Cupcake in full wind up


Carla Anderson Peters
 

Hello,
I haven’t updated my case history, due to a huge life change.  Anyway, Cupcake was doing very well until she wasn’t.  Her last ACTH/Insulin test was in July.  Her ACTH was 22 (I believe) and insulin greater than 200.  At that time she was asysmptomatic.  Then right around August 8th, she became a little off and then it just progressed.  Her diet is tight and balanced (however, she isn’t really eating her Stabul 1), hay has been tested and under 10% sugar + starch.  She has been stalled for weeks.  During that time she managed to tear her lower eyelid. She is sore in all 4 limbs, more in the hinds.  She WAS laying down a lot, and difficult to get up so the vet became more aggressive on treatment.  She is currently under veterinarian care (1x-2x/week).  I believe it was last week, when the vet did a treatment of IV DMSO which helped get her out of severe wind up (laying down, a lot of shifting the hinds).  Then we tried oral DMSO 10ml, for a short protocol...It worked while she was on the DMSO, but then relapsed a bit after the oral is terminated.  She re injured her eye a bit, so there needed to be more sutures, so she became sore again...used the short oral DMSO treatment again. Again, once off she became sore.  She is in soft rides on the front, and cast with DIM and Easy Care shells (from the fit kit) with pads.  She is also on  9 tabs of SMZs, 8 tabs of Tylenol, 1/2 gram of bute (which will end within a couple of days.  She is on 2.5 grams of Prascend. The vet just started her on Gabapentin (one tab).  I am just so overwhelmed with worry for her.
Thank you!
--
Carla

 

December 2013, WI

Cupcake and Gunnar's Case Histories 

Cupcake's Photos

Gunnar's Photos 

Ω



Eleanor Kellon, VMD
 

Sorry to hear that, Carla. I'm going to do this is DDT format because it should  be easier to follow.

D: Diagnosis.

The timing here is highly suspicious for the seasonal rise tipping her already high insulin over the edge, although insulin was already more than high enough to trigger acute laminitis.

D: Diet and Drugs

Diet sounds controlled but it could still be helpful to soak her hay until this calms down. If the timing coincides with night temperatures in the 40s, leg wraps and socks in boots might also be helpful. A bump up in pergolide could be useful and if she's not on it, start metformin at 30 mg/kg, twice a day (daily total 60  mg/kg). Retest her insulin and ACTH after a week.  If insulin still high (80 or over), consider Invokana.  The SMZ could be an issue; consider switching to doxycycline. You didn't mention any bute or other NSAID, which is good. You could try the DMSO on her coronary bands instead of orally if concerned about continuing that. (There's no information pro or con about extended courses of systemic DMSO.) I would also start her on Jiaogulan.

T: Trim

Not likely to be part of the cause but trim is often a big factor in comfort. Post photos if you can.
--
Eleanor in PA

www.drkellon.com 
EC Owner 2001


Carla Anderson Peters
 

Hello Dr. Kellon,
Unfortunately, she is back on bute 1/2 gram 2x/daily.  
I will talk to my vet about switching medications from SMZs to the doxy.
Also, what is the role of Cabergoline with PPID horses?  Is this a replacement medication when pergolide isn’t effective anymore?
Thank you!

--
Carla

 

December 2013, WI

Cupcake and Gunnar's Case Histories 

Cupcake's Photos

Gunnar's Photos 

Ω



Carla Anderson Peters
 

Oh, I also retested her ACTH, the results just came back and her ACTH is 30 and her insulin is 97.  Which in July her ACTH was 22 and her insulin was greater then 200.
--
Carla

 

December 2013, WI

Cupcake and Gunnar's Case Histories 

Cupcake's Photos

Gunnar's Photos 

Ω



Carla Anderson Peters
 

My vet also said, that she is at the toxic level of Prascend.
--
Carla

 

December 2013, WI

Cupcake and Gunnar's Case Histories 

Cupcake's Photos

Gunnar's Photos 

Ω



 

Hi Carla,
Your case history states that you increased her Prascend to 1.75 mg on 2-4-17.  Is that the last increase you’ve made?  On what basis did vet describe this as toxic?  Is she responding poorly to the drug?  Normally that would not be considered a large dose.  I have a Shetland on 5 mg now and a mini on more.
--
Martha in Vermont
ECIR Group Primary Response
July 2012 
 
Logo (dec. 7/20/19), Tobit(EC) and Pumpkin, Handy and Silver (EC/IR)

Martha and Logo


 
 


Carla Anderson Peters
 

Hello Martha,
No, she was on 2 g, then I titrated her up to 2.5 g. She has been on that for about 4 weeks, and her ACTH went up since July.
--
Carla

 

December 2013, WI

Cupcake and Gunnar's Case Histories 

Cupcake's Photos

Gunnar's Photos 

Ω



Carla Anderson Peters
 

Martha,
She didn’t give me any reason supporting that...It was a blanket statement.  I feel that she is currently not responding to that level (2.5g) for sure.  Does pain override the efficacy of pergolide?
--
Carla

 

December 2013, WI

Cupcake and Gunnar's Case Histories 

Cupcake's Photos

Gunnar's Photos 

Ω



 

Carla, it’s to be expected that she may well need more pergolide with time.  Some horses are lucky and don’t but needing more is a reasonable finding.  It’s possible that her current struggles are causing her to need more pergolide, not because the pergolide is less effective just that there is no longer enough to do the job.
We have a dosage database somewhere here but last I checked, I think it was being refurbished.  I have a 30 yo horse on 24 mg now.  He seems to be doing well.  I know there are some horses which don’t tolerate it well but I’ve never heard a toxic dose described before.  Maybe ask for a trial?
--
Martha in Vermont
ECIR Group Primary Response
July 2012 
 
Logo (dec. 7/20/19), Tobit(EC) and Pumpkin, Handy and Silver (EC/IR)

Martha and Logo


 
 


LJ Friedman
 

How did you titrate from 2.0 to 2.5? And why?

--
LJ Friedman  Nov 2014 Vista,   Northern  San Diego, CA

Jesse and majestic ‘s Case History 
Jesse's Photos

 


Sherry Morse
 

Hi Carla,

As we're in the midst of the seasonal rise it's not surprising that her ACTH level went up since July but her elevated insulin is more concerning at this point. 




Eleanor Kellon, VMD
 

There are alternatives to the bute that don't have the side effects, like the Uckele Devi's Claw products Hemp Joint or PhytoQuench pellets.

We have some members using the cabergoline injections as an alternative to pergolide.
--
Eleanor in PA

www.drkellon.com 
EC Owner 2001


Carla Anderson Peters
 

LJ,
I did it to try and manage her footyness. I diluted a 1/2 tab drew up 4mls of water and then put 2mls in 2 syringes.
--
Carla

 

December 2013, WI

Cupcake and Gunnar's Case Histories 

Cupcake's Photos

Gunnar's Photos 

Ω



Carla Anderson Peters
 

Hello Dr. Kellon,
Is the cabergoline, recommended by the group for those members that are using it?
I would love her to be off of the bute, but the vet recommended it.  Can I stop bute abruptly?  Can I use the j-herb with those other alternatives to bute?
Thank you!

--
Carla

 

December 2013, WI

Cupcake and Gunnar's Case Histories 

Cupcake's Photos

Gunnar's Photos 

Ω



Kirsten Rasmussen
 
Edited

Hi Carla,

The cabergoline is usually given to horses that aren't responding to pergolide anymore or cannot be fed a daily dose of pergolide.  It is more expensive and is done by injection once every 10-14 days.  At 2.5mg of Prascend, however, you haven't exhausted the possibility that it's not working.  The reason for your vet's concern is likely that Prascend has only been approved (ie, tested) for horses at up to 3mg/day in the US.   In the UK the same drug has been approved for up to 5mg/day.  Many of our members have exceeded these limits because controlling the disease is more important than worrying about drug toxicity.  In other words, if the disease can't be managed and will cause death or euthanasia, then why worry about a higher dose (than is proven by testing to be safe) of the drug if it actually controls the disease and prevents death/euthanasia and improves quality of life.

See these posts:
https://ecir.groups.io/g/main/message/233704
https://ecir.groups.io/g/main/message/208193
A search of past messages and "upper+limit+Prascend" will bring up lots of posts on how increasing pergolide past the established safe dose saved their horse's lives.

You can start either of those other supplements while she is on Bute, and slowly taper off the Bute by spacing the same dose further apart as described in our files.

--
Kirsten and Shaku (IR) - 2019
Kitimat, BC, Canada
ECIR Group Moderator
 
Shaku's Case History  
Shaku's Photo Album   


Kirsten Rasmussen
 
Edited

Hi Carla, I just want to respond in the group to your private message to me.  

It's true that pergolide is dosed by body weight, at first.
https://ecir.groups.io/g/main/message/242587
https://ecir.groups.io/g/main/message/242587

However, PPID is a progressive condition that worsens with time.  If ACTH is not kept in check by increasing the pergolide dose as needed, " the hypertrophy/adenoma is growing unchecked. Sooner or later, the horse will pay the price for that" - as per Dr Kellon in this extremely informative post:  https://ecir.groups.io/g/main/message/134888

and, "the only correct dose - cabergoline or pergolide - is the one that controls the ACTH. There may be common doses, starting doses, etc but no set amount should be called a recommended dose"
https://ecir.groups.io/g/main/message/248236

MANY of our members have their equines on higher than recommended (by the manufacturer) doses, and they have not reported toxic effects.  If they had, we would not recommend increasing the dose above what the manufacturer has tested and determined to be "safe".  If you look at our database on this you'll see just how high some of the doses can get, without negative side effects. 
https://ecir.groups.io/g/main/files/3%20Cushings%20Disease%20-%20PPID/Cushings%20Disease%20Treatments/Pergolide/2.%20Pergolide%20Dosage/ECIR%20Pergolide%20Dosage%20Database.pdf

If it is your vet that needs convincing that increasing pergolide is in the better interest of your pony rather than letting PPID progress unchecked, the best way to do this is to educate yourself as much as possible, listen to the reasons for his/her concerns, and maintain a respectful and good working relationship with your vet.  For example, ask if she will consider a trial at a higher dose, then take daily notes of your pony's condition and signs of PPID, with follow up bloodwork during the trial or at the end of the trial for ACTH and to look for liver damage.  Maybe if you agree to regular checks of liver function she will consent to a higher pergolide dose.  Hopefully there is some compromise that works for you both.
https://ecir.groups.io/g/main/topic/1046099#134893
https://ecir.groups.io/g/main/files/9b%20Pulling%20it%20Together/Getting%20Your%20Veterinarian%20on%20Board.pdf

I hope this helps you a bit.

--
Kirsten and Shaku (IR) - 2019
Kitimat, BC, Canada
ECIR Group Moderator
 
Shaku's Case History  
Shaku's Photo Album