I was advised to increase Apollo's Prascend from 1.0 mg/day to 3.0 mg per day to cover him for the upcoming seasonal rise based on his past history of acute laminitis last year.  Hee started on Prascend 1.0 mg/day in October after having positive TRH stim test with normal baseline ACTH levels. When last tested in June his ACTH was still in low range of normal. He has not been having any signs/symptoms of PPID at this time.

His Prascend was increased from 1.0 mg to 1.5 mg on 6/28.  He had mild appetite decrease after about 3 days which improved to normal levels in couple of days.  Prascend was increased from 1.5 to 2.0 mg/day on 7/6 without any decrease in appetite.  On 7/14 his Prascend was increased from 2.0 to 2.5 mg/day and today he is refusing to eat his OD timothy balance cues with all of his supplements in it.  A few days ago he was devoring his mash and looking for more.  He will eat his soaked hay but I have only a very limited supply (on list to get new low S/S hay from commercial supplier) so can't give him more hay and even if I could this hay has high iron levels that need to be balanced with copper and zinc so he needs to get his mineral supplements.  I tried adding Stabul 1 pellets which he likes, to mash but which helped a little at first but not now.  Also tried adding stevia (which he normally likes) and Stabul peppermint nugget treats (something he's never had) crumbled in small amount of mash but he won't touch it.  He seems hungry, scouring ground near his feeder for any stray piece of hay.  He doesn't seem lethargic.  Pain doesn't seem to be issue even though farrier cut his sole on Friday.  He's walking without a limp wearing Cloud boots with soft pads inside and we also cut hole over area of wound to relieve any pressure.  I did hold 2 does of Jiaogulan out of caution given how difficult sole laceration bleeding was to stop but he was restarted on usual dose (1 heaping teaspoon) last night.  He gets 1 heaping teaspoon both a.m. and p.m. 20 minutes before eating.

I have some APF which I've tried in past but Apollo hates it and it 's battle to get it in.  I'm willing to try it again but should I give 1 ml or 2 ml per 100 pounds body weight daily which is range for "recovery" given on APF container?  Should that amount be given all at once or can it be split into 2 equal doses? 

And the big question, should I decrease his Prascend back to 2.0 mg/day which was well tolerated and wait a bit longer to increase it back to 2.5 mg/day?  And if so, how long before I increase it again?

Doesn't seem like things are ever going to get any better!
--
Karen B.
Wisconsin
2022
Apollo Case History: https://ecir.groups.io/g/CaseHistory/files/Karen%20and%20Apollo
Photo album:  https://ecir.groups.io/g/CaseHistory/album?id=275817

Karen,
I increase acceptance of APF by putting the dose on a pellet my horse likes and let it sit a while for the alcohol to evaporate. I use the maximum dose twice a day when I increased pergolide early in PPID. In any event, the pergolide veil goes away and horses will regain normal appetite. 

I find it essential to keep a flavor enhancement toolkit for introducing new stuff. Odd smelling additions often get the cold shoulder with my mares. My kit is:
Nuzu Stabul1, whole or sometimes ground
FORCO, both pellets and granular 
CocoSoya Granular
Keep these delights special by NOT over-using them. For the really bad smelling stuff, I might feed on Stabul1 and sprinkle with Coco Soya Granular.

Don’t give up and don’t give in! My last resort is to hand hold the feeder, which for my mares is the ultimate. 

--
Cass, Sonoma Co., CA 2012
ECIR Group Moderator
Cayuse and Diamond Case History Folder                
Cayuse Photos                Diamond Photos

Hi Karen,

I believe Martha advised you to increase to 2 mg then retest with the TRH Stim: 
https://ecir.groups.io/g/main/message/279282
It's possible you will need to go higher, but that was her suggested starting point.  Wait 3 weeks after reaching the target dose before retesting.  That will give Apollo some time to adjust and if you need to increase more at that time, he might respond better having had a break from the increases.

If you have been advised by other volunteers in this group to go up to 3 mg, however, I won't argue as am in favor of being fairly aggressive and risking over-medicating rather than under-medicating, especially if there is a history of fall laminitis.  But I think Martha's suggestion was very reasonable given how low baseline ACTH was at the last test.

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

Hi Sherry,
You and everyone else are to be commended for working so hard to help so many horse owners at once.  I apologize if I confused you.

I went back through my messages regarding increasing Apollo's Prascend.  On June 23, you recommended I increase to at least 2.0 mg/day (message #279262) and also on June 23, Martha McSherry recommended to increase to 2.0 mg/day and retest (message #279282).  Apollo had TRH stim test for Dr. Kellon's study on June 3; test results:  ACTH pre TRH response was 11.2 pg/mL (reference range 2-30) and 10 min. post TRH response was 304 pg/mL (reference range 2-110).  Apollo on 1 mg of Prascend since 10/29/2021.

I was confused as to why I needed to increase Apollo's Prascend and retest his ACTH given it was already in low normal range. So I privately messaged Dr. Kellon for further explanation to make sure I understood correctly and could explain it to my vet since I'd be using a lot more Prascend.

Dr. Kellon replied:  "The biggest thing that stands out for me is that his first laminitis episode was during the seasonal rise.  The TRH response test tells you the tissue proliferation is not controlled. I would take him up at least 1 mg for the high risk rise period. How rapidly should be based on his prior reactions and you can use APF to help protect from side effects. Don't bother retesting after you make the increase.  He does not have to stay on this all year. You can back it down again in December and retest him in February".


--
Karen B.
Wisconsin
2022
Apollo Case History: https://ecir.groups.io/g/CaseHistory/files/Karen%20and%20Apollo
Photo album:  https://ecir.groups.io/g/CaseHistory/album?id=275817

Hi Karen, I believe Sherry may have meant to ask who advised you to go up to 3mg (not 2mg).  I would have the same question.  Sherry and I both suggested increasing to 2mg and then testing again.  It won’t hurt to go to 3mg if needed but you won’t know if you don’t test again and it is a strain on the finances.
Some of my horses love APF, some hate it and some could care less.  It doesn’t matter.  If they need it, they get it, squirted into their mouths with a small oral syringe.

Karen, I saw that you posted while I was replying.  I know that you would like to believe his ACTH test is normal.  We don’t know how abnormal it is but the value returned for the post TRH stim was well above (3x) the range the lab designated as ‘normal’.  There is no rationale for doing the stim test if it’s results are just ignored. 
--

Maybe "normal" is wrong word but my understanding from reading other posts is that target range for ACTH when using pergolide is low teens/mid twenties.  Apollo's ACTH was range when last tested.  As for TRH stim test my understanding is that it's a diagnostic test and not a test for adjusting dose of pergolide or at least it hadn't been and the purpose of repeat TRH stim study was to determine if it would be helpful in managing horse just like Apollo.
I wasn't trying to ignore Apollo's TRH stim test results but understand them which is why I privately messaged Dr. Kellon.  I went up to 2.5 mg because the suggestion was to increase by "at least 1.0 mg".  Going up to 2.5 mg/day is just above increasing by at least 1.0 mg.  I asked Dr. Kellon about retesting. It is very expensive as is Prascend.  Don't know if my vet would give me a prescription for compounded pergolide. I am trying to do everything I'm told but I don't have unlimited funds. I need to prioritize. I also need to buy hay, have it mineral balanced and buy needed minerals as well as flax and vitamin E.  Apollo also needs another set of hoof x-rays.

So what dose of Prascend should Apollo be given based on his TRH stim test results?  How do I know if it's enough to protect him during seasonal rise?  When and how often should ACTH levels be done ideally?

I'm confused and worried I'm not doing what's best for Apollo.
--
Karen B.
Wisconsin
2022
Apollo Case History: https://ecir.groups.io/g/CaseHistory/files/Karen%20and%20Apollo
Photo album:  https://ecir.groups.io/g/CaseHistory/album?id=275817

Karen,

We don't know enough yet about TRH response results in horses on pergolide to use them to guide pergolide dose. From information available to date, we do know the response should go down. If it didn't, I would definitely increase. Otherwise, we don't know what to expect.

For example, previous research has found horses could have hypertrophied intermediate lobes that were not putting out increased hormone levels. However, under TRH stimulation those pituitaries could produce abnormal levels. Do those horses need treatment? We don't know.

It's also possible that pergolide establishes a more normal hormonal profile quickly but over time causes shrinkage of the hypertrophied pituitary. This happens in people. In that case, baseline ACTH would normalize before TRH stimulated ACTH.

My guess, which could be wrong because that's all it is, is that your current dose will be adequate. You should check mid September to be sure, just for a reference value.

Maybe by next year we'll know more.
--
Eleanor in PA

www.drkellon.com 
EC Owner 2001

Thanks for additional info.  I understand that PPID is a very complicated disease and there's still so much that's unknown.  And I realize everyone is doing there best with what is known.  I apologize for misinterpreting everyone's recommendations.  Hopefully over time I'll become more comfortable in managing Apollo's IR and PPID but for now I'm finding it overwhelming.
--
Karen B.
Wisconsin
2022
Apollo Case History: https://ecir.groups.io/g/CaseHistory/files/Karen%20and%20Apollo
Photo album:  https://ecir.groups.io/g/CaseHistory/album?id=275817

Karen it is indeed overwhelming,and I don't see any apologies warranted.

Just know that this group has been around for a very long time ( 2000?) and its members have been ,in some cases,blazing the way for new and better information.There is always more to learn,but we have been boots- on- the- ground participants,as horse owners and care givers.
Most of us know what it's like to be where you are now,not that that is much comfort to you,really. But through our tears we have been able to determine what works and what does not work. Horses vary,of course,so can vary in their responses to various treatments.
One of the hardest things to do is go against 'common practices' and professional advice,when these run counter to what we have learned here,in the field,with thousands of horses.
Now I feel as if *I* should be apologizing for the rant,but am just trying to help give you a leg up.
--
Lorna in Eastern Ontario
2002

Karen, we all understand about feeling overwhelmed because the vast majority of us have been there. One of the frustrating problems with pergolide dosage is getting the dosage right when you cannot test constantly. And few of us can afford to test after each increase. I can't. I just increased Juniper's dose from 1/2 tab to 1 full tab today as she became a bit footy yesterday. Her ACTH was 33 pg/ml ( range <30) She symptomatically responded to the 1/2 mg. for two weeks, then became footy yesterday. Nothing in her feed, hay, routine, etc. changed but we are in the seasonal rise and I believe I am fighting that. We'll see. I want her in the teens and low 20's, but for now I need to monitor symptoms. You may have to simply increase in slow amounts and monitor symptoms. They all react differently to pergolide and numbers are not the only story for them. Sometimes you have to go by symptoms, which is hard when you are not familiar with what to look for. Taking photos of crests on your cell phone, eye weeping , etc. can help provide dates, etc. so you can see improvements. Make notes of if there is soreness, loss of appetite etc. Plan testing for when you get the most bang for your buck. Meanwhile, discontinue anything that isn't necessary and of benefit.( so often people come here with a wagon load of supplements that either duplicate or aren't of value )  Drop anything you know isn't working and let the group help you trim down to what does. That will help your finances.




Dawn Wagstaff and Tipperary   

Saline, MI  2003

Tipperary Case History

Juniper Case history: https://ecir.groups.io/g/CaseHistory/files/Dawn%20and%20Juniper/Case%20history%20Juniper.pdf .

Karen, my thought about increasing the pergolide was to see if you could get his insulin down further.  I probably wasn’t clear on that.  You wouldn’t need to test ACTH or do a TRH stim test but testing his insulin would let you know if more pergolide helped.  I know all that is expensive and it’s not absolutely necessary to test.  I just feel that it would give Apollo more protection going into the rise and potentially even going forward from there.

When I first began my PPID adventure, I had the same questions you do.  I could get guidance but no absolutes.  Just as every horse is an individual, each PPID situation is also unique.  Fortunately, it appears that in most cases you can give more than adequate pergolide without causing harm.  If I were going to to plan on testing twice yearly, I would test just after the rise and again before the next rise, increasing the dose each time as needed.  While you can increase the dose during the rise, it seems that the increases are less effective than they would be at other times.

Don’t worry.  Your’e doing fine and we’re doing our best to give you good advice!
--

Martha,
You all do a wonderful job at helping.  Maybe I read too much on this site.  I usually print off those posts with info I want for future reference but not always.  I remember reading on someone's post that most horse usually need at least 2.5 mg but can't find it now. Maybe that was stuck somewhere in back of my mind too.  I'm very nervous what is going to happen this year with seasonal rise especially now that farrier trimmed too much.  He was doing fantastic before that, could trot and canter a bit on his side of paddock and was walking heel first contact wearing his boots. Yes, I should have learned how to trim him myself but I didn't.  Now I will learn regardless of whatever else is going on in my life because it's obvious it would be better than what I've been paying for.  And I would also save money so it's a win/win proposition.  But I have another horse and I really don't want to have to trim him too.  Don't know what I'm going to say to farrier but he won't be trimming Apollo any time soon.  I won't say never because universe has way of making you eat your words!  I anticipate he will probably quit just like last one. Our vet has been much easier to reason with and more willing to learn from ECIR's vast knowledge and years of experience working in the trenches helping horses with IR and PPID.  This is probably going to sound crazy but sometimes this feels like doing hospice care (been there/done that) because neither IR or PPID can be cured making Apollo an equine time bomb.  Of course, this is also a real life lesson in learning how to live in the now and taking each day at a time knowing the only thing we can truly control is our reaction to what happens.
--
Karen B.
Wisconsin
2022
Apollo Case History: https://ecir.groups.io/g/CaseHistory/files/Karen%20and%20Apollo
Photo album:  https://ecir.groups.io/g/CaseHistory/album?id=275817

Karen, have you asked your vet about farrier recommendations?  Remind them how appreciative you are of their willingness to learn and you’d like to see that quality in your trimmer too.

I found your discussion of hospice care really thought provoking.  Thank you!   I wanted to reassure you that these horses with special management needs may well outlive most other horses due to the more tightly managed care they receive..  My horse, Logo, lived with PPID for at least 15 years.  It gets a lot easier.

--

Hi Martha,
Actually surprised our vet took ECIR info so well since I literally handed him printed info at his first visit!  (My dentist recommended him).  I think having worked worked with doctors in human health care for 35+ years helped me know how to present it and my medical knowledge gave me some credibility.  He was a bit leery of ECIR being a "forum" where everyone posts info but I've assured him it's very research/science based info which Dr. Kellon oversees.  When it comes to farriers, I'd say I'd have an easier time finding another good horse vet than a good farrier.  When I asked vet about his farrier, he said he's very aggressive and don't need that.  Asked guy we just bought hay from (his daughter shows horses), described farrier as grumpy guy who had difficulty scheduling appointments because he also shows draft horses.  Tried vet clinics too and did get list but most of them are not close by.  Will keep trying in case current farrier quits. I want to focus on Apollo but would like someone else to trim our other horse, at least for now. On positive side, trimming Apollo myself will save money I can use elsewhere.

The fact that high insulin levels can caused by both uncontrolled IR or uncontrolled PPID or both at same time means at least some periodic testing is necessary for proper management of both.  Could you give me your ideal recommended testing routine (which specific tests and when/how often to do them)?  Then I can figure out a schedule I can manage financially.  Fortunately, my husband's still working and has a good job but he's due to join me in retirement possibly as early as next December.  We've planned well for retirement but didn't anticipate having a horse requiring expensive medical care.  He's concerned we're spending a lot of money on Apollo and just prolonging his inevitable decline.  At this point, the past 9 months do seem like one endless struggle and there's always something else we should be doing.  Since Apollo's PPID was picked up early, I'm hoping there's a good chance he can still live a long and productive life. Maybe even be able to pull the sleigh again this winter.
--
Karen B.
Wisconsin
2022
Apollo Case History: https://ecir.groups.io/g/CaseHistory/files/Karen%20and%20Apollo
Photo album:  https://ecir.groups.io/g/CaseHistory/album?id=275817

Hi Dawn,
Thanks for sharing your knowledge and experience. Keeping a written and/or visual recording of Apollo's symptoms, treatment, etc is a great idea.  I've asked ECIR volunteers for list of their "ideal" testing routines so I can set up a schedule that provides needed information yet affordable vet bills.  Unfortunately, there's nothing I can think of to eliminate to help save money other than trimming his hooves myself.  Apollo gets just recommended supplements. We own the property he lives on. My husband and I already live a minimalist lifestyle except of course for having horses!  Things often have a way of working themselves out so I'm optimistic we'll find a way.
--
Karen B.
Wisconsin
2022
Apollo Case History: https://ecir.groups.io/g/CaseHistory/files/Karen%20and%20Apollo
Photo album:  https://ecir.groups.io/g/CaseHistory/album?id=275817

Here on ECIR we recommend testing a horse with PPID in late July to make sure their ACTH isn't climbing too fast.  If it is, then you'll have time before the peak of the rise to increase pergolide dose.  I personally also like testing at the peak of the rise to see how well ACTH remained controlled.  That's 2x a year, and includes ACTH, insulin and glucose.

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

Hi Kirsten,
Thanks, that's what I needed.  When is peak of rise?  Also, ideally shouldn't one test ACTH, insulin and glucose after increasing pergolide dose?  And how long after increasing pergolide should test be done?
Have new hay which tested safe per Equi-analytical being mixed with old hay.  Soaking both for now just to be extra safe.  Should I wait until Apollo is eating only new hay before testing? 


-
Karen B.
Wisconsin
2022
Apollo Case History: https://ecir.groups.io/g/CaseHistory/files/Karen%20and%20Apollo
Photo album:  https://ecir.groups.io/g/CaseHistory/album?id=275817