Date
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Help for Mare following extreme over-trimming to sole
It seems reasonable that pain is a stress and would increase cortisol but research has not shown that to be true: https://pubmed.ncbi.nlm.nih.gov/32824027/ , https://pubmed.ncbi.nlm.nih.gov/15315700/ .
DMSO has potent effects on tissue swelling and may have direct pain relieving effects; e.g. https://pubmed.ncbi.nlm.nih.gov/35130398/ . It's a routine treatment for laminitis with some vets, as well as other conditions, even encephalitis.
Metformin does work for most horses, at least short term, but since she has improved no need to push it. You can't make medical decisions for the horse, neither can we. It has to be the treating veterinarian. If they know she has improved they may agree to a taper of the phenylbutazone. When she's down to 1 gram you can start the Laminox.
Pentoxifylline orally is more controversial in the research literature than metformin! Like metformin, in studies that found any effect it decreases over time.
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Eleanor in PA
DMSO has potent effects on tissue swelling and may have direct pain relieving effects; e.g. https://pubmed.ncbi.nlm.nih.gov/35130398/ . It's a routine treatment for laminitis with some vets, as well as other conditions, even encephalitis.
Metformin does work for most horses, at least short term, but since she has improved no need to push it. You can't make medical decisions for the horse, neither can we. It has to be the treating veterinarian. If they know she has improved they may agree to a taper of the phenylbutazone. When she's down to 1 gram you can start the Laminox.
Pentoxifylline orally is more controversial in the research literature than metformin! Like metformin, in studies that found any effect it decreases over time.
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Eleanor in PA
www.drkellon.com
EC Owner 2001
Sherry Morse
Hi Makendra,
Considering the x-rays I'm not surprised she wouldn't want a heel wedge. It sounds like there are now 4 vets involved - are they all from the same practice? Is one taking the lead?
Was the IV fluids just saline or something else?
So as a reminder of some basics: Bute is contraindicated if the pain is due to laminitis due to elevated insulin. If it's not doing any good (ie: she was still laying down for extended periods and not wanting to move while on it) it might as well be stopped, but you do need to wean her off of it. Details here: https://ecir.groups.io/g/main/files/Pain%20Medication%20and%20Alternatives/How%20to%20Taper%20Off%20NSAIDs.pdf. Bute can be replaced with Phytoquench with Devil's Claw as outlined here: https://ecir.groups.io/g/main/files/Pain%20Medication%20and%20Alternatives/Pain%20control,%20switching%20from%20Bute%20to%20Phyto-Quench.pdf
Why was the mare put on Thyro-L? If the hope is it will be bring insulin down there is no evidence it works on that. If her thyroid numbers are out of the reference range we have found that getting IR under control usually corrects that. Since Thyro-L replaces regular thyroid function she'll need to be waned off of that as well. Information on doing that: Re: Need help ASAP - painful mini (groups.io)
Metformin does not work in all horses but for those it does work in you can see a difference in bloodwork 7 - 10 days after starting. If the next blood draw is on the 11th that gives her a week to get the vets on board with prescribing metformin if the insulin comes back as still elevated. You might want to reference any of the studies of Metformin showing it does work in the files: https://ecir.groups.io/g/main/files/4%20Insulin%20Resistance/Metformin
As far as where to get Metformin - it's one of the most commonly prescribed drugs for human diabetics so pretty much any pharmacy will carry it. If they want to use a compounder for some reason I'm fairly certain Wedgewood or Dorneyville could both compound it.
Pentoxifylline has been discussed on the list frequently and as Dr. Kellon most recently recounted, it doesn't work: Re: Banamine/Gabapentin/Pentoxifylline (groups.io)
We really need a full case history on this mare but as always, now that there's a DIAGNOSIS, the TRIM is being addressed and she's on medication for the PPID and she can't be EXERCISED, the missing piece is DIET and MEDICATION for the IR if diet and weight reduction alone have not brought down her insulin. MEDICATION would be Metformin and if that doesn't work, Invokana.
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
Thank you Dr. Kellon and Sherry, the client has this information now and is subscribed to ECIR but is having trouble posting - so on her behalf I am posting an update.
This Saturday I brought the mare's toes back (trim) more and made a thin, soft DIM pad in her cloud boots. We've found she does best in a half pad made of an old felted wool saddle pad I had that is at the dorsal (toe) end of the boot. She HATES the cloud pads with the heel wedge that I expected her to find comfort in. She doesn't seem to like a cut-out or low section for P3 as one would think. Soles are looking good and owner is keeping arti-mud on them in boots and letting hooves air for a while and changing boots each day (she has a pair of Rx boots and a pair of Cloud boots). The great news is that she is doing better - moving around her small paddock (booted) and in and out of stall, flirting and bossing around th gelding next to her and the yearling colt on the other side. So nice to see her feeling more herself although not moving freely or fully comfortably, the pain seems to be much reduced, most likely from the info to follow:
I wanted to update based on a new (third) vet's input and see if anything is counter-indicated. This vet suggested some things I have not heard of before and it does seem to be helping.
This Saturday I brought the mare's toes back (trim) more and made a thin, soft DIM pad in her cloud boots. We've found she does best in a half pad made of an old felted wool saddle pad I had that is at the dorsal (toe) end of the boot. She HATES the cloud pads with the heel wedge that I expected her to find comfort in. She doesn't seem to like a cut-out or low section for P3 as one would think. Soles are looking good and owner is keeping arti-mud on them in boots and letting hooves air for a while and changing boots each day (she has a pair of Rx boots and a pair of Cloud boots). The great news is that she is doing better - moving around her small paddock (booted) and in and out of stall, flirting and bossing around th gelding next to her and the yearling colt on the other side. So nice to see her feeling more herself although not moving freely or fully comfortably, the pain seems to be much reduced, most likely from the info to follow:
I wanted to update based on a new (third) vet's input and see if anything is counter-indicated. This vet suggested some things I have not heard of before and it does seem to be helping.
Here are the details from Sunny's owner who is getting mixed messages from the vets, me (based on what I learned here primarily) and is in need of guidance:
"Sunny is on bute 2 g a day, 1 pill of prascend a day, 2 scoops of thyro -l a day. Yesterday she was given IV fluids and DMSO. That made a remarkable difference in her pain level, after 2 weeks of agony she was walking to her water tank, pestering her herd mates and could rest comfortably without leaning backwards and see-sawing. I received the laminox today .
Both attending vets say that Metformin doesn’t work in horses 
so I’m stuck on that med. {Also all four vets consulted say that they don't know where to get Metformin). They are concerned that her extreme levels of pain and stress are causing her cortisol to go up and affecting her insulin. The treatment yesterday was a last resort to get her pain under control and it worked! She’s also got new DIM pads and she seems to be liking those.
so I’m stuck on that med. {Also all four vets consulted say that they don't know where to get Metformin). They are concerned that her extreme levels of pain and stress are causing her cortisol to go up and affecting her insulin. The treatment yesterday was a last resort to get her pain under control and it worked! She’s also got new DIM pads and she seems to be liking those. I’m wondering if I should stop bute and start the laminox and if it’s ok with all the other meds she is on . She will have new radiographs taken and have blood drawn to check levels of insulin on July 11. That’s the soonest they can get here.
The vets have recommended a drug called pentoxifylline er. They want her on this because it still allows blood flow to the foot while she is on the high doses of NSAIDs. They explained it as changing the shape of the red blood cell to increase oxygen and blood flow. I have it but have not started it yet as I wanted to get feedback.
Thank you so much - from Makendra and Sunny's owner
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Makendra and Arrow
Denver Colorado, 2021
Arrow's Case History: https://ecir.groups.io/g/CaseHistory/files/Makendra%20and%20Arrow
Arrow's Photo Album: https://ecir.groups.io/g/CaseHistory/album?id=262625
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Makendra and Arrow
Denver Colorado, 2021
Arrow's Case History: https://ecir.groups.io/g/CaseHistory/files/Makendra%20and%20Arrow
Arrow's Photo Album: https://ecir.groups.io/g/CaseHistory/album?id=262625
Insulin should be retested within 3 to 7 days of starting metformin to see if it's working. If not, switch to an SGLT2 inhibitor. Wait no longer than 3 weeks to retest ACTH. We are already within the seasonal rise zone and perilously close to the peak rise so getting ACTH down well into a safe zone is critical.
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Eleanor in PA
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Eleanor in PA
www.drkellon.com
EC Owner 2001
Sherry Morse
Hi Makendra,
If she's on Metformin you want to retest insulin 7 - 10 days after starting to see if it's effective. Retesting ACTH is done 3 weeks after reaching the target dose of Prascend.
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
Thank you, Dr. Kellon so very much. That is extremely helpful and the horse's owner may also be posting a reply (she was having some technical difficulties last we talked). I believe a new vet (whom I recommended and seems more well-educated on EMS) came out today and also did an acupuncture treatment. Hoping that the Metformin will soon be on board too and Thyro-L out.
It is helpful to keep at front of mind that we don't know if this is mechanical and/or acute laminitis - but addressing both seems to be the best game plan. We're going to see if perhaps custom firm DIM pads with soft DIM at the rim of P3 may be helpful. I had originally made her a sort of medicine shoe with EasyCare 12mm soft and firm pads but I think they weren't enough for her weight. She's a large mare with Cloud boot size 5 draft hooves.
The radiographs were indeed pre-trim.
Is there a recommended time frame for which you would re-test insulin, glucose and ACTH or just see how she is doing and judge from there?
THANK YOU. This is excruciating for this wonderful horse and her owner so especially grateful to you and the ECIR for your advice.
All best, Makendra
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Makendra and Arrow
Denver Colorado, 2021
Arrow's Case History: https://ecir.groups.io/g/CaseHistory/files/Makendra%20and%20Arrow
Arrow's Photo Album: https://ecir.groups.io/g/CaseHistory/album?id=262625
It is helpful to keep at front of mind that we don't know if this is mechanical and/or acute laminitis - but addressing both seems to be the best game plan. We're going to see if perhaps custom firm DIM pads with soft DIM at the rim of P3 may be helpful. I had originally made her a sort of medicine shoe with EasyCare 12mm soft and firm pads but I think they weren't enough for her weight. She's a large mare with Cloud boot size 5 draft hooves.
The radiographs were indeed pre-trim.
Is there a recommended time frame for which you would re-test insulin, glucose and ACTH or just see how she is doing and judge from there?
THANK YOU. This is excruciating for this wonderful horse and her owner so especially grateful to you and the ECIR for your advice.
All best, Makendra
--
Makendra and Arrow
Denver Colorado, 2021
Arrow's Case History: https://ecir.groups.io/g/CaseHistory/files/Makendra%20and%20Arrow
Arrow's Photo Album: https://ecir.groups.io/g/CaseHistory/album?id=262625
Starshine Ranch
HI Makendra
What a horrid thing for a "trimmer" to do! I would definitely post something on FB to warn others.
One time when my mare got cut too short, we bypassed the boots and got some thick foam to duct tape to her feet. Changed it as it got smashed down. I don't know but maybe that might help more since it wouldn't be so confining.
Please tell the owner how sorry I am and you are wonderful to help her so much.
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Linda in Grass Valley, CA 2020 Midnight and Ostara
https://ecir.groups.io/g/CaseHistory/files/Linda%20Midnight%20OStara
What a horrid thing for a "trimmer" to do! I would definitely post something on FB to warn others.
One time when my mare got cut too short, we bypassed the boots and got some thick foam to duct tape to her feet. Changed it as it got smashed down. I don't know but maybe that might help more since it wouldn't be so confining.
Please tell the owner how sorry I am and you are wonderful to help her so much.
--
Linda in Grass Valley, CA 2020 Midnight and Ostara
https://ecir.groups.io/g/CaseHistory/files/Linda%20Midnight%20OStara
It's impossible to tell right now if the pain is mostly mechanical and/or from the high insulin.Thyro-L isn't going to help anything but won't hurt. She definitely needs the Prascend. That is addressing the core problem. I would also suggest metformin 30 mg/kg twice a day to get that insulin down. LaminOX would be my choice but it can't work with the NSAIDs on board - they block the Jiaogulan effect.
How long can they stay down? Read this http://www.ironfreehoof.com/severe-laminitis-case-study.html and Lorna can speak to that also.
You may have done this already but any pads should be grooved out in the area of the rim of the coffin bone to relieve pressure.
Are the radiographs pre trim?
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Eleanor in PA
How long can they stay down? Read this http://www.ironfreehoof.com/severe-laminitis-case-study.html and Lorna can speak to that also.
You may have done this already but any pads should be grooved out in the area of the rim of the coffin bone to relieve pressure.
Are the radiographs pre trim?
--
Eleanor in PA
www.drkellon.com
EC Owner 2001
Hello,
Posting on behalf of a new hoof care client with a horse in need of ECIR help (she'll get a case history and profile set up soon).
Situation: 16 year old Gypsy Vanner Mare (heavy build around 14.1 hh, guessing in the 1200-1500 lb range). The mare has always been sound and strong "rock crunching" hooves. A "hoof trimmer" came about ten days ago with a grinder in a period of wet weather here in Colorado and took this mares soles down an extreme amount, dropped her heels 1-2" and didn't take toes back. The mare came up lame the next day and continued to get worse over several days. Owner had vet out and radiographs are quite gut-wrenching to see with very little sole depth and P3 dangerously close to ground level. I met the mare as a result of this and owner said she used to have quite deep collateral grooves but they are nearly gone now at apex of frog and shallow at frog base. We got her in Cloud boots last Wednesday and she seemed better for two days but since this weekend has been in more and more pain. On Thursday I brought her toes back trying to not loose any height and leave toe-pillars untouched. She's now rocking back and trying to get weight off her toes (in boots or without) and will go down to her knees if you aren't quick enough in changing boots. Owner is finding she is a tiny bit more comfortable in flat 12mm easycare pads than the Cloud boot pad which she has flattened at the toe. Tonight we tried putting DIM (dental impression material) in her boots (arti-mud underneath) to see if she likes a more contoured pad- no immediate signs of relief yet. Owner hasn't seen a lot of difference between boots/pads and barefoot. The mare is buckling over at her fetlock joint and knees in pain at times and will lay down as well. I've told owner to just let her lay down and bring food and water to her and let her rest in deeply bedded stall. She has a new vet coming Thursday who also does acupuncture. I don't have a lot of confidence in the vet who came last week to take rads.
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Makendra and Arrow
Denver Colorado, 2021
Arrow's Case History: https://ecir.groups.io/g/CaseHistory/files/Makendra%20and%20Arrow
Arrow's Photo Album: https://ecir.groups.io/g/CaseHistory/album?id=26262
Posting on behalf of a new hoof care client with a horse in need of ECIR help (she'll get a case history and profile set up soon).
Situation: 16 year old Gypsy Vanner Mare (heavy build around 14.1 hh, guessing in the 1200-1500 lb range). The mare has always been sound and strong "rock crunching" hooves. A "hoof trimmer" came about ten days ago with a grinder in a period of wet weather here in Colorado and took this mares soles down an extreme amount, dropped her heels 1-2" and didn't take toes back. The mare came up lame the next day and continued to get worse over several days. Owner had vet out and radiographs are quite gut-wrenching to see with very little sole depth and P3 dangerously close to ground level. I met the mare as a result of this and owner said she used to have quite deep collateral grooves but they are nearly gone now at apex of frog and shallow at frog base. We got her in Cloud boots last Wednesday and she seemed better for two days but since this weekend has been in more and more pain. On Thursday I brought her toes back trying to not loose any height and leave toe-pillars untouched. She's now rocking back and trying to get weight off her toes (in boots or without) and will go down to her knees if you aren't quick enough in changing boots. Owner is finding she is a tiny bit more comfortable in flat 12mm easycare pads than the Cloud boot pad which she has flattened at the toe. Tonight we tried putting DIM (dental impression material) in her boots (arti-mud underneath) to see if she likes a more contoured pad- no immediate signs of relief yet. Owner hasn't seen a lot of difference between boots/pads and barefoot. The mare is buckling over at her fetlock joint and knees in pain at times and will lay down as well. I've told owner to just let her lay down and bring food and water to her and let her rest in deeply bedded stall. She has a new vet coming Thursday who also does acupuncture. I don't have a lot of confidence in the vet who came last week to take rads.
Background: Mare has foaled 5 times with previous owner and with current owner of several years has lost several hundred pounds but is still cresty and has fat pads despite being on an EMS diet for past two years. (18 pounds of 5% nsc hay a day, she is out in a 2 acre dry lot and owner spreads the hay out every morning in small piles to keep them moving , cal trace, salt and equinety. Have been soaking hay for past five days as well). I advised adding Magnesium and flax as well. Mare was diagnosed with PPID and IR last week and vet had owner start on Thyro-L and Prascend last Wednesday just as soreness was greatly increasing to "emergency levels". Mare was on bute for about 7 days and switched to Equioxx today.
The mare presents currently as an acute laminitis case but we're not seeing any relief from booting/padding, soaking hay etc. I've been consulting with hoofcare mentors but nothing we've tried has helped over the past five days. I got some Ground Control glue-on shoes to see if she might like a flat, flat surface to redistribute the weight but we have not tried them yet as we want to be able to monitor her soles. I thought perhaps I could add heat welded tabs and we could attach them with a couple of tabs that owner could then cut off to remove and check her soles and super-glue back on with another tab if the mare likes standing on them. I also got RATE hoof packing that is supposed to help bruised soles and others have told me it is helpful for super sensitive soles from trusted hoof care practitioners. I left the owner with a thick felted pad and multiple foam padding options but mare isn't seeming to find relief from anything we've tried to date.Until case history is uploaded, I put the blood test results, a few photos and rads into a folder called "Sunny and Amanda" at https://ecir.groups.io/g/CaseHistory/album?id=276317. Owner will get everything labeled properly - I just got a few shots before and after I took her toes back a little from the ground while she was standing in her shavings.
Zoeitis lab blood test results: End. ACTH 72.3 pg/mL and insulin 164 UIu/mL -- non-fasting but not sure how sample was handled post pull or if Zoeitis is comparable to Cornell.
Main questions from me and the owner:
-ideas for relief of pain? CBD? I know she needs to get off the NSAIDS but pain level is staggering and this mare is apparently normally quite stoic.
-would Jiogulan and/or Phyto-Quench be advisable for pain to speed up hoof and sole growth? We can keep her toes trimmed back as often as daily by owner.
Main questions from me and the owner:
-ideas for relief of pain? CBD? I know she needs to get off the NSAIDS but pain level is staggering and this mare is apparently normally quite stoic.
-would Jiogulan and/or Phyto-Quench be advisable for pain to speed up hoof and sole growth? We can keep her toes trimmed back as often as daily by owner.
-Starting Thyro-L and Prascend during this acute situation is concerning to me - is that advisable?
-How long laying down is too long? So far I think it has just been a few hours at a time.
-How long laying down is too long? So far I think it has just been a few hours at a time.
Thank you so very much and if not allowed for me to post on behalf of a client, I very much understand and I'll help her get her case history etc. posted ASAP.
Makendra
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Makendra and Arrow
Denver Colorado, 2021
Arrow's Case History: https://ecir.groups.io/g/CaseHistory/files/Makendra%20and%20Arrow
Arrow's Photo Album: https://ecir.groups.io/g/CaseHistory/album?id=26262