Why The Rush To Judgment?

Kent H. Stirling
February 20, 2014
 
It seems the Racing Medication and Testing Consortium (RMTC) and the Association of Racing Commissioners International (ARCI or just RCI) were in a great hurry to institute the adoption of the “Terrific 24” Controlled Therapeutic Substances throughout the United States by January 1, 2014.  It was also hoped that the Multiple Medication Violations (MMV) would also soon be adopted nationally.
 
In 2003, the RMTC Board of Directors reviewed a list of 51 therapeutic medications that would need thresholds and withdrawal times.  Furosemide (Lasix) was not on this list as it already had thresholds and, in most states, a 4 hour withdrawal time.  This list of 51 therapeutic came from a survey where over 75 veterinarians were asked to list all the medications they felt “necessary” for use in their practice.  They were not “asked to list all medications that they used in 2001” as was cited in a November 2013 RMTC letter to a state racing commission.
 
This list of 51 medications, 52 with Lasix, was then prioritized into five groups by the RMTC and two further groups titled Research Under Way and Already in Body of Model Rules.  During this process, Acetylsalicylic Acid (Aspirin) was dropped and Furosemide added to the last category.  So from a world of 52 medications, we then gave up the four anabolic steroids and added the new NSAIDs, Firocoxib and Diclofenac, for a total of 50 therapeutics for which RMTC hoped to establish thresholds and withdrawal times.
 
One day in Baltimore in January of 2012, the RMTC Penalty Guidelines Subcommittee met and essentially picked the 24 Controlled Therapeutics from an AAEP survey which prioritized therapeutic medications into three categories which were Highest, Moderate and Low.  Of the 17 medications in the Highest Priority category,  Albuterol (Ventolin),  Hydroxyzine (Atarax)  and Phentoin were dropped from consideration by this Subcommittee.  Of the four medications in the Moderate category, Atropine and Pentoxyflline (Trental) did not make the cut.  Of the 26 medications that the AAEP listed as Low Priority five were chosen by this committee made up of represenitatives or observers of the Jockey Club, RMTC, a number of laboratory directors , a few regulators and two practicing veterinarians who were past Presidents of the AAEP.
 
The RMTC had also prioritized their 50 therapeutic medications as mentioned above.  Of the eight medications in the First Priority Group, only Pyrilamine (Equihist) didn’t make the “Terrific 24.”  In the Second Priority Group containing nine medications,  Fluphenazine (Prolixin) and Hydroxyzine (Atarax) didn’t make the cut.  Of the 8 medications in the Third Priority Group, Albuterol (Ventolin), Reserpine (Serpasil) and Trichlormethiazide (Naquazone) fell by the wayside.  The Fourth Priority Group was decimated by the “Terrific 24,” of the eight therapeutics only Prednisolone made the cut.  Gone were Atropine, Beclomethasone (Beclovent, Buscopan, Cromolyn (Intal), Isoxsuprine, Pentoxyfylline, and Phenytoin (Dilantin).
 
So it was eventually decreed by the RMTC and the RCI that these 24 medications would be the law of the land and everything else would be “strictly prohibited.”  This then left 26 therapeutics, 19 of which are Class lV or Vs, that would now be handled as prohibited medications.  At first there was a mixed message from leaders of the RMTC and RCI about whether these 24 were to be the final permitted number of therapeutics as the HBPA thought more should be added.  The “Yes” answer finally morphed into it was possible to add more if an organization (HBPA) came up with about “$60,000” for scientific research for a threshold and withdrawal time that could be blessed by the RMTC and RCI.
 
The AAEP submitted a list of six additional medications in early 2013 for inclusion with the “terrific 24”.  These were Cimitidine, Guafenesin, Hydroyzine, Isoflupredone (Predef 2X), Ranitidine (Zantac) and Trichlormethiazide (Naquazone).  Apparently the RMTC is studying the first five, but has dropped Trichlormethiazide (Naquazone), because it is usually used “in combination with Dexamethasone” which is now prohibited.  It appears the $60,000 was a special rate for the HBPA.
 
Once it was established that there could possibly be more than 24 Controlled Therapeutic Substances, the question was asked about what happens to thresholds and withdrawal times already permitted in certain states?  The answer was you can use them too beyond the “Terrific 24”, but just not with the same “confidence.”  Whatever that means?
 
O.K.  So that means that Kentucky and New York each have about 20 more medications with withdrawal times, which means there is a threshold somewhere at the testing laboratory. California and Washington each have numerous other medications beyond the “24”.  Arizona looks to have about 15 permitted medications beyond the “24”, Virginia more than that and Delaware with over 60 more withdrawal times.  Oh, and Florida has three thresholds beyond the “Terrific 24”.  And so this is uniformity?
 
In an email to a veterinarian looking for clarification on those medications outside the “24”, an officer of the RMTC wrote, “The list (24) does not prohibit the use of the other drugs and substances not on the list.  However, they may not be present in a horse in a post -race sample.  That is no different than the current practice.  It will be up to the lab to determine what constitutes a positive, but it must be pharmacologically significant.”  “Pharmacologically significant”, bring on the lawyers!  My lab Director has no background in pharmacology so how would she know if something is pharmacologically significant?
 
Remember when I stated that Furosemide (Lasix) had a 4 hour withdrawal time in most states, well it turns out that in the Mid-Atlantic, the home of the “Terrific 24”, there is no uniformity on the withdrawal time for Lasix.  According to a Blood-Horse article, Lasix can be administered at 3 hours in Maryland, 3 ½ hours in Delaware and 4 hours in Pennsylvania and New Jersey.
 
In this particular article, there was also concern over the Flunixin (Banamine) threshold once again.  The RMTC had had a difference of opinion between certain East and West Coast states for years about whether the threshold should be 20 ng/ml or 50 ng/ml.  One would think for fairness to horsemen that the higher threshold would be adopted, but the RMTC and RCI adopted the 20 ng/ml.  In Florida, after a number of positives at 20 ng/ml, most vets moved their administration time back from 24 hours prior to post to closer to 36 hours to avoid inadvertent overages/positives.
 
New York THA President, Rick Violette Jr.,  recently dosed 20 of his horses with Flunixin, using the RMTC/RCI advised dose and administration time, and at least 4 of his horses tested over the 20 ng/ml threshold.  Violette likened this process as similar to “using a sundial” to set administration or withdrawal times, but then using the world’s most sensitive testing or pinpoint technology  to test for the substance.
 
This reminds me of the 2 mcg/ml threshold with a 24 hour withdrawal time that the RMTC and RCI set for Phenylbutazone (Bute).  But when research was reviewed, it appeared that a 2 gram, 4.4 mg/kg, dose of Bute, the normal AAEP recommended dose, would put some horses over the 2 mcg/ml threshold.  In a December 2012 RCI meeting, they had the 2 mcg/ml threshold at 24 hours tied to a single IV dose with the amount not stated.  Later the RMTC listed the amount of the bute dose at 4 mcg/ml, a 10 percent reduction from the normal 4.4 mcg/ml.  The bute dose continued to “silently” float downwards until today it is 2.2 mcg/ml, or a half dose.  This new 2.2 mcg/ml threshold works perfectly with a 24 hour withdrawal time, but did you or your veterinarian know the threshold and 24 hour withdrawal time was for a half dose of bute?
 
Florida dropped from 5 mcg/ml to 2 mcg/ml after a 6 month phase in, but after numerous overages when the phase in period ended, most vets found that a 24 hours withdrawal time was too close for comfort, and so they  backed that withdrawal time back to about 28 hours.
 
Years ago, the RMTC decreed that although they did not follow the “preponderance of scientific research” when it came to permitting the use of Furosemide (Lasix), it would be the only medication to get a free pass, so to speak.  Every other medication that the RMTC was to set a threshold or withdrawal time on would be accomplished by following the preponderance of scientific evidence.  In 2009, along came the South African Lasix Study that vindicated the free pass that the RMTC had given Furosemide.  There is certainly some question in my mind and others as to how much “science” was used in establishing thresholds and withdrawal times for some of the “Terrific 24.”
 
While I am all for uniformity, I want it to be true uniformity for everyone,  We are on the right track, but we need to get it right and not rushed by someone or some organization setting an  arbitrary deadline.  Also a phase-in period should be automatic when any new threshold or withdrawal time is passed by RMTC or RCI so that horsemen and their veterinarians can adjust, because as pointed out above, these thresholds and withdrawal times are not always accurate.  A year ago or more in Florida, the laboratory dropped its internal threshold for Clenbuterol from 25 pg/ml to 5 pg/ml, and opted not to inform the horsemen and veterinarians.  The result was over 150 positives.
 
Last summer,t the RCI Board of Directors tried to pass the Multiple Medication Violations penalty system which the HBPA had been the sole negative vote when it passed the RMTC.  Ohio Executive Director, Dave Basler, poked numerous well thought out holes in the MMV when it was presented.  Some of them very simple, like which penalty group does 3 ½ points fall into, the first or the second?
 
According to the Blood-Horse, while a number of racing commissioners were concerned that it would be imprudent to pass a clearly flawed rule.  RCI Chairman, Duncan Patterson, said, “That he would be ‘embarrassed’ for the organization’ if the proposal didn’t pass the committee.  ‘We will be severely criticized, and justifiably so, within the industry if we don’t pass this.’”
 
Such a rush to judgment . . . and to satisfy whom?