NEW MEMBER - urgent advice needed for IR pony in constant pain
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On Tue, Feb 2, 2021 at 10:48 AM, <jenny.comish@...> wrote:
When you say about boots adjusted to best beak over, do you mean rasping the actual boots?Hi Jenny That is indeed what we mean. It's easier if you use a new sharp rasp, or a grinder if you have access to one. There are a couple of photos here: https://ecir.groups.io/g/main/album?id=45323 -- Maxine and Indy (PPID) and Dangles (PPID) Canberra, Australia 2010 https://ecir.groups.io/g/CaseHistory/files/Maxine%20and%20Indy%20and%20Dangles
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jenny.comish@...
Thanks Eleanor and Kirsten. He is now on the Forage Plus Laminae Plus balancer and also jiaogulan (2g per day). He is also on a herbal Devil’s Claw, meadowsweet and white poplar bark liquid supplement to see if it helps at all with his pain levels and I will begin weaning him off the Danilon. I will update my case history. He also had his feet trimmed again a couple of days ago so I have some more photos to add to my photo album.
When you say about boots adjusted to best beak over, do you mean rasping the actual boots?
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Hi Jenny,
DDT D = Diagnosis He clearly has severe EMS. I don't see any convincing evidence of PPID but even the normal seasonal rise can be a problem for horses with elevated insulin and I suspect that is the case here. D = Diet and Medications/Supplements You're off to a good start but would definitely avoid alfalfa and ryegrass. Hard to tell without hay analysis but you may not be able to get good control without medication. Exercise is the most efficient way to control insulin but obviously not an option when you have hoof pain. To make some decisions here you need to start with hay analysis. Forageplus.co.uk can handle submitting the same for you and in the meantime I would use their Laminae-Plus Balancer. Get off the Danilon. It doesn't help and can hurt in more ways than one. Switch to Jiaogulan ASAP https://forageplus.co.uk/product/jiaogulan-herb-for-horses/ . T = Trim Your trim isn't horrible - we've seen much worse - but there is room for improvement. Repeat radiographs if in the budget are always helpful but it's safe to assume your horse needs pads, boots and boots adjusted to best breakover to get the most benefit. -- Eleanor in PA www.drkellon.com |
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His pre-TRH number looks very normal, but I'm not sure how to interpret the post-TRH number (your Case History says 112) if it is equivocal. I'm hoping someone else will chime in on that.
I just wonder with the hay if it's so high in sugar or starch that even soaking it isn't enough for Dewi, and maybe he needs a new hay altogether. Even if you only had it tested for ESC+starch, which should be cheaper than the whole mineral package, at least you'd know those numbers. It might be cheaper to find new hay than putting him on medication if that is all he needs to feel better. -- Kirsten and Shaku (IR) - 2019 Kitimat, BC, Canada ECIR Group Moderator Shaku's Photo Album |
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jenny.comish@...
Hi Kirsten,
I've not sent his hay for testing yet - only because the companies that offer testing services in the UK are quite expensive and sending it direct from the UK to the company ECIR recommends looks complicated (due to sending it to the States & the fact it is hay - so sending in a plant based product from one country to another) and I've not had time to work it all out. I will do. There won't be any alfalfa in it but there could be clover and ryegrass. In my last message I added Dewi's TRH stimulation test results as someone asked for them in a previous message - they asked for the pre-TRH number. Do you understand these results and know if his pre-TRH number shows anything abnormal? Thanks very much for your help. Jenny -- Jenny Comish England, UK Dewi Case History: https://ecir.groups.io/g/CaseHistory/files/Jenny%20Dewi Dewi Photos: https://ecir.groups.io/g/CaseHistory/album?id=257833 |
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Hi Jenny,
You absolutely can try Metformin again without blood work if your pony is clearly in pain and there is absolutely no way to tighten up his diet. I have a preference for bloodwork because numbers tell us in a quantitative way how our horses are doing at a given moment in time (and will confirm that it IS high insulin that is causing the pain and that there is no need to look for other causes), but you can also rely on your observations of how he is and knowing his history of laminitis you can make decisions about medication. It is hard to know if the Metformin helped him previously because his 2014-04 test was a glucose-in feed test, and his 2014-07 test was baseline, so there should be a dramatic difference, whigh there was. I'm assuming the 2014-07 test was AFTER he had been on Metformin because his insulin is so low on it, so I'm assuming it helped him in the past. Did you notice that it helped him in 2014? You could try it again. Metformin might help him again, at least initially for a few weeks, but the effects do fade with time so you might need to make a longer term plan for managing his EMS. If there is no way to further tighten up diet, that's where considering trying Invokana could help. It is kind of a last resort drug and it is expensive but it does seem to be effective so far. If your vet will consider it, Dr Kellon has a protocol for trying Invokana that she can email to your vet, and that is important information for your vet to have if evaluating it. Have you sent his hay for testing yet? And are there any legumes in it (lucerne/alfalfa, clover)? -- Kirsten and Shaku (IR) - 2019 Kitimat, BC, Canada ECIR Group Moderator Shaku's Photo Album |
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jenny.comish@...
Thank you Sherry. I’m keen to get my vet back out to test resting insulin and glucose - although he doesn’t seem convinced of the point of this. If it is tested and comes back high I guess all I can do is try metformin again? But I could try that any way without the blood test? My vet has said he will look into invokana - he’s not heard of it before. Thanks |
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Sherry Morse
Hi Jenny, I think you're on Lavinia's list for markups so I'd wait for those and get his trim in better order before I'd go through another round of x-rays. Lavinia may say otherwise though and since she's the hoof expert I defer to her on that. :-)
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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jenny.comish@...
Hi Kirsten,
thanks very much for your message from a couple of weeks back now. I don’t know how but I missed it. I’m wondering if I also ought to get more x-rays done seeing as he has been in such pain there must be something happening in there and his last x-rays were done in October? I must admit I could do without the extra cost! But I’m not sure if the October x-rays are still helpful. Thanks Jenny -- Jenny Comish England, UK Dewi Case History: https://ecir.groups.io/g/CaseHistory/files/Jenny%20Dewi Dewi Photos: https://ecir.groups.io/g/CaseHistory/album?id=257833 |
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Hi Jenny,
It sounds like you are having a tough time right now and I'm so sorry for the loss of your friend. I read through your case hx and all I can suggest is: - try to get your new hay analyzed ASAP - get baseline/resting insulin and glucose ASAP - consider another course of Metformin and dose it by syringe - ask Dr Kellon to send your vet information on invokana, which is the medication we now recommend for horses that already have very tight diet control but still have high insulin or ongoing laminitis, it has been very successful so far - ask your vet to consider a trial of Prascend/pergolide as ACTH is only one of the hormones that indicate PPID and rarely some horses have normal ACTH but will respond to pergolide. I would do this before considering euthanasia just in case Dewey is one of those rare horses. The fact that all his laminitis events, except his most recent, occurred in the fall/early winter is compatible with PPID, although he would have been young for this disease in 2013 and it seems unlikely...however as he ages it could be a complicating factor (I believe that we have had at least one example of a horse as young as 7 diagnosed with PPID though). Agree with Sherry, definitely no Karo syrup test now. It's not necessary because it is a diagnostic test and he has already had a positive result 2x in the past. You already KNOW he is IR. How high his insulin is on sugar syrup now is irrelevant. Plus he is actively laminitic and this test should only be done on stable horses. So now you just need to know what Dewey's baseline/resting insulin and glucose are going forward because that will tell you how he is managing his current diet. -- Kirsten and Shaku (IR) - 2019 Kitimat, BC, Canada ECIR Group Moderator Shaku's Photo Album |
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Hi Jenny,
I’m so sorry about your friend. We’ll still be here should you need to take a break from this for a bit. No one knows the reason behind the alfalfa sensitivity, just that it affects some horses and not others. My PPID horse was not sensitive but he was also not IR. It’s wise to avoid it unless Dewi has been eating it without issues, which would be hard to tell in his case. I wondered why your vet chose to do a TRH test as the previous testing was apparently not. Was he thinking Dewi might be PPID? That also crossed my mind as his laminitis seems so closely related to the fall rise. You could try him on some pergolide to see if that gives him any relief. He is obviously IR, even not being PPID, as his symptoms began at a younger age than most PPID horses exhibit symptoms. With respect to pain relief, there really isn’t anything available which would control laminitis pain except for addressing the cause. In a way that’s a good thing because a good number of us would avail ourselves of it and lose focus on correcting the cause, which as Sherry states is probably related to the high insulin and inappropriate trim. As you seem to be paying attention to his diet, it may be time to look into metformin (again) or invokana. You can search the messages for invokana for more information. There’s been a lot of discussion about it recently so there’s lots to read. It doesn’t go back very far as it’s a fairly new application. -- Martha in Vermont
ECIR Group Primary Response July 2012
Logo (dec. 7/20/19), Tobit(EC) and Pumpkin, Handy and Silver (EC/IR)
Martha and Logo |
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jenny.comish@...
Hi Sherry,
thank you for your very thorough response, which I will go through with a fine toothed comb and will check out all of the links. But just one question, if he is continuing to have elevated insulin levels but his diet is low sugar and starch, why might that be, and what can be done to control it? (On the basis that metformin may or may not work). Thanks very much. Jenny -- Jenny Comish England, UK Dewi Case History: https://ecir.groups.io/g/CaseHistory/files/Jenny%20Dewi Dewi Photos: https://ecir.groups.io/g/CaseHistory/album?id=257833 |
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Sherry Morse
Hi Jenny, The short answer on alfalfa is that while it's usually lower than 10% ESC+starch some horses just can't tolerate it. Much like while we use 10% ESC+starch as our cutoff for safe hay some horses need much lower than that or they have issues. Even random bits of grass may be too much for some, but others might be ok in the same situation. It's very much something that isn't cut and dry so if you have a horse that's known to be very sensitive it's just best to avoid things that might set them off.
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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Sherry Morse
Hi Jenny, So sorry to read about your friend. That kind of puts everything else on the back burner so no worries on not responding. As far as the metformin - got it. The next time you do a CH update you may just want to put a note in on the line with it that it was only for a short time and not current. When he was on the metformin is that when he had the change in insulin from 485 to 4.1? If so you may want to trial it again. We have many members here who are using it and they administer it by syringe but you do need to be careful to rinse their mouths after to avoid mouth ulcers, so that's not without issues. You can read more about it here: https://ecir.groups.io/g/main/files/4%20Insulin%20Resistance/Metformin Danilon (known as bute here in the US) is a problem - if he's still in pain while on it I'd say that's a good indication it's not working for him. We have some members using paracetamol (Tylenol here in the US) with limited success but again it's meant for short term use. I'm hoping some of our other UK members will chime in with suggestions for you but if you can source Devil's Claw (we usually recommend Uckele PhytoQuench pellets but again, I'm not sure if they're available in the UK) you can substitute that for bute. I just did a bit of a search and found this: https://www.equineanswers.co.uk/bute-substitute-powder/p25 which has MSM in it as well which can be tricky with some IR horses (you can read more on that here: https://ecir.groups.io/g/main/files/Joint%20Supplements/Glucosamine,%20MSM,%20Yucca,%20HA.pdf). We have another recent member here whose horse has been on bute since last March I believe and she's now weaned him off of it and he's on the Phytoquench pellets and she said he looks better than he has in quite a while - this is a snippet of that conversation: https://ecir.groups.io/g/main/message/259786) This is the general guidance for tapering off NSAIDS: https://ecir.groups.io/g/main/files/Pain%20Medication%20and%20Alternatives/How%20to%20Taper%20Off%20NSAIDs.pdf My suggestion would be to stop one of the 2 doses for 2 days and then start stretching out the time between doses as outlined in that document. You need to do the tapering slowly because there is a NSAID rebound effect that can be seen if you stop quickly, especially after so long a period of time on the drug. His pain level can certainly be due to the trim and lack of sole depth as well as possibly (probably) elevated insulin levels. It's all part of what needs to be brought under control to get him feeling better. Using bute to control pain (which it doesn't seem to be doing at this point) is putting a band aid on the problem but to get him feeling better you need to remove the triggers which is what we focus on here. Is your vet thinking that Dewi needs to lose weight so his feet feel better? Or is to help with his insulin levels or ??? For me, although it's hard to tell with the winter coat, he looks to be at a good weight for his size. We recommend feeding 2% of ideal weight in hay+concentrates per day, which would be about 5.8kg for him. So you may want to cut his hay ration down a bit and make sure you're weighing what he's eating. I know there have been a bunch of studies on soaking hay for extended periods of time(we have a few here: https://ecir.groups.io/g/main/files/5%20Core%20Diet/1.%20Hay%20Information/Hay%20Soaking) but the short answer is you then lose a bunch of minerals as well as the protein and sugar content and that creates other issues. For the purposes of lowering the sugar content you're really ok with just an hour if the water is cold Yes to getting insulin and glucose tested again - definitely NO for the karo test, especially in a horse with known high insulin and already having laminitic issue that's playing with fire. I know it's hard but you are his advocate and you need to do what's right for him and don't let the vets cow you into thinking they know best because they often don't. Can you get the actual test results for the TRH test from your vet? That should list the pre-test number as well as the 112 post test result. For example when we did a TRH test on my gelding in 2019 the lab report lists: TRH Response ACTH: Pre: 20.9pg/ml (range 9 - 35) Post: 69.5pg/ml (range 9-110) For a horse that's early PPID the pre-test result might be in range but the post number will be out of the range, but for one that the post-result is equivocal (like Dewy) we might be able to glean some information from what his pre-test number was. Hopefully that makes sense!
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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jenny.comish@...
Thanks for your support Francine. I’ve read a number of times that alfalfa is not great for IR horses but I am not clear as to why - as so long as the sugar and starch are low enough it seems a bit strange. There must be a reason out there - I need to do more reading!
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jenny.comish@...
Hi Sherry, As regards the Danilon, yes he’s still on this - on advice of my vet it has been reduced a little more to 2 thirds of a sachet per day - I give him one third in the morning and another third in the evening. My vet also suggested he could have 8 paracetamol per day, 4 in the morning and 4 in the evening. I did that for a few days, but stopped as I thought I can’t carry it on long-term - or can I? Dewi is absolutely crippled, so he needs some pain relief. What else can I do if he’s not on Danilon? I just don’t understand why he is in so much pain. Do you think it’s all down to a bad trim and thin soles? As regards how long I soak the hay, I’ve only been soaking it for 12 hours for a short amount of time - usually I only soak it for an hour, but my vet said an hour was not long enough, and as I have been so worried about him, against my better judgement I listened to my vet as I am desperate to make his pain go away. But the 12 hour soaking has made no difference to his pain. Also a well- known UK nutritionist suggested a 12 hour soak would reduce the calorie content of it so would help with weight loss. My vet thinks it would be helpful if he lost more weight. Do you think I should I get his insulin tested again? I know my vet will want to do the post Karo light syrup test - and I know you don’t recommend that. I will have to be very insistent with them that I don’t want that done. As for the TRH stimulation test, the guidance I read from Liphook Equine Hospital in the UK, who are supposed to be an authority on laminitis, is that it’s fine to do it in December (and my vet said it is). It was quite expensive so I can’t afford to get it done again any time soon. If it is imperative that I get it re-done to save Dewi’s life then I will of course and would get into debt to do it. I’ll be honest though, and this is not a dig at ECIR, just a general gripe after years of having a laminitic, I am getting really weary of all the contradictory advice on laminitis and I don’t know who is right and who is wrong. I don’t know the pre TRH number - sorry if this is a daft question, but when you say ‘number’, what number do you mean and should my vet have it?
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jenny.comish@...
Thanks for the quick reply Martha, and sorry for my slow reply. I’ve had some bad news this week as a good friend of mine has died, so I have not had time to look on here. I don’t think I made my case history clear about the metformin. He was only on metformin for a few weeks years and years ago. He’s not been on it since, I was never sure it was doing anything and it was very hard to get him to eat it as it came in huge tablets that clearly taste awful. What he has been on many times is Danilon. He is on it now and has been on it since June. He’s in terrible pain, so whilst I understand that long-term use is not good, my vet keeps prescribing it and I don’t know what else to give him. She did also suggest giving him 8 paracetamol per day, which I did for a short time, but stopped as was worried it wasn’t a good idea to carry on for too long. Any other pain relief advice would be really appreciated. |
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Hi Jenny
I was just looking at the analysis of Thunderbrooks Hay Cobs - it doesn’t specify which grasses they use, other than more than 50 varieties of alpine grasses and herbs, but the analysis shows 11.13% 'Digestible Energy', 7.6% sugar and <2% starch, so it might be useful to avoid these ones for Dewi. For treats (and to hide his Prascend) I used the flax/cinnamon/apple sauce recipe in the ECIR files. We don’t have access to feeds like Stabul 1 over here in the UK, but there are others around that fit in with the emergency diet when you check through their analysis and composition. There’s helpful information in the ECIR files on UK resources, which you’ve probably already come across, although I chose to buy most of Omar's supplements from My Best Horse in the US and I used DairyOne/Equi-Analytical (also in the US) for his hay samples. Getting his diet under control, his trim properly sorted out and having regular bloodwork done really turned things around for him. Omar’s over the rainbow bridge now, but that happened because of colic and very poor veterinary help, and not any IR or PPID related issues. Best wishes Lesley & over the bridge Omar, 2012, UK -- Lesley, 11-2012 Norfolk, UK Omar - Case History |
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lamarleau@...
Really sorry to read this and I know how terrible it is to see them like this. My boy cannot have any alfafa at all in anything, even in very small amount. I was not suspecting this and he suffered for months. Juste in case it can help.
Good luck. -- Francine & Magic in Quebec Nov 2020 Was a member 10 yrs ago with Shamy |
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Sherry Morse
Hi Jenny, Dewi looks to be a good weight but the lack of current bloodwork makes it hard to judge where he's at right now with regard to his IR being controlled or not. Martha's already emailed you our welcome letter but to reiterate a few points: Danilon and any NSAIDs are not helpful in metabolic laminitis and they can cause digestive problems when used long term. You should probably start weaning Dewi off it as soon as possible to avoid any further issues. Let us know if he is in fact still on the 3/4 of a sachet dose and if that's once or twice a day and we can help you develop a plan for weaning him off it. As Martha noted Metformin has been found to stop working in some cases and since Dewi has been on it for 6 years and his last insulin test was well above normal it's very likely it's no longer working for him. I'm not sure what the availability of Invokana is in the UK but if his diet is tightly controlled and his insulin is still high it may be an option if available. Now, as far as his diet - the hay only needs to be soaked for 30 minutes in hot water or an hour in cold water to reduce sugar. Soaking it more doesn't necessarily do any more reducing of sugar but it can effect other nutrients so I wouldn't go that far at this point in time. While our general recommendation is hay under 10% ESC+starch we have a number of horses on the list who can't tolerate hay that high so at 8.6% if you're still using the same hay you had in August, I would continue to soak it. The TRH stim test is one we don't recommend doing during the fall and early winter due to there not being an adjustment for the rise available for it. Do you know what the pre-TRH number was? That would be a better indicator of his PPID status than the 112 post-TRH number. His trim shows room for improvement - he has a ski tip on the both front coffin bones and very little sole on either front foot so it's not surprising he's in pain without boots. From looking at the pictures he's not wearing his hooves evenly (I would guess trying to compensate for the pain when he walks) and the trimming of the soles is not helping matters. If you could post another note saying something like "Trim advice needed" to alert Lavinia she can comment more but I'd say there's nothing here that can't be fixed, it's just going to take a bit of time.
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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