Help, please..!
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Pauli432 . <jannepauli@...>
Dear all, After an extended period of good health, Pauli went down hill again last week. We first thought she had foundered again on ALL FOURS, but I am really in doubt if there is laminitis at play here. We had her blood retested: ACTH 12 ( refvalue 0-12) Glucose 10.0mmol/L ( ref 4.0-5.6) Insulin (300.0 mU/L ( ref <10.0 mU/L) First thought: severe IR, but I am not sure. She does not drink a lot, she's not fat (ribs show), she's been on a low Sugar dier (< 10%) for years.. She's quite stiff, raises her hind legs in turns, sweats profusely, refuses to walk.. could this possibly be EPSM? And could it be that if this is so that that could also account for high glucose and thus high insulin if glucose cannot 'enter' the muscle cells when these are severly affected? Or am I totally on a wrong track? I will ask the vet to test muscle enzymes tomorrow, but could you shed some light on this? A specialist at the Bern University, Switzerland ( Dr Han v.d. Kolk, I'm sure Dr Kellon will know his name) advised to stop with pergolide and to start a high dosis Bromocriptine instead for a 14 week trial. I don't see the sense in that to lowe Gluc/Ins.. am I wrong? Please, anyone? Marianne EC 2011/ The Netherlands |
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Lavinia Fiscaletti
Hi Marianne,
Sorry to hear Pauli has had a setback. When was the most recent blood work done? The ACTH is at the top of the lab's normal range so it is possible there is a PPID component here. Her glucose puts her in the diabetic range and her insulin is really high as well. Yes, severe IR. With those numbers laminitis is likely. Can you put up current hoof pics? Have asked Dr. Kellon to take a look. Lavinia, Dante, george Too and peanut Jan 05, RI EC Support Team >>>>> We had her blood retested: ACTH 12 ( refvalue 0-12) Glucose 10.0mmol/L ( ref 4.0-5.6) Insulin (300.0 mU/L ( ref <10.0 mU/L) First thought: severe IR, but I |
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It sounds like uncontrolled PPID with exacerbated IR (could be made worse by cold weather stress) is the most likely issue here. Instead of muscle enzymes I would nerve block the feet. If that creates improvement, be sure to get radiographs. Would also check thyroid hormone level. Higher T4 is a normal part of the response to cold and may not happen with a PPID horse. Cold induced vasoconstriction may be causing pain as well.
You could either increase pergolide or try Dr. van der Kolk's suggestion. I haven't seen bromocriptine used in about 35 years, and it supposedly needs to be given very frequently when oral, but if he has a protocol he thinks is successful you could certainly try that. Eleanor in PA www.drkellon.com
EC Co-owner Feb 2001 |
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jannepauli@...
Thank you Dr Kellon and Lavinia for your speedy replies. We had X-rays taken of Pauli's fore feet mid September - she was at that time limping a bit and we suspected a hoof abces which incidently was never found. The X-rays showed no changes, no rotation, no sinking, but did show a very good improvement of the soles in comparison to all previous X-rays. The problem in her left front hoof remains a mystery - all that we did find were small blood specs in the soles. The incident lasted for about a week and then all of a sudden, really from one day to the other, she was back to normal. To date I donot understand this. The onset of the present problem was about a week ago when I noticed her gaits were slightly stiff. The next thing I knew was that she broke out in sweat - coat completely drenched. Ofcourse we are late autumn and she has started her winter coat but as the wheather has been unusually warm, also at night ( it has been the warmest october and november ever recorded since temps were recorded in the 19th century) I first thought that she was simply suffering from these high temperatures. And then the stiffness progressed, getting worse and her feet were slightly, but not alarmingly warm, slight digital pulse. So the farrier who was supposed to do her hoves decided to leave her be and not mess with her too much till she was better, but did slightly lower the heels ( really only a fraction). This was last week thursday - The vet came in that same day and did the blood draws. She was in pain at that time, which according to Dr Ellen Roelfsema of the Utrecht veterinairy university may have also caused a rise inthe glucose/insulin. Even though the ACTH is at the high end ( 12pmol/L), the vet was content that the PPID seemed to be under control by the Prascend. Looking at the previous test in May of 2014, the ACTH at that time was higher. Unfortunately I don't have the document with me, I can check that tomorrow. In IR test however was much better at that time: Glucose 5.5 mmol/L and Insulin 142.0mU/L I am really at a loss - I know that Dr v.d. Kolk is a fan of bromocriptine, the medicaton of choice before pergolide. But I read too many reports of bromocriptine NOT being the medication of choice anymore. Utrecht tells me there is not much too be expected from increasing a dopamine antagonist such as bromocriptine or pergolide to control the IR. Van der Kolk and my own vet say it will..? And here I am with a really, really sick horse whose nostril are spread wide open and her breath is pumping in pain. She cannot move, will not move. The poor girl is only 17 years old, so not ready to give up. But she is suffering severely, it breaks my heart - and worse is that I am no longer 'clear-headed' to take the right decision. When I was feeling her back and her muscles just now, it felt hard and stiff. She does not like to be touched. Is there any sense in thinking that EPSM could be at play? I will follow your advice and ask our vet to do nerve blocks tomorrow. That, I agree, will shed some light on it. But what if not? Thanks so much for your help and keeping me sane :) Marianne The Netherlands EC 2011 |
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Sherry Morse
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jannepauli@...
Thank you for helping the thought-process, Sherry! No, we have not had her checked for that - I will ask our vet tomorrow but I doubt that he will want to do this. The general symptoms donot quite fit. But - one never knows so I will ask him about it. However, would tick-born diseases also have an effect on gluc/insulin running so high? Marianne The Netherlands EC2011 |
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Sherry Morse
Hi Marianne, I know it doesn't quite fit BUT my thought is that in this area (North East United States) when we see horses that are suddenly reluctant to be touched or are acting 'off' with no apparent reason why and/or who also are suddenly lame but the exact cause cannot be determined there's a very good chance that they will test positive for one of the tick borne diseases. I do not know if Ehrlichia is commonly diagnosed in horses in the Netherlands, but I would want to rule it out at this point. I am not sure if there would be a connection with the glucose/insulin levels either, but perhaps the vet would be able to answer that question.
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Lavinia Fiscaletti
Hi Marianne,
The timing of the first lameness screams PPID being the underlying cause as that would be the prime time for the seasonal rise to be affecting her. Really encourage you to post those xrays and pics of her feet. The blood spots in the soles are evidence of older trauma growing out. Whenever there are hoof issues making sure the trim is scrupulously perfect is the way to go rather than to leave things as they are until later. Yes, pain can influence insulin/glucose values but in this case it is more likely that the I/G were already elevated and causing the pain. The 12pmol/L upper normal value for your lab is 20% higher than the ones we see here regularly. Normal readings should fall somewhere in the middle of the range so would want to see something like 4-5pmol/L in a horse that is well controlled. It is good that her ACTH has come down but by the sounds of it, she is still not well controlled enough FOR HER as she is experiencing quite a bit of pain now. The insulin and glucose values that she had in May were still much too high and showed her to be severely IR and at serious risk for laminitis. Her insulin (142) was 14 times what a healthy insulin(10) should be and her glucose was bordering on diabetic. Again, your lab's ranges on the glucose are higher than has been found to be healthy. Top of the healthy range would be 5mmol and Pauli was at 5.5. This put her in the category of balancing precariously on the edge of a major laminitic episode and only needing the slightest nudge to tip her over that edge. It sounds like the seasonal rise did just that. The only dose of Prascend (pergolide) that is correct is the one that controls the ACTH. In most horses, this is achievable but you need to get on top of it as soon as possible. It appears that Pauli's dose really needs to be increased to make this happen, which is what your vet agrees with as well. Her tight muscles and not wanting to be touched are classic for a horse with laminitic pain because she is using her whole body to attempt to keep as much weight off her feet as is possible. This would make her muscles rigid, her attitude crabby and her gait stilted. Good that you are going to have the nerve blocks done. Hang in there. Lavinia,Dante, George Too and Peanut Jan 05, RI EC Support Team |
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