The Role of Insulin in Endocrinopathic Laminitis

Laminitis is a devastating disease of horses that usually arises as a consequence of major systemic disease or endocrine disturbances. Research has been confounded by apparently disparate results and theories on pathogenesis. Models of laminitis have greatly advanced our understanding of the disease, yet have mostly involved perturbations of the gastrointestinal tract or inflammatory models. A major trend in research on laminitis in the past few years has been the increasing interest in endocrine dysfunction resulting in laminitis. A new model of laminitis associated with hyperinsulinemia has recently been discovered and the central role of high insulin in triggering endocrinopathic laminitis highlighted. This review discusses the pathophysiology of insulin resistance and hyperinsulinemia in horses and possible mechanisms of insulin-induced laminitis.     

Nutrition and Exercise in the Management of Horses and Ponies at High Risk for Laminitis

Obesity, insulin resistance (IR) and hyperinsulinemia are risk factors for laminitis in horses and ponies. Alterations in management, especially diet and physical activity, can be helpful in the management of these risk factors. Caloric restriction, ideally combined with increased physical activity, to promote weight loss and improve insulin sensitivity is indicated for the management of obese animals. Strict control of dietary NSC through the elimination of grains and sweet feeds and by restricted access to NSC-rich pastures is recommended for insulin-resistant animals, regardless of whether they are obese or not. Medical treatment with levothyroxine or metformin may be indicated in obese or insulin-resistant animals that do not respond to conservative management.     

Assessment of Insulin and Glucose Dynamics by Using an Oral Sugar Test in Horses

Straightforward testing procedures are needed to facilitate the diagnosis of insulin dysregulation in horses because hyperinsulinemia and insulin resistance are associated with laminitis. Results of an oral sugar test (OST) were compared with those of the intravenous glucose tolerance test (IVGTT). We hypothesized that OST and IVGTT area under the curve values for glucose (AUCg) and insulin (AUCi) would be closely correlated, as defined by a correlation coefficient value ≥0.90. Both tests were performed in 10 horses meeting the criteria for equine metabolic syndrome (EMS) and 8 Quarter horse crossbred mares from a university teaching herd (control group). The OST was also performed in 21 Quarter horse crossbred mares from the same herd, and test repeatability was evaluated in 8 of these horses. All testing was performed under fasting conditions. Median AUCg and AUCi values were 1.3- and 9.0-fold higher, respectively, for the IVGTT and 1.3- and 6.8-fold higher, respectively, for the OST in the EMS group than those in the control group. AUCg (Spearman correlation coefficient [r_s] = 0.58; P = .012) and AUCi (r_s = 0.90; P < .001) values for the two tests were positively correlated. Mean ± SD coefficients of variation for repeated tests in 8 mares were 6.4% ± 3.1% and 45.1% ± 36.2% for AUCg and AUCi, respectively. We conclude that OST and IVGTT insulin results are closely correlated, so the OST warrants further consideration as a field test for insulin dysregulation in horses.     

Effect of Dietary Nonstructural Carbohydrate Content on Activation of 5′‐Adenosine Monophosphate‐Activated Protein Kinase in Liver,Skeletal Muscle,and Digital Laminae of Lean and Obese Ponies

Background

In EMS‐associated laminitis, laminar failure may occur in response to energy failure related to insulin resistance (IR) or to the effect of hyperinsulinemia on laminar tissue. 5′‐Adenosine‐monophosphate‐activated protein kinase (AMPK) is a marker of tissue energy deprivation, which may occur in IR.

Hypothesis/Objectives

To characterize tissue AMPK regulation in ponies subjected to a dietary carbohydrate (CHO) challenge.

Animals

Twenty‐two mixed‐breed ponies.

Methods

Immunohistochemistry and immunoblotting for total AMPK and phospho(P)‐AMPK and RT‐qPCR for AMPK‐responsive genes were performed on laminar, liver, and skeletal muscle samples collected after a 7‐day feeding protocol in which ponies stratified on body condition score (BCS; obese or lean) were fed either a low‐CHO diet (ESC + starch, approximately 7% DM; n = 5 obese, 5 lean) or a high‐CHO diet (ESC + starch, approximately 42% DM; n = 6 obese, 6 lean).

Results

5′‐Adenosine‐monophosphate‐activated protein kinase was immunolocalized to laminar keratinocytes, dermal constituents, and hepatocytes. A high‐CHO diet resulted in significantly decreased laminar [P‐AMPK] in lean ponies (P = .03), but no changes in skeletal muscle (lean, P = .33; obese, P = .43) or liver (lean, P = .84; obese, P = .13) [P‐AMPK]. An inverse correlation existed between [blood glucose] and laminar [P‐AMPK] in obese ponies on a high‐CHO diet.

Conclusions and Clinical Importance

Laminar tissue exhibited a normal response to a high‐CHO diet (decreased [P‐AMPK]), whereas this response was not observed in liver and skeletal muscle in both lean (skeletal muscle, P = .33; liver, P = .84) and obese (skeletal muscle, P = .43; liver, P = .13) ponies.     

Potential Proteomic-Based Strategies for Understanding Laminitis: Predictions and Pathogenesis

With today's understanding of the genome, advanced molecular techniques, and our growing ability to analyze complex biologic data, proteomics, the broad-based study of the repertoire of proteins expressed by cells or organisms, offers great promise for understanding the causes of complex diseases. Identifying and measuring novel protein biomarkers present in blood that predict the onset and resolution of laminitis would both aid clinical management of at-risk equine patients and shed light on underlying mechanisms with the intent of developing novel preventive strategies and therapeutic approaches. Identifying alterations in the profiles of proteins present in tissues of horses that develop laminitis or within in vitro model systems also can advance our understanding of this puzzling disease.     

Update on Metabolic Diseases Associated With Laminitis in Horses and Ponies

Several recent scientific publications describe some important findings that may further improve our ability to diagnose and manage both equine Cushing's disease (ECD) and equine metabolic disease (EMD). This abstract provides a brief summary of recent findings in ECD and EMD that have immediate application for clinical practice.     

Correlation of Plasma Insulin Concentration with Laminitis Score in a Field Study of Equine Cushing's Disease and Equine Metabolic Syndrome

This study aimed to investigate endocrinologic test values and the response to treatment of two commonly encountered causes of endocrinopathic laminitis, equine Cushing's disease (ECD) and equine metabolic syndrome (EMS), in a veterinary practice setting. In particular, the study aimed to determine whether insulin concentration correlated to the severity of clinical laminitis in horses with EMS or ECD. Twenty-five horses were included in the study and assigned to one of three groups: ECD (n = 6), EMS (n = 10), and controls (n = 9). Blood samples were collected at an initial visit and then at regular intervals for the next 12 months. Plasma concentrations of adrenocorticotropin (ACTH), cortisol, and insulin and serum concentrations of glucose and total thyroxine (T4) were obtained. Horses with ECD had significantly higher plasma ACTH concentrations than EMS horses or controls. Horses with EMS and ECD both had significantly higher plasma insulin concentrations than control horses, which was correlated with the Obel grade of laminitis (r = 0.63). After treatment, there was a trend for a reduction in plasma ACTH concentration in horses with ECD. A program of diet and exercise for horses with EMS resulted in reductions in both plasma insulin concentrations and bodyweight, which was variable, depending on the individual. There was a significant correlation between the change in plasma insulin concentration and Obel grade of laminitis (r = 0.69). This study has highlighted the importance of baseline plasma insulin concentration as a potential indicator of the susceptibility of horses to laminitis and the response to a program of diet and exercise.     

The Effect of Feeding Two or Three Meals Per Day of Either Low or High Nonstructural Carbohydrate Concentrates on Postprandial Glucose and Insulin Concentrations in Horses

Eight mature idle gelding horses (mean body weight [BW], 558 ± 45 kg) were used in a replicated 2 × 2 Latin square design study. Horses received either two or three meals per day (MPD) for 7 days, of either a high (H; 43%; 215 g/100 kg BW) or low (L; 18%; 90 g/100 kg BW) nonstructural carbohydrate (NSC) concentrate feed to achieve four treatment groups: low NSC in two MPD (L2), low NSC in three MPD (L3), high NSC in two MPD (H2), and high NSC in three MPD (H3). On day 7 of the treatments, blood was collected before (baseline) and for 5 hours after feeding the morning meal (10, 20, 30, 40, 50, 60, 90, 120, 150, 180, 210, 240, 270, and 300 minutes after feeding). Baseline insulin concentrations tended (P = .093) to be higher for horses fed high NSC than low NSC, and horses fed two MPD tended (P = .092) to have higher baseline insulin concentrations than horses fed three MPD. In addition, baseline glucose-to-insulin ratio (GIR) was higher in horses fed high NSC compared with low NSC (P < .001). Horses fed high NSC had higher area under the curve of insulin and higher peak insulin after feeding than those fed low NSC. These findings suggest that NSC content of a concentrate feed has an impact on baseline insulin and GIRs and on postprandial insulin concentrations. Meanwhile, the number (and therefore size) of MPD had fewer impacts on glucose metabolism.     

Laminitis: Recognition of At-Risk Individuals,and Methods of Prevention

Even with the many advances made in the understanding of the pathophysiology, new treatments and preventative measures, laminitis continues to plague the equine population. Identification of risk factor and at-risk individuals remains the best approach with this disease.     

The prevalence of endocrinopathic laminitis among horses presented for laminitis at a first-opinion/referral equine hospital

Endocrinopathic causes of laminitis may be a common underlying causative pathogenesis in first-opinion or field cases presenting with laminitis, as opposed to laminitis produced in inflammatory research models. This study aimed to determine whether evidence of an underlying endocrinopathy was present in horses presented for laminitis to a first-opinion/referral veterinary teaching hospital. A second aim was to compare the signalment of horses and ponies with laminitis with the equine hospital population during the same period. All horses presenting for laminitis at Helsinki University Equine Teaching Hospital, Finland, over a 16-month period were examined for an underlying endocrinopathy. Horses presenting for laminitis were compared with the hospitalized population over the same period. There were 36 horses presented for laminitis, and evidence of endocrinopathy was present in 89%. Of the horses showing an underlying endocrinopathy, one-third had a diagnosis of pituitary pars intermedia dysfunction, and two-thirds showed basal hyperinsulinemia indicative of insulin resistance, without evidence of hirsutism. Phenotypic indicators of obesity were present in 95% of horses with basal hyperinsulinemia without hirsutism. Compared with the hospital population during the same period, horses with laminitis associated with an underlying endocrinopathy were significantly older and more likely to be pony breeds. Our data support that endocrine testing should be performed on all cases of laminitis that do not have a clear inflammatory or gastrointestinal origin.