Got the results 2 days ago, vet finally rang this morning.

Have updated case history but here they are:

***These bloods were taken after 3 weeks on pergolide - no prior bloods to compare to for various reasons, see case history for info pls***

ACTH *>600 pg/mL (no actual figure as above lab's range - lab's normal range is <100, and >300 considered very high)

Cortisol 105 nmol/L (normal 25-155)

Insulin 54 uIU/mL (normal 8.9-65)

Glucose 5.8 mmol/L (normal 3.4-5.9)

which by my calculations puts his G:I at 1.93 and RISQI at 0.14 and means severe IR.

Vet however is happy that cortisol, insulin and glucose are all in normal range and says though he's put other horses on metformin alongside the pergolide Paddy doesn't need it. Not interested in G:I ratio. He's (and I quote) "not a big believer in doubling the dose of pergolide" at which point I asked whether we should increase to 1.5mg but he wants to continue at 1mg for a further 4 weeks and then reassess physical symptoms.

We went straight in at 1mg and though Paddy picked up fairly quickly we have been struggling with appetite for the last couple weeks but I have changed his chaff to something even lower sugar/starch (moved from 6% combined to one which is 3% combined) but with different flavour and he loves it and is now licking bowl clean again. Was struggling to get APF into him but is taking it now and is much improved generally. No change to any fat pads, still footy over stones but nowhere near as footsore as he was prior to starting pergolide. Coat seems to have improved a bit, better condition.

I'm concerned at his G:I ratio and that PPID is not under control at all despite 1mg pergolide and feel we should be increasing it not watching him for another 4 weeks.... I also have very little faith in current vet due to events in the past with my other horses, if I was to ask for 2nd opinion from other vets at the practice it wouldn't be the first time I'd done so.

Am I right to be concerned about those results or am I over reacting and should be more patient?!

Thanks in advance,

Robyn and Paddy
Sept 2011, UK

Case History:
http://pets.groups.yahoo.com/group/ECHistory5/files/Robyn%20-%20UK/
Photos:
http://groups.yahoo.com/group/ECHistory5/photos/album/823009075/pic/list

Am I right to be concerned about those results or am I over reacting and should be more patient?!

Hi Robyn,

You are SO RIGHT to be concerned about those numbers!
Good for you!

No way would I wait another 4 weeks and rely on clinical signs ,if it were me.But you know that already,or you wouldn't have asked.

He's already showing you that a little pergolide can make his feet feel a little better.So let's go big or go home.Let's get those feet *comfortable*.

Would our new data base numbers help your vet understand how much pergolide can be needed ?

http://pets.groups.yahoo.com/group/EquineCushings/database?method=reportRows&tbl=11

Good luck!


Lorna in Eastern Ontario
2002
EC Moderator
http://www.ecirhorse.com
http://www.nolaminitis.org/first-annual-no-laminitis-conference

Hi Robyn

I presume you had Paddy's blood tested at Cambridge - The Hormone Lab?

I have queried their ACTH normal range before. According to their website they use RIA (radioimmunoassay), as do most labs testing equine ACTH. I don't remember seeing any/many (?) labs with a normal range in excess of 47 pg/ml - Liphook's range for Aug-Oct. And nearly all the labs I've seen used for ACTH testing have a normal range of around <35 pg/mg - other than those that now adjust for the seasonal rise.

See p27-28 of their lab manual for ACTH & insulin testing:
http://thehormonelab.com/core/..uploads/csls/Lab-Service-Information-Manual-March-2011.pdf
"However very high levels (>300pg/mL) are still highly suggestive of ECS and a normal level in the autumn (<100 pg/mL) is more likely to be truly negative."

Is it possible for normal ranges to differ this much??

If not, then yes without a doubt Paddy's ACTH is far too high, and I would increase his pergolide - you don't even know how high his ACTH actually is, it could be far higher than 600 pg/ml. Andy Durham said in his Aug Prascend webinar that horses need different doses of pergolide and he has horses on anything from 1-2 mg/day to 8 mg/day. The correct dose is the dose that controls the clinical symptoms and the ACTH.

For this reason I always recommend that people in the UK ask to have their blood tested at Liphook - not only are Liphook doing a lot of research into endocrine testing, but their results are in line with most of the other good labs recommended by this group.

I would also say that his insulin is above normal - I believe it has been mentioned on here that some labs in the USA have results approx. 2 x higher than Cornell, so perhaps this is similar with Cambridge. But nonetheless you are looking for an insulin result <20 uIU/ml according to most vets, and ideally <10 uIU/ml. And his glucose is right at the top of the normal range given, and over 100 mg/dl.

Cortisol isn't considered diagnostic of PPID by most vets.

I'd be grateful if someone with more knowledge than me could comment on the ACTH normal range mentioned above - I'm currently researching this but it's taking a while. If no one has an answer, I'll contact the lab next week and see what I can find out.

Andrea
UK/France Jan 2010
www.thelaminitissite.org

Hi Andrea,

I presume you had Paddy's blood tested at Cambridge - The Hormone Lab?

Yes the bloods went to CSLS, I did request that they went to Liphook but the vet assured me that Cambridge ran the same procedure and used the same ref ranges etc as Liphook. Realised when I tried to compare Paddy's >600 pg/mL to Liphook's mean PPID ACTH levels that something wasn't quite adding up! *angry mad face*

If not, then yes without a doubt Paddy's ACTH is far too high, and I would increase his pergolide - you don't even know how high his ACTH actually is, it could be far higher than 600 pg/ml.

Completely agree and said the same to vet this morning but he apparently doesn't believe in high doses.

I would also say that his insulin is above normal - I believe it has been mentioned on here that some labs in the USA have results approx. 2 x higher than Cornell, so perhaps this is similar with Cambridge. But nonetheless you are looking for an insulin result <20 uIU/ml according to most vets, and ideally <10 uIU/ml. And his glucose is right at the top of the normal range given, and over 100 mg/dl.

So should we be looking at putting him on metformin in the interim or just increase the pergolide in an attempt to gain control of the IR?



Lorna, I said to vet this morning that there are horses on large doses of pergolide but he insisted that he believes it's not necessary... I am going to speak to senior partner on monday and get him to look at results and put a few things to him, including info from here, I will at least direct him here.

I just can't understand why vet doesn't want to increase it, we've proved he's got PPID with these bloods, which this vet had to persuade me to run when I just wanted to try increasing pergolide in the first place, so now we've done that he just wants to sit back and watch the horse?!
He doesn't consider that Paddy is at real risk of laminitis and I don't really know what I can do to convince him otherwise... but I'm really not prepared to risk it when we CAN increase the pergolide and at least go some way to lessening the chances. Hopefully I'll get somewhere with other vet on monday.

Andrea - am hoping someone has some idea as to the differing lab normal ranges, would be interested to know what lab has to say if no one here has any ideas.


Thank you both, am glad to have it confirmed that I'm not worrying over nothing, although wish I was!

Robyn and Paddy
Sept 2011, UK

Case History:
http://pets.groups.yahoo.com/group/ECHistory5/files/Robyn%20-%20UK/
Photos:
http://groups.yahoo.com/group/ECHistory5/photos/album/823009075/pic/list

On Sat, Oct 22, 2011 at 1:58 PM, bigears298 <brightsyde@...> wrote:

Realised when I tried to compare Paddy's >600 pg/mL to Liphook's mean PPID ACTH levels that something wasn't quite adding up! *angry > mad face*

I FINALLY got my old Arab's ACTH test done and sent to Cornell and the
vet called me with the results last week. He said he'd bring me the
hard copy when he got it. My horse's level was 606, so yours is in
the same area for sure. I got the Pergolide and started him on it
last night, so will anxiously wait until I see some improvement. I
told my vet about the datebase showing the high levels of Pergolide
use by some on this list and he thought it was very interesting. He
thought that going up to 2 or 3 mg was the highest he had heard of.
If it becomes an issue, I will print out the database for him. He is
interested in the ECIR information and very cooperative so far.

I was the first client of his that had requested (insisted??) on using
Cornell and so he said I would be the Guinea Pig and it all worked out
fine. I think he was encouraged by that. Then if Velvet makes a
miraculous recovery, he will really be on board!
Ferne Fedeli
No. California
4/2010

Hi Robyn

I did request that they went to Liphook but the vet assured me that Cambridge ran the same procedure

You might like to check out the RCVS professional conduct if you get a problem - your vet is meant to give due consideration to your wishes!
http://www.thelaminitissite.org/u-v-w-x-y-z.html

So should we be looking at putting him on metformin in the interim or just increase the pergolide in an attempt to gain control of the IR?

I would say he doesn't need Metformin, but he (almost certainly) does need his pergolide increased. Reducing his ACTH should reduce his IR, along with low sugar/starch diet, weight loss if necessary, and exercise when able.

There are several papers referring to pergolide dosage at the end of this website:
http://vetmed.tamu.edu/common/docs/public/aavpt/pergolide.pdf

And I'd recommend your vets watch the Prascend webinars if they haven't already - testing ACTH and pergolide dosage is covered.
http://www.fsmevents.com/prascend/

He doesn't consider that Paddy is at real risk of laminitis

You might ask him to confirm that he will in that case treat Paddy free of charge if he does develop laminitis, and also to put his opinion in writing! It's likely that the "footiness" you've seen is due to laminitis so I think Paddy's ACTH level and laminitis risk need to be taken seriously. Has he shown any laminitic changes in his feet, e.g. stretched white line, change of angle in the hoof wall, laminitic rings (wider at the heel than the toe), bruising...?

I'll contact the lab and see if I can get an answer. Another horse tested there had ACTH in excess of 100 but was not diagnosed as having Cushing's because of their normal ranges. Several months later the owner insisted on trying pergolide and the horse started to improve after months of laminitis.

Andrea
UK/France Jan 2010
www.thelaminitissite.org

Lorna, I said to vet this morning that there are horses on large doses of pergolide but he insisted that he believes it's not necessary...

There's that word again....believes.
The necessary dose is the dose which controls the PPID.I know you know that.I was whispering to your vet.
Print off the data base for dosages.Maybe black & white would help him.
Surely he doesn't believe(ahem) that all of us using high doses can't read lab reports,and have so much money to burn that we choose to spend more money when less would control the disease?
Of course that's rhetorical.

*Why* is he not prepared to increase the dose?I'm not interested in his belief system but in the data which tells him the dose shouldn't be increased.
I know you are,too,Robyn.
Frustrating,or what!

You'll find a way.
Most people here have.

It just takes 'stick with itness', and you sound like you have more then enough of that.

Lorna in Eastern Ontario
2002
EC Moderator
http://www.ecirhorse.com
http://www.nolaminitis.org/first-annual-no-laminitis-conference

You might like to check out the RCVS professional conduct if you get a problem - your vet is meant to give due consideration to your wishes!
http://www.thelaminitissite.org/u-v-w-x-y-z.html

Have to say I didn't press the issue... because he was so sure they did everything the same as Liphook.

There are several papers referring to pergolide dosage at the end of this website:
http://vetmed.tamu.edu/common/docs/public/aavpt/pergolide.pdf

I can't get those to load, have searched pergolide on the main site and found the papers but still won't load for me!

And I'd recommend your vets watch the Prascend webinars if they haven't already - testing ACTH and pergolide dosage is covered.
http://www.fsmevents.com/prascend/

Will point him in that direction, thank you.

I'll contact the lab and see if I can get an answer. Another horse tested there had ACTH in excess of 100 but was not diagnosed as having Cushing's because of their normal ranges. Several months later the owner insisted on trying pergolide and the horse started to improve after months of laminitis.

Hmm, doesn't sound all that reliable as "normal ranges" then does it?!

*Why* is he not prepared to increase the dose?I'm not interested in his belief system but in the data which tells him the dose shouldn't be increased.

I am going to ask him just that! I have found a couple of references to a 6 - 12 week period to gain maximum benefit from pergolide while I've been searching this afternoon for info to put to him so maybe that's his thinking....


I have put together and printed out various research papers/information re pergolide dosage, and also about testing for and diagnosing IR and the G:I, some of it may well be like teaching my grandmother to suck eggs to him but it all backs up my request to up the dose and stresses about the G:I and laminitis.
Have decided I am going to try and present him with this info/educate him to change his thinking before I ask for senior partner to get involved otherwise it's not going to help anyone else he has to deal with in my situation. I may end up banging my head against a brick wall but it's worth a try.

Am also going to point out the accompanying info for the Prascend which he is prescribing :
http://www.noahcompendium.co.uk/Boehringer_Ingelheim_Limited/Prascend_1_mg_tablets_for_horses/-53061.html
which lists the starting dose for a horse of Paddy's weight as 1.5mg, and an average total daily dose of 0.25 - 5mg....
(also another reference to 6-12 weeks for clinical improvement though)

Am also going to include a copy of my records that I'm taking weekly to record changes in Paddy's clinical symptoms which show that although he improved, the improvement has now levelled off.
And a covering letter with my concerns, request, various quotes, some of the things you guys have pointed out etc etc and will also point out the differences between CSLS's normal lab ranges and others, just so he's aware of it if he's not already.

All will be delivered to the surgery for his urgent attention tomorrow and we'll see where it get's me!

Thanks again for all your help & advice,

Robyn and Paddy
Sept 2011, UK

Case History:
http://pets.groups.yahoo.com/group/ECHistory5/files/Robyn%20-%20UK/
Photos:
http://groups.yahoo.com/group/ECHistory5/photos/album/823009075/pic/list

All will be delivered to the surgery for his urgent attention tomorrow and we'll see where it get's me!

YAY,Robyn!

And don't forget to check out the awesome document LeeAnne just posted this afternoon:

http://tinyurl.com/yaj4g8w

Fingers crossed for positive outcome!

Lorna in Eastern Ontario
2002
EC Moderator
http://www.ecirhorse.com
http://www.nolaminitis.org/first-annual-no-laminitis-conference