Race Day Medication Summit: Management of EIPH from a Trainer’s Perspective

The panel was moderated by John Kimmel, a New York-based trainer with a degree in veterinary medicine from the University of Pennsylvania. Panelists were Christophe Clement (US/France); John Gosden (UK/AUS), Richard Mandella (US); Graham Motion (US); and John Size (HK/AUS).

The presentation was organized around questions that Kimmel asked. This isn’t a transcript, but a (representative, I hope) sample of the comments and perspectives offered.

The United States perspective (which is not entirely monolithic) dominated; John Size was on the quiet side and the attempts to play John Gosden’s pre-recorded comments didn’t go exactly as planned.

Kimmel: How often do you scope your horses?

Clement scopes after a disappointing breeze or at the appearance of other symptoms; Motion scopes after every race (“I’d hate to miss something,” he said), scoping for mucus as well as blood, and after every other breeze. For a two-year-old, he said, he’d scope every three or four breezes.

Given Motion’s status as something of a poster boy for European-style training and being clean (according to a November 2010 New York Times article, Motion has never had a medication violation) and given his British background, Motion was an intriguing, perhaps strategic, choice as a panelist. And there were times when his pro-Lasix comments seemed almost deliberately designed as responses to the comments of his European counterparts.

“I get horses from Europe that supposedly don’t bleed, but that’s because the scope is done five or six hours after the race,” Motion said. “Things aren’t always what they seem,” he added, apparently referring to the assertion that bleeding overseas is less of a problem than it is here.

Mandella said that he scoped “regularly to keep eye on” mucus and bleeding.

Clement added, “If a horse bleeds, you have to do everything you can to prevent it from becoming chronic. We can’t avoid bleeding; it’s a fact of life.”

Kimmel: At what grade of bleeding do you initiate treatment?

Kimmel referred here to the various scales on which bleeding is rated, with low numbers indicating a small quantity of blood. Some jurisdictions use a scale of 1-4, some of 1-5, some don’t appear to use any scale at all.

Clement said that he’d initiate treatment at the indication of any blood at all, “even grade 1, noting “the need to reduce risk of lesions,” referring to the fibrosis caused by repeated bleeding discussed in this post.  (Dr. Robinson’s presentation on the physical effects of bleeding can be found here.)

“It’s more complicated in Hong Kong,” said Size (Hong Kong’s approach to bleeding here). “We get jumpy if we scope grade 3 blood. We’d use clenbuterol in that case and back off on the horse.  For grade 1 or 2, we’d treat with clenbuterol and press on with the normal routine. Horses need to have a clean scope to return to racing.”

Motion said that he is “quick to treat” any sign of bleeding or mucus. “At level 2 or above we’d treat, and then use Lasix next time.”

Mandella said he looks back if a horse bleeds, wondering if the horse had been sick or if he’d missed anything.  If horse bleeds at grade 1 or 2 levels, he’d use clenbuterol and Lasix. If the horse bleeds at a higher level, he’d do a complete work-up.

Kimmel: How do you alter your training program after a horse bleeds? When is Lasix used and in what circumstances?

Clement: “Unfortunately, we went far beyond using Lasix only on horses who are bleeding.  We used to have to scope and prove that a horse was a bleeder to use Lasix, but not anymore; it’s very easy to put a horse on Lasix.”

He added, “I don’t have an opinion on whether this is good or bad. With light bleeders we carry on as usual. With major bleeders, we space out the works and avoid warmer days and a tiring dirt track.”

Size dittoed Clement, adding, “If a horse is a heavy, repeated bleeder, it’s best to retire him.”

Motion said that he’d go easier in workouts and turn the horse out, noting the “luxury” of his Fair Hill training center’s facilities for more severe bleeders and anxious horses.  “I start two-year-olds on Lasix because prevention is better than cure. I don’t want my horses to start bleeding that early.”

Mandella observed that hypertension is “the worst problem in bleeding.” “In Europe,” he said, “the stables are off the grounds. Here, horses know they’re at the track, not at the farm; they never really relax.”

Kimmel attempted at this point to play Gosden’s comments; after the room listened incomprehensibly for several minutes, Kimmel quipped, “Well, that sounded like Darth Vader,” eliciting a laugh, and said that Gosden had said that he does use Lasix on breeze days.

Mandella believes in putting a horse on Lasix if he notices bleeding. “The bleeding will get worse and do damage,” he said.

Motion said that he tries to boost the immune system of bad bleeders and that he’d had success with a hyperbaric chamber.  He also tries to reduce horses’ stress.

“Ultimately,” he said, “I think that Lasix is what helps the most.” He also said that he thinks that much of this discussion depends on how each person defines bleeding. “We see more than we did 25 years ago; we’re more on top of it.”

Clement seemed to agree. “The more you can treat bleeding, the stronger horses will be.” In response to a question, he said he would use adjunctive therapies if they were allowed.  Adjunctive therapies such as carbazochrome salicylate (“Kentucky Red”), conjugated estrogens (Premarin), and aminocaproic acid were discussed by Dr. Stephen Reed in his presentation.

Motion was more cautious. “This is a gray area where we open ourselves to criticism, using adjunctive therapies.  Any time you allow anyone in a stall before a race, you open yourself up to criticism.”

Mandella said that over the years, he had added Premarin to Lasix for some heavy bleeders, then joked, “What do they do with bleeders in Europe? Send them to America.” Motion and Clement were quick to concur (about repatriating bleeders, not about using Premarin).

Kimmel asked about the economic factors of using Lasix, including the effect on the claiming game and on trainers who don’t have Grade 1 stock in their barns, to which Mandella responded, “If you can’t afford Lasix, own fewer horses. We are privileged to own them. I do believe that horses bleed. I know that Lasix helps. Racing would go on with or without Lasix. Without Lasix some horses wouldn’t be as good.”

“But,” he asked, “is it inhumane to not treat them with Lasix?”

Motion declined to comment on the economic effects of Lasix, saying, “I don’t think economics should be a factor.”

“I know without Lasix some of the horses in my barn wouldn’t be racing,” he said, “and it would be some of the better ones.”

Mandella said that he treats “cheap horses” the same as good ones. Motion agreed.

“Sometimes better horses are the ones that bleed more. I don’t see that banning Lasix would have a greater effect on claiming operations.  It would be hard for all of us without Lasix.”

He again injected a cautionary note. “Lasix is the lesser of evils: take it away and people will look for other ways to treat bleeding. Lasix is controllable; in New York the state vets administer it, and with proper administration, it doesn’t affect other testing.”

Kimmel then asked about the practice of withdrawing water from horses before races, related to the dehydrating effects of Lasix and need for water before and during exercise.

Size: “I’ve never withdrawn water in my life.” Clement: “I withdraw it as a matter of course.”

Motion said that he withdraws water when he uses Lasix out of concern that horses would drink too much water before going to the paddock.

Mandella said that he watched marathoners drink water during a race, which made him think about horses.  “I don’t usually take water away,” he said, “I don’t draw hay, either. I learned that from being stabled near John Henry who had hay and water until he went to race.”

Kimmel: Have United States medication policies weakened the breed?

He gave the question first to Mandella, who groaned and asked, “Me? Can you start at the other end first?” to laughter from the other panelists and the crowd.

Mandella and Motion both said that bleeding seems to be a family trait and that the offspring of bleeders tend to bleed. Neither felt qualified to comment on whether the breed has been weakened.

Clement noted that there are fewer European mares in Kentucky, but thought that that could be due to a number of factors, at which point Mandella joked, “Have you all noticed how strong Christophe’s accent is up here? He doesn’t want any of you to understand him.”

Kimmel then asked about the possibility of eliminating the use of Lasix in Grade 1 racing.

Motion said, “I don’t see how you could do that,” with which Size concurred. “Horses could have qualified for the race on it and denied an opportunity to some other horse. It makes no sense.”

Clement dissented. “Why should European black type be different from U.S. black type? It’s a valid question.”  Mandella agreed. “If you’re going to eliminate Lasix, Grade 1 races are the place to do it. I think it should be considered.”

An international panel of veterinarians spoke next, discussing the management of EIPH from their perspective.

12 thoughts on “Race Day Medication Summit: Management of EIPH from a Trainer’s Perspective

  1. It is amazing to me that Germany’s model was not included in this ( we all have hidden agendas and this is our sales pitch for continued use of lasix )dissertation. If you bleed, you don’t breed ( for racing purposes ). Period.
    Humans have a way of disrupting nature’s genetic occurrences.

  2. Another interesting discussion. I’m inclined to agree with Alex, if thye know bleeding is genetic, why keep breeding bleeders for racing purposes?

  3. Alex and LindaVA: This was a discussion of TRAINING practices, not breeding.

    Alex: you are not a trainer, I can tell. Next time try reading and LEARNING something.

  4. If I learned anything last Monday, it’s that this is a complicated issue regarding horse health, bettors’ confidence, stable environment, etc.

    Linda, one of the factors that make this interesting and complex is how various countries define bleeding. There was evidence to suggest that many more horses bleed than some international horsemen suggest, because of the way that they define “bleeder” and under what circumstance bleeding is treated. I heard regularly through the day that a high percentage of horses bleed, and that’s inevitable in many species (not just horses) in instances of high exertion. If that’s the case, it sounds as though it would be pretty difficult to breed only non-bleeders.

    Later today I’ll be posting the results of a study regarding the heritability of bleeding, a report from one of the panelists.

  5. Thank you for the report, Teresa. I’m a biologist so I looked up clenbuterol on PubMed. The result tells me medication a complicated issue with a simple solution.

    Vets and trainers are focused on the short term issue of helping THIS horse run its best without bleeding. If drugs help with that it’s humane to use them. The owner, trainer and vet are all happy with the result for THIS horse. That makes sense (and money) in the short term.

    Unfortunately, what’s good for THIS horse is bad for racing and bad for the Thoroughbred long term. The trainer arguments can be countered by looking at how often horses raced in the seventies (before Lasix, for one). Theresa is going to give us the story on the heritability of bleeding – very heritable. But that’s not all: treatments have side effects. Clenbuterol in particular has side effects that counteract the improvements in breathing it may produce as a bronchodilator. The short version is that it reduces aerobic performance, can affect the heart, and acts to reduce fat and add muscle (like an anabolic steroid). For the technically inclined I added a few references on therapeutic use of Clenbuterol. The Chemical Horse may not be what we hoped for or expected.

    The simple solution is to stop race day medication and return to natural racing as the new normal. Let’s treat horses if they are sick, not as “therapy” to keep bleeders racing to the detriment of the breed (today a horse is sick if it can be chemically enhanced). We’ll probably get closer to the old Iron Horse.


    Clenbuterol diminishes aerobic performance in horses.
    Kearns CF, McKeever KH.
    Med Sci Sports Exerc. 2002 Dec;34(12):1976-85.

    “These data suggest that the combined effect of therapeutic levels of clenbuterol and training decrease aerobic performance and that the resultant reduction in plasma volume may affect improvements in cardiovascular function during recovery normally seen with exercise training.”

    Chronic clenbuterol administration negatively alters cardiac function.
    Sleeper MM, Kearns CF, McKeever KH
    Med Sci Sports Exerc. 2002 Apr;34(4):643-50.

    Clenbuterol also reduces fat and adds muscle. It is on the banned list for the Olympics. It has the same effect on horses. (Chronic administration of therapeutic levels of clenbuterol acts as a repartitioning agent. CHARLES F. KEARNS,1 KENNETH H. MCKEEVER,1 KARYN MALINOWSKI,1 MAGGIE B. STRUCK,1 AND TAKASHI ABE2)

    You can search PubMed for more.

  6. Teresa,

    I really enjoy reading your take on the panelists’ spoken thoughts; very discriminating and thoroughly journalistic. Thanks again for the ringside seat.

    And, Brigitte. Thank you for lending your expertise to the subject. I hope you’re professionally involved in horseracing, for your understanding of this issue and your obvious sympathies for the animals’ wellbeing are seldom heard with such clinical eloquence.

    Excellent posting, Teresa!

  7. This was a discussion on ‘training’ bleeders? All I see is a list of medication/drug choices. Sad to see that is what ‘training’ has become.

    Nowhere do I see anyone mention increased aerobic exercise further than 2 miles in an effort to build capillary density. Nowhere do I see a mention of improved warm-up prior to a breeze or race in an effort to pre-stretch capillary walls (the sites at which EIPH occurs).

    Even Mr. Motion disappoints with his practice of throwing all 2 year olds on Lasix as a preventative measure.

    Horses or people, it’s all the same – every drug has adverse side effects. In our race to keep bleeders running we use drugs that leach vital nutrients away from their bones, increasing equine fragility.

    Kudos to Mr. Mandella seeing the link between pulling water and dehydration, noting that the immortal John Henry did just fine without being deprived of water before a race.

    Even when controlling for surface, US Lasix-addled turf horses breakdown 300% more often than others. Ridiculous.


  8. Teresa, Superb report on this crucial issue. 66% of the respondents to the Paulick survey indicated nothing will change as a result of this summit.

    Racing needs leadership following the NBA, NHL, MLBB and NFL model.

    This leader cannot be a horseman.

  9. I’ll write more about this in a day or two, but I went into this summit with little prior knowledge and no prior opinion, and I have to say that I didn’t hear anything that convinced me, from a practice or health viewpoint, that furosemide should be banned in this country.

    I learned a lot, and hope to learn more, and certainly accept that there are elements to the topic that weren’t discussed last Monday. But based on Monday’s information, I’m not sure why the U.S. would change its current practice.

    As I said, more on that soon, I hope tomorrow.

  10. Teresa, thanks for the clarification on the bleeders. Sounds like a more complex issue than I first thought, but more conditioning, as Bill suggested, might be helpful rather than just relying on medication.

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