Compensated IR - Treatments? Vaccinations?
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Kinsey
Hello, Thank you! -- Kinsey in GA 2020 https://ecir.groups.io/g/CaseHistory/files/Kinsey%20and%20Bucky |
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Kinsey
He is also on bute (has been on it since November 5th), vet said to keep him on the bute for 30 days. I want to take him off the bute ASAP after reading more about it in the files. How can I safely taper him off the bute?
-- Kinsey in GA 2020 https://ecir.groups.io/g/CaseHistory/files/Kinsey%20and%20Bucky https://ecir.groups.io/g/CaseHistory/album?id=257041 |
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Hi Kinsey,
In regards to vaccines, some horses do best with one vaccine at a time every 2-3 weeks. Since your guy is in a current laminitis event, it would be best if you wait until he is out of it. Stress to the horse (wether it be a trailer ride, vaccine, training, food or weather changes) have affects on their system and since he is already compromised, further stress will not be a good thing and can continue damage to his feet. For the tapering of Bute, this is an example. If giving 2 grams of Bute, start by giving the 2 grams once a day. Days 1-3, give 2 grams every 36 hours. Days 4-6, give 2 grams every 48 hours. Day 7 give 1.5 grams every 48 hours. Day 8 give 1 gram every 48 hours. Day 9 give 0.5 grams once and then stop.
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. --Candice Primary Response Team September 2018, Summerfield, FL Shark's Case History: https://ecir.groups.io/g/CaseHistory/files/Candice%20and%20Shark Shark's Photo Album: https://ecir.groups.io/g/CaseHistory/album?id=71507 |
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Sherry Morse
Hi Kinsey, You've already gotten some answers from Candice but I wanted to add that with an ESC+starch of over 10% Triple Crown Lite isn't a suitable feed for a horse that is IR, particularly one that is actively laminitic. You can find the most recent test information in our files here: https://ecir.groups.io/g/main/files/9c%20Analyses%20of%20Various%20Feeds/Triple%20Crown%20Products/Triple%20Crown%20Lite%202017-06-01.pdf If you can get a full set of hoof pictures posted we can help you with trim advice but his toes were definitely too long in the x-rays from October and the November picture looks like he still has very underrun heels although the toes look a bit better. He doesn't have the thinnest soles we've ever seen but definitely keep him in his boots if he's comfortable that way. It would also be helpful to us if you could get an actual current weight for him as well as an ideal weight as we recommend feeding based on weight. For a horse that's a 6 BCS there's probably 50 - 100 pounds to come off and to determine how to do that we recommend either 1.5% of current weight or 2% of ideal weight - whichever is greater - of both hay and concentrates per day. That also means we don't need to know how many flakes per day he's eating, but how much those flakes weigh in total. Many people use a luggage scale to hang their nets and weigh the hay out. As he's laminitic now and you don't have the hay tested I would be soaking it as well. Also, no grass at all. From reading your CH you already have tried putting him out on grass and it didn't go well. Unless you can turn him out in a fully sealed muzzle so he can't get any grass I'd keep him in the dry lot to avoid any further issues. Himalayan salt gets its color from impurities including iron so also isn't suitable for an IR horse - regular table salt included in his feed or even sprinkled on his wet hay is all you need to include on a daily basis. As far as test results - do you have the actual test results? If so, could you upload them to either your CH folder or your photo album if they're a jpg? And please update your case history with the actual numbers?
Thanks, Sherry and Scutch (and Scarlet over the bridge) EC Primary Response PA 2014 https://ecir.groups.io/g/CaseHistory/files/Sherry%20and%20Scutch_Scarlet https://ecir.groups.io/g/CaseHistory/album?id=78891 |
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There's no one way to do it but cutting the dose in half every two or three days and stopping after you reach 500 mg should work.
Remember this drug has poor activity in metabolic laminitis anyway so the major thing we're trying to avoid is a chemical rebound that makes them more sensitive to pain - not removing pain relief which was poor in the first place. The important places to focus are on diet and trim which can remove the actual causes of pain. -- Eleanor in PA www.drkellon.com |
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Hi Kinsey,
A compensated IR horse should not be laminitic, although he may have hoof pain due to trim problems, thin soles or poor lamellar connections from a previous founder/laminitis. Compensated IR means that his current management would be keeping his insulin low enough that his laminae are not being damaged. To confirm/evaluate this diagnosis we need you to provide all the bloodwork results in your Case History. Can you call your vet and ask for copies of the lab reports, or for these details: what was tested, where it was done, what Bucky's results are (with the units), and what the lab's reference range is for each test that was done? His bloodwork was done fasting, which would give an abnormally low insulin, so what your vet is calling compensated IR may be different than what we base that on. It is better to know what his insulin is when he is not fasted because that will tell you how he is doing every day on his current diet. I agree with your vet that he does not look like a typical EMS/IR horse, and given his breed he is actually less likely to be EMS/IR except as a secondary condition to PPID/Cushings. The timing of his hoof pain is also consistent with the fall laminitis typical of PPID. Was he tested for Cushings/PPID? If he was, keep in mind that fasting will lower his ACTH as well, possibly giving a false negative result. If he was not tested, I would arrange another blood pull for baseline (nonfasting) ACTH, and redo the insulin and glucose non fasting at the same time. You also recently moved to the new boarding facility, so was there a change in his diet? Different hay, more pasture? Switching him to the emergency diet (soaked hay, no pasture, no supplements other than salt-flax-vitE) should provide pain relief within a few days if he is actually laminitic due to high insulin. If he is, then you will see him walking better within a few days, although he may need boots with pads and a better trim to be at his most comfortable. If he has PPID, you will also need to get him on medication to lower his ACTH, which will in turn lower insulin and help to reduce his hoof pain. Another possibility is that the hoof pain is only trim related. Since you started with the new farrier, Bucky started having hoof issues. If his bloodwork is redone nonfasting and still comes back as compensated IR and negative for PPID, then his trim should be the focus of your efforts. -- Kirsten and Shaku (IR) - 2019 Kitimat, BC, Canada ECIR Group Moderator Shaku's Photo Album |
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The heart of treatment, diet and trim, is the same for any level of insulin. Horses that continue to have high insulin and hoof pain after that may need medication.
As for vaccinations, speak with your vet about limiting them to the core vaccines and anything else where your horse is high risk. For example, some diseases are only high risk in certain areas or in crowded barns with high traffic. -- Eleanor in PA www.drkellon.com |
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Kinsey
To answer some of your questions:
Thank you so much for everyone's help! -- Kinsey in GA 2020 https://ecir.groups.io/g/CaseHistory/files/Kinsey%20and%20Bucky https://ecir.groups.io/g/CaseHistory/album?id=257041 |
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Hi Kinsey,
Just a thought about hay testing....sometimes there are farmers, or other horse people in your area ,who do test, or have tested their hay. Dairy farmers often test their hay,for example. And boarding stables are becoming more interested in doing so. So if you were able to ask around, ask for copies of their tests (assuming they are in your vicinity),and see how they compare.you could take an average.( or maybe even find this out from your local Ag Department) It's not the best way.But it's better than having no idea. I had to do this a few years ago, because of lack of funds. I was able to get copies of 17 hay test results, which had been done within 20 miles of my farm. It was interesting how little difference there was ,really. But I averaged the results, and used that to make up my supplements. As I said, it is not recommended to do that, if we want the most accurate results. But it's a step up from guessing what's in the hay, in order not to be throwing the kitchen sink into our supplement bin. Sigh. -- Lorna in Eastern Ontario |
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The blood work is not necessarily wasted money, even if it is not done exactly as we recommended. Fasting insulin results can still be interpreted, and it is still often used for diagnosis of EMS. This is why we ask for the actual data. But the next round of bloodwork should be non-fasting. You can tell your vet that now have a diagnosis from fasted bloodwork, for everyday management you need to know what his nonfasting insulin is because that's what predicts laminitis risk.
Every time my horse has had laminitis, I've missed it! (probably in denial!) It always takes me a couple days after he starts seeming ouchy to remember to check for bounding digital pulses. If he has them in all 4 hooves I consider that to be laminitis. There are other things that can cause bounding pulses in all hooves, like exercise or hot weather or even just getting up from laying down, but obviously you can rule these out fairly easily. Heat is another sign but harder to objectively evaluate. Jiaogulan can be given during laminitis BUT it will speed up hoof growth so ideally you'll have his trim fixed up a bit first before you start jiaogulan, and book your farrier to come a week or two earlier for the next trim (or do a light trim yourself with a rasp in between appointments). Ground flax is fine, about 2/3 cup a day. Refrigerate it or grind it fresh. Vit E brand does not matter, but if you feed human gel capsules make sure it lists some type of oil in the ingredients. You can also buy powdered or liquid forms from equine suppliers, but powdered does need oil added to it to maximize absorption. Salt can be iodized or not; I feed iodized salt because until recently I was not supplementing iodine, but it was only meeting about half Shaku's needs from salt to now I have iodine in my custom minerals. Dr Kellon just advised another member that testing hay is worth doing if you can store a 3 month minimum supply. So depending on how much the barn can store it may or may not be worth testing. We do recommend the 603 package at EA, or its equivalent elsewhere...as long as the analysis is by wet chemistry methods and not NIR. -- Kirsten and Shaku (IR) - 2019 Kitimat, BC, Canada ECIR Group Moderator Shaku's Photo Album |
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