Date
1 - 16 of 16
CASE HISTORY UPDATE
Have just uploaded an updated case history and latest blood test results, which are less than encouraging and would appreciate thoughts on what to do now. My current farrier is onboard with the groups recommendations, and my vet was also but now appears to be wavering a little, especially over my refusal to use Bute and my request to increase the Pergolide prior to the rise.
I have been walking Dixie around outside her stable and dirt yard on a lead for a few months now to encourage movement and relieve the boredom, then early Feb I put her into a closed muzzle and left her gate open into a very small paddock with her 2 shetland friends to give her the option to come out and while tentative at first, she eventually emerged and just stood in a corner for a while then returned by choice to her stable. On 6th Feb she actually trotted for 20 seconds (which I have on film) and was very alert and interested, on 14th Feb walked by herself about 300m to the top gate and back again, but it has now gone downhill again. Her Ertugliflozin was stopped on 21 Jan when blood test showed high triglycerides (2.5mmol/L) and Metformin was re-started 11 Feb and by 17 Feb she was again leaving most of her hard feed, not wanting to leave the stable. 23 Feb she started to eat well again, then by 5 March she is hardly touching her hard feed. She will always eat as much teff hay as she is given. Her insulin is now back up to 33 so the Metformin is not as effective as the first time, yet my vet wants to continue with it, but I cannot see the point in continuing to use the Metformin which is not working and would prefer to go back onto the Ertugliflozin and monitor the triglycerides closely as the Australian vet who did the research on Ertug here has spoken with my vet and is very keen to take an active interest in Dixie, so is there a down side to that?? Nothing has changed with Dixies feed or stabling during all of this, but we are in the first month of autumn here. ACTH was tested 18 March, with no results back yet. My vet is not onboard with the increase of Pergolide during and preferably prior to the rise, stating that the argument did not hold water as the parameters widen so Dixie will still be "normal". As I understand it, ECIR prefers that Dixies ACTH should stay at high teens, low 20's all the time, with no deviation during the rise, so "normal" parameters do not apply to PPID/IR horses like her?? There are several items on the full blood test listed in red, especially CPK and Trigs, yet I am advised they are nothing to worry about. I increased the Pergolide dose from 1 compounded 1mg capsule to 1 capsule plus half a 1mg Prascend on 24 March as I was advised that test results may take several weeks. Should have tested mid-February, I realise that now.
Would very much appreciate any guidance and advice as I seem to be taking one step forward and two steps back, which will not provide a good outcome for Dixie.
Terrie H in Australia 2021
Case history: https://ecir.groups.io/g/CaseHistory/files/Terrie%20and%20Dixie
https://ecir.groups.io/g/CaseHistory/album?id=268416
I have been walking Dixie around outside her stable and dirt yard on a lead for a few months now to encourage movement and relieve the boredom, then early Feb I put her into a closed muzzle and left her gate open into a very small paddock with her 2 shetland friends to give her the option to come out and while tentative at first, she eventually emerged and just stood in a corner for a while then returned by choice to her stable. On 6th Feb she actually trotted for 20 seconds (which I have on film) and was very alert and interested, on 14th Feb walked by herself about 300m to the top gate and back again, but it has now gone downhill again. Her Ertugliflozin was stopped on 21 Jan when blood test showed high triglycerides (2.5mmol/L) and Metformin was re-started 11 Feb and by 17 Feb she was again leaving most of her hard feed, not wanting to leave the stable. 23 Feb she started to eat well again, then by 5 March she is hardly touching her hard feed. She will always eat as much teff hay as she is given. Her insulin is now back up to 33 so the Metformin is not as effective as the first time, yet my vet wants to continue with it, but I cannot see the point in continuing to use the Metformin which is not working and would prefer to go back onto the Ertugliflozin and monitor the triglycerides closely as the Australian vet who did the research on Ertug here has spoken with my vet and is very keen to take an active interest in Dixie, so is there a down side to that?? Nothing has changed with Dixies feed or stabling during all of this, but we are in the first month of autumn here. ACTH was tested 18 March, with no results back yet. My vet is not onboard with the increase of Pergolide during and preferably prior to the rise, stating that the argument did not hold water as the parameters widen so Dixie will still be "normal". As I understand it, ECIR prefers that Dixies ACTH should stay at high teens, low 20's all the time, with no deviation during the rise, so "normal" parameters do not apply to PPID/IR horses like her?? There are several items on the full blood test listed in red, especially CPK and Trigs, yet I am advised they are nothing to worry about. I increased the Pergolide dose from 1 compounded 1mg capsule to 1 capsule plus half a 1mg Prascend on 24 March as I was advised that test results may take several weeks. Should have tested mid-February, I realise that now.
Would very much appreciate any guidance and advice as I seem to be taking one step forward and two steps back, which will not provide a good outcome for Dixie.
Terrie H in Australia 2021
Case history: https://ecir.groups.io/g/CaseHistory/files/Terrie%20and%20Dixie
https://ecir.groups.io/g/CaseHistory/album?id=268416
Hi Terrie,
My overall impression from reading your case history is that things were finally going well in February when you had trim and diet lined up well, but unfortunately if the pergolide dose isn't controlling the PPID hormones well enough then entering the peak of the rise in mid-March derailed things. It's good that you increased pergolide before getting your test results, but research has shown that small (1-2 mg) increases in pergolide at the peak of the rise are not very effective. That's why we recommend testing and adjusting dose about 2 months prior. I also think increasing the dose generously is safer than not increasing enough, especially in a horse that has been struggling. Yes we recommend keeping ACTH at the middle of the normal range year round. This is based on ECIR observations that many of our PPID horses do best with tightly controlled ACTH.
Will leave your questions on bloodwork to Dr Kellon to address.
I'd say you are taking 2 steps forward, one back, so overall things are improving. The peak of the rise is probably the worst time of year so once you start to come out of it I'm sure things will start to look up again. Getting the pergolide dose correct is probably the biggest thing left to fix, as long as the trim also continues to improve and you keep her diet controlled. Her insulin isn't really high enough to warrant medication *Metformin or Ertugliflozin) , although if it helps her then by all means continue. But I wonder if her refusal of hard feed is due to mouth ulcers from the Metformin? After you syringe it in, are you thoroughly rinsing Trixie's mouth with water?
--
Kirsten and Shaku (IR + PPID) - 2019
Kitimat, BC, Canada
ECIR Group Moderator
Shaku's Case History
Shaku's Photo Album
My overall impression from reading your case history is that things were finally going well in February when you had trim and diet lined up well, but unfortunately if the pergolide dose isn't controlling the PPID hormones well enough then entering the peak of the rise in mid-March derailed things. It's good that you increased pergolide before getting your test results, but research has shown that small (1-2 mg) increases in pergolide at the peak of the rise are not very effective. That's why we recommend testing and adjusting dose about 2 months prior. I also think increasing the dose generously is safer than not increasing enough, especially in a horse that has been struggling. Yes we recommend keeping ACTH at the middle of the normal range year round. This is based on ECIR observations that many of our PPID horses do best with tightly controlled ACTH.
Will leave your questions on bloodwork to Dr Kellon to address.
I'd say you are taking 2 steps forward, one back, so overall things are improving. The peak of the rise is probably the worst time of year so once you start to come out of it I'm sure things will start to look up again. Getting the pergolide dose correct is probably the biggest thing left to fix, as long as the trim also continues to improve and you keep her diet controlled. Her insulin isn't really high enough to warrant medication *Metformin or Ertugliflozin) , although if it helps her then by all means continue. But I wonder if her refusal of hard feed is due to mouth ulcers from the Metformin? After you syringe it in, are you thoroughly rinsing Trixie's mouth with water?
--
Kirsten and Shaku (IR + PPID) - 2019
Kitimat, BC, Canada
ECIR Group Moderator
Shaku's Photo Album
Terrie,
The refusal of hard feed is one of the cardinal signs of gastric ulcers. I would treat her.
How much salt is she getting and how much water is being consumed? Her bloods look like some degree of dehydration. The CPK elevation commonly accompanies the energy disruption the ertugliflozin causes when the diet doesn't have sufficient energy. Low BUN and creatinine are most consistent with insufficient protein intake.
The TGs are not terribly elevated and would come down if she ate more. She should have free choice hay.
Her insulin wasn't elevated enough to cause acute laminitis pain but she definitely has chronic damage with bone loss. Her hoof rehab isn't far enough along to expect her to be comfortable.
--
Eleanor in PA
The refusal of hard feed is one of the cardinal signs of gastric ulcers. I would treat her.
How much salt is she getting and how much water is being consumed? Her bloods look like some degree of dehydration. The CPK elevation commonly accompanies the energy disruption the ertugliflozin causes when the diet doesn't have sufficient energy. Low BUN and creatinine are most consistent with insufficient protein intake.
The TGs are not terribly elevated and would come down if she ate more. She should have free choice hay.
Her insulin wasn't elevated enough to cause acute laminitis pain but she definitely has chronic damage with bone loss. Her hoof rehab isn't far enough along to expect her to be comfortable.
--
Eleanor in PA
www.drkellon.com
EC Owner 2001
Thanks Kirsten,
I have 1mg Pergolide capsules compounded and also have a box of 1mg Prascend (4 of my 5 horses are PPID but only Dixie is IR as well). When you say to increase the dose generously, should I double Dixies original dose to say 2mg daily now or more than that, or have I missed the boat for this year? I did search the ECIR files that recommended .25mg increases every 3 days which I did twice getting her currently to 1.5mg daily so what would be my best course of action now please?
I did not rinse out Dixies mouth after giving her the Metformin so will have my vet check for mouth ulcers and have downloaded a Dr Kellon post from 2005 with her recommendations for treatment if needed. Dixie always went straight for her hay after I gave her the Metformin so hopefully she was producing enough saliva to prevent ulceration, and she is certainly powering through the free choice hay right now. I stopped giving Dixie Metformin nearly two weeks ago. Dixie responded to Metformin really well the first time around in Oct/Nov with a rapid decrease in insulin, then Metformin was stopped and insulin increased again, so vet put Dixie onto Ertugliflozin end December but Dixie was very lethargic and footsore, not eating her hard feed while on Ertug and triglycerides went very high so Ertug was stopped. Her insulin started to rise again so Metformin started again mid-Feb as my vet was unable to get any information regarding Dixies reaction to Ertug, however she has now been in contact with someone over here so is keen to get Dixie back onto the Ertug now that she has expert backup but I am not keen so we have reached an impasse on that. If Dixie is not eating well then she will not improve in any way, so that is the priority IMHO.
As always, the help and support from this group is very much appreciated.
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Terrie H in Australia 2021
Case history: https://ecir.groups.io/g/CaseHistory/files/Terrie%20and%20Dixie
https://ecir.groups.io/g/CaseHistory/album?id=268416
Thank you Dr Kellon.
Dixie is getting 2 tblsp of iodised salt daily, however as she is not eating most of her hard feed, a lot of the additives she should be eating
are being thrown away. She has been drinking between 15/20 litres of water per 24 hours over the past week, however when having free
choice hay today she drank almost 15 litres in 12 hours. The free choice hay today was very well received and she also ate half of her
hard feed from this morning during the day, which is a huge improvement. Hopefully this afternoons feed bowl will be empty in the morning.
Carol has approved increasing the amount of Hygain Zero in Dixies diet which will not affect the balance, so have done that today.
What do you recommend for treating Dixies gastric ulcers? I know my vet will prescribe Omeprazole but wondering if CEN Ulcer Protect
would be appropriate as it is a more natural formulation? I had hoped to start Dixie on ProN8ture Soluble Probiotics when they arrive
in the post, as I was intending to try to improve her gut health as much as possible. Am I dreaming? Would appreciate your thoughts please.
Many thanks
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Terrie H in Australia 2021
Case history: https://ecir.groups.io/g/CaseHistory/files/Terrie%20and%20Dixie
https://ecir.groups.io/g/CaseHistory/album?id=268416
You could try the hydrolyzed collagen product first. Microbial counts on that probiotic are low. You want to see 10 to 20 billion cfu.
--
Eleanor in PA
--
Eleanor in PA
www.drkellon.com
EC Owner 2001
Hi Terrie,
Its hard to say without seeing her bloodwork but given that ACTH was so high when diagnosed a year ago, and given that she is struggling again at the approach of the peak of the seasonal rise, it suggests her dosage wasn't increased soon enough and/or high enough. At this point you could wait for the results and decide then, or you could increase by another half Prascend to make 1 mg Prascend + 1 mg compounded pergolide. Either way, as the seasonal rise fades over the next few weeks to months, if high ACTH was the problem she will likely improve.
Dr Kellon: should the free choice hay be only while on Ertugliflozin?
--
Kirsten and Shaku (IR + PPID) - 2019
Kitimat, BC, Canada
ECIR Group Moderator
Shaku's Case History
Shaku's Photo Album
Its hard to say without seeing her bloodwork but given that ACTH was so high when diagnosed a year ago, and given that she is struggling again at the approach of the peak of the seasonal rise, it suggests her dosage wasn't increased soon enough and/or high enough. At this point you could wait for the results and decide then, or you could increase by another half Prascend to make 1 mg Prascend + 1 mg compounded pergolide. Either way, as the seasonal rise fades over the next few weeks to months, if high ACTH was the problem she will likely improve.
Dr Kellon: should the free choice hay be only while on Ertugliflozin?
--
Kirsten and Shaku (IR + PPID) - 2019
Kitimat, BC, Canada
ECIR Group Moderator
Shaku's Photo Album
Hi Kirsten
I will have Dixie up to 2mg Pergolide per day by mid-next week which I hope may help her.
ACTH result back yesterday is 113 pg/mL, up from 20 pg/mL in September 2021 so I just have to be proactive and keep it down, which I guess is the aim of pretty much everyone in this group. All test results have been uploaded.
Dixie is not on Ertugliflozin or Metformin right now. Dr Kellon has kindly explained the blood test results and the insulin at 33 mU/L is not high enough at this time to need either medication.
Thank you for your help.
--
Terrie H in Australia 2021
Case history: https://ecir.groups.io/g/CaseHistory/files/Terrie%20and%20Dixie
https://ecir.groups.io/g/CaseHistory/album?id=268416
Dr Kellon,
Can Dixie have human probiotics as they always specify the microbial count? There are a lot of equine probiotics listed online available in Australia, however nothing specifying 10-20 billion CFU, and most not specifying CFU count at all, so it is hard to judge which equine product is best for her.
I have uploaded the ACTH result received yesterday which is 113 pg/mL, up from 20 pg/mL in September 2021, explaining her present discomfort. Dixie will be up to 2mg Pergolide by mid-next week but I realise that it will probably be too little, too late. I will have her tested more often during the next 12 months to try to establish her pattern so I do not repeat my mistakes.
Many thanks
--
Terrie H in Australia 2021
Case history: https://ecir.groups.io/g/CaseHistory/files/Terrie%20and%20Dixie
https://ecir.groups.io/g/CaseHistory/album?id=268416
Hi Terrie
Protexin specifies 60 million CFU per gram (if you zoom onto the front label, that info is at the bottom). It's pricey but that's the one my vet usually recommends, and it does usually help Dangles when he is going through one of his periodic sloppy manure episodes.
Buy Protexin Probiotic Online | Australia Wide Fast Shipping - vet-n-pet DIRECT (vetnpetdirect.com.au)
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Maxine and Indy (PPID) and Dangles (PPID)
Protexin specifies 60 million CFU per gram (if you zoom onto the front label, that info is at the bottom). It's pricey but that's the one my vet usually recommends, and it does usually help Dangles when he is going through one of his periodic sloppy manure episodes.
Buy Protexin Probiotic Online | Australia Wide Fast Shipping - vet-n-pet DIRECT (vetnpetdirect.com.au)
--
Maxine and Indy (PPID) and Dangles (PPID)
Canberra, Australia 2010
ECIR Primary Response
https://ecir.groups.io/g/CaseHistory/files/Maxine%20and%20Indy%20and%20Dangles
https://ecir.groups.io/g/CaseHistory/album?id=933
This product doesn't give cfu either but I like the array of ingredients https://poseidon-equine.com/collections/all/products/digestive-eq .
--
Eleanor in PA
--
Eleanor in PA
www.drkellon.com
EC Owner 2001
Sherry Morse
Hi Terri,
Were this my horse with a result that high I would not be doing a slow titer up nor would I be going up by just 1mg. I would plan on tripling the dose (to 3mg/daily) as you're already behind on getting her controlled before your seasonal rise. 1mg may be enough for her the rest of the year, but I think you're going to need to be proactive about getting her up to a higher dose prior to the rise.
Thanks,
Sherry and Scutch (and Scarlet over the bridge)
EC Primary Response
PA 2014
https://ecir.groups.io/g/CaseHistory/files/Sherry%20and%20Scutch_Scarlet
https://ecir.groups.io/g/CaseHistory/album?id=78891
Sherry and Scutch (and Scarlet over the bridge)
EC Primary Response
PA 2014
https://ecir.groups.io/g/CaseHistory/files/Sherry%20and%20Scutch_Scarlet
https://ecir.groups.io/g/CaseHistory/album?id=78891
Hi Sherry,
I will take Dixie straight up to 3mg this morning. She has tolerated past increases without any problems, I was being too hesitant.
Thank you
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Terrie H in Australia 2021
Case history: https://ecir.groups.io/g/CaseHistory/files/Terrie%20and%20Dixie
https://ecir.groups.io/g/CaseHistory/album?id=268416
Thanks Dr Kellon. Will give it a try.
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Terrie H in Australia 2021
Case history: https://ecir.groups.io/g/CaseHistory/files/Terrie%20and%20Dixie
https://ecir.groups.io/g/CaseHistory/album?id=268416
Hi Maxine,
Dixie has never had sloppy manure so maybe her gut is OK. Am just trying to cover all bases as she has had a lot of Bute in the past with possible gastric ulcers right now and I would like to avoid Omeprazole if I can.
Thanks for your advice.
--
Terrie H in Australia 2021
Case history: https://ecir.groups.io/g/CaseHistory/files/Terrie%20and%20Dixie
https://ecir.groups.io/g/CaseHistory/album?id=268416
Thanks Dr Kellon, that's actually what I'm using now. Once I can get Dangles to eat more than a pinch.... sigh.
Terrie, always good to cover all bases!
--
Maxine and Indy (PPID) and Dangles (PPID)
Terrie, always good to cover all bases!
--
Maxine and Indy (PPID) and Dangles (PPID)
Canberra, Australia 2010
ECIR Primary Response
https://ecir.groups.io/g/CaseHistory/files/Maxine%20and%20Indy%20and%20Dangles
https://ecir.groups.io/g/CaseHistory/album?id=933