Friday, June 17, 2011

Lasix: What Is To Be Done?

My previous two posts (here and here) dealt with the scientific evidence regarding Lasix use in thoroughbreds and with the policies of the racing world outside North America. Here’s a brief summary of what we know, as presented at the open-to-the-public Monday session of the NTRA.AAEP/RMTC “Summit” on Lasix:

Most horses bleed.

Very few horses (less than 1%) bleed at a level that seriously impairs their racing ability.

Lasix works; it reduces both the incidence and the severity of bleeding, though it doesn’t eliminate low-grade bleeding.

Horses run better with Lasix than without it; whether you call the drug a “performance enhancer,” “performance enabler,” or “performance optimizer,” horses that get Lasix run faster.

Lasix does not appear to interfere with testing for other drugs.

The rest of this post discusses what the US and Canada, the principal holdouts that allow race-day use of Lasix, should do. Two principal camps have emerged. One, led by the Jockey Club and a number of prominent owners, is calling for the rapid elimination of race-day Lasix. The other, probably representing the majority of US trainers and horsemen’s associations, contends that North America should continue to permit race-day Lasix or even that other countries should also permit it.

(Before going on, I should probably note that my views don’t necessarily – in fact I’m sure they don’t – represent the official views of the New York Thoroughbred Horsemen’s Association, even though I ‘m a member of the NYTHA Board of Directors.)

The horsemen’s case for Lasix appears to have two basic elements. First, they argue, Lasix is actually good for the horse. By reducing the incidence and the severity of bleeding, Lasix spares horses from the pain that severe bleeding inflicts and enables a racehorse to perform up to its potential. Second, the racing environment is so much different in the US, as compared to most of the rest of the world, that’s it’s a case of comparing apples and oranges . In this view, the fact that the rest of the world eschews Lasix has no bearing on what’s right for the US.

What are the merits of these arguments? Of course, all (or almost all) of us in the game want to spare horses unnecessary pain. Most of us are in racing because we love horses; if we were in it solely for the money, there’d be serious cause to question our sanity, as most owners, and some trainers, actually lose money. And the use of Lasix apparently does spare horses some pain, particularly by reducing what would otherwise be painful Class 3 or 4 bleeding, or the even more severe bleeding that’s visible at the nostrils (bilateral epitaxis, in vet-speak) to a milder Class 1 or 2 smattering of blood in the trachea after a race. But if sparing some horses – fewer than 1% show Class 3 or 4 bleeding or bilateral epitaxis in a strict no-Lasix jurisdiction like Hong Kong – then the logical question to ask is why 95% or more of US starters race with Lasix? In most countries that ban the drug, repeated bleeders are simply banned from racing. And in most of those jurisdictions where racing is allowed in training, but not on race day, trainers report that they treat fewer than 10% of their horses with the drug.

As for the argument that racing permits horses to run to their potential, that all depends on how one defines “potential.” In the days before anti-bleeding medication, “bleeders” were shunned by owners and systematically removed from the gene pool. (Of course, not all bleeders were so identified; the great trainer Woody Stephens had his grooms carry a red towel, so they could wipe away the evidence of bleeding before anyone noticed.) And the argument is a slippery one; what about the use of painkillers to permit a horse to run to its potential despite internal warnings that something’s amiss? Bute and other pain meds aren’t permitted on race day in most US jurisdictions, though they're frequently used in training. If Lasix reduces pain in the lungs from bleeding, why not allow drugs that reduce pain elsewhere?

And the gene pool inevitably suffers. As Denis Egan, head of the Irish racing authority, noted at Monday’s drug summit, many foreign buyers and breeders view US-bred thoroughbreds as suspect, and not as sound as their foreign-bred counterparts, despite figures that show that the number of starts per horse per year is pretty much the same all over. There’s also a concern, as yet not proven by scientific research, that long-term Lasix use reduces calcium and therefore leads to more brittle bones. Many US trainers acknowledge a decline in soundness and durability as well. My conversations with Allen Jerkens at the rail of the Belmont training track certainly bear this out; the “Chief” says most current US race horses couldn’t stand up to the intensity of training that he used to give all his charges in decades past. On the other hand, repeated bleeding episodes, which might be avoided with widespread Lasix use, have been proven to produce scarring of the lungs and remodeling of the pulmonary blood vessels, both of which reduce lung function and make a horse prone to even more bleeding.

Regardless of what’s happening elsewhere, horses in the US do run less often and have shorter careers than they used to. Not all, or even most, of this decline can be blamed solely on Lasix. Breeding to sire lines prone to unsoundness (especially Mr. Prospector and Northern Dancer); corrective surgery on foals that don’t look good enough for the sale ring; kid-glove treatment of babies, denying them the opportunity to run around in the field as much as they used to; and trainers’ concerns for a high win percentage to attract owners, thus largely eliminating the old practice of racing a horse into shape, all play a part. And the rapid expansion of the foal crop in response to the boom market of the 1970s and 1980s meant that many more questionable mares were kept in production. But Lasix also enters into the equation. According to data presented at the Summit, bleeding is to some degree an inherited trait, and the more horses whose bleeding was controlled by Lasix go to the breeding shed, the more that trait will tend to appear in subsequent generation.

Despite all those negatives, US trainers’ argument that racing here differs from the rest of the world has some merit. Our industry differs significantly from other countries'. First, we run many more races per year – too many -- with (necessarily) shorter fields. We run much more on dirt, and less on turf, than other countries; it’s plausible that horses’ inhaling dirt and blowback from synthetic tracks leads to more lung problems than racing on grass. We have many more minor-league tracks, where the horse population consists disproportionately of older horses with an accumulation of infirmities; see the all-too-true description of the barely-fictionalized Mountaineer in Jaimy Gordon’s National Book Award-winning novel, Lord of Misrule. We have a lot more owners who don’t have inherited or self-made real wealth and therefore can’t afford to make a small fortune in racing by starting out with a big fortune. The local building contractor who, with a few pals, owns a couple of claimers, or the partnerships that appeal to average race fans, don’t like to see their horses shipped out to the farm for R&R; that means bills to pay with no purse money coming in. We have too many horses, even with the recent reduction in matings and foals crops following the 2008 financial crisis. And, three decades into the legal Lasix era, we have too many trainers and too many vets who’ve never had to manage bleeding without chemical assistance; a lot of lore in the heads of old-time trainers and vets has simply been lost.

For all these reasons, Lasix makes a good bit of sense in US racing.

But we have a problem of political and public perception that seems to me more important than a narrow balancing of the day-to-day pluses and minuses of Lasix. Even though, as reported by the NTRA’s pollster at the Summit, more racing fans today perceive the game as fair, and drug use under control, than was true three years ago, before the elimination of some steroids and the increased concern for track safety in the wake of Eight Belles’ collapse at the end of that year’s Kentucky Derby, drug use is still a huge perception problem. While most sports are seen as relatively clean, horse racing and cycling still carry a stigma, facts notwithstanding.

And the perception can lead to huge over-reaction. The bill currently before Congress that would require horses to race “drug-free,” whatever that means, and impose draconian penalties on even inadvertent violations, is a case in point. If racing doesn’t act, the public will continue to act, by betting ever-less on US racing, and the political system will impose its own over-the-top solutions. What a leader does in this situation is figure out where the followers (in this case the public that still cares about racing) is going and get out in front of them.

Part of the perception problem is that the public and politicians see vets entering horses’ stalls with a Lasix injection and assume that the vet could be giving a whole lot of other meds as well. The New York Racing Association has actually solved that problem by requiring that Lasix shots be given only by the official track vets, and not letting private vets in the stall before a race, but that’s an initiative no one knows about and is hardly likely to change the views who have weak knowledge and strong opinions.

Even if Lasix is good for horses, human athletes run or play through pain all the time; in fact, being able to do that is part of the definition of a great athlete. Humans, as contrasted to horses, are supposed to have some choice in the matter (though try telling that to an NFL lineman trying to hang onto his roster spot). Not all thoroughbreds are great athletes, and maybe some just shouldn’t be racing.

At the Summit, a variety of trainers and vets described training regimens that seemed to reduce the incidence of bleeding without resorting to race-day Lasix. These ranged from training horses away from the race track to at least giving them periodic breaks, both of which reduced the stress induced by full-time residence at the track. Stress levels do seem to be correlated with bleeding. Also, training patterns in most countries appear to involve more stamina work and less high-speed sprint breezes, in which a horse is performing at close to 100% of its potential. Even where horses are stabled at the track, the use of dust-free bedding and other similar management techniques can help ease the problem.

Given the current state of US racing, it’s not economically feasible for all owners and trainers to adopt such measures immediately. Owners at tracks where the win purse is $5,000 can’t afford to take their horses out of training, and trainers whose horses are primarily low-level claimers face the same pressure. Abolition of race-day Lasix might work for the upper end of the business, where owners either make a lot of money with their horses or have a lot of money to take care of them. That’s why the suggestion that graded stakes in the US become Lasix-free isn’t a bad starting point. Trainer Richard Mandella, one of the Summit participants, said he could live with such a ban. So that’s one place to begin. Another is with new two-year-olds. Two-year-old racing has already begun this year, but perhaps, starting with next year’s crop, Lasix could be banned in any race restricted to horses of a particular age: two-year-olds beginning in 2012, three-year-olds in 2013, etc. , for a phase-in period of perhaps five years, by which time most of the Lasix habitu├ęs would be retired. Or perhaps that ban would take effect only at, say, major league and “Triple A”-level tracks, perhaps those offering $125,000 and up in average overnight purses.

Whatever good Lasix does, we’re prisoners of public and politicians’ opinions. If we can’t change them, and the last decade suggests that we’ve had only limited success in that endeavor, than we need to adjust to save the industry. Trainers will need to develop new methods of dealing with bleeding, owners will have to adjust to new patterns for a horse’s career. The status quo regarding Lasix, no matter how justifiable it is in scientific terms, just can’t be maintained.

Wednesday, June 15, 2011

Lasix: What the Rest of the World Does

Yesterday's post addressed some of the scientific findings regarding Lasix use. Gina Rarick, an American who trains in France, where Lasix cannot be used on race day, but is permissible in training, wrote to ask whether the discussion at the NTRA/AAEP/RMTC "Summit" had dealt with the possibility that repeated Lasix use contributes to the leaching of calcium and other minerals from the horse's system and therefore to increasing fragility in a horse's musculo-skeletal system and, ultimately, to a higher rate of fatal breakdowns. Good question. My own, admittedly amateur, review of the available information suggests that it is definitely established that the use of Lasix lowers a horse's levels of calcium in the blood. What's not so clear is whether that short-term calcium loss translates into long-term bone fragility and more frequent breakdowns. Lots of opinions on the subject, but, at least as far as I can determine, not a whole lot of science. I'd love to see a well-designed study on the topic.

Science notwithstanding, it's true that, for whatever reason, the US and Canada stand alone among major racing jurisdictions in permitting race-day use of Lasix. Here's what other major racing countries do, as reported to the "Summit":

Australia: No race-day Lasix permitted, with a suggested withdrawal time of 48 hours (in practice, that means that a prudent trainer won't give a horse Lasix less than 4-5 days before a race). Trainers are permitted to use Lasix for horses in training, and some do before a breeze. Horses are reported as "bleeders" only if they show bilateral epitaxis (bleeding from both nostrils), either after a race or in training. Bleeding that is evident only on scoping, even at the performance-affecting 3/4 levels, doesn't count. If a horse is observed bleeding, then it's taken out of training for at least three months and isn't permitted to race again for at least three months, and then only after a 5/8ths-mile gallop with no bleeding.

France : Similar to Australia -- no race-day Lasix with a 48-hour withdrawal time, but Lasix use permitted in training at the trainer's discretion. No specific rules on barring horses that have been observed to bleed, but tthey do have to pass a vet exam before being allowed to race again.

Germany: Lasix appears to be banned both on race day and in training, and horses are banned for breeding purposes if they've ever raced on drugs, or if they've ever bled.

Hong Kong: The Hong Kong Jockey Club, which runs the tracks, licenses owners, trainers and jockeys, makes and administers the rules, and runs the test lab (a collection of power in a single entity that, I suspect, makes Frank Stronach salivate), does not permit Lasix either on race day or in training. There are two categories of "bleeders." If a horse bleeds from the nostrils, it's categorized as an "official bleeder" and cannot race for at least three months, pending an official vet exam. After a third bleeding episode, the horse is barred from racing for life. The second category is a horse that appears to the stewards to have performed below expectations, in which case the stewards can order a vet exam and, if the horse scores a 3 or 4 rating for blood in the trachea, then they're required to have an official vet exam after a track gallop and can't be entered in a race for at least two weeks. In the past five years, Hong Kong reports that 0.5% of all horses were "official bleeders," and another 0.6% were reported as having "substantial blood in the trachea." Over the same time period, just under 1% of the Hong Kong race horse population was compusorily retired because of bleeding.

Ireland: No Lasix on race day, though it can be used in training. The definition of bleeding is very tight, with only horses that bleed visibly at the nostrils being classified as bleeders and subject to mandatory time off before returning to the races. Under that definition, only some 0.15% of starters are labeled as bleeders.

Japan: Lasix is banned for 10 days prior to race day, though it may be used in training, subject to the 10-day limit. Bleeding is defined as visibly bleeding from the nostrils, with no specific rules about blood that's visible on a scope. Horses that bleed visibly are barred from racing for one month in the first instance, two months in the second, and three months in the third. Visible bleeding was reported in between 0.1% and 0.2% in most recent racing years in Japan.

Singapore: No Lasix permitted on race day, though it can be used in training up to 3 1/2 days prior to a race. Bleeding is defined as in Hong Kong, but is reported to occur in less than 0.5% of starters.

UAE (Dubai): No drugs permitted within 48 hours of post time, with a recommended three-day withdrawal period for Lasix, but Lasix is allowed in training. As in most of the other jurisdictions, bleeding is defined as bleeding visibly at the nostrils, and horses are barered from racing for gradually longer periods after each bleeding episode. The prevalence of bleeders is somewhat higher than in other jurisdictions, perhaps because of the climate, at about 0.4% of all starters.

United Kingdom: No Lasix on race day, though it can be used in training.

To summarize: all the major racing jurisdictions outside North America ban the use of Lasix on race day. Most jurisdictions, Hong Kong and Germany excepted, permit the use of Lasix in training, as long as it's not given within a defined period prior to a race. And most of the jurisdictions report very low rates of "bleeding," by which they almost all mean that a horse bleeds visibly from both nostrils; the rates range from a low of one per 1,000 starters up to a high, in Hong Kong and Singapore, of perhaps five per 1,000 starts.

So how can we reconcile the fact that, according to the South African study that I reported on yesterday, "most horses bleed," with the very low rates of bleeding reported in non-Lasix countries?

A few possible explanations stand out, though there's little science so far to prove or disprove any of them.

First, training practices differ substantially as between North America and most of the rest of the world. Here, most horses train at the race track, are exercised for comparatively short times, and get comparatively more speed work, with racing-speed breezes. Elsewhere, it's more common to train away from the track, in a less pressured atmosphere. It's notable that the relatively higher rates of bleeding in non-Lasix jurisdictions occur in those places -- Hong Kong, Singapore and Dubai -- where horses do train at the race track.

Second, most jurisdictions' definitions of bleeding don't include horses that score a 3 or 4 when scoped, even though those hores are clearly compromised in performance. According to the South African study, nearly 10% of horses have serious tracheal bleeding without Lasix (reduced to essentially zero with Lasix), enough to affect their racing performance.

Third, there's much more dirt racing in the US than elsewhere. It's not clear how that affects the tendency to bleed, and the South African study was conducted with turf racing, not on dirt.

Fourth, there are racing style, distance and pedigree differences. More races in the US are at short distances, with horses running at maximum effort all the way. In many turf-racing jurisdictions, horses tend to gallop along, at less than maximum effort, for a good part of the race

Could US racing survive without race-day Lasix? It would undoubtedly require major changes in training patterns and, ultimately, in breeding patterns as well. Is it possible? That's a question for tomoorow's post.

Tuesday, June 14, 2011

The Science of Lasix: a View from the "Summit"

There has already been considerable media coverage of this week’s “International Summit on Race Day Medication, EIPH and the Racehorse.” (See, e.g., here,here, and here.) But most of these reports offer the always-tempting us vs. them scenario: “rest of world presses US to eliminate race-day meds.” In fact, the summit was far more informative, and thought-provoking, than that simplistic view suggests. So informative and thought-provoking, in fact, that I will be reporting on it in a series of three blog posts. Today: the science of Lasix and EIPH (“bleeding” in race horses. Next, what the rest of the world actually does. And, finally, some thoughts on how to resolve the conflict between foreign and media pressure to ban all race-days drugs with the economic realities of racing in the US.

(Lots of the presentations at the Summit have been posted online here, so I'll forego the pictures of bloody trachea and scarred lungs.)

I had earlier commented on the Lasix issue, among other drug-related problems in racing, in a piece for the New York Times’ The Rail blog. I’m delighted that attending the “summit” yesterday deepened my understanding of Lasix and its costs and benefits. But, as we’ll see, understanding a problem doesn’t necessarily lead to a solution.

On to the science of Lasix, a topic almost entirely absent from the media reports on the summit.

The first question is how many race horses bleed under the stress of a race or a high-speed breeze? The answer depends on how you define “bleed.” If it means actually bleeding from the nostrils, then the answer is about 1%. If it mains showing even a trace of blood in the trachea when a horse is “scoped” after a race, then the answer is somewhere near 80%, plus or minus 10%. Obviously, the definition that you use determines the scope of the problem and therefore the appropriate solution.

Fortunately, there’s now pretty good evidence to help define the issue better. A recent study of several hundred race horses in South Africa, conducted by researchers from the US, Australia and South Africa and frequently cited at the Summit, used the common veterinary practice of grading bleeding that shows up when a horse is scoped on a scale of 1-4. In the study, 79% of horses showed some signs of blood after racing without Lasix, but so did 57% of those that raced with Lasix. So, while Lasix does reduce both the incidence and the severity of bleeding in a majority of horses, it doesn’t eliminate it. What Lasix does do is to reduce the pressure on the very thin capillaries in the horse’s lung by some 15-20%. And that in turn reduces the “remodeling” of blood vessels and scarring of the lung tissue, making them less likely to bleed next time.

Most horses that “bleed” have a score of 1 or 2 on the 1-4 scale. In the opinion of most of the vets who spoke at yesterday’s meeting, a score of 1 has no impact on a horse’s racing performance, and a score of 2 is more or less on the borderline for performance-affecting. All the vets agreed that severe bleeding (a score of 3 or 4) definitely has an impact on racing performance, as does actual bleeding from the nostril, which is seen in only 1% or so of horses. In the South African study, 20% of horses without Lasix didn’t bleed at all, another 45% bled only to the 1 level, and another25% at the 2 level. In contrast, among horses treated with Lasix pre-race, 43% didn’t bleed at all, 48% bled at the 1 level, and only 9% bled at the 2 level. Thus, some 9% of the horses in the study that did not get Lasix bled at a level that all vets agreed clearly compromised their racing performance, while none of those treated with Lasix bled at that level. Lasix “works,” and in this study at least, it created a level playing field by letting horses that are more likely to bleed perform up to their potential. In that sense, Lasix can be thought of as a performance “enabler” or “optimizer.”

Bleeding also tends to get worse over time, so a horse that starts on Lasix presumably has a lower lifetime incidence of bleeding than one that races without the drug. That effect, though, doesn’t seem to translate into more starts per season or per racing career. Since the introduction of Lasix as a permitted drug in the US, starts per season and starts per career, as reported in the Jockey Club’s Fact Book, have declined by some 25%, to a level that’s on a par with most of the rest of the (non-Lasix) world. One can’t necessarily blame the use of Lasix for the decline in the number of starts, but Lasix apparently hasn’t helped.

Of course, Lasix is also a performance enhancer. Horses treated with Lasix, in the aggregate, perform better than those without the drug. Part of the difference reflects Lasix’s ability to suppress the kind of bleeding that would otherwise interfere with a horse’s performance. And part undoubtedly reflects Lasix’s reduction in a horse’s weight; in the South African study, horses treated with Lasix lost an average of 28 pounds pre-race, while those treated with a placebo lost only 12 pounds. That 16-pound advantage would be considered significant by almost any handicapper. Whatever the mechanism, horses on Lasix do better. That’s why 95% of US race horses run on Lasix, even though, based on the South African study, fewer than 10% of those horses would bleed at a level that substantially interfered with their performance if they raced without the drug.

One thing that Lasix does not do, the vets at the Summit agreed, is mask other drugs that racing authorities test for. Modern testing techniques are very sophisticated, and the only jurisdiction that still believes Lasix interferes with other drug testing is Hong Kong, where Lasix is not permitted at any time, not just when a horse is racing. Hong Kong notwithstanding, the experts at the Summit convinced me that the “masking” argument is no longer valid as a reason for getting rid of race-day Lasix.

One of the most interesting aspects of yesterday’s scientific discussion was the surprising (for me at least) finding that the Flair nasal strip has much the same effect on bleeding as Lasix does. While the Flair’s human equivalent, the Breathe Right strip, appears to have little or no effect on human athletes’ performance, several of the vets in attendance yesterday said that the Flair strip did help in horses. Some trainers used the Flair strip a few years ago, but it seems to have fallen out of fashion and has been banned in some racing jurisdictions, even though its manufacturer is a sponsor of the NTRA’s Safety and Integrity Alliance. If its efficacy is confirmed by additional scientific studies, the Flair strip might be a viable substitute for Lasix.

Tomorrow: how other countries deal with bleeding.