, this is an issue that affects our horses, our jockeys, our fans, and our sport.  Considering the scope for things to go wrong, I am not sure that treating horses with pain killers when they are competing is in the best interests of any of those groups.

The mandates of Phumelela, Gold Circle and the NHA read as follows:-

Phumelela:  “Vision – To be acknowledged as the worldwide leader in the informed betting market.  Mission – To create exciting opportunities that enable informed betting on live events.  Purpose – To grow the SA horseracing industry on a sustainable basis and make it globally respected and desirable.”

“Gold Circle (Pty) Ltd has as its primary focus the promotion and advancement of thoroughbred horse racing in KwaZulu-Natal and Western Province.”

The NHA website states:  “The core function of the NHA Racing Division is to ensure that thoroughbred racing is provided with a competent and efficient racehorse and jockey control & monitoring service.”

What concerns me is that not one of them mentions the welfare of the horse…..

Those against the use of medication are of the opinion that they can enhance performance and give the user an unfair advantage.  By masking or removing pain, these substances can allow injured horses to race at their peak, despite not being fit to do so.

The people who are for the use of substances state that no medicine can increase an animal’s ability or make it run beyond its physical limits and that their judicious use is needed to aid the healing process and allow horses to recover and resume training more quickly.

The debate around the use of medications has raged for decades and will no doubt continue to do so for some time to come.  One thing I can say for certain is that it cannot be viewed purely from a scientific perspective and ethical values and legal issues will certainly also need to be considered.

For any interested parties, the FEI conference is available in its entirety on the FEI website (www.fei.org).  The FEI aim to keep their debate alive in the interim and will be voting on the use of NSAIDs on competition horses at their General Assembly in November.

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