Help with newly diagnosed horse with PPID -- higher meds or different management?

Laura Caplins


My 20 year old Tennessee Walking Horse gelding Dandy was diagnosed with PPID in the spring. He has been on 1mg of Presend since that time however I question if this is the right dosage. I also have concerns regarding his current management. 

He is continuing to have intermittent trouble with his feet (some days are OK, some he is very sore) and is not sound. He is now ribby with a significant loss in topline. I asked my Vet this question- about appropriate dosages a month after starting the medicine- however he said most horse do fine with one pill. He also stated there was no way to test to see if the medicine is working. I have been following the IR/PPID messages on this site for a few weeks and it seems that this may not be the case.

I have also unfortunately made some mistakes in my feeding and management of the horse due to ignorance. I both let him out on what I thought was 'safe' dry grass pasture once the field turned brown for up to 3 hours a day, and also started increasing his hay ration as he is now thin and its getting cold here in Montana as winter approaches. Perhaps these actions greatly impacted his feet. I detail my actions step by step in our case history. I am, like perhaps everyone else on this site, desperate for my horse to be comfortable. I live in a very cold climate, and traditionally I have fed free choice first cutting grass hay during the winter to keep him warm, however if he must be on a restricted diet I um unclear how to keep him warm. He is prone to getting cold, more so than any of my other horses. He does not grow much of a winter coat. 

I would appreciate any advise on medicine dosage/testing and feeding. Thank you so much. 
Dosage: how do I know if the dosage is correct for my particular horse?
Testing: is there a reliable test to see if his PPID is under control? when is it best to do this test?
Feeding: what are you feeding recommendations for a thin, and prone to be cold horse during the inter in Montana, when too much hay seems to set his feet off....?

Thank you so much, 


Link to Laura and Dandy Case History:
Link to Laura and Dandy Photos & X Rays:

Laura C in Montana 2021

Eleanor Kellon, VMD


The issue with testing to see if his pergolide dose is correct is that his baseline ACTH is normal and only the TRH stimulation showed a high level.  No one has published results of pergolide on TRH tests but it's reasonable to expect it to improve. You could repeat the test in December.

His breed and his past history raise the question of whether he had EMS before becoming PPID. PPID will cause insulin resistance, or worsen it in a horse that has EMS already. You are correct that dormant pastures aren't necessarily safe but you can solve that issue with a muzzle. The problem with your hay in any amount is that the sugar and starch are too high.You don't have to limit how much he gets when he's thin - just make sure it has safe sugar and starch levels. It also sounds like there's a good chance you are dealing with pain triggered by cold .
Eleanor in PA 
EC Owner 2001

Cindy Q

Hi Laura

Welcome to the group! I will be setting out our official welcome letter below.

Dr Kellon has already commented on your hays not being suitable. Soaking the hay for 1 hour (30mins if hot water) will reduce the sugars but not the starch. The starch is too high as well. Could you source for a different hay? You can see below under the DIET section the details of what hay would be suitable but our recommendations here are not based off WSC (as was commented by you in your Case History notes at the end) but on ESC + Starch not being more than 10% and Starch itself not being more than 4%.

Do you have access to unmolassed beet pulp like Speedibeet? If this is rinsed, soaked then rinsed again (to remove all the surface dirt and iron), it is safe to feed and helps with horses that need more calories. Again this is set out in the DIET section. Please look at the details of the emergency diet as there are other things recommended as well such as white table salt and flaxseed.

Under the TRIM section below are also instructions on how to setup your albums and take clear hoof pictures so that you can get some input from Lavinia how to optimise your trim. Your earlier rads seem to be from June and show quite long toes increasing the leverage on the compromised laminae. 

Right here comes the letter and there's a lots of details so take the time to go through it and ask more questions if you need to.

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. 

Cindy and Glow (over the rainbow bridge) - Sep 2017, Singapore
ECIR Primary Response

Laura Caplins

If Dandy ends up getting too much sugar in his hay/rations/grass etc what is the response time between when he eats 'too much sugar' and when it shows up as discomfort in his body or feet? I am having a hard time identifying triggers for him and thus weighing different management choices. 

Also, I was clearly reading my hay analysis incorrectly. Thank you for the connection. If I am aiming for 10% or less of combined ESC and Starch and my hay comes in at 10.5% - 11% (MT is currently experiencing a MASSIVE hay shortage, and I am frankly shocked I was able to get hay this low) how dramatically bad is this hay? Clearly less than 10% is better, but how 'bad' is slightly higher hay? Im trying to understand the relative nature of increasing ESC/Starch numbers. Is it a exponentially negatively bad relationship after 10%? Linear relationship? Is 10% a tipping point?

Thank you. 

Laura C in Montana 2021

Sherry Morse

Hi Laura,

The answer is "it depends on the horse".  Some horses can't even tolerate hay that's close to 10% and will start showing discomfort within hours of eating it.  If your hay is over 10% ESC+starch I would be soaking that hay.  Even if your hay is under 10% if your horse is showing any signs of discomfort soaking is the first thing to try to see if that helps.

Kirsten Rasmussen

Hi Laura, 

My suggestion would be to completely eliminate triggers in the diet, such as winter grass, if you haven't already.   Then watch for signs of discomfort.  If he is still tender, try soaking the hay.  You should see a reduction in pain in 24-72 hours but it can be subtle at first.  Similarly, onset of pain from a diet indiscretion is usually within 24 hours, but may also be subtle at first.

Your Steve Brown hay actually tested at 10.0% ESC + starch As Fed (after moisture in the hay is accounted for) so it's a bit lower than the Dry Matter number reported.   Your Anderson hay is actually 9.5%.  The difference in these is negligible.  Also note that your ESC and starch analyses were done by NIR, methods, which is less accurate than the wet chemistry methods we recommend.  Often NIR under estimates sugars in hay, so you could easily be dealing with hay a couple % over 10% ESC +starch.

Safe ways to add forage-based calories include rinsed, soaked, rinsed beet pulp (Cindy suggested Speedbeet in her welcome letter, but unmollassed beet pulp pellets are fine, too), soy hull pellets, ground flaxseed, and Triple Crown Naturals Timothy Balance cubes, which are guaranteed to be <10% ESC + starch.  Beet pulp has high calcium so if you feed over 1lb (dry weight) a day you may need to adjust the minerals you feed with it, but the TC Timothy Balance cubes are already mineral balanced and can be fed in as high of an amount as you need to keep weight on your horse.  3 lbs of TC cubes = 4 lbs hay in terms of calories. 

Great job on your Case History timeline!

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

Cindy Q

Hi Laura

I just wanted to say - I agree with Kirsten's and Sherry's comments. Apologies if I caused confusion with my remarks on your hay tests! I had misread your hay tests starch numbers and they are both reflected as below 4% (as per the recommended DIET section of the Welcome Letter). However, both figures are based on NIR, which is not as accurate as wet chemical analysis. 

Some portions of your hay test are shown in bold and there is a small footer saying the results in bold are by wet chemical analysis (the more accurate method). ESC and starch are NOT in bold and hence by NIR. So if you are around the recommended limit or your horse is sensitive, it would be worth soaking the hay and monitoring.

Cindy and Glow (over the rainbow bridge) - Sep 2017, Singapore
ECIR Primary Response