The adrenocorticotropin stimulation test: contribution of a physiologically based model developed in horse for its interpretation in different pathophysiological situations encountered in man

Rutland C. Equine Stress: Neuroendocrine Physiology and Pathophysiology

This review presents new aspects to understanding the neuroendocrine regulation of equine stress responses, and their influences on the physiological, pathophysiological, and behavioral processes. Horse management, in essence, is more frequently confirmed by external and internal stress factors, than in other domestic animals. Regardless of the nature of the stimulus, the equine stress response is an effective and highly conservative set of interconnected relationships designed to maintain physiological integrity even in the most challenging circumstances (e.g., orthopedic injuries, abdominal pain, transport, competitions, weaning, surgery, and inflammation). The equine stress response is commonly a complementary homeostatic mechanism that provides protection (not an adaptation) when the body is disturbed or threatened. It activates numerous neural and hormonal networks to optimize metabolic, cardiovascular, musculoskeletal, and immunological functions. This review looks into the various mechanisms involved in stress responses, stress-related diseases, and assessment, prevention or control, and management of these diseases and stress. Stress-related diseases can not only be identified and assessed better, given the latest research and techniques but also prevented or controlled.

Clinical Pathology in the Foal

The dynamic physiologic changes and unique diet during the neonatal period contribute to key differences in clinicopathologic test results of healthy foals relative to healthy adult horses. When reporting results, most diagnostic laboratories only provide reference intervals for mature horses. Thus, failure to recognize the unique differences that occur in foals relative to adult horses can lead to erroneous interpretation of neonatal clinical pathologic values. Thus, the main objective of this article was to review distinct features of common clinicopathologic tests in foals, relative to mature horses.

Diagnostic accuracy of post-ACTH challenge salivary cortisol concentrations for identifying horses with equine glandular gastric disease

The aims of this study were to better characterize the adrenal response to i.v. adrenocorticotropic hormone (ACTH) in horses with and without gastric disease and to validate and simplify the ACTH stimulation test by determining the diagnostic accuracy of six consecutive sampling time points after ACTH administration for equine glandular gastric disease (EGGD) and equine squamous gastric disease (ESGD). Twenty-six endurance and eventing horses without clinical disease [Sport Horse Population (SHP)] and an independent population of 62 horses [General Population (GP)] were grouped by gastroscopic findings (no/mild vs. moderate/severe EGGD, grade 0-1 vs. 2-4 ESGD, respectively) and underwent an ACTH stimulation test. Salivary cortisol (ng/mL) was analyzed before and 30, 60, 90, 120, and 150 min after i.v. injection of 1 µg/kg BW synthetic ACTH1-24. The association between having moderate or severe EGGD or ESGD and the amount of salivary cortisol was analyzed by means of receiver-operating characteristic (ROC) analysis. The following explanatory variables were considered: cortisol values for every time point, the area under the curve (AUC)-including all time points and corrected for the baseline-and the partial areas under the curve AUC0-90 and AUC90-150. Sampling after 60 min had highest association with moderate/severe EGGD. The diagnostic potential of the ACTH test was higher for the SHP [sensitivity 100% (95% CI 54% to 100%), specificity 75% (95% CI 51% to 91%), ROC-AUC 91% (95% CI 69% to 98%), 1-sided P-value < 0.001] than for the GP [sensitivity 75% (95% CI 48% to 93%), specificity 52% (95% CI 37% to 67%), ROC-AUC 68% (95% CI 51% to 79%), 1-sided P-value = 0.0064]. There were, however, no significant associations with ESGD. The superiority of sampling after 60 min suggests that the initial release of cortisol rather than its peak or the AUC are relevant regarding EGGD. Even though the wide confidence intervals and thus the lack of diagnostic accuracy do not presently support clinical use, characterization of the adrenal response to an ACTH stimulus improves the understanding of EGGD pathophysiology and its relation to stress.

Relationship between saliva and blood cortisol in handled cows

Objective

The objective of the study was to determine the relationship between plasma and salivary cortisol concentrations in beef cattle that were subjected to handling prior to sampling.

Methods

Twenty-one Nguni cows of three age categories; 5 to 7 yr (n = 7), 8 to 10 yr (n = 6), and 11 to 13 yr (n = 8) were handled for five consecutive weeks. In the pen, a human avoidance test was performed and cattle responses to restraint in the chute and crush were observed. In addition, rectal temperature readings were taken and, faecal samples were collected and analysed for glucocorticoid metabolites. Through the handling and restraint process, excretory and vocalisation behaviour, as a sign of stress were observed and recorded. Thereafter, six cows were randomly selected and subjected to an adrenocorticotropic hormone (ACTH) challenge. Blood and saliva samples were extracted to determine cortisol concentrations.

Results

Repeated handling affected (p<0.05) faecal glucocorticoid metabolites, rectal temperatures, avoidance distance, crush scores as well as urination and defaecation behaviour. Acclimation to handling was variable based on each respective parameter. Saliva cortisol concentrations increased and decreased significantly (p<0.001). A peak value of 136.78± 15.869 nmol/L was observed 30min after administration of ACTH, from a baseline value of 8.75± 15.869 nmol/L. Plasma cortisol concentrations did not differ (p>0.05) across the time of sampling. A low and insignificant correlation (r = 0.0131, p>0.05) between plasma and saliva cortisol was therefore observed.

Conclusion

We conclude that if beef cows are subjected to handling prior to sampling, a weak relationship exists between plasma and salivary cortisol levels.

Free and bound cortisol in plasma and saliva during ACTH challenge in dairy cows and horses

Cortisol levels reflect hypothalamic-pituitary-adrenocortical (HPA) axis activity. While most plasma cortisol is supposed to be bound to the soluble corticosteroid-binding globulin (CBG), only free cortisol (FC) actively regulates metabolic and immunological processes. We aimed to establish a multispecies suitable method to assess FC in cows and horses which in combination with total cortisol (TC) allows interpreting proportional changes of cortisol in saliva as well as in blood in response to a standardized HPA axis activation via ACTH. We further investigated if the ratios of cortisol fractions as obtained at basal levels in healthy horses (herbivorous and monogastric) and dairy cows (herbivorous and ruminant) change during HPA axis activation, and to which extent saliva cortisol (SC) is representative for alterations in plasma FC and adrenal cortex reactivity. However, it was not the objective of the present study to directly compare the two species. Dosages of ACTH applied in cows and horses were based on published data. Synthetic ACTH was intravenously administered to eight dairy cows (0.16 µg/kg BW) and five horses (1 µg/kg BW). Blood and saliva were collected every 30 min for 3 h from a jugular vein catheter, and analyzed for TC and SC, the ratio of free cortisol (rFC), and the concentration of FC (cFC) in plasma. During the entire sampling period of the ACTH test, plasma TC was paralleled by blood cFC, rFC, and SC in both cows and horses. All cortisol fractions increased within 30 min of ACTH administration compared to basal values (0 min, P < 0.05). Peak TC concentration reached 63.2 ± 9.6 ng/mL and 73.2 ± 11.8 ng/mL in bovine and equine plasma, respectively. Peak values of rFC averaged 17.9 ± 4.5% in cows and 19.2 ± 7.8% in horses. The ratio of SC to cFC in horses remained similar during the ACTH challenge suggesting that SC is recruited from plasma FC. However, SC increased less compared to plasma TC and FC during HPA axis activation in cows. In conclusion, the short-term activation of the HPA axis caused not only an elevation of TC, but also a similar increase of rFC in both species. SC closely reflected changes of FC in horses, but less accurately in cows. The concomitant evaluation of changes among cortisol fractions might give further indications on adaptation mechanisms in glucocorticoid regulation as well as differentiate cortisol-related health disorders.

A comparison between the equine and bovine hypothalamus-pituitary-adrenocortical axis

In this review, we address the function of the hypothalamus-pituitary-adrenocortical (HPA) axis with special emphasis on the comparison between the bovine and equine species. The pars intermedia of the pituitary gland is particularly well developed in horses and cattle. However, its function is not well appreciated in cattle yet. The Wulzen's cone of the adenohypophysis is a special feature of ruminants. Total basal cortisol concentration is much higher in horses than that in cows with similar free cortisol fractions. Corticotropin-releasing factor (CRF) concentrations in equine pituitary venous blood are lower compared with other species, whereas plasma ACTH concentrations in cows are higher than those in horses. A CRF challenge test induced a more pronounced cortisol response in horses compared with cattle, whereas regarding ACTH challenge testing, the opposite seems true. Based on data from literature, the bovine species is characterized by relatively high basal blood CRF and ACTH and low cortisol and glucose concentrations. Obviously, further lowering of blood cortisol in cattle is easily prevented by the high sensitivity to ACTH, and as a consequence, subsequent increased gluconeogenesis prevents imminent hypoglycemia. Hypoglycemia is less likely in horses given their high muscle glycogen content and their relatively high cortisol concentration. When assessing HPA axis reactivity, response patterns to exogenous ACTH or CRH might be used as a reliable indicator of animal welfare status in cows and horses, respectively, although it is emphasized that considerable caution should be exercised in using measures of HPA activity solely to assess animal welfare.

Monitoring the circadian rhythm of serum and salivary cortisol concentrations in the horse

Daily fluctuations of cortisol concentration in the blood or saliva have been repeatedly reported. However, several contradictions in the existing literature appear on this subject. The present study was performed to definitively establish options for testing adrenocortical function. To the best of our knowledge, this is the first study to evaluate parallel circadian rhythms in salivary and serum cortisol concentrations during a 24-h period. Twenty horses were examined under the same conditions. Blood and saliva samples were taken every 2 h for 24 h to determine the daily changes in cortisol concentrations of saliva and serum at rest and to determine the relationship between salivary and serum cortisol levels. Cosinor analysis of group mean data confirmed a significant circadian component for both serum and salivary cortisol concentrations (P < 0.001 in both cases). The serum cortisol circadian rhythm had an acrophase at 10:50 AM (95% CI, 10:00 AM-11:40 AM), a MESOR of 22.67 ng/mL, and an amplitude of 11.93 ng/mL. The salivary cortisol circadian rhythm had an acrophase at 10:00 AM (95% CI, 9:00 AM-11:00 AM), a MESOR of 0.52 ng/mL, and an amplitude of 0.12 ng/mL. We found a significant but weak association between salivary and serum cortisol concentrations; the Pearson correlation coefficient was 0.32 (P < 0.001). The use of salivary cortisol level as an indicator of hypothalamic-pituitary-adrenal axis activity may be warranted. However, the salivary cortisol levels are more likely to be correlated with free plasma cortisol than with the total plasma cortisol concentration.

Validation of a low-dose ACTH stimulation test in healthy adult horses

OBJECTIVE

To determine the lowest ACTH dose that would induce a maximum increase in serum cortisol concentration in healthy adult horses and identify the time to peak cortisol concentration.

DESIGN

Evaluation study.

ANIMALS

8 healthy adult horses.

PROCEDURES

Saline (0.9% NaCl) solution or 1 of 4 doses (0.02, 0.1, 0.25, and 0.5 μg/kg [0.009, 0.045, 0.114, and 0.227 μg/lb]) of cosyntropin (synthetic ACTH) were administered IV (5 treatments/horse). Serum cortisol concentrations were measured before and 30, 60, 90, 120, 180, and 240 minutes after injection of cosyntropin or saline solution; CBCs were performed before and 30, 60, 120, and 240 minutes after injection.

RESULTS

For all 4 doses, serum cortisol concentration was significantly increased, compared with the baseline value, by 30 minutes after administration of cosyntropin; no significant differences were detected among maximum serum cortisol concentrations obtained in response to administration of doses of 0.1, 0.25, and 0.5 μg/kg. Serum cortisol concentration peaked 30 minutes after administration of cosyntropin at a dose of 0.02 or 0.1 μg/kg, with peak concentrations 1.5 and 1.9 times, respectively, the baseline concentration. Serum cortisol concentration peaked 90 minutes after administration of cosyntropin at a dose of 0.25 or 0.5 μg/kg, with peak concentrations 2.0 and 2.3 times, respectively, the baseline concentration. Cosyntropin administration significantly affected WBC, neutrophil, and eosinophil counts and the neutrophil-to-lymphocyte ratio.

CONCLUSIONS AND CLINICAL RELEVANCE

Results suggested that in healthy horses, administration of cosyntropin at a dose of 0.1 μg/kg resulted in maximum adrenal stimulation, with peak cortisol concentration 30 minutes after cosyntropin administration.

Adrenocortical insufficiency in horses and foals

The adrenal cortices produce various steroid hormones that play vital roles in several physiologic processes. Although permanent adrenocortical insufficiency is rare in all species, emerging evidence in both human and equine medicine suggests that transient reversible adrenocortical dysfunction resulting in cortisol insufficiency frequently develops during critical illness. This syndrome is termed relative adrenal insufficiency (RAI) or critical illness-related corticosteroid insufficiency (CIRCI) and can contribute substantially to morbidity and mortality associated with the primary disease. This review discusses the mechanisms, diagnosis, and clinical consequences of adrenocortical insufficiency, with particular focus on the current understanding of RAI/CIRCI in horses and foals.

Baseline plasma cortisol and ACTH concentrations and response to low-dose ACTH stimulation testing in ill foals

OBJECTIVE

To evaluate baseline plasma cortisol and ACTH concentrations and responses to low-dose ACTH stimulation testing in ill foals.

DESIGN

Cross-sectional study.

ANIMALS

58 ill foals.

PROCEDURES

Baseline cortisol and ACTH concentrations and cortisol concentrations after administration of a low dose of cosyntropin were determined within 6 hours after admission. Foals were assigned to 4 groups on the basis of age (<or=24 hours vs 1 to 56 days) and presence of septicemia (yes vs no). Values were compared among groups and with values previously reported for healthy foals.

RESULTS

Plasma cortisol concentrations 30 and 60 minutes after cosyntropin administration in foals<or=24 hours old were significantly higher than corresponding cortisol concentrations in older foals. In all 4 groups, plasma cortisol concentration 30 minutes after cosyntropin administration was significantly higher than baseline cortisol concentration or concentration 60 minutes after cosyntropin administration. No differences in baseline cortisol or ACTH concentration or in the ACTH-to-cortisol ratio were detected between groups or when ill foals were compared with healthy foals. A small number of ill foals had low baseline cortisol and ACTH concentrations or low responses to cosyntropin administration, compared with healthy foals.

CONCLUSIONS AND CLINICAL RELEVANCE

Results indicated that most ill foals in the present study population had adequate responses to cosyntropin administration. However, a small subset of ill foals appeared to have dysfunction of the hypothalamic-pituitary-adrenal axis.