Need Advice ASAP -- PPID/IR Horse Won't Walk


sbcable@...
 

My 16 year-old Gelding was diagnosed with PPID and IR on July 17. He's on one Prascend per day (split in halves and given twice daily). I have followed almost all guidelines since his diagnosis except I can't get hay tested (cannot buy in quantity) and soaking is not a long-term solution. He's finicky with the soaked hay and won't eat beet pulp. So I switched his hay over a 4-day period starting last Sunday from soaked Bermuda to Triple Crown Safe Starch. One week later (starting yesterday), he's experiencing the worst laminitic episode he's ever had. He will not put down one foot and cannot walk. I called my vet but of course no response. He's due to get a re-test and new radiographs this coming Wednesday. But I don't think I can wait. I increased his Bute to 2 grams in am. He was on 1 gram twice per day. I've been trying to wean him off, but he always relapses. However, not this bad. My vet is not concerned about the Bute and wants me to keep giving it to him. I called an emergency vet and they are sending an intern who just graduated vet school in May. She wants me to ice his feet until she can get here in a few hours, which I am reluctant to do. I'm really struggling with this poor horse's treatment plan. I can't seem to get a vet "partner." And this horse is getting worse since he was diagnosed and started Prascend treatment. I'm hoping he has an abscess and this isn't a severe bout of laminitis. Could the switch to the new hay trigger this severe of an episode? It's 8.7 NSC. I have not created his case history yet because I haven't had the time to figure it out. I will do so asap, but I'm frazzled right now with the emergency situation with this horse. Any advice would be greatly appreciated!
 
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--
Susan C in Central AZ, July 2020


Eleanor Kellon, VMD
 

Hi Susan,

We can't diagnose or prescribe here, but can share with you what is in the published literature and our experience over the last 20+ years.

Regarding pergolide/Prascend, when you split the dose like that you are reducing the peak blood levels. Better to give the entire dose all at once. Starting the Prascend has nothing to do with his current situation.  If anything, he's struggling because he is not getting a therapeutic level.

We have found, as have others outside this group, that the Safe Starch is not a good choice a s a complete diet. That 8.7% is only an average and varies by both batch ingredients and because of substitutions.  Read the small print on their site. It is also high in omega-6 fats. He would likely do better on the bermuda, soaked as often as you can.

We have not had positive experiences with long term phenylbutazone on many levels - but I think you already know that. In addition to the side effects of ulcers and kidney damage, it can delay resolution of abscess collections and lead to increased pain sensitivity when you try to stop it. At the same time, NSAIDs can lose their effectiveness over time (tolerance) https://pubmed.ncbi.nlm.nih.gov/27923161/ and as you have seen, don't work that well in the first place. There are effective alternatives, like Phyto-Quench pellets https://uckele.com/phyto-quench-pellet.html in acute stages and with abscesses, and LaminOX https://uckele.com/laminox-3lbs.html .

We know it can be overwhelming - we've been there.
--
Eleanor in PA

www.drkellon.com 
EC Owner 2001


Sherry Morse
 

Hi Susan,

You'll get a full welcome message shortly a couple of things jump out from your email - splitting a Prascend and feeding it 2x a day is not recommended as it decreases the amount of the dosage.  To be most effective the full pill must be given once a day.  Depending on your gelding's ACTH level .5mg a day may not be enough to have controlled his PPID.  As we're currently at the peak of the seasonal rise and a time when many horses with uncontrolled PPID and/or IR experience fall laminitis the timing of his laminitis may have less to do with the change in forage but simply the time of year and the lack of control of his ACTH and/or insulin. 

Bute is contraindicated for metabolic laminitis (there will be more on this in your welcome letter) and can create it's own issues with NSAID rebound effects which is probably what you're seeing.  If he's been laminitic for an extended period of time and it's due to metabolic issues icing will also not help. 

Triple Crown Safe Starch Forage was last tested as being 6.1% ESC+starch (which is the number we are concerned with, not the NSC) and therefore should be ok for an IR or PPID horse but there are so many other elements that go into treatment of a horse with both conditions that without a case history we're going to be limited in what we can help you with.



sbcable@...
 

Thank you Dr.Kellon and Sherry. I will start giving the Prascend once per day. I was originally told to break it up to help avoid the veil. I reached another equine emergency group that had a more experienced vet available to come out. She suspected an abscess and took radiographs. Unfortunately, she could not definitively locate an abscess. She saw what she thinks are a few small gas pockets. She put a patch on the sole to try and draw out the abscess if there is one. She also administered DMSO gastrically.

Most disturbing were his radiographs. They showed significant rotation from the previous radiographs taken two months ago. Those from two months ago showed no changes from the ones taken two years ago. But in two months, we've seen drastic changes. She is not positive, but suspects he may even have a P3 fracture. This is heartbreaking news.

She advised putting him back on the Bermuda and continuing with the maximum dosage of Bute (2 grams twice per day). I know Bute is an issue but every vet I've worked with says to keep him on it. I've tried to wean him off but he relapses. And this confirms what you're talking about in terms of rebound. But do I let him suffer? I can get the products you recommended, but I can't bear to see him in so much pain in the meantime. He has never been in such pain.

I will work on the case history now. I will put as much info in as I can, but the learning curve for this platform is pretty steep (for me at least). I do not have copies of his radiographs from today but will upload them when the vet sends them. 

Thank you again for your help and understanding. This has been a very frustrating journey with countless opinions and very little local vet and trimmer support. And now I'm worried by not adopting the best program from the get-go my poor horse may have irreparable, debilitating damage.
--
Susan C in Central AZ, July 2020


Bobbie Day
 

Susan,
I know things look grim right now but you have absolutely came to the right place. I know exactly how you feel, I’m in a very small town where we have NO Farrier’s and I had to kick and scream to get my vets to do what I’ve learned here. But these protocols work, it’s so hard to see our babies in pain, we’ve all came here for help just as you are.
And abscess are the absolute worst, if you have boots it helps, and soak his feet in Epsom salt a couple times a day if you can. Keep the faith because you can do it, as Dr.K says hope is only lost if you choose to abandon it. There’s always hope, we’re all evidence of that.

--
Bobbie and Desi
NRC March 2020
Utah, Nov 2018

https://ecir.groups.io/g/CaseHistory/files/Bobbie%20and%20Desi 

https://ecir.groups.io/g/CaseHistory/album?id=78821


Cindy Q
 

Hello Susan

Welcome to the group! 

You've gotten some helpful advice from Dr Kellon and the others already. Below I will set out our full welcome letter, it is not so much just a welcome as it is a full run down of the Diagnosis, Diet, Trim + Exercise philosophy of ECIR which has helped many horses before.

- Comfort: Get some eva foam or other cushiony padding on those feet right away. I've seen that give a lot of quick relief especially using Cloud eva pads (from Easycare) with or without Cloud boots. You may want to tape them on with duct tape to test before committing to buying the boots or spring for the boots right away (they include a set of pads). Some horses also like it even better if you dig out a shallow depression in the hoof pad around where the tip of the frog would be (to estimate the tip of the coffin bone- but refer to your xrays as well). The fit is quite forgiving and Easycare can advise sizing. Generous amounts of foot powder/antibacterial generic powder helps keep things dryer and fresh. Easycare also makes 12mm black (medium) eva foam pads that are a little cheaper. Smaller horses or ponies may get by on cheap children gym mat foam (about half inch thick) but on bigger horses, these often do not last more than a day.

- Bute: 
If you are ready to try weaning off again, please look at the following description from Dr Jaini previously about spreading out the time between doses rather than reducing the dose: https://ecir.groups.io/g/main/message/239008 :

"There is a good anti-oxidant pain reliever called PhytoQuench, that people have had success with:  https://uckele.com/phyto-quench-powder.html  Another anti-oxidant/pain reliever is Mov-Ease from My Best Horse:  http://mybesthorse.com/movease.html    Rather than stopping the bute cold-turkey, it is best to take a week or so, and stretch out the doses. So, go from twice daily to once daily for 2 doses, then next dose 36 hours later, then go 48 hours, then stop. (longer weaning off of bute to avoid "NSAID rebound pain" when they have been on the bute a long time, but for Brandy you can fast-track as he hasn't been on it that long).  There is more information in this folder:  https://ecir.groups.io/g/main/files/Pain%20Medication%20and%20Alternatives  , including a file on transitioning from bute to Phytoquench."
- There are some members who found success drying their hay AFTER soaking it and that may help in your situation, see some ideas here: https://ecir.groups.io/g/main/topic/31248644

Here is our full letter with all the details on testing, diet, trim and taking photographs to get specific advice on the feet -  take a deep breath and read it carefully. Step by step.

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 etiquettewhat 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:

  • 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.

EXERCISEThe 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. 

--
Cindy and Glow - Sep 2017, Singapore
ECIR Primary Response





Eleanor Kellon, VMD
 

Susan,

First, there's no room for regretting the past. It can't be changed and thinking about it is counterproductive. Don't assume there's anything irreparable here either. Definitely post those films as soon as you get them, and ask your regular vet to take views to rule out a fracture if that's necessary.  Even the rotation  may not be what you think if his feet need to be trimmed.

As for the bute, keep it on board until you get the alternatives. You will then double up while you wean off the bute, not go cold turkey. Just remember it's prolonging his pain, not helping it.
--
Eleanor in PA

www.drkellon.com 
EC Owner 2001


Cheryl Oickle
 

Words of encouragement sent your way. Dont give up. My beloved Jewel experienced the exact same thing including rotation to both fronts in 2017. I almost had her put down in Oct of that year but found this group after 6 months of heartache. Be patient, be kind to yourself, and take LOTS of time to rehab her once the pain subsides, like months. Follow this groups suggestions and DDT and E. It gives your horse the best chance.
Hang in there. 
Forward to 2020...We are riding again up to 100 miles a month. She is 19 and fitter than ever. 

--
Cheryl and Jewel
Oct 2018
Port Alberni BC Canada
https://ecir.groups.io/g/CaseHistory/files/Cheryl%20and%20Jewel
https://ecir.groups.io/g/CaseHistory/album?id=81063


sbcable@...
 

Thank you Dr. Kellon. I appreciate your words.

I posted the latest radiographs from yesterday in my photo album. I would love to hear your thoughts because he has definitely gotten worse. The changes are pretty drastic from just two months ago. I don't know what could have caused such a change. He has gotten rambunctious a couple of times and was running and turning quite a bit when a new neighbor brought in his horses. The other change was the migration to TC Safe Starch which I originally thought would be better than the untested, unsoaked Bermuda. If his PPID/IR is not yet controlled, could that lead to the significant rotation change? The only other thing I can think of is my barefoot trimmer had a death in the family and he didn't come for over eight weeks. I tried unsuccessfully to find another competent barefoot trimmer. So Aspen had quite a long time between trims.

I ordered the Bute alternatives you suggested. Do I give them both at the same time, or one during acute phase and the other for maintenance, or is it one or the other? Are these supplements in addition to other supplements I may start to give? I noticed similar ingredients.

I had my regular vet out today for bloodwork. She wants to wait for these results before she provides a prognosis. She wants to see if he's responding to the Prascend. She doesn't believe there's a fracture, but she is concerned about the gas streaks running parallel to the hoof wall. She believes his pain is more a result of serious rotation rather than an abscess. She wants to come every other day this week to administer DMSO for pain, on top of the 2 grams twice per day of Bute. She says we need to get the inflammation down.

I'm back to feeding the Bermuda rather than the TC Safe Starch. I tried soaking again, but he picks at it and leaves most of it in his feeder. The vet thinks it's more important to get him eating. In this situation, what else should I be adding to his diet? A ration balancer?

He is due for a trim next week, but vet said not to do it. Since Aspen can't stand on his left foot, this makes sense. I hope a longer trimming cycle will not adversely affect his healing?

Someone referred me to laser therapy for laminitis. I asked my vet and she referred me to a DVM who provides this treatment. My vet had no knowledge of this therapy and could not provide any insights or recommendations. Do you think this is a treatment worth pursuing?

So...I need to finalize a diet, get further input on his radiographs in terms of what we're dealing with, determine any changes to his Prascend dosage based on bloodwork results, and plot the best course of action in terms of his treatment to get over this acute phase and then get him on a solid maintenance plan.

As always, your input, as well as the advice of everyone else in this group, is so much appreciated. Thank you for all you do!
--
Susan C in Central AZ, July 2020
https://ecir.groups.io/g/CaseHistory/files/Susan%20C%20and%20Aspen
https://ecir.groups.io/g/CaseHistory/album?id=253984


LJ Friedman
 

Let’s hope it’s an abscess. Remember icing is wasteful assuming it’s in metabolic which is usually 85 to 90% of the time. As well this time of the year is when many horses get laminitis due to insulin being driven up by uncontrolled PPID levels. What about boots? Many of us an emergency use Styrofoam and duct tape for almost immediate relief.
-- all the best
LJ Friedman  Nov 2014 Vista,   Northern  San Diego, CA

Jesse and majestic ‘s Case History 
Jesse's Photos

 


Eleanor Kellon, VMD
 

 No evidence of fracture.

VERY IMPORTANT:  There is no change in the  degree of true rotation. True, aka bony, rotation is when the coffiin bone is out of alignment with the the bones above it. There is slight true rotation that hasn't changed.  What has changed is called  capsular rotation which can be fixed with trimming. A laminar wedge has formed which increased the size of the horn lamellar zone -   the distance from the edge of the coffin bone out to the hoof wall.  Because of the weak connections and  formation of the  wedge, the hoof wall has been forced away from the bone and each step is putting lever forces on the wall and forcing it further out. The long toe is also preventing development of any concavity and contributing to the  bone loss in the coffin bone.

Those "gas streaks" are pockets in the lamellar wedge.  Very common. They can be air, old blood or infection.

 Imagine your fingertip is a hoof. If the nail is longer than the tip of the finger itself, when you stand it on end and "walk" on it  the nail is forced away from the finger.

 When you can get a full set of hoof photos up Lavinia can do mark ups. Getting the trim corrected needs to be added to the top of your To Do list.

Use the emergency diet supplements. Do you know where your hay was grown? If it is irrigated hay there is a significant risk of high nitrate levels. Fortunately these can be lowered significantly with soaking.  Try finding some high quality, fragrant alfalfa pellets and throw a handful in with your soaking water to see if it improves the appeal of the hay. You can also make alfalfa "tea" by soaking pellets in boiling hot water then filter after cooling.  Spray that on the soaked hay. Another option is to sprinkle on salt or red beet powder - "beet root powder" here http://www.herbalcom.com/index.cfm?fuseaction=cEcommerce.dspProducts&CategoryID=2403&LinkKey=A&OrderClause=Price,DESC .

As for bute alternatives, go with Phyto Quench pellets only for now. No Jiaogulan until trim is fixed and he's on a tight trim schedule.

Homework:  https://hoofrehab.com/AuburnUvetschool.htm
--
Eleanor in PA

www.drkellon.com 
EC Owner 2001


sbcable@...
 

Thank you so much Dr. Kellon. My head is still swimming but I was encouraged by your findings and advice. 

I am waiting for a possible trimmer referral from Paige Poss. Unfortunately, she no longer travels up to my area. 

Aspen started to lay down a lot now. I’m not sure how he will be trimmed when he can’t stand on his left foot? 

I will keep you posted. His latest bloodwork test results should be available tomorrow. 

--
Susan C in Central AZ, July 2020
https://ecir.groups.io/g/CaseHistory/files/Susan%20C%20and%20Aspen
https://ecir.groups.io/g/CaseHistory/album?id=253984


Lavinia Fiscaletti
 

Hi Susan,

If he can't lift the RF, you can have him stand on a 2x4 then trim around that. Or have him stand on a thick bed of shavings/sand/and trim thru the footing material. More work for the trimmer but you can get the job done that way.

Could also see about having the vet present so you could do a nerve block on the LF so that he is able to stand on it for the trimming session.

If he's laying down, just let him. It's good for him to rest his feet and body. Just make sure he can reach his food and water from that position if he needs to.

--
Lavinia, George Too, Calvin (PPID) and Dinky (PPID/IR)
Nappi, George and Dante Over the Bridge
Jan 05, RI
Moderator ECIR


sbcable@...
 

Lavinia...your expertise is amazing and your willingness to help so much appreciated! I hope I can find a trimmer soon who knows what to do. Thank you!
--
Susan C in Central AZ, July 2020
https://ecir.groups.io/g/CaseHistory/files/Susan%20C%20and%20Aspen
https://ecir.groups.io/g/CaseHistory/album?id=253984


Sherry Morse
 

Hi Susan,

If Paige isn't traveling up your way she may have some recommendations of trimmers in the area.  There were a number of local farriers/trimmers who attended the last conference in Tucson and I may be able to pull some names from my old emails for you as well.




sbcable@...
 

Thank you Sherry! I haven’t heard back from Paige yet on recommendations. I’m also waiting for a couple vets to recommend, including some that work with Midwestern University. But so far nothing. That’s good to know you may have some leads. Lots of trimmers and farriers here. But very few that I’ve found who will work with vets and radiographs. 

Waiting for new bloodwork results. Aspen is about the same.


As always, I appreciate your help!
--
Susan C in Central AZ, July 2020
https://ecir.groups.io/g/CaseHistory/files/Susan%20C%20and%20Aspen
https://ecir.groups.io/g/CaseHistory/album?id=253984


sbcable@...
 

UPDATE:

Aspen continues to suffer with laminits. He has improved somewhat, but still cannot put full weight on his left front or walk easily. I'm afraid the small improvement might be attributed to starting Gabapentin (since he's doing a little better and the Gabapentin might be helping, the vet agreed to once again try and wean him off Bute). I loaded the latest radiographs. He also lays down frequently, which the vet says is a good thing to rest his feet. His attitude and appetite seems good. No diarrhea and he plays through the fence with his herd. 

I finally found a trimmer to start fixing his trim. It has not been easy! This trimmer began on 9/29 and will make small adjustments on a weekly or biweekly basis, and eventually settling into a three-week schedule. The trimmer expects a long process and is somewhat optimistic about rehabbing his hooves. He believes Aspen's issues lie with the poor state of his hooves first and foremost and the job poorly skilled trimmers did over many years.

Aspen was retested for ACTH and Insulin on 9/21/20. I asked the vet about testing Glucose at the time and she said she was. But that result was not provided in the test results. Aspen's results improved slightly from his first test in July. ACTH went from 118 to 87.8. Insulin went from 71 to 44.22. Coming down, but still out of range. However, all of the three vets I've been working with were not happy with these results. They are concerned he may not be responding to medication and are afraid we may have a poor outlook. I was actually happy to see his levels not increase -- he's in grave pain and it's the peak of the seasonal rise. Vet recommended we increase Prascend from 1 mg to 2 mg per day.

Here are my questions:

Should I be concerned with these latest test results that Aspen is not responding to treatment? 
How long can laminitic episodes this severe last? Should he have been improving more by now? This recent episode started 9/20/20.
I am treating him with Prascend and will test regularly. I have changed his diet as much as possible, but certain things he just won't eat. I soak Bermuda, although not for the full hour because he won't eat it when it's like spinach. I am mixing the recommended supplements in LMF Stage 1. But many times he will not eat the supplements if I include flax, salt, vitamin E, etc. He seems to only want to eat his hay and LMF. I do sneak the Phyto Quench in. I am trimming him regularly now with a new trimmer; I put sand in his pen at the trimmer's and vet's recommendation. What else should I be doing?

Thank you for your help!

--
Susan C in Central AZ, July 2020
https://ecir.groups.io/g/CaseHistory/files/Susan%20C%20and%20Aspen
https://ecir.groups.io/g/CaseHistory/album?id=253984


Sherry Morse
 

Hi Susan,

Aspen has some pretty significant bony changes in the latest x-rays (ski tips on both feet) which could certainly be causing him foot pain at this point.  Have you tried putting him in boots to see if that helps with his comfort level?  Is he off of bute at this point?  Did you see this message from Dr. Kellon regarding the last xrays? https://ecir.groups.io/g/main/message/255215.  Getting his trim corrected is going to go a long way to getting him more comfortable but adding boots or even taping EVA foam to his feet can help at this point.  Cindy mentioned how to do this in your welcome letter (https://ecir.groups.io/g/main/message/255128)

The fact that he has a good attitude, is eating and playing with the other horses are all good signs.  The fact that his ACTH has come down in the midst of the fall rise and his insulin is also dropping are also signs you are moving in a positive direction.  Since you just bumped his Prascend dosage up you'll want to retest him again at the end of the month to see where he's at but this is a tricky time of year for ACTH control.  Is he still getting the dose all at one time now?

So for your questions:
1 - Aspen is responding to treatment as evidenced by his decreasing ACTH and insulin.
2 - Dealing with PPID and laminitis is a marathon, not a sprint.  At this point you are dealing with trim, possibly abscesses and possible bute rebound issues - trying to figure out which one is the main driver at the moment means weaning off bute if not already done, getting Aspen in boots to see if that helps with his comfort level and then keep chipping away at the trim. It will get better, but it will take time. 
3 - Can you soak the Bermuda in hot water for a shorter period of time? (We recommend 30 minutes for hot water).  It may not end up as mushy as being in cold water for an hour but regardless, any soaking is better than none.
4 - If possible you may want to break the supplements up to figure out which one he's really objecting to. So just do salt for one feed, just flax for another and so on - if he eats all of the supplements individually you can then try adding them together but again I'd do them 2 at a time to start. (Yes it's a pain, and it could be related to a bit of a veil effect or just the way certain combinations taste to him.)

Have you had the hay tested?  Have you tried the alfalfa tea that Dr. Kellon mentioned?  Is he holding weight right now?

Most important - Keep breathing.  I know it sucks to see our kids hurting but he is on the right path.




sbcable@...
 

Thank you Sherry for your response. Here are my answers:

Yes, Aspen has been in Soft Ride boots for over six months. Current trimmer wants me to move to Clouds. Says the design is not good on Soft Rides. So I will! 

He is not off Bute. We just reduced it to 1 gram twice a day. Will continue to wean off slowly. 

I did see the original message from Dr. Kellon and shared it with vet team and trimmer. They all agreed.

I did try breaking up supplements to figure out what he doesn’t like. Turns out he doesn’t like anything added. He’s become really picky and often leaves some of the things he seems to like (LMF). He does eat all his hay (if it’s not too mushy).

The vet team and trimmer suggested soaking for 20 minutes. Vet said that removes 20% and soaking longer does not increase that percentage by much. If he would eat it, I’d definitely use your guidelines here. But he just won’t. Hot water is impractical as is testing in my situation. 

I am prepared for a marathon. I was just a little miffed at the vets’ negative prognosis at this point. I am realistic, but their doom and gloom attitudes were premature IMO. That’s why I sought more input here. 

I have tried the Alfalfa tea. No go. 

Aspen lost a little weight over the past six months but the vets still gave him a body score of 5. 

I will keep moving forward and do the best I can for Aspen.

One last question: Vet suggests keeping Aspen in his 20x30 pen indefinitely. Trimmer said he should be turned out with the herd in the larger dry 120x120 paddock. He said he needs to get blood moving to his feet. But when he starts to feel better, he starts running around. I really think the last time he did this he caused more damage and we’re starting over. What do you think? Turnout or pen...after he is walking better? 

Thank you again for your help. You do so much good for people and more importantly these wonderful animals.

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Susan C in Central AZ, July 2020
https://ecir.groups.io/g/CaseHistory/files/Susan%20C%20and%20Aspen
https://ecir.groups.io/g/CaseHistory/album?id=253984


Lavinia Fiscaletti
 

Hi Susan,

Allowing him access to a controlled area, including the larger turnout, is fine so he can wander around quietly but not if he will run around. If he's sore footed and still on bute, absolutely do NOT turn him out with a herd in a larger area to run around. Spreading his hay, water out around the area will encourage safe, but not excessive, movement.

A BCS of 5 is where you want him to be. Most of us are too conditioned to seeing a horse that is overweight and considered healthy.

There's no way to know how much sugar will be soaked out of any given hay in a particular time period as there are too many variables involved. Generally, there is some amount, with the average of up to 30% lost in an hour of soaking without changing the water. Any soaking is better than none, esp. when you don't know what the ESC+starch level IS in the hay you are feeding.

What boots, which pads are best depends on what Aspen's needs are at any given time and what fits him. Be prepared for that to change, sometimes rather quickly, as his feet evolve.

Agree with you that the Doom and Gloom prognosis is premature at this point so hang in there.

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Lavinia, George Too, Calvin (PPID) and Dinky (PPID/IR)
Nappi, George and Dante Over the Bridge
Jan 05, RI
Moderator ECIR