Acute laminitis - unable to control pain


shannon.behmann@...
 

Hello,
My 9 year old Paso Fino mare started an acute laminitis episode 5 days ago.  She is overweight by 200lbs. She currently weighs 1150 and she should be 950 at 14’2 hands.  She has been on Levothyroxin for 2 years and limited pasture, muzzle - all the usual measures.  Since Wednesday she has been in a stall on a mat and 8-10 inches of shavings.  She is wearing easy boot clouds.  She is on bute and gabapentin and just started Prescend today. She is EMS but I strongly suspect she is also PPID. Seems like bloodwork to confirm is pointless right now due to the pain response.  Her rads show very little rotation and I have the farrier and vet booked tomorrow for corrective trim. But the pain just won’t stop.  I’m a nurse and I just can’t deal with not getting her pain under control. Any help would be so appreciated. 
--
Shannon B in Ontario 2020


Eleanor Kellon, VMD
 

Pain doesn't interfere with PPID testing https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7459856/ .

Gabapentin is worthless is my experience, and bute may be making things worse.

She needs leg wraps and socks on her feet inside the boots. More details coming soon.
--
Eleanor in PA

www.drkellon.com 
EC Owner 2001


Candice Piraino
 

Hi Shannon!

Welcome to the group! 

The ECIR Group provides the best, most up to date information on Cushing's (PPID) and Equine Metabolic Syndrome (EMS)/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 Equine Metabolic Syndrome (EMS)/Insulin Resistance (IR). These are two separate issues that share some overlapping symptoms. An equine may be either PPID or EMS/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 EMS/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: EMS 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 EMS/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 EMS/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 EMS/IR individuals.

We do not recommend feeding alfalfa hay to EMS/IR 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. 

 

--

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 

PHCP Barefoot Trimmer @ www.arkhavenfarm.com

 


Shannon and Postina <shannon.behmann@...>
 

Thank-you.  I put stall wraps on this morning.  I will wean her off the bute and gabapentin.  And draw some blood for the blood test that you recommended for PPID.  She is on the emergency diet  

I will also work on filling out the case history to give more info.  
--
Shannon B in Ontario 2020


Tracy
 

Hi Shannon - 
I am another Paso member here, there are several of us with Pasos.

Keep us posted- this group is a wealth of info and has helped many horses and their humans. You are in the right place!
If you hit information overload don’t forget to just breathe. 


Tracy

--
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


Shannon and Postina <shannon.behmann@...>
 

Thanks so much Tracy!  Feels good to connect with another Paso person.  I am so happy to have found this group.  I really appreciate all the information because I feel so helpless as I watch my horse struggle. Just an awful place to be right now.  But this group gives me direction and actions to take. Today we will trim her feet and hope for some pain relief. 
--
Shannon B in Ontario 2020


Eleanor Kellon, VMD
 

Shannon,

The impulse to alleviate the pain is totally understandable and I'm sure even more difficult for you, but focusing on pain per se can distract from the real pressing issue - getting rid of the cause. It's a bit like loading up a patient with a broken leg with fentanyl then sending them out the door. With endocrinopathic laminitis the single most important thing in relieving their pain is to get the insulin down so start the emergency diet now. These horses have abnormally high levels of circulating vasoconstrictors which predisposes them to cold induced hoof pain. It's very common.

As you wean off the drugs you can substitute Devil's Claw extract https://canada.desertcart.com/products/45272674-devil-s-claw-extract-powder-by-bulksupplements-pain-relief-amp-anti-inflammatory-100-grams 2500 mg twice a day. Just as, if not more, effective as the NSAIDs without the side effects. For cold induced pain, in addition to boots, socks and wraps, try 15 g/day of Rainey Ginseng https://raineyginseng.com/shop/powder and 5 g of arginine three times a day, between "meals" and syringed in with water or oil https://canadianprotein.com/products/l-arginine . The arginine can be increased to 10 g per dose if needed.  ACTH testing ASAP because you won't be able to get good control if that piece of the puzzle is missing.
--
Eleanor in PA

www.drkellon.com 
EC Owner 2001


Shannon and Postina <shannon.behmann@...>
 

Thanks for the information.  I’ve had her on the emergency for over a week with no change in pain level.  Trimmed her today. She remains very painful. I’ve wrapped her legs and she is in a stall - so not too cold.  Started her on Prescend. Blood taken for insulin, glucose and ACTH.  I think I should try fentanyl patches.  Her rads show thin sole but no big rotation. I will work on my case history. 
--
Shannon B in Ontario 2020


Lorna Cane
 

Hi Shannon,

It would be really good if you could take pictures,and post them for our hoof people to take a look at. Our frigid temps aren't going to help with doing that, but there may be trim issues that could be worked on,which are affecting pain levels right now.

--

Lorna  in Eastern  Ontario
2002
Check out FAQ : https://www.ecirhorse.org/FAQ.php


Pat
 

I used boots with thick pads inserted , 24-7 for a couple months (cleaned often, with foot powder to avoid fungus). I haven’t read back far enough to know if you’ve tried this, just throwing it out there. Six months in, with all clear on laminitis from vet, mine still needs boots on all the time for a few days after trim.

--
Pat
August 2020
Metro Vancouver BC Canada
Case: https://ecir.groups.io/g/CaseHistory/files/Pat%20and%20Willow
Photos: https://ecir.groups.io/g/CaseHistory/album?id=253325


Michele Goldberg <ladipus@...>
 

If she is that painful your vet can come give IV DMSO, add acetaminophen & Pentoxyphilline to your bute, Gabapentin, Metformin and Thyro L ...this is the protocol that University of Pennsylvania New Bolten Center uses for acute cases ...also put her in Softride Boots with the gel orthotic inserts ..if you don’t have those duct tape some styrofoam board to her feet until you get them.


--
Michele Goldberg
Bernville, Pa
joined 5/19/2016


Lavinia Fiscaletti
 

Hi Shannon,

Dr. Kellon has already provided you with some ideas for safer pain management options.

It would be very helpful to see the radiographs and pictures of her feet to see if the trim is in any way impeding her progress. Unfortunately, we have found that can be a contributing factor too many times to count.

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


Sherry Morse
 

To be clear (and I do love the New Bolton vets in general) that approach is basically what I would call "Throw everything and the kitchen sink at it" aka "a Hail Mary".  As Dr. Kellon already mentioned we haven't found as a group that Gabapentin does a whole lot for the pain associated with a metabolic laminitis, Bute is contraindicated in metabolic laminitis, Metformin treats high insulin levels so if you're not dealing with that it's not necessarily going to do anything and Thyro-L can jump start weight loss, but as a treatment for laminitis it's not going to do anything quickly. 

A better approach is figuring out what the underlying cause is and removing the trigger, then fixing the trim and getting the diet in order going forward.




Bendhorsetalk@...
 

I am having a similarly hard time getting pain under control. I ordered the items mentioned here so I can stop bute. I noticed, though, that ginseng is not to be combined with jiaogulan on one of the sheets here on the site. I'm still waiting for bright pink gums with 3 tsp 2 x day, but once I get the ginseng, do I stop the jiaogulan?

Thank you.
--
Shera Felde, Central Oregon, 2020
https://ecir.groups.io/g/CaseHistory/files/Story%20and%20Shera
https://ecir.groups.io/g/CaseHistory/album?id=253720