Evidence-based medicine has become the new standard. Making diagnostic and treatment decisions based on cold, hard scientific
evidence puts the clinician on much firmer footing both scientifically and ethically, so the argument goes. But it can be
disturbing when scientific evidence challenges the way things have historically been done.
Traditionally, when faced with an obese horse with dry and scaly skin and a long coat that sheds slowly, a slower heart rate,
poor performance or a history of infertility and a dull lethargic attitude, most clinicians would turn to blood work analysis
to help with a diagnosis. All of these clinical signs lead one to consider a metabolic problem such as Cushing's disease,
metabolic syndrome or hypothyroidism. The results of a simple blood chemistry profile might, in fact, confirm a lower than
normal concentration of the two major thyroid hormones in horses—triiodothyronine (T3) and thyroxine (T4).
This would have qualified as evidence-based medicine since the clinical signs and blood results support the diagnosis, and
horses such as these would be treated with supplemental thyroid hormone and periodic blood monitoring. Often horses treated
in this manner respond with more energy, better attitudes and improved body condition, and subsequent testing often shows
increased T3 and T4 concentrations—a triumph for science, a healthier patient and another positive case outcome for the esteemed
The problem with the way that thyroid function has typically been evaluated and the way these horses have been treated is
that it does not match what we know and can prove regarding thyroid disorders in horses.
The implications of low thyroid hormone concentrations
"There are no scientific studies to support the assertion that low thyroid hormone concentrations negatively impact the health
of horses or that supplementation is necessary," says Nicholas Frank, DVM, PhD, an associate professor at the University of
Tennessee College of Veterinary Medicine.
And Franks is not alone in this view. Betta Breuhaus, MS, DVM, PhD, an associate professor at the College of Veterinary Medicine
at North Carolina State University, addressed the American Association of Equine Practitioners and explained, "Horses with
clinical signs or syndromes traditionally associated with hypothyroidism often have normal thyroid function.
"Thyroid hormone status," adds Breuhaus, "should be carefully evaluated, and other potential endocrine or metabolic problems
should be ruled out before a horse is placed on long-term thyroid hormone supplementation."
But what about those low thyroid hormone concentrations often found on blood tests? This is part of the hypothyroidism myth,
according to Frank. "The detection of low levels of thyroid hormones in the blood is not the same as hypothyroidism," he says.
"The assays used to measure T3 and T4 concentrations are well established and accurate, and the hormones are relatively stable
in serum. However, the major issue with measuring thyroid hormones is that concentrations vary over time and within the same
individual horse and respond to many different environmental and medical conditions."
The "normal" concentrations for T3 and T4 in horses represent such a wide range that it can be difficult for clinicians to
interpret results. For example, a horse may have a T3 concentration of 12 but, because of the wide normal range for T3 concentrations,
we don't know if this horse always has a concentration of 12 or if this horse normally has a concentration of 24 and is depleted
by 50 percent and possibly hypothyroid.
Additionally, most laboratories test for T3 and T4 concentrations that reflect the amount of hormone bound to carrier proteins
such as albumin, as well as the biologically active "free" hormone. Carrier proteins are also affected by numerous medical
conditions, creating another source of variability. Many laboratories now offer an evaluation of free T3 and T4 concentrations,
and, while better than total hormone concentrations, various diseases and conditions outside of the thyroid gland can also
affect these values.
"Common diseases such as viral respiratory infections, digestive disturbances and colic can all affect thyroid hormone concentration,"
says Frank, "as can different feeding patterns, transport and training stress and changes in body composition such as weight
loss or obesity."
This presents an enormous challenge to practitioners. A low thyroid concentration in an individual horse is most likely a
reflection of normal day-to-day variability. "Only the detection of persistently low free T3 and T4 concentrations over several
days to weeks should cause concern," says Frank, "and only if the horse is free of other medical problems."
Can TSH help?
An additional test available in human medicine is a measure of thyroid-stimulating hormone (TSH). This hormone is produced
by the pituitary gland to stimulate the thyroid gland. Elevated TSH concentrations in people with clinical signs of hypothyroidism
provide a much more accurate and scientifically valid diagnosis. Response to TSH is also used as an indicator of thyroid function.
"Function testing is necessary to determine whether the thyroid gland is able to respond to stimulation," says Mark Crisman,
DVM, a professor at the Virginia-Maryland Regional College of Veterinary Medicine at Virginia Technical Institute. "But TSH
for horses is difficult and expensive to produce, making this type of thyroid testing more problematic in the horse."
When horses are injected with TSH and thyroid hormone concentrations are later measured, clinicians can evaluate whether the
T3 and T4 levels went up (euthyroid) or remained unchanged (abnormal thyroid response and possibly hypothyroid). Based on
the many horses that Frank and others have worked with and tested, it seems that few fail to respond to TSH. "When this more
advanced diagnostic test is used," says Frank, "it becomes clear that true hypothyroidism is a very rare endocrine disorder
in the horse."