Oh thank you, Lavinia! I feel a little less panicked now. First order of the day--get diet tightened. Good to know the non-shedding coat is not necessarily an indication of a problem.

Yes, you are right that we are coming into our spring now. Everyone around me is delighted at the new green grass, while I'm secretly plotting ways to kill it all. The mares are being very tarty. 

--

Maxine and Indy

Canberra, Australia 2010

https://ecir.groups.io/g/CaseHistory/files/Maxine%20and%20Indy

https://ecir.groups.io/g/CaseHistory/album?id=933

Rise in blood glucose with PPID is secondary to the insulin resistance that it causes.  If the insulin resistance is not completely compensated for by increased insulin levels, glucose will be elevated.

Although I agree this level is higher than it should be, it's not high enough to cause any panic.  In fact, the only consequence of elevated BG I've consistently noted in horses is weight loss.  If there are other hyperglycemic consequences occurring they are not being noticed but it's also worth pointing out that human diabetics can run BG considerably higher than what the horses do.  I don't recall any horses being 200 or higher.

Back in the 1980s there were a report of pergolide suppressing insulin release and elevating glucose in rats:

http://www.ncbi.nlm.nih.gov/pubmed/6147289

and another showing no effect of pergolide:

http://www.ncbi.nlm.nih.gov/pubmed/6135620

Durham et al in Equine Veterinary Journal (2009) 41 (9) 924 - 929 reported on 3 horses with type 2 DM and pancreatic beta cell dysfunction (low insulin with hyperglycemia). One horse was diagnosed with PPID and started on pergolide.  After the first dose of pergolide there was a spike in insulin to 35 uIU/L and a drop in glucose from 14.1 mmol/L to 7.5 mmol/L.  Thereafter, glucose remained around 5 and insulin progressively dropped to a high of 5 after feeding.

An abstract in  2013 JEVS found that injection of 5 mg cabergoline in a slow release vehicle in nonPPID mare did not have any effect on IR or insulin response to glucose:

http://www.j-evs.com/article/S0737-0806(13)00198-6/fulltext?mobileUi=0

These two studies suggest that low dose pergolide is not likely to reduce insulin in horses but there is still a possibility that high doses may do so, especially since this study found low dose pergolide to stimulate insulin in rat pancreas (as Durham saw) while high dose suppresses the insulin response to glucose:

http://onlinelibrary.wiley.com/doi/10.1080/15216540600687993/full

--

Eleanor in PA

www.drkellon.com

EC Owner 2001

Hi Maxine,

It's OK to ask questions - that's what we're here for.

Diet affects glucose, with or without the additional push from uncontrolled PPID, so getting the diet optimized is important.

Getting the PPID well controlled should help in getting the IR further controlled.

High glucose doesn't affect horses the way elevated insulin does, so although it isn't a good thing, it's preferable (sort of) to having sky-high insulin as it normally doesn't trigger laminitis. If it helps - one of mine has glucose over 200mg/dL at the moment with PPID well controlled, tight diet so I know that panicked feeling all too well.

That Indy has just started coming into season may also be a factor in the insulin/glucose levels being elevated as you are heading into your spring time now (correct?) and when mares first begin cycling again it can wreak some havoc on the hormonal systems.

That she seems bright, more energetic and sound are all good signs. Not shedding isn't a reliable indicator of PPID status once a horse is already confirmed PPID as the coat may never respond "normally" again.
--

Lavinia, Dante, George Too and Peanut

Jan 05, RI

EC Support Team

Hi Dr. Kellon,

Thank you very much for looking at his x-ray! What do I do for the ringbone? Do you agree with the vet's instructions to reduce dorsal hoof(toe), and lower the heel(then shoe with pad wedges to slowly realign)? Or not? The vet isn't very experienced in dealing with hoof issues. Is there anything I can give him to help? 

The vet recommended that I start him on Previcox, 1/2 of a 227mg tab per day, for his pain but I'm hesitant since I know that Previcox can damage hoof growth, and can cause more IR issues since it is an NSAID(correct?). He is hobbling around but in very good spirits. Do you think I should give Previcox, or is there something else for pain that I can give him that is safer/more effective?

King and I say thank you very much for all your help. I can't imagine what I would do without your advice. 

--
Stephanie & King
October 2014
Oregon
Case History 

I'm so sorry to keep asking questions. I do search the message archives and the files fairly obsessively, and I'm doing the CIR course, but I really couldn't find the answers to this. 

The issue: I'm worried that Indy's blood glucose has come back at 6.2mmol/L (111mg/dl) twice now, in two blood tests taken 3 weeks apart. Case history is updated and uploaded, but summary of results is:

2014/06  glucose 4.4mmol/L insulin 3.4mU/L. In yard with dry untested hay.

2016/03/30 glucose 4.68mmol/l  insulin 2mU/L ACTH  33.9pg/ml . [Yarded all night and some possibility they didn't get enough soaked hay before this test and that the I/G was artificially low. Started Prascend, titrated up to 0.75mg over 10 days. Improvement in attitude, energy.]

2016/07/08 glucose 6.23mmol/L  insulin 12mU/L ACTH  117pg/ml . [Increased Prascend over a week to 1.5mg. Test time:11.30am air temp around 12deg C. Tested after soaked hay and small bp feed around 9.30am, winter pasture all night.]

2016/07/29 glucose 6.2mmol/L insulin [still waiting for result]. Also ran a PCV as in the past it had been under 30, result was 33. {Test time: 8.30am, air temp a bit cold, about 1 degree C. Tested after winter pasture all night.]

Obviously I need to really tighten the DIET. She will go in the muddy yard with soaked hay and I'll rotate her companions. I am looking for new agistment but it is not easy to find. Ditto low s/s hay, but I'm working on it.

My (admittedly limited) understanding is that on forage the blood glucose should be under 100mg/dL or 5.6mmol/L. And that uncontrolled PPID can cause high blood glucose. 

Indy's ACTH on 8 July (when I finally got the results, as the clinic hadn't sent the blood when they should have) was 117pg/ml. The clinic said the blood was chilled, spun within 2 hours of the draw, then frozen. The blood was only in transit overnight and the lab did the test on the day the blood arrived. 

She was on 0.75mg of Prascend. She is now on Day 5 of 1.5mg Prascend, and I am planning to retest when it is 3 weeks on that dose.

So my questions are: 1. Could the uncontrolled PPID be the cause of the high BG? The insulin last time wasn't through the roof, although I am still waiting for the results for the blood taken yesterday.  

2. If so, when the ACTH comes down, is it likely we will see an improvement in the BG levels? 

3. If the PPID is causing the high BG, will we likely see any improvement in the BG levels until the ACTH drops, even with strict diet control? Dr Kellon wrote a post where she said in reference to an IR horse (this post was a huge lightbulb moment for: me)  **the magnitude of the insulin rise will be

directly proportional to how high her glucose goes** and that is

Does this still apply if PPID is causing the BG to stay high? (sorry for the large font, I can't get rid of it)

4. Is it worthwhile monitoring the BG with a glucometer until the vet comes in 2 and a bit weeks to test again? If nothing more than for my peace of mind...

5. What are the health and management implications of diabetes type 2 in horses? There seem to be some members whose horses' BG is never in normal range--what does this mean on the ground?

She is not noticeably footsore, or stranger than usual. Hollows over her eyes not puffy. She seems to be handling the 1.5mg of Prascend okay now. She is very hungry, but so are the other horses as we don't have much grass at the moment. She has just come into season. She is not starting to shed even though most of the other horses are losing the top wispy hairs on their coats. She is getting ridden or hand walked most days, from 30min to 1 hour, mostly walk, some trot/canter. I would have said in fact she has slightly more energy than a few weeks ago, so I was hoping this was a good sign that the increased Prascend was working, but if her BG is still high, perhaps it is not?

Thank you all so much again for 'being there'. I'm feeling very overwhelmed at the moment and this group is the only place I have to turn to for truly informed advice. 

--

Maxine and Indy

Canberra, Australia 2010

https://ecir.groups.io/g/CaseHistory/files/Maxine%20and%20Indy

https://ecir.groups.io/g/CaseHistory/album?id=933

Eleanor in PA

www.drkellon.com

EC Owner 2001

Hi Gail,

Dr. Kellon has addressed the timing of administration vs blood draws and testing conundrum.

The most important part is to make sure you are giving the pergolide daily on a fairly consistent schedule. Some horses that are very hard to get controlled may benefit from having their dose in the AM vs PM ( or by adding a second, daily "booster" dose) but for most the time of day is not an issue.
--

Lavinia, Dante, George Too and Peanut

Jan 05, RI

EC Support Team

Hi All, 

I got an x-ray of King's front right hoof this morning since he has been very sore on it recently. I would love your corrections/thoughts on what you see besides significant rotation - I have the farrier coming out ASAP to do some correctional work. Besides taking off a significant amount of toe(he is 2 weeks past due right now since he was too sore to reset his shoes before), what angles would you change? Is there a specific shoe you would put him in? He must have shoes and pads on, unfortunately. The vet wants to remove toe, and take down his heel significantly(about 4 - 5 degrees) and then put him in wedge pads and slowly reduce the wedge every couple weeks. He has significant tendon damage so it also makes it challenging. Do you agree? 

I took a picture of the x-rays off my phone so sorry about the reflection on the photos. They are suppose to send me a JPEG copy so I can post that here when I get it. (I posted 2 different pictures of the same x-ray so hopefully one will work for you guys to see) Have you seen stress fractures of the P3 like this before? (Please say yes!!) 

https://ecir.groups.io/g/CaseHistory/album?id=1402

Thank you very much. 

--
Stephanie & King
October 2014
Oregon
Case History 

Hi Leela,

Those lab results say Heidi IS IR - the fact that the glucose was above normal range was already a tip-off. You can plug them into the IR calculator here:

http://www.ecirhorse.com/index.php/insulin-resistance/ir-calculator-leptin

First cut hay is no guarantee it is safe/better than any other cut. Timothy pellets are also an unknown unless you've had them tested. Good that you are supplying vit E and flax as these are necessary for any horse not on ample, quality pasture. Getting her hay tested and the entire diet mineral balanced, no pasture access unless in a sealed muzzle would be the safest thing for her at this time.

That ACTH was quite high for January - in a normal horse, the numbers should have come back below 35 at that time of year. By now, as we are entering the seasonal rise period, it is highly likely that the numbers have risen even further and Heidi is in the "ticking time bomb" scenario.

Good that you are starting the Prascend (pergolide). It is also likely that 1mg will not be enough to get her numbers back into the normal ranges at this point so making a plan to further raise the dose and do some retesting is warranted.

--

Lavinia, Dante, George Too and Peanut

Jan 05, RI

EC Support Team

Thank you for the response. She is on first cut hay, very little grass access. She eats Timothy Pellets with Vit E, Flax and extra Magnesium. I put her on this diet for the most part when my gelding developed IR (he has since passed) 

In January her number were

ACTH 87.6 pg/mL

Insulin baseline 15.25 uIU/mL

Her Glucose was high at 131 mg/dL

I can't find her Leptin results, but the numbers were within normal range. 

I will get some APF for sure!

Thanks again,

Leela & Heidi, 25 yr old Egyptian Arabian mare

Members of original yahoo group since 2011

Deering, NH

The only information available so far on ACTH response to pergolide is from the study I was talking about yesterday.  They established that the suppression of ACTH disappears slower than the drop in pergolide blood levels.  For example, blood levels peak at under an hour after administration but ACTH remains suppressed by 50% for anywhere from 2 to 10 days after the last dose.  No further information was given though.  Is it the same at 4 hours after dosing as at 24 hours after dosing?  Don't know.  What we do know is you will still be seeing a pergolide effect and any rise by 24 hours should be minimal.  However, individuals may vary widely.
--

Eleanor in PA

www.drkellon.com

EC Owner 2001

Timeline Photos

For more information about the use of pergolide for treatment of PPID, go to ecirhorse.org and our outreach group: https://ecir.groups.io/g/main

Also good to know that you switched from Prascend to compounded and it works out fine. My vet’s first comment was: switch to Prascend to get the number down.

Karin,

From all I've read in the files, Prascend seems likely to be more accurate in supplying 1mg pergolide per tablet than a compounded 1mg capsule product. This is due, in good part, to the well-engineered manufacture packaging that protects the pergolide in Prascend from degrading.

However, at the point when Silhouette needed 3mg of Prascend to stay in range, the cost was just too high not to switch to compounded. That only became more so over time with increasing doses -- Silhouette is now getting 8mg, and my other mare 7mg. Because I dose adjust and test, as long as her ACTH is well within range, I don't see a downside to using the compounded capsules even if the dosage might be less accurate. That said -- If money grew on trees (and I had lots of trees), I might well use Prascend.

Claudia & Silhouette 2014 California Central Coast 

https://ecir.groups.io/g/CaseHistory/files/Claudia%20and%20Silhouette

LJ Friedman San Diego Nov 2014

>Are you saying that every January her "regular" pergolide dose is increased from last year's regular dose and stays that way until the next seaonal rise?

Mimi,

Yes, this has been the case for my mare.( I don't know if this is frequently the case for most horses in our group.)

I test several times a year because my mare seems to be one who requires careful monitoring to keep her in a good range. Every year, she needs a higher than the year. 

Claudia & Silhouette 2014 California Central Coast   https://ecir.groups.io/g/CaseHistory/files/Claudia%20and%20Silhouette

LJ Friedman San Diego Nov 2014