Hi all.

 I first joined this group in July with questions about my other horse, but now I think my 19-year-old Arabian, Raleigh, may have more serious issues. 

I had my vet test him for Cushings and IR last week while he was out testing my other horse.  I have had Raleigh since he was two.  He has always been a hard keeper, been scoped and treated for ulcers over the years, etc.  The last year or so, I felt like he had a slight cresty neck and I have been battling white line separation with him.  

Vet put him on 1 tablet of Prascend daily for the PPID.  He started it on Saturday (9/26) and went off hard feed on Sunday (9/27) and seems lethargic.  My vet says to continue with 1 tablet and he should work through it.

Vet said insulin was normal and did not mention glucose (although it is low).  When I put the numbers in the EMS calculator, it looks to me that he is very high risk.  Can someone please take a look at his history and help me understand these results?  

He is not lame and has never had any hoof related lameness issues.

I have posted his case history here.  https://ecir.groups.io/g/CaseHistory/filessearch?q=Raleigh

P.S.  I need to start a case history for my other horse who is "normal insulin" and "borderline PPID", but I am super worried about my Arab.
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Dana Wicher
Atlanta, GA  
Joined July 2020

Dana I am posting a link to a document in the ECIR files about pergolide. 
https://ecir.groups.io/g/main/files/3%20Cushings%20Disease%20-%20PPID/Cushings%20Disease%20Treatments/Pergolide/Pergolide%20101.pdf
Most horses need to tapered gradually onto pergolide/Prascend. This document will explain the "Veil" or depression that is a common side affect when initially started on pergolide. Use of APF may help reduce the Veil as the horse is tapered gradually onto the initial common dose of 1 mg Pergolide. The article explains everything that I have briefly mentioned. When I had to start my old horse on Pergolide I purchased APF and started him on a small dose of that first then began giving him a 1/4 mg dose which was gradually increased. He never lost his appetite or suffered and depression. Please read this well written document for the detailed explanation.
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Bonnie Snodgrass 07-2016

ECIR Group Primary Response 

White Cloud, Michigan, USA

Mouse Case History, Photo Album

Hi Dana,

I took a quick look at your Case History and 2 things jumped out at me.  The TC Senior is not a safe feed for Raleigh, especially at 4lbs/day.   I know it is hard to keep weight on him but if access to more hay is not enough you could try unmolassed rinsed, soaked,  rinsed beet pulp (an easy to digest source of calories from forage that can be fed at several lbs/day, or up to 1/3 of the diet, although you will need to account for the added calcium in your mineral balancing), or TC Natural Balance Timothy cubes (already mineral balanced and can be fed as up to 100% of the diet).  The crest is a sign of high insulin and anything in his diet contributing to that (grass, unsafe feeds, hay with high ESC+starch) needs to be fixed.

Second, your extremely low glucose value indicates that the blood sample was not handled correctly.  Likely it was not put on ice after pulling, or centrifuged soon enough, and/or not shipped to the lab frozen or overnight.  The lab will have made a note of the condition of the sample upon arrival, if you can get a copy if the results from your vet.  What this means for Raleigh is his insulin and ACTH are also compromised and the actual values are likely higher than reported.  That glucose cannot be used in the ECIR calculator, but even just the "poorly compensated IR" RISQI result based on insulin is not accurate either.  However, you still have a strong positive diagnosis for PPID.

It is very possible the veterinary clinic is responsible for the compromised blood sample,  and because we recommend testing again after Raleigh has been on the prescribed dose of Prascend for 3-4 weeks you could ask your vet to repeat the bloodwork for ACTH (to make sure it is controlled at the prescribed dose), as well as insulin and glucose at their expense?  Even if you have to pay for it, we strongly recommend checking again.   Please review the blood collection and processing instructions https://www.ecirhorse.org/DDT+E-diagnosis.php, and make sure your vet is familiar with them as well.  It's too expensive to not get accurate data and I'm sure you know both ACTH and insulin are really important for Raleigh's care.

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

Thank you, Bonnie and Kirsten, for taking the time to respond.  I have switched Raleigh to soaked/rinsed beet pulp (w/o molasses), Standlee timothy pellets, and ground flax.  He ate a better this morning (I gave him his pill after he ate per my vet's advice) but did not eat much this evening.  He is eating hay ok.  I cannot keep it in front of him 24/7 because he is turned out with my other two horses and one of them will eat non stop.  I do hay the horses 4-5 times per day and they are fed through slow feed hay nets at night (in turn out or when stalled). 

Regarding the low glucose levels, one of my other horses was also tested for IR and PPID at the same time.  His glucose came back at 79 (range 70-120), so should I still suspect that the blood sample for Raleigh was not handled properly?

I also have a question about testing hay and mineral balancing.  I cannot store more than two weeks worth of hay at a time.  I primarily buy from one source that has 250 acres in hay fields.  Does it make sense for my to try to test hay and balance minerals? I wondered if I tested every few months to see if I can get an average?  Will the mineral levels vary much? I am sure the sugars could vary greatly....

Lastly, how do you all deal with push back from/to your vet?  I have used my vet for 13+ years and he is great to work with (and a good vet).  I am trying to pick my battles so to speak. Obviously, I do not want to put my horses' health in jeopardy but still want to maintain the great working relationship that we have.  

Oh, one more thing.... I noticed a few minor mistakes and a couple of things I left out in his case history.  When I update his case history, do I replace the old case history and will the links to it still work the same?  There's so much information, it can be a little confusing. :)  (I also somehow ended up with someone else's hay analysis in my folder).
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Dana Wicher
Atlanta, GA  
Joined July 2020

Hi Dana -

I used to only have storage for about 20 bales - it's frustrating for sure not being able to test your hay because you can't store lots of it!  Buying hay in January also sucks.  Been there, done that.

Try searching on things like 'regional hay analysis' etc - on here, online and call your local ag extension agency - see if they have some averages or can point you in a good direction.
If you can find out some averages on hays in the area where your hay is coming from - it's a good start.

If you always buy from the one source and it's 'their' hay that they cut - maybe talk with them and see if they'd be willing to let you test - or if they can test it?  Shoot - if you bought/borrowed a core sample tool and went out with a drill would they 'let' you do that?  Guess it depends on your relationship with your hay person.  Hay people must hate us horse people sometimes.

There are also good multi-vitamin minerals from Mad Barn, Uckele and California Trace to name a few that I've learned have far higher levels of vitamins and minerals than pounds of feed. 
Looking back when I was in your shoes with the "can't buy a lot of hay at once" situation - I wish I'd at least gone with one of those really good vitamin/minerals vs other supplements/feeds I tried - heck - maybe just rotated the super-good-ones a bit for a little variety.   My horse would have been better off and would have been getting more meaningful quantities of nutrients and my money would have been better spent.  We live and learn.

Others will chime in too and hopefully have some more advice for you.

The case history - yes - valuable but SO difficult to work with the form itself.  I need to update mine too with new supplement info and I'm about to get vet out for yearly and will need to update bloodwork results.  Sigh.

You can do this!  And even if you can't get your hay sampled - you can take good steps to get better nutrition and good vitamin/mineral levels in your horses diets and that will help a lot!

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Tracy and Salsa (1999 model year Paso Fino)
Middle TN USA, September 2019
Case History  https://ecir.groups.io/g/CaseHistory/files/Tracy%20and%20Salsa
Photos https://ecir.groups.io/g/CaseHistory/album?id=95827

Hi Dana,

First technical stuff because it's easier!  :)  You actually didn't end up with someone else's hay analysis in your folder.  Instead, the link in your signature to your Case History actually takes us to the results of a search you did for "Raleigh", and 3 items came up: your Case History folder at the top, a hay analysis with the word Raleigh in it somewhere, and Raleigh's actual case history.  If you click on the case history folder, you'll see his case history is saved in it.   The link to the folder is what we want.   Then, when you update your case history,  as long as you put it back in the correct folder,  your links in the case history and your signature will always work!

A glucose of 16 is probably too low to support life so it was definitely compromised.  I suppose it could have been the lab instead, although I would expect them to have commented on it on the paperwork or rerun it for you.  If it arrived at the lab degraded there will be a note on the lab results.  Your other horse's glucose is likely compromised, too, because it is near the low end of the range.  Normal is 90-100.  No need to be confrontational with your vet though.  Just ask how the sample was handled and why they think the glucose was so degraded for Raleigh.  If you're comfortable, tell them you've learned that degraded glucose is a reflection of a problem with sample care and prep, or due to shipping delays and thawing, and that you've learned insulin and ACTH also degrade as well, although not to the same extreme.  Would they consider rerunning bloodwork for you, or at least coming and collecting another sample free of charge?  One of the reasons we recommend running glucose too, especially if sample handling is suspect, is because it is more obvious when the sample is compromised.  You would never have known if you only tested insulin and ACTH.

Some horses gain weight again once ACTH is better controlled, so when he gets through the pergolide veil and starts eating normally he might start to put on weight again.  Otherwise separating him for extra calories is something you could try once or twice a day.  The nights he is stalled would be a great time for free-feeding hay instead of a slow feed net, too.

Tracy gave you some great ideas about hay.  There are also old posts here and in Horsekeeping on how to build temporary hay storage with pallets and tarps if the problem is lack of barn space.  I personally use a 40' sea can, with a spray-foam insulated ceiling.  10' is blocked off for a fully insulated tack/feed room, but in the remaining 30' I can fit 256 45-lb bales, just barely enough to see 2 1000 lb horses through 1 year (extra bales get stored outside and fed first before they get too moldy from our high humidity).

In addition to Tracy's tips, have 2 more thoughts on hay.  One, in your situation I would test a few batches for the full mineral profile to see if it's similar and get an average.  This works if it's the same type of hay; but different grass species will give more variable results so it depends on that as well as the soil and fertilization of the different hay fields.  Ideally you would test each batch for ESC and starch but I just can't see doing that every 2 weeks.  Or two, if you have a good relationship with the hay supplier, could you arrange to buy hay only from one field (ideally one that was cut earliest in the morning) and test that hay, then see if maybe they can store it for you (they are obviously storing hay somewhere, so if they made you a pile and put a rope around it or something)?  Maybe offer to pay a little extra per bale for the extra effort on their part?

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

I found this little tidbit from Dr Kellon:

Horses on a mixed concentrate/hay diet typically have glucose in the high 90s to low 100s while horses on hay or pasture (North American pasture anyway) will run in the high 80s to 90s

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

Ok.  So I think I have the case history link figured out (Thanks, Sherry, for the instructions for adding to my signature).  I work on computers all day using Excel, accounting software, etc. so I'm not sure why I struggled so much with this site.  :)

I definitely need to figure out the hay situation.  I did start Raleigh on California Trace Plus today (one of my other horses that I thought had more issues has been on it, and Raleigh has in the past).  The hay producer bales 44,000 bales of Tift44 bermuda a year, so I'm probably not a big client with my 700 bales a year.  :)   Being the humid south, hay storage can be tricky. I like the idea of testing a few batches to see if I can get an average.  I have asked the supplier if they test and they do not  and were not interested in doing it.  I also plan on contacting the county extension agent.

The vet may take a little more work.  I eased into questioning the low glucose level.... and he may take some convincing to get on board. He said glucose breaks when it sits too long but it's not a big deal.  I wanted to ask him why bother testing glucose levels then, but I did not.  (Please no bashing my vet. I will continue discussions with him.)

Anyway, I am so appreciative of this group and the knowledge that people are willing to share.  It's all a bit overwhelming and sometimes frustrating but it is good to know I am not alone. :) 
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Dana Wicher
Atlanta, GA  
Joined July 2020
Raleigh Case History

Hi Dana,
Just wanted to clarify something about your balancing supplement, in this case California Trace Plus.  When you figure out what the best supplement is to balance your hay, whether it’s CTP, another premixed blend or a custom mix, it will be a good choice for all of your horses eating that hay.  There is nothing special about the mix that is related to our challenged horses, just that it’s more important for them to have their hay tightly balanced.  The others will benefit as well.
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Don't worry, bashing of anyone--whether vets, trimmers, other members, etc--is not allowed in this group, nor is naming of vets, trimmers or other professionals unless you have their permission to do so.

Our vets are critical members of our horse care team and should always be treated with respect.  But you can still question them and ask for more/better next time.  That's one way they learn, too.  The most important thing though is to maintain a respectful working relationship with them, and how to manage that is between you and your vet.  :)

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

Thanks for the good reminder, Martha.  :) At one point, all three of mine were on the CTP, but I took the two "oldies" off it when I put them on the TC Senior.  I am learning the error of my ways and will get everyone back on an appropriate diet. 

FWIW, Raleigh did not eat much hay last night and only ate a few bites of breakfast, so I have stopped the Prascend for a few days and will ease him back onto it per the information that Bonnie shared.
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Dana Wicher
Atlanta, GA  
Joined July 2020
Raleigh Case History