New, Overwhelmed, seeking help for my OTTB
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hi y'all,
thanks for allowing me to join your group. The last three weeks have been really stressful and expensive. I'm hoping you can educate me a little about Cushings in horses. I moved from CC to the backwoods of WV and am not near a vet I feel terribly confident with, and the vets here want to put my 15 yo Thoroughbred on meds for Cushings because he just tested positive for the “very early stages”. He is on beet pulp based feed (Triple Crown Senior), soaked alfalfa cubes, brome hay, and no pasture to speak of. This has been his diet for over a year now. I’d just like to know more about it. He’s had abscesses 1- 2x yr since we moved to rocky soil that stays wet for long periods, and has had one in each fore in the last month. The vets here have thrown everything at me from Potomac fever (he’s been vaccinated this spring) to Lyme, to EPM to Cushings and so on. I asked them to test for Lyme and they did not, said his bloodwork didn’t indicate the need for it. I never got a clearer response than that. Initial bloodwork showed slightly elevated WBC, but that’s all I know. They put him on bute and doxycycline and a laminitis medicine pentoxifylline. Then they took him off the laminitis meds a week later because they said it was for prevention and he already had laminitis. Told me no need to finish the doxycycline because bloodwork a week later showed “nothing remarkable”. Then they put him on Hot Hoof 2. We finished the last 2 doses of doxy anyway. They did radiographs of his fronts and say he’s “very mildly rotated”. I don’t have measurements or numbers (I’ve asked and hope to get them) and they often don’t share information without my asking, just “here, do this”. My farrier is skeptical as well, of their opinion and them in general, sometimes. I understand from the little bit of reading I’ve done that Cushings test isn’t 100% reliable. I’ve been told this is the wrong time of year to test, due to natural hormonal levels changing. I also heard that an abscess may possibly “warp” a radiograph. I have done all they’ve asked while we have vague answers and I want to treat my horse the best way I can. I am just in a position where I feel I’m being charged a ton of money for what feels somewhat like guesswork. We don’t have unlimited funding. I could be wrong, too, because I don’t WANT him to have another disease (he has heaves and we finally have that mostly managed and he looks better than he has since it first hit him- even has dapples). I do not necessarily believe the vets are wrong, I feel what they've shared with me is an incomplete picture. I'm left wondering if an old or light case of Lyme is affecting his metabolism now and that is the root of it all. What I really want is to feel confident in the vet care available to me, but between treatment of my horse and my other pets issues, there’s a long list of iffy stuff with this clinic, but there is not another large animal vet nearby. So I feel my best available option at the moment is to educate myself. I really feel like I stepped back in time when I moved here, but I’m hoping y’all can visit with me and help me understand and maybe help me decide which questions I really DO need to press for answers on. I'm wondering if dietary changes and low dose of doxy for 30-45 days would be appropriate, even if they don't want to test for Lyme. thank you Thank you, Anna -- Anna Dolly Keyser, WV Sept. 2020 |
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Hi Anna, you will get the full welcome message shortly, but I thought I'd add my 2 cents.
It sounds like you need better communication from the clinic about why they are making their recommendations. As the owner of the horse who is also paying for the costs of tests and treatment, you have a right to politely insist on more information so you can make informed decisions. It might be that they are really busy and struggle to find more time to answer your questions and send your radiographs, so you will have to be a squeaky wheel. You paid for it. This includes your radiograph images, with or without measurements, and copies of all bloodwork results. You can also tell them that regardless of the lack of evidence for Lyme, you'd still like a test so YOU can set YOUR mind at ease and that is worth the cost of the test to you. I'm curious how where the positive PPID diagnosis came from, did you have bloodwork for Endogenous ACTH done? There are few false positives for this test, and this is actually an excellent time of year to test because a true positive will have a more elevated ACTH than normal horses. In fact this time of year it is possible to detect early onset of PPID before serious symptoms manifest in full-blown cases. Stress, exercise, and fasting can affect ACTH diagnosis to some degree, so if the results are equivocal we often recommend retesting under ideal conditions. The details of the testing conditions are important, as are the actual results. This is why we would really appreciate it if you could fill out a Case History with all the data you have so you can get a second opinion here. -- Kirsten and Shaku (IR) - 2019 Kitimat, BC, Canada ECIR Group Moderator Shaku's Photo Album |
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Hi Anna
Welcome to the group. I'm sorry you are going through this with your boy. It is very stressful not to have confidence in one's veterinarians, but I can assure you that you're in the right place to learn more about Cushings (PPID)! You will have received instructions on filling out a case history so that we have all the details in one place for our moderators to look at. You can also upload photos and x-rays to a folder in the case history group. Shortly one of our experienced moderators or Dr Kellon will address your concerns re the Lyme and other medications. This message is to send you our welcome letter, which contains a lot of information about PPID, IR and the philosophy and protocols of the group. Please read through it carefully, follow the many links to further information. Hopefully this will answer many of your questions, and please ask further questions as they arise. You will need to get a copy of the actual test results from your vet, ditto the x-rays. You paid for these, they are yours and you have a right to a copy. Otherwise we are flying blind. Hoof photos would be helpful too (link to instructions in the Trim section below). I can quickly answer a couple of your questions right now--the endogenous (baseline) ACTH test for Cushings is pretty reliable if the blood is handled correctly (details in the Diagnosis section below). There are cutoff levels for every month of the year, so you can test at any time. Right now is a good time to test for early Cushings, as these horses will have a greater rise in the hormone at this time of year than non-PPID horses. Abcesses do not 'warp' a radiograph, but they may make interpretation of a radiograph a bit more difficult. If you can post the rads, our hoof guru can give you feedback. That's all for the moment, sit back and enjoy the reading. Hello Welcome to the group! The ECIR Group 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. Have you started your Case History? If you haven't done so yet, please join our case history sub-group. We appreciate you following the uploading instructions so your folder is properly set up with the documents inside. Go to this CH message with info on how to use various devices and forms. If you have any trouble, just post a message to let us know 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 and glucose. The fat-derived hormone leptin is also usually abnormally elevated in insulin resistance but because there are many other things which can lower or increase leptin ECIR is not recommending routine testing for this hormone. Leptin is the hormone that says "stop eating". In Europe, adiponectin is tested instead of leptin. Adiponectin helps regulate glucose and fat burning, and maintain insulin sensitivity. Low levels are associated with EMS. It has come to be preferred over leptin because it is not influenced by things like weight or exercise, and also because it was the only factor other than insulin levels that predicted laminitis risk *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:
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. 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. --Maxine and Indy (PPID) and Dangles (PPID) Canberra, Australia 2010 https://ecir.groups.io/g/CaseHistory/files/Maxine%20and%20Indy%20and%20Dangles
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thank you for the welcome!
I am working on the case history, there is much I do not know. I know that this test was free and they wanted fasting blood and non-fasting blood, but I do not know the name of the test or what all it included or didn't include. I do not understand leaping into meds without even discussing dietary changes that might be needed, but as I said, they do not share much information with me. I recall asking this same clinic to test for Lyme three years ago and was put off then, too. I don't understand the resistance to checking for Lyme. We live in the mountains in the woods. I have a call in to a second vet, she is not local but the farrier thinks highly of her and says she does come to this area. I hope to hear back from her soon and either confirm what this clinic says or shine new light on the situation, one of the two. I'll get pictures of Babe's hooves. The current sore foot has an abscess that started draining late today, finally. He has some swelling up his cannon bone. Anna~ You can find my artwork at Txjest on Instagram and Charcoal Filly Gallery by Anna Dolly on Facebook -- Anna Dolly Keyser, WV Sept. 2020 |
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Great, put what you know in it for now! I would definitely call the clinic and politely insist on copies of all test results and radiographs on your horse. If it was free, they would have benefited from the data in some way (either reimbursed by a research group or drug company, or its part of a study they are involved in). You can post a PDF of the test results in the same folder as your Case History.
If he truly is positive for PPID, the only option is treatment with pergolide. Dietary changes are also important if their insulin is high due to the PPID and they are at risk for laminitis, but the only thing that helps slow the progression and severity of the disease is medication. We have had members describe what it's like to lose a horse to untreated or uncontrollable PPID eventually, if they aren't euthanized for severe founder first, both are heart-breaking to watch. Along with PPID, there are lots of secondary issues like hyper-reactivity to allergic stimuli (ranging from goopy eyes to hives from insect bites), increased risk of tendon/ligament injury, compromised immune system (which reduces the effectiveness of vaccines), and so on....these things resolve once PPID is being properly controlled by medication. If PPID is well-controlled these horses can live long healthy lives and will often pass due to unrelated issues. -- Kirsten and Shaku (IR) - 2019 Kitimat, BC, Canada ECIR Group Moderator Shaku's Photo Album |
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Thanks, Kirsten, I guess this is why I'm here! I was under the distinct impression that early onset could be managed with diet. And fully admit I know nothing, just lots of input from well meaning friends.
I DO intend to get my hands on the labs/radiographs. The lab who offers the test is who offered it to the vet clinic for free (I think they got 3 spots and we were one of them), so I do not know if maybe it was new, for a study, or what. Babe's second abscess has started draining, but it's obvious that he's pretty sore from over three weeks of having to compensate for abscesses in two different feet. I haven't seen him lay down today, and there was a lot of that yesterday. He's standing slightly camped out and there's still considerable inflammation around the coronet band where the abscess blew. I still want to visit with a vet not associated with that clinic, to see if I can get a better grasp on understanding the mess we've been in here. I am still working on those data sheets. Anna -- Anna Dolly Keyser, WV Sept. 2020 |
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celestinefarm
Anna,
I would also urge you to read the sidebar selections in the ECIR website that was linked in your welcome letter. It will help you understand better what is Cushings, what is Insulin Resistance, when the two overlap and what symptoms are unique to each issue. The information in the website is based on best veterinary practices as the result of what valid studies are currently available for both Cushings (PPID) and IR. The definitions, physiological symptoms , changes. etc. are science based from research here and in other countries . If you have a better understanding of what may be happening with your horse, you can make better decisions for him and be able to judge better if you have professionals you are working with that are up to date in recommendations. https://www.ecirhorse.org/ Dawn Wagstaff and Tipperary Saline, MI 2003 Tipperary Case History |
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