ACTH and Insulin Testing Help/Questions


Stephanie Stout
 

Hi Everyone,

I have a couple questions regarding ACTH and Insulin testing through Cornell(using EDTA Plasma). My vet(bless her dearly, but she's not the most organized) drew the blood samples on January 31st. Supposedly she did spin and freeze the samples within 4 hours, however the samples were not tested/finalized at Cornell until February 14th. 

I ran the blood work because King is extremely skinny and lethargic so I'm thinking his ACTH might be high - he's at 20mg Pergolide. The results came back at: 

ACTH 330 pg/mL (reference 9 - 35)
Insulin 81.04 iIU/mL (reference 10 - 40)

His last test was in August 2016 at 51 pg/mL ACTH. So, could he have actually risen that much? I bumped him up from 16mg to 20mg for the seasonal rise after that the August result came back. 

Is it possible the blood was too old and not accurate? Can the blood stay that long and still be accurate/good? I know that Cornell had confusion/trouble with the blood(but they wouldn't give me the exact issue). Is there a way to test the potency of the capsules from Pet Health? If he did shoot up from 51 pg/mL to 330, why would it go so high? Nothing has changed besides upping his Pergolide from 16 to 20mg for the rise.

The vet also did the same ACTH and Insulin test for a couple other of my horses(they don't have a Case History) and another one also came back super high compared to their August test.

Thank you for your help. I think I need some wine now. Panic attack on these numbers!

-- 

Stephanie & King
October 2014
Oregon
Case History 


Maggie
 

Hi Stephanie,

I think the first thing I would want to know is what was the issue with the blood.  Was there a mix up, ie was the sample really King's?  Could there have been a mix up anywhere along the line from your vet through to Cornell?  Everyone makes mistakes, but you have a right to know if the blood you sent is actually giving you accurate results.  At the very least, I would ask both your vet and Cornell to repeat the lab work on a fresh sample, free of charge.

That said, if the the sample was spun and frozen within 4 hours, and stayed frozen, the sample should be accurate.  Since ACTH degrades quickly, the problem with blood not properly handled is that it gives a false low ACTH, not a false high ACTH.  So if the blood was not properly handled, you would expect to see the ACTH too low, not too high.  Really need one of the vets to comment, but based on King's symptoms, I would increase his pergolide.  Did you see any decrease in symptoms when you increased after the August results?  

Yes, there is a place where you can check the potency of your pergolide.  http://www.eagleanalytical.com/sitecontent/578/potency/category/462/about-testing.aspx 

You might also be interested int his recent conversation:  https://ecir.groups.io/g/main/topic/4369383#205468 

Please update King's CH so we can see everything in one place.  It's not just helpful for us, but for you as well, to see everything in chronological order.  Here's a recent post from LeeAnne with important details about how to update your CH:  https://ecir.groups.io/g/main/message/205480   And filling out a CH on the other horse that came back with an elevated ACTH would help us to help you sort things out there as well.

Deep breaths Stephanie!  And the wine--that's good too :)  Hang in there while we help you get this sorted out.

Maggie, Chancey and Spiral in VA 
March 2011
EC moderator/Primary Response


Lorna Cane
 

Hi Stephanie,


Can you update King's CH ?


--

Lorna in Eastern Ontario, Canada
ECIR Moderator 2002




Ernie <kbarranch@...>
 

Hi Lorna,

I have found that the people at Cornell to be very uncooperative with their real customers.  They claim to only communicate with the vet.  I told them that I pay their bill.  The girl said,  "No, the vet does."  What a bunch of BS.
--
Ernie 7-2016

Brazoria County, Texas

Cheyenne

https://ecir.groups.io/g/CaseHistory/files/Ernie%20and%20Cheyenne 

https://ecir.groups.io/g/CaseHistory/album?id=1709 


Stephanie Stout
 

Hi Lorna and Maggie,

I just uploaded a new version of King's CH. It wouldn't let me delete the old one, but the new one says 'updated' in the file name. I hope that helps. If you can delete the old CH, please do! 

Unfortunately, the vet that did the blood has now moved out of state so I'm not going to be able to get her to rerun the blood work. I do have an appointment with a different vet tomorrow to hopefully rerun the blood work. I know I will have to pay for it again, but I don't think there is much I can do about it at this point. 

There is confusion with Cornell. I called Cornell to ask if they had received the blood samples(vet was in the middle of moving, so I knew I couldn't get a hold of her) and Cornell said blood samples were not testable due to receiving whole blood and not plasma. So, I started figuring out who could redo the blood work, etc and then yesterday the original vet forwarded me the results...So I am not sure who to believe, or if the blood was accurate or inaccurate. 

I don't have any Pergolide capsules besides the 20mg. Should I wait until I get the next blood work(hopefully this week if the vet shows up tomorrow) to increase his dosage? Or should I break apart a 20mg capsule, divide it up the best I can to give him more? How much higher should I increase if I do that?

He was in good weight and doing well back in the end of August/September when I increased him from 16mg to 20mg. He started declining(weight and energy) around Thanksgiving, and I kept asking to run ACTH and Insulin. It took the vet forever(January) to get out here to run the blood. I guess something about 54 inches of snow and being snowed in for 3 months didn't help either!

--
Stephanie & King
October 2014
Oregon
Case History 


Maggie
 

Hi Stephanie,

I see that LeeAnne uploaded your CH before, which is probably why you can't delete it.  I will shoot her an email.  Thanks for the updated one. 

What a mess with getting King's labs drawn!  54" of snow--ugh!  

A few ideas/thoughts....

I wish I could comment on the confusion with the blood, but that's a real mess.  I can't imagine that Cornell would have actually run the ACTH on whole blood.  Again, the ACTH results would have been artificially low if the blood was not handled properly.  I agree that at this point you are just going to have to bite the bullet and pay to rerun the blood work. Maybe the old vet would consider reimbursing you if she didn't process the blood correctly.

How old is your pergolide?  Do you order only 30 days at a time and store it in the fridge, as recommended to ensure maximum potency?  Have you asked Pet Health to provide a potency test and an expiration date on the pergolide?  I see that the ACTH dated 2/15/2017 was done in the PM.  How long after the last dose of pergolide was that?  How does it compare to the one done in August (no time noted on that one)?

We do normally recommend that the pergolide be given in one dose, but have found over the years that some horses, can benefit from adding a second smaller dose later in the day (assuming you are giving the 20mg dose in the morning).  

As far as waiting to increase his dose, I would ask the vet that is coming today to sell you some of Prascend that you could use to increase his dose after she does the blood draw today.  Maybe you could buy just part of a box from her.  You already know King's ACTH is high, just not really how high.  That will give you some time to either order some smaller compounded capsules to use for increasing his dose, or settle on a new dose to order.  You could also use it to add a second smaller dose later in the day if you want to try that.  Sometimes you just have to do some experimenting to see what works best.  They are all so different and work hard to keep us on our toes!  I might give the vet a call early and make sure she has has some Prascend in her truck.

Are you keeping a journal on King?  It can be really helpful in determining if he needs an increase in pergolide in the absence of an ACTH test.  Read this post by Patti for some really great tips:  https://ecir.groups.io/g/main/message/111558   Weight loss and declining energy are classic signs of elevated ACTH.  Read more here:  https://ecirhorse.org/physiology-ppid.php  Lots of folks use symptoms to make pergolide increases.  Of course, it doesn't replace testing, but can sure help.  If you get into the same conundrum again, of not being able to get the testing done in a timely manner, you can use the journal to track his symptoms and make pergolide increases until you can get him tested.

I see in your CH that you are using Haystack Low sugar/starch grain.  Is this the one?  http://haystackfeeds.com/?page_id=69   That actually looks like a decent carrier for your supplements, low sugar and starch, and at one cup/day, should be just fine.  It does contain some alfalfa which some horses are sensitive to and rice bran which has an upside down Omega 3:6 ratio, but if feeding ground flax seed it should be OK.  I don't see that you are feeding King any flax seed.  Would definitely want to add 2-4 oz of that to his diet to replace the Omega 3's and 6's lost when grass is cured into hay.  I see your hay analysis, but I don't see any mineral supplementation in your CH. It's really important to get your minerals balanced to your hay.  Maybe you just forgot to add that?  If not would consider at least adding one of the the following until you can get your hay balanced.
 
California Trace:  http://www.californiatrace.com/ 
 
Best to get your minerals balanced to your hay, but one of these can hold you until you do that.  Would also make sure his trim is really tight.  With his ACTH and insulin so high he is at high risk for laminitis.  A really tight trim can't prevent that but can be really helpful if it does occur.

Hang in there Stephanie!  

Maggie, Chancey and Spiral in VA 
March 2011
EC moderator/Primary Response