Hello, 

My little Welsh mare in her late teens remains in a cycle of laminitic episodes no matter what treatment we follow. 

My vet has diagnosed EMS/IR and we have been following a highly stringent protocol following the advice of this group and horse carers successful in getting positive and lasting results. Diet wise; we have been following the ECIR guidance to a T and have been extremely strict/overly cautious with the diet management. Grass has been eliminated from her diet for well over 6 months and around April/May 2021, we appeared to make good progress but have since sadly have regressed. 

Recent ACTH and TRH results show her levels are normal but vet advice is to trail Prascend to determine if any positive changes occur. 

She has always had a very firm and cresty neck but the fatty pockets have exploded in recent weeks and are at the worst I have known. Pulses fluctuate but on certain days they are bounding and on others, hard to detect. An nightmare rollercoaster of frustration in that the root cause is not being addressed and I feel horrendously guilty that I can’t stem the cause. 

Recent bloods taken (October) show no cause for concern with functioning of major organs but iron levels were abnormally high. 

Any advice offered would be greatly appreciated. I feel I’m so concerned and engrossed in searching for answers that I can’t see the wood for the trees and I must be missing something vital.

I use an iPad and I am waiting on the correct form to complete her entire case history. 

In hope, 
--
Rebecca , Surrey UK 2021

Hi Rebecca,

Here’s a link to the case history form used on anything Apple related.  I use an iPad myself without issues so feel free to contact me with related concerns.  We will be looking forward to reviewing your case history once you post it as so much is lost in the relaying of messages.

My assumption is that you’ve had ACTH, glucose and insulin tested as the vet has made diagnoses with those in mind.  I agree that adding pergolide would be a good thing to try if the diet is tight and insulin remains high.  Not all PPID horses show an elevated ACTH as there are many other hormones involved.  Her fall relapse may well be aligned with the fall rise, which elevates the hormones associated with PPID even further, increasing insulin and the probability of laminitis.  The fact that she still has concerning fat pockets indicates to me that you still may have room for further diet improvements.

Not sure what you’re feeding but any pelleted feed will be higher in iron than something less processed.  I also have used a filter meant for an RV to screw onto my water tap.  As it gets well below freezing here, I cannot use it in winter so I subsequently installed a filter closer to the water source, in my basement.  This is purely a mechanical filter so I’m not sure how much good it does but the filter does turn dark and iron colored.  If her reported iron levels are from serum, that would be reflective of dietary iron.  It’s more complicated to learn if she’s iron overloaded but it can be done with the correct testing.

Looking forward to reading your case history!
--

Hi, Rebecca. 

You need a word-processing app like Apple’s Pages.app on your iPad to work on a case history. Kirsten sent you instructions back on December 7. Let us know if you’d like us to send those instructions again. Details are in the Wiki too. Here’s the link: https://ecir.groups.io/g/main/wiki#Case-History-Help
--
Cass, Sonoma Co., CA 2012
ECIR Group Moderator
Cayuse and Diamond Case History Folder                
Cayuse Photos                Diamond Photos

Hi Rebecca,  

I agree with Martha that regression at this time of year could be PPID-related.  It could also just be colder temps, which will elevate insulin.  Or a combination of both.

If she is struggling she should be on our Emergency diet, which is detailed in your welcome letter from Candice here.  Even if her hay has low ESC and starch, it should be soaked 1 hr in cold water, rinsed and drained.  Maybe you are already doing that?  A complete Case History really is needed.  Even if you can only get her current details in it for now, that will help us.

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

Hi Rebecca,

I agree with getting more definitive iron testing done at KSU. Another possibility is an ovarian involvement similar to PCOS in women. Are you able to tell when she is cycling and whether her cycles are regular? Have her ovaries been palpated or, better yet, ultrasounded? Has she had udder enlargement?
--
Eleanor in PA

www.drkellon.com 
EC Owner 2001

To everyone above who has kindly commented - huge thanks. 

Today has been a better day with very small signs of positive progress. I am heeding everyone’s advice and suggestions above and hope to reply to everyone ASAP. 

Following today’s vet visit, it has been suggested bloods are taken to determine any signs of PCOS as my vet thinks a rectal examination could be too risky for a pony of her small size. Her cycles are very erratic and she regularly flank watches and has considerable sensitivity around her teat area. Thank you for suggesting this line of enquiry as it has been something I thought could be troubling her and I need to rule out every possibility. Hopefully a simple blood test can show anything untoward. 

I’m in the process of completing her case history and hope the coming Christmas break will give me the downtime I need to fill it in as accurately as possible. 

Thank you everyone. This forum is a lifeline. X
--
Rebecca , Surrey UK 2021

Dead Dr Kellon, 

please excuse my complete ignorance but can further testing for raised iron be carried out at KSU if from the UK or are there alternatives? 
--
Rebecca , Surrey UK 2021

 You would have to check with the KSU lab to see if there is a current import permit. If not, you should at least be able to get a total iron binding capacity - TIBC - and from that can calculate transferrin saturation (iron/TIBC x 100 = % saturation).
--
Eleanor in PA

www.drkellon.com 
EC Owner 2001

Thank you for the above Eleanor, 

My vet is back out to visit us early next week so I will make the above suggestion regarding iron levels once we have an up to date reading. Last levels were checked in October so a more recent result would be good. Regarding your suggestion of ovarian involvement; her cycles are actually more or less non existent and she displays discomfort around her udder area. As explained above, my vet would rather not run the risk of an internal examination and would start with a blood test. Would this be sufficient enough to determine? Would iron levels be raised with a PCOS type disruption? 

I am in the process of completing our case history but was hoping to check that I have no triggers in her current diet regime if I may?

Emme is 12hh and approx 250kg - wretched fatty pockets making her look heavier but there has been recent weight loss - albeit slight. 

Currently on box rest as X-rays show rotation and sinking.
Hay - organic and Forage Plus analysed under 10% but I still soak for an hour and rinse. 2kg during the day and 2.5kg overnight. 
Two very small feeds am and pm.
Agrobs Leitchgenus (small handful) Add to this 1 tbsp of salt, 1/2 tbsp micronised linseed, 1 tsp jiaogulan, small handful of comfrey herb, Vitamin/mineral balancer @33g as below (am feed only) Below breakdown is for 67g/500kg horse so I have adjusted to (hopefully) suit.

• 12g Magnesium (Magnesium Oxide)
• 10g L-Lysine
• 5g Phosphorous (Monosodium Phosphate)
• 3g Methionine
• 1200mg Zinc (Sulphate)
• 400mg Copper ( Sulphate)
• 30mg Biotin (Vit.B7)
• 1mg Selenium (Sodium Selenium)
• 2000iu Vitamin E (all rac-alpha tocopheryl acetate)

Many thanks x

--
Rebecca , Surrey UK 2021

In women, iron overload (ferritin) is closely correlated with PCOS. Serum iron though is NOT a reliable measure of body iron burden. You probably can't get ferritin checked but should be able to get iron and TIBC.

What blood test would you be doing for the ovaries?

Have you stopped pain medication?

--
Eleanor in PA

www.drkellon.com 
EC Owner 2001

Many thanks Eleanor, 

Makes sense re iron overload if suffering with PCOS. Had this issue myself in late teens and it’s pretty miserable. 
I will double check with vet that correct iron tests will be carried out. I’ve asked them to confirm the test for ovaries - didn’t note it when they visited last week but they said it’s a safer alternative to an internal examination which has risks for a pony her size. 

Pain medication is ongoing. Vet agreed we can lower the dose gradually and carefully. I add it to a tiny amount of separate feed so she at least gets to enjoy her other small feeds without meds added.

Thank you. 
--

Rebecca , Surrey UK 2021

At 1.8% of body weight you are overfeeding her a bit for weight loss.

The long term pain medication, assuming this is NSAIDs, is a problem. They are blocking the Jiaogulan. You have probably already noticed they don't do much for the pain. This is because endocrinopathic laminitis is not inflammatory. They will slow or stop the process of abscess/fluid drainage which only prolongs the pain.  They also have negative effects on tissue perfusion, which is likely a major factor in laminitis. That said, you do have to withdraw it slowly because there can be withdrawal increased pain sensitivity.  What you should NOT do is stop the taper or bring the dose back up if you see more pain. You could start Devil's Claw https://forageplus.co.uk/product/devils-claw-root-powder-horses/ at 10 g/day when you are halfway through the taper and increase as needed. Some horses actually improve once you get them off NSAIDs. Others may need to go through a period of abscessing.
--
Eleanor in PA

www.drkellon.com 
EC Owner 2001

Rebecca,

Also please review the instructions for hoof photos in the Wiki and get those up ASAP.

One of the biggest reasons for treatment failure is not adequately addressing all aspects of DDT-E

D - Diagnosis
D - Diet and drugs
T - Trim

That's why we ask about or talk about things other than what you asked.

If her insulin really is normal or at least well below the acute laminitis threshold, there's a very good chance there is a problem in the feet themselves - the long term NSAIDs, need to drain collections, possible trim issues, cold effects or any combination of these.
--
Eleanor in PA

www.drkellon.com 
EC Owner 2001

Dear Eleanor, 

Thank you. I was completely unaware of this info regarding stopping the pain medication. She was on 1/2 Danilon sachet am & pm but I will slowly withdraw and closely monitor in the coming days in hope the Jiaogulan takes effect. 
--
Rebecca , Surrey UK 2021

Thank you & understood. My trimmer is due in the next few days so I will be sure to upload the latest photos and also her recent X-rays which my trimmer has already seen. 

I will aim to complete the case study ASAP. Intended to last night but I ended sleeping at our yard due to incredibly inconsiderate neighbours celertaing New Year’s Eve with wretched fireworks. Last thing we all needed. 

Re slight over-feeding at 1.8% for weight loss - I understand. There’s often a healthy amount left that she never finishes so I’m hopeful I have the quota just about right. She does prefer the dry hay compared to the soaked so I’m sure if I were feeding dry, it’d all be gone but for now, it’s all soaked. 

Thank you & Happy New Year to you all x
--
Rebecca , Surrey UK 2021

Forgot to add - I have Devils Claw. Thank you x
--
Rebecca , Surrey UK 2021

Hello again, 

Since tapering the Danilion in the last 48hrs, an almost instant regression back to more lying down and shifting weight from side to side so I am rather concerned I might not be helping here. I’m using the Jiaogulan and Devils Claw but now wondering what, in terms of pain management, is the correct way forward if no sign of relief today. 

--
Rebecca , Surrey UK 2021

Apologies. I realise you mentioned a possibility of withdrawal increased pain sensitivity. I just feel incredibly responsible that I can’t seem to alleviate anything … 
--
Rebecca , Surrey UK 2021

Hi Rebecca,
I haven’t been actively participating here because I have no experience with PCOS and it seems like a good topic to leave to Dr. Kellon, as a vet.  However, it’s possible you are overlooking something else in her management that we might be able to address if we could see a case history.  That came up in the first post or two of this thread but I don’t know that you’ve posted one yet.  As I mentioned, I am also an iPad user and I’m happy to help with any issues that arise.
--

Rebecca,

What tapering schedule are you using? What dose of Devil's Claw? What Devil's Claw product?

There is no quick fix here. The Danilon isn't treating anything. The only way to get rid of the pain is to remove the cause(s). They won't go away on their own. Start working down the checklist.
--
Eleanor in PA

www.drkellon.com 
EC Owner 2001