Metabolic test results back; seeking interpretation of results. #file-notice


Laura and Ero
 

Good evening. I received Ero's metabolic test results back and would love help interpreting these numbers and any action steps. I included the report from Cornell in my CH folder and I updated the numbers on his CH form (along with recording his recent injuries). 

- I'm not certain if I filled in the CH "Lab Normals" section accurately as that language wasn't on the report.
- The leptin score says "pending" but I received a voicemail from my vet who said it came back "high". I'm not surprised as Ero is ALWAYS hungry and can get angry when he's not eating, and pushy when there's food in sight.
- Overall, vet was "okay" with the numbers, but said to watch his weight as he's "EMS and could develop PPID based on ACTH numbers". 
- In the past two months, I've transitioned his diet and hoof care. Both are on track, although is hooves are surprisingly not nice and tight looking. Any additional diet changes I should be making? I took photos from his trim last night and will post to his album. 
- He's recovering from an injury so movement has been minimal for the past three weeks. Vet gave the okay to start tack/hand walking this week. 
- He's extremely tight over his SI, hips and hamstrings and is short-strided behind. He externally rotates/twists his right-hind leg out and wears down his lateral hoof wall. Vet gave him a 1 out of 5 on lameness eval (RH), and said to exercise over poles and back-up, to strengthen. My barefoot trimmer suggested an osteopath first. 

Everything I'm learning here has been immensely helpful, but I feel we're not out of the woods just yet. Any advice on what to do from here would be greatly appreciated. 

Thank you!
--
Laura and Ero

October 2020 | Colgate, WI USA 

Ero Case History

Ero Photo Album


Sherry Morse
 

Hi Laura,

You did get the lab normals column correct.  The Leptin result usually does take a bit longer than the rest of the results and it would be nice to have the number but isn't essential.  Having EMS does not predict a horse's tendency to develop PPID and since Ero's ACTH is in the teens I don't think it's something you need to worry about testing again unless you have reason to suspect he is becoming PPID.  Was this test done fasting or non-fasting? 

As far as the trim, I don't know if you've asked Lavinia for input (and she's quite backed up at the moment) but once you get the pictures of the fresh trim posted I would suggest asking her for some input ASAP so you can have it before the next trim.  Have you had him checked by a chiropractor?  I would agree with the suggestion for an osteopath or a good massage therapist or a chiropractor to check him out if he's still sore and to do that before you start increasing exercise since you know he's already having an issue.

Is he still being fed the alfalfa/grass mix hay?  If he is, is it being soaked prior to feeding?



Laura and Ero
 

Thanks Sherry. Please see my responses below. 

since Ero's ACTH is in the teens I don't think it's something you need to worry about testing again unless you have reason to suspect he is becoming PPID.   

I didn't think PPID at all given his age, but it was part of the combined tests that were offered by the vets in the area and I figured I'd get a baseline. I'm happily surprised he's not IR, but alas is still EMS. Are repeat tests recommended annually or more often? Going forward, just Glucose and Insulin?

As for Leptin, I've read/understand that it's not really necessary, but the response from my report says it's a often pre-indicator of correlating insulin levels. But what do I do differently that I'm not already doing?  

Was this test done fasting or non-fasting?  

He was kept in his stall and given hay/water only that morning. He had been eating hay for at least 3 hours or more.

 

Have you had him checked by a chiropractor? 

Yes, every 8 weeks (also a vet). But she's never adjusts his hip or much below the barrel. Hence my frustration as she agrees with other vet's assessment that he's a bit off. In his most recent lameness eval, the report indicated "mild fasciculation over RH hamstring during flexion." For what it's worth, I've also tried acupressure and PEMF (but neither on a regular basis). On to an osteopath ... 


Is he still being fed the alfalfa/grass mix hay?  If he is, is it being soaked prior to feeding?

Yes, although I don't think there's a lot of alfalfa. It was the best of the two choices I have available for me at the time (boarding) and the one Dr. K suggested of the two. I had all options tested and they are posted in my file. Dr. K said I did not need to soak given the numbers. However, I have experimented with this (always spraying down if not soaked), and for the past 3 weeks have continued soaking since he's been out of work. Every bit helps, right? Frankly, I'm not sure it's making a huge difference aside from water intake. 

 

As far as the trim, I don't know if you've asked Lavinia for input (and she's quite backed up at the moment) but once you get the pictures of the fresh trim posted I would suggest asking her for some input ASAP so you can have it before the next trim.  

I will get these posted and request a look from Lavinia. He's on a two week cycle now for a bit. My trimmer has been excellent in answering my gazillion questions and helping me on this path. She's a strong supporter of ECIR and was the one who suggested I post photos and ask again about the diet given how his hoofs are looking.  

--
Laura and Ero

October 2020 | Colgate, WI USA 

Ero Case History

Ero Photo Album


Kirsten Rasmussen
 

Hi Laura,

Just to correct/clarify your comment above, Ero is IR (or what we prefer to call EMS here) and not PPID.  An insulin of 29.2 uIU/ml on hay only is abnormally high.  Remember the "lab normals" or "lab reference ranges" are not what we use to diagnose here.  Ero's insulin would have to be closer to 12 (or less!) for him to be considered not IR.  It is possible his insulin was elevated a bit more than his norm because he may not have had long enough for his blood levels to stabilize after an overnight fast.  That's why we recommend pulling blood at no less than 4 hrs after the first hay of the day.

Keep up what you are doing with the soaked hay.  I suspect if you stopped his insulin would go up.  At ~30 it's already high enough to be compromising his lamellar connection so continue to work towards lowering it.  Getting him back to regular exercise should help.  The only way to see if soaking hay is not helping would be to redo insulin on a diet of unsoaked hay (keeping everything else the same, including the timing of the blood draw) and compare the results.

Since he doesn't have PPID how often you check his bloodwork isn't as critical, other than keeping an eye on how his current management is working.  I recommend at least 1x a year (more if you like and can afford it, or if you make a major management change) and generally trying to aim for the same time of year/day/temperatures etc will allow you to better compare results from year to year.  That said, we do recommend generally doing bloodwork in the warmer months as temps below 50F can raise insulin significantly.  I would personally at a minimum do insulin and glucose every year, and ACTH every 2 years for now, and annually after the age of 15.

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


 

I’m hoping someone can fill me in.  I’ve seen several references very recently to using an osteopath and I don’t know what that is in the veterinary world.  In human medicine one graduates from a school of osteopathy, takes medical boards and practices medicine equivalent to an MD.  As far as I know there is no equivalent program for vets.  How does one become an equine osteopath and what do they do?  I’m familiar with acupuncturists, chiropractors (both of whom are also vets) and massage therapists but not equine osteopaths.  Maybe it’s a state thing because I think we have different requirements for equine dentists here than in other states.
--

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


 
 


Laura and Ero
 

Kirsten - oh! Thank you very much for that clarity! I would have missed that (although am saddened by the news). I thought EMS was a condition that could lead to IR if mismanaged. Any threads I should search for to better help explain this progression? I’m quite sad as I retired my older guy with hopes of being able to ride/explore with a younger horse. I have no desire to get rid of him (he’s family now), but it seems we’re in for a long, troubled road ... at 7. He seemed to really fall apart this fall, where a year earlier he seemed fine and on his way (or I just wasn’t educated). 


Because of ~30 insulin I’ll keep soaking his hay (despite the ESC + starch in my current hay being under 10). Makes me nervous about new loads of hay as they aren’t always low. 


Thanks for note on a follow-up test and timing. I’ll plan for June as a better annual timeframe. Just wanted to get some data finally and be out of the seasonal rise timing. 


Any other advice other than to get him back moving as he can? Is it just a matter of time before he’ll need medication (metformin or ?) assuming all else stays the same? 


--
Laura and Ero

October 2020 | Colgate, WI USA 

Ero Case History

Ero Photo Album


Sherry Morse
 

Hi Laura,


There's no reason you can't ride and compete with an EMS horse and now that you know what the source of his issues is you can manage him appropriately.  That means that there hopefully won't be a repeat of this past fall's episode.  We really can't make any predictions about medication because some horses do fine with diet and exercise control and others can be on tightly controlled diets, in regular exercise and still end up needing to be on medication.





Kirsten Rasmussen
 

I think once he recovers from his injury, easing him back to regular riding will help with the high'ish insulin, and maybe he will tolerate his hay unsoaked at that time.  But if ever in doubt, soak it, because a laminitic flare-up can set you back months in your riding and exercise program.  One of many reasons that it's not worth it.  That's what I learned this year....it took 3 flare-ups (and a full season of lost riding) for me to finally understand the hay must be soaked!

But remember even an insulin of about 30 (and of course it will vary during the day so it could go higher and lower at times) is high enough to compromise the quality of the lamellar attachment without an overt active laminitis.  We call it sub-clinical laminitis because it goes undiagnosed.  The signs are usually just a sensitivity on hard/rocky surfaces (which can have other unrelated causes) and poor lamellar attachment (ridges in the hoof wall or whiteline flaring/disease).  Other signs of the high'ish insulin are there if you look for them, like fat pads, but most people are oblivious.

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


Laura and Ero
 

All of these symptoms are present. He’s a tad more sensitive coming from the arena to the concrete aisle (even with HA applied on his soles) — although this sensitivity was not noticeable with composite shoes. He has some fat pads behind his withers and tail head, some small flares still, and we’re still working on WLD.  So, I will continue to soak. 

Q - now that he’s confirmed IR, I’m wondering if I should add more magnesium oxide to his diet? I’m not quite sure how to interpret his hay (.25% / As Sampled 1.12), but other than that he’s only getting the 2 scoops in the Equi-VM (2270 mg / 4%). 

Is 5000mg a typical base minimum? And given his injuries and IR, would adding another 2500 or more help him? (Should this be a new post?) 

--
Laura and Ero

October 2020 | Colgate, WI USA 

Ero Case History

Ero Photo Album


Sherry Morse
 

Hi Laura,

I can't recall, but do you have Ero in boots?  If not, you probably want to have him booted for turnout and any exercise under tack.  As far as his diet I believe Dr. Kellon is helping you balance his hay, is she not?  If I've misremembered that (always possible) you can find a list of people who can balance your hay in our files: https://ecir.groups.io/g/main/files/6%20Diet%20Balancing (scroll down to the haybalancing.pdf file).





Laura and Ero
 

Hi Sherry - trying to find boots to have ready when we start back under saddle again (considering Flex, Easycare Trail or Epics, possibly Scoots). Unfortunately, at the moment his hooves aren't the best shape for most boots to properly fit. This is why we're going to a two-week trim cycle. My boarding barn won't put on boots for turnout; thankfully he seems reasonably comfortable given his smaller dry lot and a good foot of snow. 

As for balancing - yes. Dr K provided the most recent recommendation, but it was prior to having any test results back yet. I'm enrolled in the current NRC+ class, but have not been able to adequately keep up to a point where I am confident in my own decisions. I'll try that sub-group ... last week was major minerals (good timing). 
--
Laura and Ero

October 2020 | Colgate, WI USA 

Ero Case History

Ero Photo Album


Kirsten Rasmussen
 

I would just stick with the balancing that was done before, and work your way through the NRC Plus course before you make any changes.  As you work through your hay analysis and have someone (Carol) check your numbers, it's fairly easy after that to add in the other supplements to see if they are correcting shortfalls and ratios in the hay.

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


Kandace Krause
 

Kirsten and Dr Kellon,
Now I am confused on two points.
1)  My hay (no alfalfa) was said okay by your Kirsten (It is in CH file, can't figure out how to more to photos) and I stopped soaking it on that, not to mention the hassle in freezing weather.  Can you clarify, am I or am I not to be worried about any of my hays?

2) Dr. Kellon said that to watch alfalfa, that just because its low doesn't mean its okay, BUT that some horses tolerate it.  How would you know if it is tolerated?

 
--
Kandace K Rocky Mountains, Alberta, Oct 2
https://ecir.groups.io/g/CaseHistory/files/Kandace%20J%20and%20K
https://ecir.groups.io/g/CaseHistory/album?id=259062


Sherry Morse
 

Hi Kandace,

1- your hay analysis files are PDFs and are fine in your CH folder - the only file type supported in photos is jpg so you can't move them.  As far as soaking - we recommend under 10% ESC+starch because most horses do ok on that without soaking. However, there are horses that just under 10% isn't enough low enough and those horses do benefit from continued soaking of their hay.  If you have a horse that's still having issues on a hay that's under 10% ESC+starch that's when we suggest soaking and seeing if that makes a difference.

2- the only way you know if your horse can tolerate alfalfa if it's not already part of their diet would be to add it in and see what happens.  If you have a horse that's sensitive to ESC+starch levels in hay without alfalfa, or one that's sensitive to other diet changes it's not something we suggest trying to find out because the results can be disastrous for the horse.



Laura and Ero
 

Updates on Ero:

- Ero's updated test results with Leptin (at 21.86 ng/ml) are on file - def high, but still not sure what I can do about it. Not a surprise given his behavior. 


- I'm going to increase his magnesium (per Dr K's response via my NRC+ subgroup) given his injury and muscle tightness. 

Upper limit is 1.2:1 or GI upset (diarrhea). Magnesium is particularly important for IR horses because low magnesium has been associated with IR and correcting this usually improves insulin sensitivity. It is also beneficial for muscle tightness in some cases - but not white line integrity (that's an insulin issue).  Because your horse is IR with muscle stiffness you could try supplementing Mg. Go to 2:1 first and take it from there.
- Requested feedback from Lavinia re: his trim. Awaiting a response and our turn, as I know she has a long list. 

- Awaiting response back from an Osteopath as Ero's back and hind-end are still very stiff. Light in-hand work for a bit (month, maybe more) might be of great help, but the RH external rotation is off-putting. I see there's been a follow-up thread on Osteopaths which Dr. K provided helpful input.
Dare I say I'm starting to wonder about PSSM as his age seems to be about right for these types of things to show up ... and from my research so far, feeding seems to be somewhat consistent with IR and PSSM1 horses (protein and fat might vary, but I have more research to do along with a verified test).

Laura and Ero

October 2020 | Colgate, WI USA 

Ero Case History

Ero Photo Album


Eleanor Kellon, VMD
 

If wondering about PSSM, get a biopsy. The testing through EquiSeq has never been validated. There is a LOT of poor advice out there.
--
Eleanor in PA

www.drkellon.com 
EC Owner 2001


Laura and Ero
 

Appreciate that advice Dr Kellon! By chance, is the biopsy valid for both PSSM 1 and 2? 

--
Laura and Ero

October 2020 | Colgate, WI USA 

Ero Case History

Ero Photo Album


Eleanor Kellon, VMD
 
Edited

Yes, PSSM is a biopsy diagnosis. The differentiation between 1 and 2 is the presence of amylase resistant PAS positive material (glycogen).  SomePSSM1 cases are caused by the GYS1 mutation.  Some PSSM2 are characterized by abnormal deposits of the protein desmin which is found with special stains.

The biopsy can also tell you if there is a problem which is not PSSM.
--
Eleanor in PA

www.drkellon.com 
EC Owner 2001


Kandace Krause
 

Sherry thank you,
Before the laminitis found us EMS and PPID, both horses had cubes, Timothy Alfalfa but "K" only a bit (as with everything but hay) because when she did an Endurance or Competitive Trail Ride she would be offered the higher value feeds, just pre ride and a day or two after while in rest.  And feed changes always upset her, so to keep them not to be changes, I just gave her small portions all the time.  Then nothing was new.

If we ever get back to those rides, I see I am only to offer for one hour post workout but I am leary of everything because of flare ups.  As I have read more, I see I am not alone, which brings me to the next point, soaking, the one hay that is a bit higher ESC+starch is mixed in with the other two, so fed at less than 1/3 of forage ration per day.
I think what you and Kirsten are saying to me is, if she flares again, go back to soaking (or just take it out of hay mix completely) and stay with less than 7%.  I have a lot of this hay to use, and can easily go back to soaking it when weather warms back up.  Because we don't know why she flared up, is there a time in a diet change that this may show, like two days after change in diet the horse goes laminitic, or two weeks after, or two months?  I am now introducing changes one at a time, but if I had a better idea of how long each change should be allowed to readapt?
Kandace
--
Kandace K Rocky Mountains, Alberta, Oct 2
https://ecir.groups.io/g/CaseHistory/files/Kandace%20J%20and%20K
https://ecir.groups.io/g/CaseHistory/album?id=259062


Kirsten Rasmussen
 

Yes, do what you can now (until she's back in work) to reduce her sugar intake, especially if she is still in pain.  You want to do your best to make sure the new hoof growing in is healthy and well-connected to shorten her downtime, so being really stringent with diet and getting insulin as low as possible and doing frequent trims are critical. 

The time frame I've seen for my horse has been within 2-3 days of a diet change he starts to seem off, maybe a little more tender footed or more head bobbing while walking.  I seem to miss these signs until about 5-7 days when it gets worse and one morning (around day 7-9?) I come out to see him hobbling around in pain and it becomes clear he is laminitic.   That's when I remember to check for bounding pulses to confirm that he is having a flare-up, then in hind sight I remember how he was a bit off a week ago and oh yeah that was just after he got into his buddy's hay or just after I stopped soaking his hay.  That was the progression 2x this year.  I hope I've learned now to pay attention the moment he looks a bit off.  However, once starting to soak hay, by 24 hrs there is a slight improvement and over 2-3 days it is clear he is walking better.  A week later he can be almost back to normal (not rideable, but more comfortable for turn-out again) but the time to heal seems to depend on how much damage was done to his hooves during the flare-up. 

I would expect a reduction in pain within a few days of soaking K's hay IF high insulin is still a problem.  If not, then it is more likely pain is related to the hoof changes from before.  Trim, soft pads in boots (not sure if that's part of the NANRIC boot, a felt pad is better than no pad though) +/- warmth might help.  My horse does not have a problem with cold temperatures and snow so not all horses do, but the experience of this group shows that it is very common.

Once they are exercising though, especially heavy exercise like endurance training, it really does help.  During exercise and for a short time after an intense workout their body does not need insulin to get glucose into the cells, so you can feed higher sugar foods like pasture or even grains like whole oats after a workout and not get a peak in insulin.  The effects of exercise also seem to improve insulin sensitivity for at least 24 hrs after exercise.

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