Baby is worsening


Jan4slt@...
 

Talked with vet about increased pain to all hooves, despite tested hay 9.6 and small amounts Teff pelleted 9 carbs. She continues Prascend daily and Bute wean down 1.5g twice daily.  She has not been out of pain in weeks. Today we began Metformin and Gabapentin ground up/water solution and oral syringe given by mouth with difficulty. She is standing on rubber mats, eating and drinking but barely walking about. No attempt to take to the arena to roll today because of her pain.  I started oral salt one -2 teaspoons sprinkled on hay. Giving platinum performance supplement as directed by vet one scoop (looks like 1/2 cup volume) and 2 ml Elevate vit D twice daily.  Our next evaluation is Monday and I’m considering I euthanasia if not out of pain. What else can I do?
--
https://ecir.groups.io/g/CaseHistory/album?id=264927
https://ecir.groups.io/g/CaseHistory/files/Jan%20Baby
Jan L in CA 2021


Eleanor Kellon, VMD
 

For one thing, soak that hay. It's too high for a horse in crisis. Substitute rinsed and soaked beet pulp for the teff pellets. Get hoof photos posted.  The phenylbutazone doesn't help and neither does gabapentin.
--
Eleanor in PA

www.drkellon.com 
EC Owner 2001 ns


 

Hi Jan,

Welcome to the ECIR group! 
This response is generated by your first post as new member.  You’ll find lots to read here on our program and philosophy.  Before digging in, let me try to address some of your pressing concerns.  I was in a similar situation with a pony last year and I know it can be frustrating and demoralizing.

She’s eating and drinking so that’s good.  Don’t try to encourage her to move about until she shows you she’s ready.  Make sure she has a deep pile of bedding under her feet and to lie on.  Don’t be discouraged if she spends time lying down.  

It doesn’t sound like she is got boots on, which would help her.  Finding the right pair can be a process so in the meantime, I suggest using insulation board.  It’s foam, a few inches thick and comes in fairly large sheets so you’ll need to cut it to fit her front feet and duct tape it on.  Here, we make a web of duct tape, the pieces of which are large enough to cover the pad and continue on a few inches on either side to adhere to the foot.  The duct tape mat is applied to the foam which is then slipped under the foot. The loose tape ends stick to the hoof.  You’ll need more tape or vet wrap going around the hoof to keep it in place.  This should work for a few days until it needs to be replaced.  That should help her comfort level somewhat.  I generally put baby diapers over the entire apparatus to hold it together.  If you have a Pony Clubber where you board, ask him/her for help.

There is no drug you can give her to alleviate the pain.  Gabapentin is not well absorbed and is not found to be very effective.  Keep weaning her off the bute, as well.  The pain will become less as the triggers are removed.

Our emergency diet suggests that the hay be soaked and rinsed and that ground flax, salt, Mg and vitamin E (Elevate) is added.  I would not worry about adding anything else such as Platinum Performance.  Metformin can be quite effective at the correct dose.  Please let us know what amount you are giving her.

After you set up her stall and get ‘boots’ on her, she should begin to feel better.  So it’s time to take a look at our guidelines.  We focus on D,D,T and E, which stand for diagnosis, diet, trim and later exercise.  We’d like to take a look at your blood work to confirm a diagnosis and the Xrays and photos of her feet so we can assess her trim.  For now, the emergency diet will be best but it’s not a permanent solution.

Please take some time to fill out our case history form.  We ask for information which is important for us to help you the best and your putting it into our format helps us to help you.  Many people balk at this but it’s quite doable if you follow the instructions carefully.  And we are here to help you out.

Now on to the nitty gritty.

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. 

 

--
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


 
 


 

I went back through your notes again, Jan, and thought I would add that with thin soles, soaking might well be contraindicated.  We don’t know how thin they are and icing is generally not useful after the first few days.
--
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


 
 


Sherry Morse
 

Hi Jan,

It would be very helpful if you could take your extended description here: https://ecir.groups.io/g/CaseHistory/files/Jan%20Baby and put that in a message to the group as it explains a lot more about the current situation.

As already indicted by both Martha and Dr. Kellon bute and gabapentin are not going to help with a laminitis caused by an endocrine issue and your hay is too high in ESC+starch to be fed to a horse in crisis.  Once you have a case history completed we'll be able to better help you but for a horse that's still eating and drinking I would not be considering euthanasia.  I would be considering ways to make her more comfortable which would include putting her in boots, no longer forcing her to move if she doesn't want to and not allowing her to eat any grass until her insulin is under better control.  I would also stop the Platinum Performance as the base is not suitable for an IR horse.

Thanks,


Jan4slt@...
 

I reviewed and tabulated the case history.  Thank you for all your ideas/suggestions. She is shod with rocker shoes and padding covered with a plastic plate by reputable farrier who works with the vet clinic. I reviewed my hay content and submitted it in the CH and it is lower than I reported earlier. Tested and sold by reputable ranch distributor

On Jun 10, 2021, at 5:49 PM, Sherry Morse via groups.io <sherry_morse@...> wrote:

Hi Jan,

It would be very helpful if you could take your extended description here: https://ecir.groups.io/g/CaseHistory/files/Jan%20Baby and put that in a message to the group as it explains a lot more about the current situation.

As already indicted by both Martha and Dr. Kellon bute and gabapentin are not going to help with a laminitis caused by an endocrine issue and your hay is too high in ESC+starch to be fed to a horse in crisis.  Once you have a case history completed we'll be able to better help you but for a horse that's still eating and drinking I would not be considering euthanasia.  I would be considering ways to make her more comfortable which would include putting her in boots, no longer forcing her to move if she doesn't want to and not allowing her to eat any grass until her insulin is under better control.  I would also stop the Platinum Performance as the base is not suitable for an IR horse.

Thanks,



 
Edited

Hi, Christopher/Jan.
Thank you for putting your information in a Case History.  Please be sure to re-read the information sent by Martha earlier today. https://ecir.groups.io/g/main/message/265527  It's a lot to take in. 

What jumps out at me is that Baby's ACTH is above the normal range at the time of the year when it should be at the lowest and that her insulin is high enough to be within the range that can cause hoof pain and laminitis. Some horses are very sensitive to uncontrolled PPID which we measure through ACTH. My own PPID horse was diagnosed in May at the high end of the normal reference range. She was dead lame and her insulin had spiked.

An increase in pergolide dose may help Baby. Prascend is an expensive unpleasant-tasting medication. With difficulties getting Baby to take Prascend, your vet is justified in prescribing compounded powdered pergolide in a capsule with flavoring that is almost sure to be easier to feed in a pill pocket or a handful of safe feed. ECIR files contain information about compounded pergolide, including a list of compounding pharmacies. https://ecir.groups.io/g/main/files/3%20Cushings%20Disease%20%20PPID/Cushings%20Disease%20Treatments/Pergolide/1.%20Compounded%20Pergolide   Pergolide must be given every day to be effective. Skipping doses will result in uncontrolled PPID, worsening Baby's pain. I suggest you find pergolide in a potent form that you can easily feed every single day.

The best way to remove hoof pain is to remove the triggers for laminitis. Suspect #1 is uncontrolled PPID as indicated by the ACTH.  Suspect #2 is hay that is not safe for a horse with Equine Metabolic Syndrome and/or PPID.  Please post a copy of your hay analysis in your Case History Folder. Details in the analysis are important.  If you have a pdf file, post it in the case history folder. If you have an image file (like a photo from your phone), post it Baby's Photo Album. It's not a dig against the reputable grower that the hay isn't quite suitable for a laminitic horse. You're in an emergency. As Dr Kellon said, soaking the hay is your best bet right now.

If you have hoof Xrays from your veterinarian, be sure to post them to the Photo Album for Dr Kellon and ECIR moderators who can read and interpret them.
--
Cass, Sonoma Co., CA 2012
ECIR Group Moderator
Cayuse and Diamond Case History Folder                
Cayuse Photos                Diamond Photos


Sherry Morse
 

Hi Jan,

Looking at your CH you have Baby listed as an ideal weight of 1000lbs which would be reasonable for the average 15.2 hand horse, but then you list her as a 7 - which is fat - with a weight of 950lbs currently.  In the picture you posted from December - as well as in the current video - she does appear to be carrying some extra weight so I would suspect her current weight is actually over the ideal listed, probably by at least 75lbs at a guess.  Is there any way you can put a weight tape on her to give us a better estimate of her current weight as this will go directly into how much she should be eating a daily basis. 

She's not walking that bad in the video so has she gotten significantly worse since you took this?  How does her trim look in comparison to the x-rays from February which showed her toes to be quite long although her soles didn't look as thin as some others we've seen.




Christopher Lynds <Jan4slt@...>
 


I posted the Hay analysis.  I reread the post by Martha and read about seasonal rise of ACTH which does seem to be showing up in her hoof pain/laminitis now.  I have a call in to the vet about increasing her 1 mg of Pergolide and possibly compounding it for the future.  For now, I have Prascend.  We can manage with an oral syringe.  My vet recommended Stevia to sweeten it and what about Erythtrol? What amount would be allowed?

I can soak her hay, but given the analysis (I reported the wrong ESC earlier, just had to find my paperwork and not trust my memory which said less than 10%)  and since it is 7.1 ESC and starch 1.0,  would you still recommend that?  I will soak it for this evening meal and on until I hear from you again. We have been weighing flakes and see that they range from 6-7.5 lbs per flake (putting it in a net and using a luggage scale.)  I aim for 20 lbs daily.  We have stopped the Performance Platinum and the teff pellets.  I don’t have any beet pulp at the present time. 

Baby has shoes all around now for her thin soles known to be present from xrays in her bilat front feet.  She is standing on stallmats. She can’t lift a foot up long enough to get the duct tape fixed as a padded boot and I’m not sure what to substitute for the insulation board? 

The Metformin is prescribed as 8 tabs BID, tablets are 1000mg each, and her weight was estimated by the vet to be 950 visually.  I don’t have a weight tape.--
Jan L in CA 2021
https://ecir.groups.io/g/CaseHistory/album?id=264927
https://ecir.groups.io/g/CaseHistory/files/Jan%20Baby


Kirsten Rasmussen
 

Hi Jan,

As long as Baby is in pain, soak her hay.  8% ESC+starch is safe for some horses, but not others.  And if she's in acute laminitis you want to do all you can to lower the sugar and starch right now.

The recommended dose for Metformin is 30mg/kg body weight, twice a day.  If she is 950 lbs (431 kg), that would be 12,930 mg 2x a day, or about thirteen 1000-mg tablets 2x a day.

Agree with Cass that increasing her Prascend is a priority.  No hay is safe if her PPID isn't controlled.  This time of year she should be in the mid-teens, not above the upper limit of the reference range.

Also working on her trim, especially her right front hoof, could help with her comfort.  I don't think insulation board will help with the shoes on anyways.  We always recommend removing shoes and using boots with pads so that frequent trim adjustments can be made (eg, every 2 weeks).  This also reduces stress on the already damaged and stretched lamellae, which is likely a significant source of pain.  You can also try different pads with boots to find out what is the most comfortable.  Some horses like firm pads, others soft; some prefer felt and others foam.  Lots of options out there.  If you'd like more specific feedback on trim, you can post a full set of hoof photos ( https://ecir.groups.io/g/main/wiki - scroll down to Hoof Photos and Evaluation Help) and start a new message requesting trm input and/or markups.


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


Christopher Lynds <Jan4slt@...>
 

I have increased her Prascend to 2 mg /day by syringe.  I am positive she is getting it.  I don't feel comfortable increasing the metformin until she gets the vet visit on Monday. The xrays were taken 2020-05-20 before the farrier came later same day and pulled shoes, new trim and placed impression material next to dry/clean frog to pad and thin soles and plastic plate placed under aluminum rocker shoes for front feet. This treatment worked for original laminitis event when PPID was diagnosed 2019-11-8 with resulted ACTH very high (964 Cornell labs ref range 9-35) insulin 30.27 ref range 10-40 and leptin 16.23) She had back shoes put on at the same time on 2021-05-20 for intended comfort.  Current crisis occurred 2021-03-31 with old hamstring injury exacerbation and LH lameness. Blood had been routinely drawn 2021-03-27 and resulted report a week later, same Cornell lab ACTH 39.6 and insulin 74.39.  She was already off pasture and in a pen for the hamstring lameness. She has progressed in pain to standing on sand over the shed mats, moving very little, maybe one manure pile outside and the rest inside the 12x12 shed area. Her food and water are in the shed area. She is still eating, I am soaking the low carb hay in nets and then letting it drain and putting it in her tub in the shed. She is eating. She did lift her feet today so I applied duct tape hoof boots with easy boot pad inserts for padding.  I have to see how that improves her pain in the morning. I have to drive 40 miles roundtrip and am making 2 trips a day to be diligent about med admin and ensuring she has hay and encouragement. I don't think this will be sustainable all summer as much as I want to help her.  I don't know why there is a discrepancy between the 8000 mg BID Metformin and your calculation. This frustrates me. I'll ask the vet Monday. I have only given one dose of Gababpentin 8 tabs because of the ECIR advice that it won't help and the struggle to oral syringe it in addition to the metformin. She still is getting 2g of Bute on weaning down, as it hasn't helped either.  It was an immediate help in her initial onset of PPID laminitis in 2019.  How many days of soaking hay are needed to lower insulin?  I read that changes in Prascend are measured by blood test 3 weeks after they are commenced. What about retesting insulin levels?  
Thanks in advance for responses. 
--
Jan L in CA 2021
https://ecir.groups.io/g/CaseHistory/album?id=264927
https://ecir.groups.io/g/CaseHistory/files/Jan%20Baby


Sherry Morse
 

Hi Jan,

This is a marathon, not a sprint.  Elevated insulin levels are often tied to elevated ACTH levels so until Baby's ACTH is under control her insulin may remain elevated.  Pain can also cause insulin to be elevated so getting her trim in order and getting her a bit slimmer may also help bring that number down.  At this point I would plan on continuing to soak her hay until her ACTH has come down and her insulin is testing below 20.  Once you've made that goal you can try not soaking the hay and see how she does but were she mine I'd be looking for some lower ESC+starch hay to use than the current hay you have.

Bute will not help metabolic laminitis so the sooner you can wean her off of that the better.  If you have not already read it please see our schedule for weaning off NSAIDs: https://ecir.groups.io/g/main/files/Pain%20Medication%20and%20Alternatives/How%20to%20Taper%20Off%20NSAIDs.pdf

You may also want to read this document on changing from Bute to Phytoquench for pain control: https://ecir.groups.io/g/main/files/Pain%20Medication%20and%20Alternatives/Pain%20control,%20switching%20from%20Bute%20to%20Phyto-Quench.pdf



Christopher Lynds <Jan4slt@...>
 

I posted in the upload area.  Can you see that or do I need to retype it all?  
--
Jan L in CA 2021
https://ecir.groups.io/g/CaseHistory/album?id=264927
https://ecir.groups.io/g/CaseHistory/files/Jan%20Baby


Sherry Morse
 

Hi Jan,

Whatever message you posted needs to be emailed to the group. You can do that by copying it and pasting it into a message and sending it the same way you did this one.




Lorna Cane
 

Do you mean your hay analysis, Jan?
I see it in your photo album.


--

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