Hi would like to pick the wise brains here

We have a warmblood mare, about 20 years old. She has lost muscle, especially over the back and topline. Despite her being worked in dressage (a measured amount of work as she's older now) by a skilled rider who was very familiar with her and previously kept her in good muscle condition in the past and increasing her feed, she didn't gain it back. Never had a lamintic episode in the 10 years that my friend has had her. Was a little broken back on right fore foot (seen in old xrays about 1.5 years ago) which seems to have resolved with corrective trims over time and she has been going well on that foot (we did not repeat xray since).

She has a longer than normal coat for where we are, which is equatorial/tropical weather. Think hot and humid. She never sheds out so we have to clip her every 6 weeks or so. Recently, she had some ligament injury which the vet had seen in ultrasound and is now in handwalk and icing routine only. I wondered if this left fore injury was due to her left foot being trimmed to lower it (to match the right foot which used to be low heel but is now better). But I also wondered if it could be cushings related. The vet has known her many years and when coming to check on her commented a few times on her loss of condition and topline. and I read somewhere on ECIR this was also a factor to consider.

She sweats well when she's worked. When she's not worked, she tends to get very sweaty between the thighs and part of the belly that I can tell, more so than other horses.

Is it possible for cushings even without any signs of IR and with these kind symptoms/ factors. The age I thought is also a big point. If so, I will look into getting endogenous ACTH tested.

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Hi Cindy,

If she were mine I would at least get blood pulled for the ACTH test, from what you have said
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Lorna in Eastern Ontario, Canada
ECIR Moderator 2002
https://ecir.groups.io/g/main/files/PPID%20and%20IR%20Success%20Stories/Success%20Story%20%233%20-%20Lorna%20and%20Ollies%20Story.pdf

 

I would test. Horses can have PPID without IR, and sounds like she has a lot of symptoms. 
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- Alicia 

September 2017, Ipswich, Massachusetts

Vinnie's Case History
Vinnie's Pictures

I started asking my vet about the option to do the ACTH test.

She asked me if I would change the management of the horse for now even if she tested positive.

My question is, if ACTH comes back showing cushings, would giving an appropriate dose of pergolide eventually help with the ability to rebuild topline (assuming she first gets cleared to do more) and/or reduce any susceptibility for ligament injury? I tried to search ECIR but I did not find much detail on the ligament issue other than it could be a symptom to consider cushings.

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Yes, the correct dose of pergolide would absolutely help reverse the muscle loss and ligament weakening.
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Eleanor in PA

www.drkellon.com 
EC Owner 2001

Hi

Grateful for the input. It's slow process communicating here as the horse is not mine. Owner is a very pregnant friend of mine and I see the horse usually 4x a week (she's on livery).

So, the vet who has seen this horse for many years said she's not the type and felt the test would waste money but we could do it if we we wanted. So I paid for the blood test so as to get it done. I got the junior vet to help me with the blood draw and lab arrangement as she had done it before. I just got the ACTH results today and it was 22.7483 pmol/L which I understand converts to 103.3 pg/ml. Question, for ACTH must it be non-fasting blood draw or is that only for insulin/glucose? Anyway, the horse got hay at about 5:30am and more hay at 7:30am all the way till the blood draw at 9ish am.

Senior vet who is the main vet for this horse says that result is not clear as it is seasonal rise time so rather than risk side effects from medication, we should retest in one month. I checked around on ECIR and bearing in mind we are very near the equator (1.3 degrees North), it doesn't seem to be obvious seasonal rise time for us yet but also saw someone had posted they were in Vermont and were seeing a rise.

As I mentioned, the horse has never had laminitis. She generally always has a nice walk with overtrack. Recent xrays were done on the front for the rehab shoeing. In fact the right fore was hoof tested just a few days ago because she twisted her shoe and stepped directly (horror) on the clip and thankfully only had a small dent without breaking through to anything red - she couldn't care less with the hoof test. So, do I need to be changing anything in a panic yet? I'm used to thinking about cushings with IR and laminitis all at once and it's possible we are only looking at cushings at the moment?

The horse is on limited handwalk daily and icing due to the injury, demeanour is good and if passes a feed bucket she will drag me over unceremoniously to inspect it (doesn't look tender footed to me). She was under condition and we had to increase her food but she was also dropping/wasting feed due to an old fractured tooth. Dental was done recently and 8 months ago before that and vet said leave the tooth there for now. Only recently vet and trainer both said she's at a good weight now so they are not looking to reduce her feed (she's a sweetheart anyway). She's currently on 3.25kg of sweet feed a day, soaked (not rinsed or drained at this yard) unmolassed beet and timothy hay. She gets zinc and copper in Best Guess minerals. She gets flaxseed meal - I was giving it for her itchy skin. Loose salt, joint supplements including MSM. Vitamin E.

I was wondering if an insulin/glucose test was needed soon or next or wait on the next ACTH first? Does high ACTH eventually bring on insulin resistance or it can be independent? Am I missing something?

Thanks for the advice

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Hi Cindy,

The lab normal range when the results are in pmols/L is generally 2-10 so a result of 22.7 is unequivocally positive for PPID. You don't want to fast as it can influence the ACTH levels as well as the insulin and glucose but in this case she wasn't fasted so that wasn't an issue.

It is technically not in the seasonal rise period yet for normal horses located north of the equator but PPID horses can certainly already be showing an increase - which is just another confirmation that she has PPID. IR and PPID are two completely different conditions: a horse may be IR only; PPID only; both; or neither. In a horse that is not IR before developing PPID, it can become IR over time if the PPID is not treated and controlled well.

That is a lot of sweet feed (over 7lbs/day) for a horse who is not competing/working heavily. Thetre is a very real risk of IR now that she is on lay-up due to the injury + the uncontrolled PPID + the diet. To save money, it would make sense to treat her as IR diet-wise, treat for the PPID factoring in the continued seasonal influence when deciding on the dose of pergolide; retest ACTH after 3 weeks on the meds plus add insulin glucose at that time to see where everything stands.

If a fractured tooth is interfering with eating (dropping/wasting feed) then it needs to come out. It is likely it is also painful to some degree and she sounds like she is pretty stoic if stepping onto the he clip of a twisted shoe and driving it into her foot  did not result in any lameness at all on her part. Plus, she is at an increase risk of infection from that tooth if material gets caught in it due to the PPID.

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Lavinia and George Too
Nappi, George and Dante Over the Bridge
Jan 05, RI
ECIR Support Team

Thank you for all that Lavinia

You have given me a lot to discuss with the owner etc. The sweet feed will be hard as it has helped her condition come up and the vet in charge doesn't think that she's cushings  Also, I not sure what would be a good substitute at this yard. More micrbeet that is not rinse soak rinse. Or whether could use fibressential from hygain which is 12.1%.esc plus starch and does not have rbo (she got very spooky on ice and separatedly on rice bran oil before).

Stupid question but does anyone know if you add say 1kg of 12.1% feed to 1 kg of 5% feed, do you get an average of 2kg of feed with esc 8.55% or does it not work that way? 

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Hi all

Not an urgent case but my update is because of this discussion, the vet did an insulin glucose test 19 July 2018. She was fed usual timothy hay around 530am. She had a blood draw done by the senior vet around 9:30am (estimates only as I only get 2nd hand updates). Results came back 5 August and she said insulin 72 glucose 3 and "these are normal and she does not have EMS". Senior vet is very busy and now away but I am trying to ask the junior vet to retrieve the actual test report for me to keep or at least to check the unit of measure.

Update visually is her body condition is now quite good. Skin itchies have cleared up dramatically. She's still on the sweet feed as it has contributed to her condition and I had asked and was told not to change that as she has done well on it. Needs to build gradually some muscle next - she now gets walked in a resistance band system called Equicore / Equiband by me 4 x a week on top of daily handwalk or limited walker. Ultrasound done on her collateral med ligament around 5 August shows 40% healing, slower than expected. But she had an episode of lymphangitis before this, so we had to walk her very frequently (she got antibiotic jabs twice a day) and we think that may have stressed the ligament when it was supposed to be mostly rested. She is in good spirits. Currently on 20 to 30min walk twice a day. Mixture of handwalk, limited walker, or my friend will ride walk on flat surface as I am now going away for 2 weeks.

My thoughts are, at least her feet and skin are good (I gave the extra chondroitin from mybesthorse that I read about on this group and also very regular shampooing of her hot spots). The test shows she isn't IR, that's good news to me! The owner just gave birth so it's really just me doing the day to day and her groom who has other horses to look after. And 1 or 2 of my friends who will check in on her when I'm away. The high ACTH is still on my mind, but the vet did previously say we could test again later and I'm sure I can get it done if I pay for it but will get disapproving looks.

Should I start working on her case history? I have kept my own notes on her health and feet going back a few years but not from an IR or cushings angle.


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Hi

Oh sorry I forgot to mention she did not have hay in front of her this time all the way till the blood draw. I estimate she would have been without hay about 2 hours after breakfast. Not sure if that affects results but maybe not much (and it is her usual routine).
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Hi Cindy,

We need the units of measure for the glucose and insulin results. I'm assuming the glucose is mmol - if not, the sample was mishandled. "Normal", or within the labs ranges, does not necessarily mean the horse isn't IR. As she is uncontrolled PPID, which will eventually drive secondary IR to occur even in horses who aren't IR at baseline, there is a high index of suspicion that she is also IR now.

Her last ACTH was definitely positive for PPID - no question about that. She needs to be on pergolide as that number has already risen, and is continuing to rise, as the seasonal rise progresses. Leaving her untreated is asking for laminitis to develop plus is interfering with the healing from the ligament damage because uncontrolled PPID destroys ligaments and interferes with healing in general. She won't build topline or muscle with uncontrolled PPID as it also causes muscle wasting.

Definitely start a case history for her, please, as she is a PPID horse and having all the info in one, easily accessible location will make it so much easier to keep track of things and answer questions. Plus, in doing so, it may make her entire situation much clearer to you (and everyone else involved in her care).

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Lavinia and George Too
Nappi, George and Dante Over the Bridge
Jan 05, RI
ECIR Support Team

Hi Lavinia

Gosh, I reversed the figures. It was "glucose 72 and insulin 3" as the correct one. I still do not have the report or the unit of measurements but I believe it is the same lab and measurement as Glow which was mg/dl and ulu/ml previously. I entered into the IR calculator and it still shows not IR.

We still have the last ACTH result which the owner is aware of. I'm not sure how to proceed. Possibly I could request ACTH next month and pay for that. If the elevated level shows out of the reference range for seasonal rise the vet can reconsider maybe. I feel a bit stuck on how best to progress but what I can do is to start working on the CH. Thank you.

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No IR so that takes some of the urgency out of your decision making. July 19 is too early for any significant seasonal rise effect.  It won't peak until the end of next month.  Your July test results were clearly abnormal.  She will look better, feel better and heal better on pergolide.
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Eleanor in PA

www.drkellon.com 
EC Owner 2001