Diagnostic testing for EMS, EC, and hypothyroidism


Kirsten Rasmussen
 

Hello, I have some questions on testing for EMS, EC, and hypothyroidism.

A couple years ago I asked my veterinarian for a quote on testing Shaku for EMS.  I have copied and pasted the response below my email.  At the time, after all the expense associated with an acute laminitis episode earlier that year, I felt I could not afford to pay 733$ + shipping + vet fees for collection to confirm what I was already fairly sure of, based his body condition and history of low-grade laminitis.  Now I'm wondering again if I should have him tested for EMS to be certain, and whether he should be tested for early Cushings as well even if he doesn't have any obvious signs of it?  I would also like to have his thyroid checked because Shaku strongly dislikes being touched, which I have heard can be caused by hypothyroidism.  My vet will be back in March/April while he is still on hay in a dry paddock for Shaku's spring checkup.  Is that a good time of year to test for these things?

I would so appreciate it if someone can tell me first if Shaku should be tested for EMS, EC, +/- thyroid based on his CH, and provide a list of primary (must do) tests I should have done first (I have read a bit on testing protocols here but am still confused).  And maybe some advice on the most affordable way to do this, given that I live in northwest BC and will be shipping blood across country...any other BC members out there? :)

(His case history says his hay is not balanced with minerals yet, but the minerals are in the mail so that will be corrected soon!)

Thank you!
---------------
From my vet:

According to Cornell University there is a series of testing that they 
recommend. Below is the Gold Standard of testing for Equine Metabolic 
Syndrome;
 
Insulin Baseline
Oral Sugar Test
Leptin Baseline
Thyroid Testing
 
The total cost to run these is $ 733.60 plus tax not including blood 
collection and shipping the samples to the lab.
--------------
--
Kirsten Rasmussen
Kitimat, BC, Canada
January 2019

Shaku's Case History:  https://ecir.groups.io/g/CaseHistory/files/Kirsten%20and%20Shaku  
Shaku's Photo Album:  https://ecir.groups.io/g/CaseHistory/album?id=82559  


Paula Hancock
 

On Fri, Feb 15, 2019 at 09:33 AM, Kirsten Rasmussen wrote:
I would so appreciate it if someone can tell me first if Shaku should be tested for EMS, EC, +/- thyroid based on his CH, and provide a list of primary (must do) tests I should have done first (I have read a bit on testing protocols here but am still confused).  And maybe some advice on the most affordable way to do this, given that I live in northwest BC and will be shipping blood across country...any other BC members out there? :)
Hi Kirsten,
It would be good to test him, but follow the protocol that Lavinia sent to you in her message  
where she directs you to:
 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.

 You don't want the oral sugar test, just follow the instructions to get the most information without spending more than you need to spend or putting your horse t risk.  Thyroid testing may not be necessary at this time.  Getting ACTH would be an excellent idea as well, which is in the ECIR diagnosis protocol.
We do have members and a moderator out your way, so they can provide more specific details.
--
Paula with Cory (IR & PPID?and Onyx (IR/PPID)

  and Remy (ir/PPID)

Bucks County, PA, USA

ECIR Primary Response

NRCplus 2011  ECIR 2014 

https://ecir.groups.io/g/CaseHistory/files/Paula%20and%20Cory

https://ecir.groups.io/g/CaseHistory/album?id=1624

https://ecir.groups.io/g/CaseHistory/files/Paula%20and%20Onyx
https://ecir.groups.io/g/CaseHistory/files/Paula%20and%20Remy

 


Eleanor Kellon, VMD
 

The two most important ones are insulin and ACTH. Thyroid dysfunction doesn't cause insulin problems. Not wanting to be touched is a sign of irritability, often from pain or just not feeling well, and is not a specific thyroid sign.
 
--
Eleanor in PA

www.drkellon.com 
EC Owner 2001


Kirsten Rasmussen
 

Thank you Paula and Eleanor,

So, I should skip the oral sugar and thyroid tests for now.  What justification should I give my vet for saying I don't want the oral sugar, in case she challenges me on this?  And does ACTH need to be done a second time in autumn, or will the results from this spring provide enough information?

UGuelf offers these 2 handy packages, both of which would work for for IR and PPID: 
1) Equine metabolic syndrome tests - insulin, leptin, glucose, ACTH, and T4
2) Equine PPID (Cushing’s) profile - ACTH, glucose, insulin

--
Kirsten Rasmussen
Kitimat, BC, Canada
January 2019

Shaku's Case History:  https://ecir.groups.io/g/CaseHistory/files/Kirsten%20and%20Shaku  
Shaku's Photo Album:  https://ecir.groups.io/g/CaseHistory/album?id=82559  


Kirsten Rasmussen
 

So I have heard back from my veterinarian on testing for IR and PPID at U Guelf and it's much more affordable than they quoted me 2 years ago! Yay!!  :)

But, they did say this:
"90 minutes prior to the blood collection he will need to be given a calculated dose of white corn syrup orally."

I understand that's how you get the most accurate diagnosis for IR, but doesn't this group recommend NOT giving sugar before the test?  It doesn't explicitly say that in the Diagnosis protocol, so how do I convince my veterinarian not to give sugar before testing and to just test Shaku's baseline values?  Or should I just go with what my veterinarian wants to do? 

--
Kirsten Rasmussen
Kitimat, BC, Canada
January 2019

Shaku's Case History:  https://ecir.groups.io/g/CaseHistory/files/Kirsten%20and%20Shaku  
Shaku's Photo Album:  https://ecir.groups.io/g/CaseHistory/album?id=82559  


celestinefarm
 

Kirsten,
Your vet is still planning to use the oral glucose challenge test on your horse. The ECIR group feels that the risk of pouring pure sugar into a potentially IR horse that may be already footsore from subclinical laminitis( the reason many people first start testing their horses) is "insane" as per a comment from Dr. Clougher several years ago.  There is zero practical reason to do this in the field, the test is based on human testing protocols, of which a horse and human do not share the same digestive physiology. It has been used as a research tool, and IMO, has no place in the real world of horse owners with  concerns about laminitis.
A simple blood pull from a horse that has been given forage (no grain, which would be on par with the karo syrup administration) will yield accurate insulin numbers. You are going to have to insist on this with your vet. 


--
Dawn Wagstaff and Tipperary   

Saline, MI  2003

Tipperary Case History


Eleanor Kellon, VMD
 

Sometimes you have to pick your battles. Compared to fasting samples (which we don't recommend anyway), the glucose challenge picks up more positives. However, it causes an insulin spike which is going to be higher with the more IR the horse is.  I definitely wouldn't do it if the horse was obviously laminitic. When the IR is controlled there is a smaller, but still real, risk of causing hoof pain.
--
Eleanor in PA

www.drkellon.com 
EC Owner 2001


Kirsten Rasmussen
 

Thank you Dawn and Eleanor.  I would be worried about the sugar syrup triggering another spring-time episode of acute laminitis (his first one was in the spring in a dry lot on hay only!)...although I am managing him far better now then when he had his last attack, he still has tender feet and fat pads, and his hay is not ideal.  The risk is definitely there. 

No offense to any veterinarians here but I also learned last fall that part of caring for Shaku is protecting him from things that a well-meaning veterinarian will do that may cause Shaku harm...after watching it take weeks for a large 1" diametre wound to stop bleeding and scab over, all for the sake of removing a mm-size cyst, I promised him I would be more discerning about what I will allow.

I have emailed my veterinarian to ask if she will consider NOT administering the oral sugar test because of the possibility of triggering acute laminitis, and again provided her the link to the ECIR Diagnosis web page.  Fingers crossed....

Thank you all again...I look forward to posting Shaku's results this spring!! :)

--
Kirsten Rasmussen
Kitimat, BC, Canada
January 2019

Shaku's Case History:  https://ecir.groups.io/g/CaseHistory/files/Kirsten%20and%20Shaku  
Shaku's Photo Album:  https://ecir.groups.io/g/CaseHistory/album?id=82559  


Jackie W
 

I am also following this conversation. After a few years of doing the standard blood draw for glucose and insulin on my IR pony, my vet now says the new information out recommends to do the oral sugar test because it is more accurate.  I objected, but he said yep, that's the right protocol and my (probably uncompensated) IR pony should be fine because it's a small amount of the type of sugar that shouldn't cause problems. So, rather than checking bloodwise to see if we're doing better with all the diet changes, I'll probably continue to just assume she's not (she still has fat-pads). Additionally, the price of ACTH is $200 and apparently Cornell changed their pricing so it doesn't add in any other checks with it now.
--
Jackie and Megan
Palm Bay, FL
Joined March 2018

https://ecir.groups.io/g/CaseHistory/files/Jackie%20and%20Megan


 
Edited

Hi, Kirsten - I am sorry that I somehow missed your first post, because I am just down the road from you in Smithers.  Since our courier (can't remember if it was DHL or Purolator) didn't get on the Banker's Dispatch contract, we have no more aircraft courier service from here, and I assume Kitimat/Terrace is in the same boat.  This makes it really tough to get blood to the lab in a timely manner. It cost me $300 for the last shipment to Guelph, and took 48 hours to get there (that was the most time-effective). I see, however, that if you can keep the weight and package size down, you should be able to do it for about $120 (I obviously had too much ice in the box!)

You have already gotten some great information from Paula, Eleanor, and Dawn - I can add a little perspective from BC.

As horse owners, we really do have to be advocates for our horses. Veterinarians are constantly exhorted to use *only* "best practices", and what that means for EMS horses is the stuff put out by the Equine Equinology Group. Yes, the oral sugar test will pick up more borderline cases, and have fewer false negatives, but the risk of precipitating a laminitic event is very real. Besides, if you have a cresty horse with sore feet and fat pads, and you get a high baseline insulin, you don't need to do the oral sugar test. If it looks like a duck, walks like a duck, and quacks like a duck, it is probably not a loon.

Regarding which tests to use: Leptin is useful in that it can help distinguish high insulin due to IR, vs high insulin driven by PPID and high ACTH.  It does add to the cost, because Guelph has to send that out to Cornell, while the other tests are done in-house.  If funds are an issue (and when are they not?) then you can skip the leptin test. At age 20, the ACTH is very definitely indicated.

Regarding when to test the ACTH for PPID, yes, you should test soon (as long as there is no overt severe pain present); If the ACTH is above normal, then start pergolide (see Pergolide 101 here:  https://ecir.groups.io/g/main/files/3%20Cushings%20Disease%20-%20PPID/Cushings%20Disease%20Treatments/Pergolide )  and then re-test ACTH in late August/September to make sure you have enough pergolide on board for the seasonal rise.   

If the ACTH is normal, then still re-test in August or September, because many early PPID horses have normal ACTH in the "low season" (February through June), but will spike an abnormal ACTH during the seasonal rise (August through November).  Here is a graph of ACTH values for the UK:  https://ecir.groups.io/g/main/files/Blood%20Testing%20for%20IR%20and%20PPID/Blood%20Testing%20for%20Cushings%20-%20PPID/Seasonal%20Influences%20on%20ACTH/Liphook%20study:%20Pituitary%20Pars%20Intermedia%20Dysfunction.pdf  

Cheers, and welcome to another BC person!
-
Jaini Clougher (BSc, BVSc)
Merlin (over the bridge), Maggie, Gypsy, Ranger
ECIR mod/support, BC 09
DDT+E = effective treatment for PPID and EMS/IR equines: https://bit.ly/2J4ZgYT

https://ecir.groups.io/g/CaseHistory/files/Jaini%20and%20Merlin-Maggie-Gypsy .
https://ecir.groups.io/g/CaseHistory/album?id=34193  
https://ecir.groups.io/g/CaseHistory/album?id=39711


Kirsten Rasmussen
 

Thank you for your input, Jaini, I have seen your articles in Canadian Horse magazine and I mentioned to my veterinarian last time she was here that we have an EMS expert in Smithers and that you are the current president of the ECIR no less!! :)

My veterinarian's office quoted me 431$ for the Guelf EMS package (insulin, glucose, ACTH, leptin and T4) including shipping, a big change from their original quote 1.5 years ago of 733$ plus shipping!  Maybe that's too good to be true but fingers crossed that it is right!  I think my hay costs for Shaku are about to double this year, if I want to buy tested low sugar hay, so my horse budget is really going to have to stretch...but the test results will worth it if they provide justification for spending more on hay. And if they pick up on early PPID.

I'm still waiting to hear if they will consider not doing the oral sugar. Fingers crossed there too!

Thanks again!
--
Kirsten Rasmussen
Kitimat, BC, Canada
January 2019

Shaku's Case History: https://ecir.groups.io/g/CaseHistory/files/Kirsten%20and%20Shaku  
 

Shaku's Photo Album:  https://ecir.groups.io/g/CaseHistory/album?id=82559&p=Name,,,20,1,0,0   


Lavinia Fiscaletti
 
Edited

Hi Jackie,

ACTH, insulin, leptin, glucose, T4 have always been available as individual tests from Cornell. They also offer various combinations of the tests, which save money over the cost of doing each one individually.The "Equine Metabolic Syndrome Diagnostic Plan" combines all 5 of them as a package.  It is up to the vet to choose what is done. The oral sugar test is not used to monitor an already-confirmed-IR individual's status so wouldn't be appropriate in your circumstances anyway.

Here is the link to the latest Cornell pricing, direct from Cornell (scroll down the pages for the various combination tests and for glucose individually):

https://ahdc.vet.cornell.edu/docs/Test_and_Fee_List_Equine_only.pdf

Here is the link to the info on discounted shipping to Cornell (from anywhere):

https://ahdc.vet.cornell.edu/docs/Shipping_Discount_Program_Information.pdf

These are the actual costs of the tests/shipping as billed to the vet. What your vet charges his clients is an entirely different thing.

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


 

Lavinia,
I think your link above to Cornell's pricing is incorrect. It took me to the tomstests.goup and a message pop-up says "you do not have permission to access that page". I am a member of that group and still got the error.
--
Bonnie Snodgrass 07-2016

ECIR Primary Response 

White Cloud, Michigan, USA

Mouse Case History, Photo Album


Lavinia Fiscaletti
 

Oops - thanks Bonnie - fixed it.

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


 

Yes, $431 looks a lot more like what we charge here.  Phew!
--
Jaini Clougher (BSc, BVSc)
Merlin (over the bridge), Maggie, Gypsy, Ranger
ECIR mod/support, BC 09
DDT+E = effective treatment for PPID and EMS/IR equines: https://bit.ly/2J4ZgYT

https://ecir.groups.io/g/CaseHistory/files/Jaini%20and%20Merlin-Maggie-Gypsy .
https://ecir.groups.io/g/CaseHistory/album?id=34193  
https://ecir.groups.io/g/CaseHistory/album?id=39711


Jackie W
 

Thank you so much for the links!  I really appreciate having this additional insight into the pricing structure and options. There is obviously some confusion at the vet's office.  Thanks, also for the info on the oral sugar test. As per Jaini Clougher's comment, she is exactly right; my vet uses the Equine Endocrinology Group as their primary resource for IR/PPID information.
--
Jackie and Megan
Palm Bay, FL
Joined March 2018

https://ecir.groups.io/g/CaseHistory/files/Jackie%20and%20Megan


 

Kirsten,
Out of personal curiosity I'd like to know if your horse gets supplemental Selenium. I was doing some reading about Se and Se deficient areas in the USA, NW  region and BC. From what I have read the coastal region of BC is typically low in Selenium. If you do not supplement Se then it might be useful to have a blood sample tested for Se levels at the same time as the other tests.

My suggestion has no connection to IR or PPID but your mention of your horse's dislike of being touched made me think of body soreness which can be a symptom of Se deficiency. I'm just interested in this subject.
--
Bonnie Snodgrass 07-2016

ECIR Primary Response 

White Cloud, Michigan, USA

Mouse Case History, Photo Album


Kirsten Rasmussen
 

Hi Bonnie,

With the exception of this year, Shaku's hay has come from an area with adequate Se plus for at least the last 2 years he had been getting 1/8 cup (0.65 mg Se) to 1/4 cup (1.3 mg Se) of Dr Reeds Formula 1 mineral supplement.  I stopped the Dr Reeds this Xmas when I learned the Fe in it was not good for Shaku.  When my new minerals arrive (any day now, YAY!!) he will be back to 1.0 mg Se....plus whatever is in his new hay, which very well could be deficient because it's from a coastal area (I really regret not testing this year's hay for Se....I definitely will next time!).

I'm wondering if it's pain from chronic laminitis, but then why would he step out so nicely when we ride (in boots, with pads on his fronts) if he is in pain? It is possible that he dislikes being touched more in the winter when we aren't riding so maybe it's the colder weather affecting his feet?

I'm hoping his new minerals and some jiaogulin will perk him up....I know now his hay has definitely been deficient in Zn and Cu for years....and the Dr Reeds was not helping balance it at all! (Thank you NRC Plus course!!!!)

--
Kirsten Rasmussen
Kitimat, BC, Canada
January 2019

Shaku's Case History: https://ecir.groups.io/g/CaseHistory/files/Kirsten%20and%20Shaku  
 

Shaku's Photo Album:  https://ecir.groups.io/g/CaseHistory/album?id=82559&p=Name,,,20,1,0,0   


Cheryl Oickle
 

I am curious to your new vitamin mineral supplement. Where are you getting it from and a contact/ website please.I too have been giving Dr Reeds only formula two as it is much lower in iron and although it does contain some starch, it’s low enough that my mare is tolerating. She’s PPID and IR. I live on VancouverIsland. 
Thank Cheryl and Jewel
--

--
Cheryl and Jewel
Oct 2018

https://ecir.groups.io/g/CaseHistory/files/Cheryl%20and%20Jewel

https://ecir.groups.io/g/CaseHistory/album?id=81063


 

HI, Cheryl - there are only really 3 good ration balancers available here in Canada (although you can get some other ones from HorseTech in the States). These are: Mad Barn Amino Trace+: https://www.madbarn.com/ca/product/aminotrace-pellet/    Vif Argent Cheval au Naturel:  http://lechevalaunaturel.blogspot.com/p/blog-page_13.html   or a custom mix from Mad Barn (which is much less expensive that you might think: my custom mix is $1.44 per day per horse). 

There is a table of comparison of commercial ration balancers for *average* BC grass hays (if there is such a thing) in the Diet Balancing folder:       https://ecir.groups.io/g/main/files/6%20Diet%20Balancing/Comparison%20of%20Various%20Commercial%20Balancers%20to%202%20Regional%20Mixes/Comparison%20of%20Various%20Commercial%20Supplements%20and%20BC%20Regional%20Mix%20on%20Grass%20Hay.pdf   (the Diet Balancing folder is here:  https://ecir.groups.io/g/main/files/6%20Diet%20Balancing  )  One of the bigger issues with Dr. Reed's is the high manganese. Thanks to Mt. St. Helen's, and other volcanoes around the Rim of Fire, we have more than enough manganese in our soils and hay. Manganese can interfere with copper and zinc absorption, similarly to iron. 
--
Jaini Clougher (BSc, BVSc)
Merlin (over the bridge), Maggie, Gypsy, Ranger
ECIR mod/support, BC 09
DDT+E = effective treatment for PPID and EMS/IR equines: https://bit.ly/2J4ZgYT

https://ecir.groups.io/g/CaseHistory/files/Jaini%20and%20Merlin-Maggie-Gypsy .
https://ecir.groups.io/g/CaseHistory/album?id=34193  
https://ecir.groups.io/g/CaseHistory/album?id=39711