Need to help a friend in crisis. How can I add a case history for her? Can a moderator please assist with this quesiton?


Mary Gokey
 

Dear Dr. Kellon and moderators:
I have been a member of this group since 2016, and have found it invaluable. A friend has joined ECIR, but needs help getting her case history and xrays uploaded. I have a copy of her case history, since I helped her complete it. I would love it some help if someone in the group could upload it into her account. Her name is Jessica Gunderson

jr_gundersonn@... is her email. Her horse has been in crisis really since April 1, 2021, and they have tried almost everything. I was hoping Dr. Kellon could look at the information for Jessica and her horse Kahn who is close to being euthanized. Please get back to me as soon as you can! Thank you!


Candice Piraino
 

Hello Mary and Jessica,

Welcome to the group! You will find the below information to help you with uploading the case history, which will help us better assist you and the horse.

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 (look under the Hay Balancing file if you want professional help balancing). 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 Piraino

Primary Response Team

September 2018, Summerfield, FL

Shark's Case History

Shark's Photo Album 

PHCP Barefoot Trimmer @www.arkhavenfarm.com

 


 

Hello Mary and Jessica,

Thank you, Mary, for bringing Jessica on board.  
Posting a case history involves a few steps but it isn’t hard to do.  If you’ve got the case history put together, you’re most of the way there.  We don’t post case histories for members because that takes away your ownership of the material and adds complications; however, I would be happy to help.  I’ve just finished assembling a video on just that topic to be used at the No Laminitis Conference next weekend.  How about I send you a copy?  It’s only 8 minutes long so not too big a time waster.  If you have problems understanding the steps, you can contact me privately and I’ll try to help.  We can consider it a trial run and hope it’s more helpful than not.  

--

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


 
 


debost@...
 

Could I get a copy of that video also?  debost@...
--
Deborah Ostrofsky
Year of joining: 2021
Location: Northwestern Pa


Jessica Gunderson
 

Radiographs and case history have been posted. Please let me know if there is anything else you need from me. 
My primary question that any other question would be dependent on is with the aggressive progression since April 10th over the last 4 months, extreme rotation with solar prolapse (I do not have images) is there a reasonable chance Khan could come back from this or would it be kinder to euthanize?
--
Jessica and Khan
N.D., 2021


 

Here’s a link to Jessica’s and Khan’s case history and radiographs.
--
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


 
 


 
Edited

Hi Jess,
There were no lab standards for the ACTH test.  Was that done at Cornell as well?  I know Khan is quite young to have PPID.  Did the vet have an alternate explanation for the high ACTH?  It would be interesting to see if starting her on pergolide would bring that number down.  

How long have you been soaking her hay?  Has any testing been done since you began soaking?

When you tried metformin, were you syringing it in or adding it to her feed?  The mouth ulcers have been noticed with syringing but not so much when it’s in feed.  The suggestion is to suspend it in Milk of Magnesia.  Here’s a link to a user’s guide to metformin, in case that helps.  Metformin, as you probably know, is our first choice for bringing insulin down.  Her insulin isn’t dangerously high now and might actually be somewhat elevated due to her hoof pain.  She would be much more comfortable with a different trim and padded boots but I’d like to leave that discussion to the hoof pros here.
--

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 Jess,

Based on the radiographs Khan started this journey with very thin soles and long toes.  Neither of these conditions have been addressed and they appear to have both gotten worse from April until the most recent set of x-rays.  In addition there appear to be bony changes happening on the tip of the coffin bone.  However, we have seen much worse x-rays and horses can come back from this but it does mean a complete change in trimming philosophy to do that. 

To get the most help for Khan it would really help us if you could create a photo album in the CH subgroup (https://ecir.groups.io/g/CaseHistory/photos) and then post a full set of current hoof images there. Information on how to get good hoof pictures as well as useful x-rays is here: https://ecir.groups.io/g/main/wiki/1482#Photos-and-Hoof-Evaluation-Help

Can you please update your signature with your case history link? https://ecir.groups.io/g/CaseHistory/files/Jessica%20and%20Khan

To do that:

1) Go to this link to amend your auto-signature: https://ecir.groups.io/g/main/editsub
2) Look at the bottom of that page for the window where you have your signature. to type in your name, general location, and year of joining.
3) Copy the link to your case history into the line below your location.  You may need to add a space after it or click enter to make the link live (turn it blue)

4) IMPORTANT: Scroll to the bottom and hit SAVE




Sherry Morse
 

Hi Jess,

So to address the information in your case history:

1- we need actual weights for Khan - both ideal and current.  As a 14.3 hand TWH I'm going to guess she should be about 900lbs but that is dependent on her build and with no pictures I have no idea on that.  If you want to provide us with an estimated current weight you can use the weight calculator instead of a weight tape.  Information on how to do that can be found here: https://ecir.groups.io/g/main/files/Case%20History%20Tools/Tools%20and%20How-To%20Help/Horse%20Weight%20Calculator.xls

2 - With an estimated weight of 900lbs she should be eating 18lbs a day total.  Is the hay she's being fed actually being weighed or is the 18lbs an estimate?  Stabul-1 is a safe carrier but that weight needs to be taken into account for what she's eating so keep that in mind.

3 - Is she still on Thyro-L? Just as an FYI while Thyro-L can help jump start weight loss it will not help with insulin control and needs to be weaned off of gradually so the horse's thyroid can start working again.

4 - Is she still on Insulin wise?  Most of our members have not seen a significant drop in insulin with this product but they do offer a money back guarantee I believe so that's a bit of good news.

5 - Bute is contraindicated in cases of metabolic laminitis.  In addition, long term use of NSAIDs can cause other issues.  However, much like Thyro-L you need to wean off of bute gradually.  For better pain control we recommend straight devil's claw or Phyto-Quench with Devil's claw in it.  Information on tapering bute: https://ecir.groups.io/g/main/files/Pain%20Medication%20and%20Alternatives/How%20to%20Taper%20Off%20NSAIDs.pdf.  Information on switching to Devil's Claw: https://ecir.groups.io/g/main/files/Pain%20Medication%20and%20Alternatives/Pain%20control,%20switching%20from%20Bute%20to%20Phyto-Quench.pdf

6- Fentanyl patches may help with soft tissue issues but have a poor response in terms of lameness. You can read more about that in this post from 2015: https://ecir.groups.io/g/main/message/193003

7 - Equinety doesn't provide a whole lot of anything so you'd be better off saving your money and putting it to minerals that actually balance the hay you're feeding once you have that tested: https://ecir.groups.io/g/main/message/239903 and https://ecir.groups.io/g/main/topic/33069113#239897 on that.

8 - P45...if it's this: https://trinity-consultants.com/shop/detoxification/p45/ I'm going to go out on a limb and suggest you stop it and save your money because it's probably not doing any good.  I'll refer you back to the Emergency Diet: https://www.ecirhorse.org/DDT+E-diet.php and strongly recommend you follow those recommendations.  Again, another reference to this in a prior discussion - from 2017 -  https://ecir.groups.io/g/main/topic/5945408#211672

Now a couple of questions for you:

1 - do you have a copy of the ACTH test showing the 340 total?  Was it a TRH response test or something else?  What lab did the bloodwork?
2 - with a result of 340 is there a reason Khan wasn't started on Prascend after that result was received?
3 - was the insulin and glucose bloodwork done fasting or non-fasting?
4 - I am guessing that Khan is completely off the Purina but can you confirm please.

And some final observations:
1- young horses are not bulbous over their eyes, they are smooth. 

2 - From your description Khan is most definitely IR and in need of a corrective trim as well as tight diet management which you have mostly in place.

3 - if she is currently in shoes I would remove those and go back to boots so she can be trimmed more frequently and changes to padding made as her comfort level dictates.  Looking at the x-rays it appears the pad material is pressing directly onto the tip of her coffin bone so it's no surprise she's not comfortable standing up and moving.

To summarize:
Diet - may need a reduction in hay depending on current/ideal weight. Until hay is tested keep soaking.  Add in Flax, Vitamin E. Remove things that are not working
Diagnosis - may need to repeat ACTH bloodwork to confirm diagnosis and may want to repeat insulin/glucose NON-FASTING to see where she's at right now
Trim - post pictures for feedback, remove shoes and return to boots

There's no reason Khan can't come back from this but removing the cause and treating the underlying issues is key.




ferne fedeli
 

Sherry, when I used this link of yours,
If you want to provide us with an estimated current weight you can use the weight calculator instead of a weight tape.  Information on how to do that can be found here: https://ecir.groups.io/g/main/files/Case%20History%20Tools/Tools%20and%20How-To%20Help/Horse%20Weight%20Calculator.xls

I couldn't figure out where on earth the weight calculator was...  Could you give us a direct link to the calculator?
--

Ferne Fedeli  Magic & Jack   2007

No. California
Case History

 

 


Sherry Morse
 

Sorry Ferne, I forget that we didn't update that link...






ferne fedeli
 

Thanks so much, Sherry!  And even an Excel version that calculates.  Woo Woo!!!
--

Ferne Fedeli  Magic & Jack   2007

No. California
Case History

 

 


Jessica Gunderson
 

Re: ACTH, the test that is currently out is at Cornell and I did request my vet overnight it with expedited processing so hopefully I will have that back early next week. I used an interim vet because my vet has had limited availability and I never received the actual lab work so I cannot confirm if that was Cornell or not.  Both vets here felt it is just stress from laminitis however I contacted an equine podiatrist who sees a higher volume of laminitis cases then vets here and he said they are seeing three year old's coming in with PPID and in temperature controlled barns such as where I am coat changes may be less obvious.

Re: soaked hay, we have been soaking the hay since April 1st or 2nd.

Re: Metformin, it was syringed, 
--
Jessica and Khan
N.D., 2021


Jessica Gunderson
 

She had a girth measurement of 75 and is now 68 so approximate 1185 pounds to 915 pounds, her ideal weight is probably just a little higher than she is currently. Right now her ribs are clearly visible, spine protrudes when arching back/laying down, neck has become slightly u-necked, and inadequate musculature. Zero crest at this point.

The hay is not estimated it is weighed.

She is still on Thyro-L and InsulinWise.

Response to 1. I don't have the information you are looking for but I don't think it was a stim test - the vets do not consider that safe for Khan.
Response to 2. Too young, just laminitis stress.
Response to 3. non-fasting.
Response to 4. Correct, she was on Purina WellSolve W/C for 2ish months but not since the first week in April.
--
Jessica and Khan
N.D., 2021
https://ecir.groups.io/g/CaseHistory/files/Jessica%20and%20Khan


Jessica Gunderson
 

The hay has been tested and it is safe, we are soaking to be on the safe side. Khan will not eat flax or beet pulp, we tried for about 2 weeks and the vet felt it was more important to get her thyro-l and insulinwise rather than continue to have her refuse to eat beet pulp. We tried peppermint, equi-sweet, banana flavoring I think was one and the only way she would touch it was with Stabul-1 so we started giving her the Stabul-1 at that point.

This hay has already been balanced to Equi-VM but my vet is very much against Khan using Equi-VM because it has corn, alfalfa and kelp in it.  Is there another balancer with this profile that does not have these ingredients?

The trim is a absolutely a huge problem, has been frustrating for myself and my vet and looking at her rear hooves I wonder if the trim was problematic even prior to laminitis.  The problem is she gets better and then we trim and she crashes, its like we cannot touch her feet without having 3 bad weeks after.  Has anyone else experienced this? Unfortunately we are in an area where the skill level Khan needs from a podiatrist/farrier is not easy to come by.  I have looked at the ECIR farrier list and non of them are close.  Does anyone have any recommendations for the upper midwest or someone who travels? I have contacted a couple of equine podiatrists and while I think they sent me good markups they do not travel and my farrier did not trim according to their markups which was to really take back the toe and flatten the palmar angle. This may be my biggest concern is finding to realign through trimming without crashing each time.
--
Jessica and Khan
N.D., 2021
https://ecir.groups.io/g/CaseHistory/files/Jessica%20and%20Khan


Sherry Morse
 

Hi Jess,

We would be interested in knowing who you contacted who said he's seeing 3 year olds with PPID as that's very unusual. Not unheard of but definitely unusual, especially to see more than one at a time.

If she is below what you consider her ideal weight you may want to consider weaning off of the Thyro-L which should be done over a period of several weeks (we recommend a 6 week taper to allow the horse's thyroid to start working again. You can read more about that here: https://ecir.groups.io/g/main/message/265797)

If you could post pictures of her current condition that would be helpful.  Adding pictures of the current trim would allow you to get help on how she should be trimmed going forward.  To do that please see https://ecir.groups.io/g/main/wiki#Photos-and-Hoof-Evaluation-Help.  If your farrier is open to helping Khan he should be receptive to having somebody with experience with PPID/IR horses give tips on trimming.  We have many members who have started trimming their own horses feet either because they can't find a farrier who will work with them or the farrier can not come often enough to keep ahead of the trim.  It sounds like you've already tried to get him to bring her toes back - which has not been done - so you may need to consider finding someone who is more willing to work with you. 

Are you feeding the Equi-VM now?  It is safe for a PPID horse but ideally you would want to have your minerals balanced to your hay.  You can contact one of the people on the balancing list: https://ecir.groups.io/g/main/files/6%20Diet%20Balancing/HAY%20BALANCING-1.pdf for assistance with that.




Jessica Gunderson
 

We are weaning the thyro-L. We were at 3 scoops and now we are at 1 scoop. 
Mary and I use the same hay and she did have it balanced. Equi-VM is the match for this hay. I have it, but I am not feeding it because my vet was worried it may be triggering for Khan because of the kelp, alfalfa and corn.
--
Jessica and Khan
N.D., 2021
https://ecir.groups.io/g/CaseHistory/files/Jessica%20and%20Khan


Sherry Morse
 

If the Equi-VM balances the hay I would suggest stopping the Equinety and P45 and replace both of those with the balancer that you know is correct for that hay rather than using things that may not be correct.  Again, it's been developed by Dr. Kellon she has never said it's not safe for an IR horse that I can recall. 




 

Hi Jessica,
Equi VM is a very concentrated supplement so it needs a little something which tastes enticing.  A serving is 40 grams, most of which is probably active ingredients.  Even if it were entirely things we like to avoid, that is only 40 grams when you are feeding Khan over 9,000 grams of hay.  Just to add some perspective.
--
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


 
 


Kirsten Rasmussen
 

Hi Jessica (and Mary), 

It sounds like the trim and damage done to her hooves after shoes were put on are the biggest problem at the moment.  I hope she is back in the soft ride boots with pads now.  If you have markups and she is in boots, could you work on her trim yourself?  Just a little bit at a time, you don't have to accomplish everything in one trim.  If you are willing to try, all you need are gloves and a good quality rasp (Bellota Top Sharp is one option).  A lot of us have had to start trimming ourselves because we couldn't find a farrier that was willing to work with us.  Study the markups and pick just one thing to work on, like shortening the toe, then try taking a little bit off.  You might be surprised at what you can do when you have to do it yourself!  Plus you can do a little each day, which will be much less painful for Khan overall because she won't have major changes to her hoof mechanics occurring in 1 trim.  It is also very possible she has abscesses.  You could add jiaogulan to her diet, which will help mobilize them if she does, and will also act as an adaptogen if you do start her on pergolide.  It might also help a bit with pain.
https://ecir.groups.io/g/main/filessearch?p=name%2C%2C%2C20%2C1%2C0%2C0&q=Jiaogulan+
(scroll down and read the 4 articles on "Jiaogulan")
Jiaogulan will speed up hoof growth though so it is not advised unless her trim will get frequent attention.

Khan's insulin was abnormal in April but not high enough to cause pain, so at that point I think you had her EMS (if that's the cause) under good control.  Her diet looks good, although I agree adding the Equi-VM back in is a safe and a good idea.  Have you had insulin done since?  As a general rule I always advise doing ACTH, insulin and glucose together at the same lab.  You will get more information for your buck that way.  Although ACTH is critical if PPID is a factor, it's the insulin number that tells you how high her risk is for laminitis and/or if the cause of her pain is due to active laminitis or not.  Glucose is less important but still recommended.  Your 2 glucose numbers are probably not from Cornell as the reference range reported does not match their reference range.  I suspect it was done "in-house".

Please let us know your new ACTH results with the lab reference range when you get them.

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