Cornell ACTH came back at 202 pg/mL with a reference range of 9 - 35. Vet says he wants me to give the .5mg for another week and then I’m clear to bump it to 1 mg.  I can already see some signs it’s working.  Less goopy eyes and she’s starting to suggest that she’s thinking of shedding out. I’ll update the case history later tonight.  

As as far as keeping her wet, I mean like when you go into the hospital and they give you IV fluids and by the time you leave you look like a balloon.  Could the excessive drinking be hindering the ability to process the edema?  Removed the salt block and less pee today.  Lower legs looked better too.  

She’s not happy about a grazing muzzle and I don’t have any other way to keep her off grass except to stall her.  I can keep her on less good grass that has been beaten up by muddy turnout conditions but that’s about it.  She at least preferences hay there.  I think we are going to have high chances of rain for most of the next 6 days anyway.

--
Stefanie D.
central TX
Jewel's Case History

The main thing to heal her gut is just to stop the bute. You an also supplement with glutamine, 15 grams/250 kg daily. She could also be losing protein in her urine from kidney damage. Very easy to test by catching a urine sample. Pharmacies have urine test strips. There shouldn't be any protein in the urine.

What do you mean by the drinking/salt keeping her wet?
--
Eleanor in PA

www.drkellon.com 
EC Owner 2001

 

Hello  Stefanie

Welcome to the group! 

Thanks so much for filling out a a case history and supplying a link. It’s a big help.

I see that Dr Kellon has made some suggestions regarding the salt consumption- so please do reduce the dose to the 2 oz and keep a daily record of results.

As soon as you get a copy of the blood results, please add them to your case history. Did the vet run a glucose and insulin test as well? It is rare for a TB to be insulin resistant unless he is also PPID.  Once you get the PPID under control, his glucose and insulin may return to normal.  Meanwhile he needs to be treated as both PPID and IR.  That also means no grass access until you have a definitive answer.

With the group, we have found that a majority of horses are not well controlled on a dose as small as .5mg- so please have a word to your vet about increasing the dose to at least 1mg and retest the ACTH in 3 weeks time (add a Glucose & Insulin test as well)

Regarding the diet- below in this message is the emergency diet- start to implement that- it does include beet pulp & stop the 12.8 pellets all together. They are not suitable for a horse with a metabolic issue.

With the hay- it may be prudent to soak it – one hour on cold or half and hour in hot- until you can find a away to store more bales(3-4 months worth)  to make it worth while testing. Many members are in the same position & have come with ways to store hay- in a car port, garden shed, rented loft space, etc. 

Below is the rest of the new members message:

The ECIR provides the best, most up to date information on Cushing's (PPID) and Insulin Resistance (IR). Please explore our website where you'll find tons of great information that will help you to quickly understand the main things you need to know to start helping your horse. Also open any of the links below (in blue font) for more information/instructions that will save you time.

In order to help you and your equine quickly and effectively, we need you to explain your equine's situation by following the instructions you were sent upon joining. Your completed case history form and ECIR Signature will save days of back and forth questions. If you haven't done so yet, please join our case history sub-group. Follow the uploading instructions so your folder is properly set up and then upload your case history. If you have any trouble, just post a message or email the case history group explaining specifically where you are stuck.

Orienting information, such as how the different ECIR sections relate to each other, message etiquette, what goes where and many how-to pages are in the Wiki. There is also an FAQs on our website that will help answer the most common and important questions new members have. 

Below is a general summary of our DDT/E philosophy which is short for Diagnosis, Diet, Trim and Exercise.

 

DIAGNOSIS: There are two conditions dealt with here: Cushings (PPID) and Insulin Resistance (IR). These are two separate issues that share some overlapping symptoms. An equine may be either PPID or IR, neither or both. While increasing age is the greatest risk factor for developing PPID, IR can appear at any age and may have a genetic component. Blood work is used for diagnosis as well as monitoring the level of control of each.

PPID is diagnosed using the Endogenous ACTH test, while IR is diagnosed by testing non-fasting insulin, glucose and Leptin. Leptin is the hormone that says "stop eating". Knowing this helps to differentiate if a horse is IR "at baseline" or if an elevated ACTH is "driving" the insulin up. In Europe, substitute adiponectin for the leptin test.

*Before calling your vet to draw blood for tests, we suggest saving time and wasted money by reading these details and then sharing them with your vet so that everyone is on the same page regarding correct testing and protocols.

*Please remember to request copies of the results of all the tests done rather than just relying on verbal information. Your vet should be able to email these to you. If you have previous test results, please include those as well. All should go in your CH, but if you are having any trouble with the CH, just post in the messages for now. 

Treatment: IR is a metabolic type - not a disease - that is managed with a low sugar+starch diet and exercise (as able). The super-efficient easy keeper type breeds such as minis, ponies, Morgans, Arabs, Rockies are some of the classic examples. PPID is a progressive disease that is treated with the medication pergolide. Some, but not all, individuals may experience a temporary loss of appetite, lethargy and/or depression when first starting the medication. To avoid this "pergolide veil" (scroll down for side effects), we recommend weaning onto the drug slowly and the use of the product APF. The best long term results are seen when the ACTH is maintained in the middle of the normal range at all times, including during the annual seasonal rise. To accomplish this, the amount of medication may need to increase over time. Neither condition is ever "cured", only properly controlled for the remainder of the equine's life. If your partner is both PPID and IR then both medication and diet management will be needed. 

 

DIET: Almost all commercial feeds are not suitable - no matter what it says on the bag. Please see the International Safe Feeds List for the safest suggestions.

No hay is "safe" until proven so by chemical analysis. The diet that works for IR is:

• low carb (less than 10% sugar+starch)
• low fat (4% or less) 
• mineral balanced  

We use grass hay, tested to be under 10% ESC + starch, with minerals added to balance the excesses and deficiencies in the hay, plus salt, and to replace the fragile ingredients that are lost when grass is cured into hay, we add ground flax seed and Vitamin E. This diet is crucial for an IR horse, but also supports the delicate immune system of a PPID horse. 

*Until you can get your hay tested and balanced we recommend that you soak your hay and use the emergency diet (scroll down for it).  The emergency diet is not intended for long term use, but addresses some of the most common major deficiencies. Testing your hay and getting the minerals balanced to its excesses and deficiencies is the best way to feed any equine. If you absolutely cannot test your hay and balance the minerals to it, or would like to use a "stop gap" product until you get your hay balanced, here's a list of "acceptable" ration balancers. 

There is a lot of helpful information in the start here folder so it is important you read all the documents found there. The emergency diet involves soaking your untested hay for an hour in cold water or 30 minutes in hot water. This removes up to 30% of the sugar content, but no starch. Starch is worse than sugar since it converts 100% to glucose while sugar only converts 50%, so starch causes a bigger insulin spike. Make sure you dump the soaking water where the equine(s) can't get to it. 

What you don't feed on the IR diet is every bit as, if not more important than, what you do feed! No grass. No grain. No sugary treats, including apples and carrots. No brown/red salt blocks which contain iron (and sometimes molasses) which interferes with mineral balancing, so white salt blocks only. 

No products containing molasses. No bagged feeds with a combined sugar and starch of over 10% or starch over about 4%, or fat over about 4%. Unfortunately, even bagged feeds that say they are designed for IR and/or PPID equines are usually too high in sugar, starch and/or fat. It’s really important to know the actual analysis and not be fooled by a name that says it is suitable for IR/PPID individuals.

We do not recommend feeding alfalfa hay to IR/PPID equines as it makes many of them laminitic. Although it tends to be low in sugar, many times the starch is higher and does not soak out. Additionally, protein and calcium are quite high, which can contribute to sore footedness and make mineral balancing very difficult.

TRIM: A proper trim is toes backed and heels lowered so that the hoof capsule closely hugs and supports the internal structures of the foot. Though important for all equines, it's essential for IR and/or PPID equines to have a proper trim in place since they are at increased risk for laminitis. After any potential triggers are removed from the diet, and in PPID individuals, the ACTH is under control, the realigning trim is often the missing link in getting a laminitic equine comfortable. In general, laminitic hooves require more frequent trim adjustments to maintain the proper alignment so we recommend the use of padded boots rather than fixed appliances (i.e. shoes, clogs), at least during the initial phases of treatment.

Sometimes subclinical laminitis can be misdiagnosed as arthritis, navicular, or a host of other problems as the animal attempts to compensate for sore feet. 

You are encouraged to make an album and post hoof pictures and any radiographs you might have so we can to look to see if you have an optimal trim in place. Read this section of the wiki for how to get a hoof evaluation, what photos are needed, and how to get the best hoof shots and radiographs.

 

EXERCISE: The best IR buster there is, but only if the equine is comfortable and non-laminitic. An individual that has had laminitis needs 6-9 months of correct realigning trims before any serious exercise can begin. Once the equine is moving around comfortably at liberty, hand walking can begin in long straight lines with no tight turns. Do not force a laminitic individual to move, or allow its other companions to do so. It will begin to move once the pain begins to subside. Resting its fragile feet is needed for healing to take place so if the animal wants to lay down, do not encourage it to get up. Place feed and water where it can be reached easily without having to move any more than necessary. Be extremely careful about movement while using NSAIDs (bute, banamine, previcox, etc.) as it masks pain and encourages more movement than these fragile feet are actually able to withstand. Additionally, NSAIDs (and icing) do not work on metabolic laminitis and long term NSAID use interferes with healing. Therefore, we recommend tapering off NSAIDs after the first week or so of use. If after a week's time your equine's comfort level has not increased, then the cause of the laminitis has not been removed and keeping up the NSAIDs isn't the answer - you need to address the underlying cause.

 There is lots more information in our files and archived messages and also on our website. It is a lot of information, so take some time to go over it and feel free to ask any questions. If you are feeling overwhelmed, don't worry, you will catch on, and we are always here to help you! Once you have your case history uploaded, we can help you help your equine partner even better.

We ask all members to sign their first name, general location, date of joining and link to the case history and photo album every time they post. It helps us to find your info faster to answer your questions better. You can set up an automatic signature so you don't have to remember to do it. 

For members outside North America, there are country specific folders in the files and many international lists in the wiki to help you find local resources.
If you have any technical difficulties, please let us know so we can help you. 

--

Pauline

Geelong. Vic

Australia Aug 07

ECIR Mod/Primary Response

 

 Harry, Jack and Spur's Case Histories   

We did.  The vet didn’t feel she’d been given on average more than 2 gms/day.  The drinking/salt is not new but has been a feature since I bought her and is the ACTH.  I just was just wondering if the drinking/salt was keeping her wet. And if there was anything I could do to help heal her gut.

--
Stefanie D.
central TX
Jewel's Case History

Hi Stefanie,

Having witnessed this same behavior of salt and water consumption in a friend's horse in what turned out to be Kidney Disease, and with your mare's history of being overly medicated with Bute by the boarding barn, I might recommend the additional precaution of doing blood work to test her for kidney function.
--
Sally in Big Park, Arizona/April 2013

https://ecir.groups.io/g/CaseHistory/files/Sally%20with%20Tabby%20and%20Maisie 

  

 

 

No. The salt is not causing the edema but it might be contributing to the drinking. Try taking the block away and just putting 2 oz of salt in the bottom of her feed tub every day. If that doesn't resolve the drinking and urination issue it might be a sign of uncontrolled PPID. Need to make sure the ACTH is controlled. The usual procedure is to get them up to 1 mg/day then retest in 3 weeks.
--
Eleanor in PA

www.drkellon.com 
EC Owner 2001

Bute was stopped months ago.  She will drink 5 buckets dry in a 24 hour period.  She got a new salt block a week ago and has already licked the top eighth of it gone.  Considering the continuing edema, is that much salt consumption contributing to the edema?


--
Stefanie D.
central TX
Jewel's Case History

If she's still on bute, even reduced dose, you need to stop that to heal her gut - and stop what is likely ongoing damage to her kidneys as well.

What is the issue with drinking and urinating?
--
Eleanor in PA

www.drkellon.com 
EC Owner 2001

Is this horse without a herd mate?   That should be the first thing you fix imho--
LJ Friedman  Nov 2014  San Diego, CA

Jesse's Case History 
Jesse's Photos

 

Needing some advice on where to go in my horse's management.  Jewel is a 15.2h TB mare.

Timeline:  
May 2018 - Sent to boarding barn for socialization so she wouldn't be an only horse.  Turnout 8 -12 hours, mostly dry lot.  
Sept 2018 - Chiropractic appt.  Vet said she was very slightly off on r hock but moved much better than he expected.  Recommended Bute to get through to when we'd need an injection.  Was supposed to be getting 1 scoop Bute M-F off on weekends.  Had tolerated low levels of Bute in the past.
Oct 2018 - Presented ventral edema.  Found out boarding barn had been giving heaping scoops....and had gone through over half of the 100 dose container.  Vet did bloodwork and confirmed low blood protein.  Advised upping the protein in her ration and lots of exercise/turnout.  Edema was gone within the month.  No changes in appetite, poo or attitude.  Had blood drawn for ACTH but messed up and it never got sent/results back.
Dec 2018 - Brought home.  Spent most of December and half of Jan pretty much refusing to leave her stall for any real length of time (we are pretty wild for the area).  Appetite, poo and attitude ok otherwise.  If she was forced to turn out away from her stall/run she would be fine for about an hour and then get frantic.  Lots of mud and rain weekly has meant not a lot of movement anyway.
Jan 2019 - Ventral edema is back.  Still has good appetite, poo and attitude.  Got a new pony two weeks ago so she's now happy to be out of her stall even if not turned out with the pony and is visibly much more relaxed.  Vet relooked at the edema but four days with the pony home and the edema pockets are gone from her midline and are only really visible high up in her udder.  Redrew ACTH and sent home with Prascend to start at .5mg based on her physical symptoms.  I got the call on Thursday that the blood came back with a strong positive but haven't be able to get a copy yet. She's been on Prascend for 5 days and some things already seem to be improving.

She's done well on grass, coastal hay, and 12-8 pellets.  I've currently backed off the grain and am feeding either California bermuda or coastal bermuda, and psyllium husk.  

I'm specifically confused on where I need to go based on the edema.  Continue to feed hay/forage, or try to eliminate it and substitute beet pulp to heal the gut.  Jewel won't eat a ton of beet pulp plain but she'll eat a complete feed.  Also, she has a love affair with her salt block and wears off quite a bit of it each day.  Considering the drinking/urinating/edema should I some how limit her salt?  Hay testing isn't really an option as I can only store a few bales at a time.  Would anything else be helpful?

--
Stefanie D.
central TX
Jewel's Case History