Hi there, Zahr started on his 3mg CP + 0.5mg prascend for an equivalent of 2.8mg prascend on July 12th so that he could be mostly on the new meds at least 2 weeks before the vet draws blood on the 27th to recheck ACTH. Unfortunately because of the complications I encountered in getting his prescription (see https://ecir.groups.io/g/main/message/279782?p=%2C%2C%2C20%2C0%2C0%2C0%3A%3Arecentpostdate%2Fsticky%2C%2CZahr%2C20%2C2%2C0%2C91167718 ) this is a slight reduction in meds of approximately 0.2mg  from the 3mg prascend he had bee getting daily. His old symptoms of goopy eyes and sweating more than normal cleared up at the higher dose, and have not returned since lowering it slightly.

Zahr pulled up lame on Monday and it was very obviously his right hind. We had a fair amount of rain that day and I'm guessing he slipped, he was acting stifle-ey as we walked and it was particularly noticeable on backing up (he has pretty advanced arthritis in his back end, so this is something we have dealt with before). By Wednesday he was starting to head bob on his left front as we walked, I'm guessing due to compensation. He had a farrier appointment that day too, and he appeared more sore than the last time while she was doing his feet and after his trim. The LF head bob she also suspects is due to RH soreness and compensation. However this trim, more bruising than he has recently had showed up above the point of his frog.

I'm guessing this bruising is probably from approximately 6 weeks ago, he finally had enough of the shoes and panicked when the farrier went to put new ones on. There was a lot of hopping around and he slammed his front feet pretty good. Long story short I regret not following my feeling on going back to boots or following the group's recommendation to do so as well. I do believe he may have incurred some mechanical damage to his feet from that. So I am unsure if the sensitivity would be showing up now as the damaged sole is growing out, it just seems to be somewhat of a red flag that he was more tender this trim.

Friday he continued to be stiff in his hind end, but his front feet still seem to be bugging him too. We also had a nasty weather system come through that day, and whenever that has happened this summer it seems to result in small flare ups of "footiness" - I have read in the group that some horses do respond to big fluctuations in barometric pressure in this manner. There are so many possible confounding factors for this one, I want to say that it was poor timing with him hurting his RH and this weather system causing his soreness.

I don't think it is metabolic, as I don't expect that the tiny reduction in pergolide would have such a large impact in only a week and a half? But it also isn't a possibility I want to overlook. The vet will be out next Wednesday to do his bloodwork, so I'd rather not start mucking about with his pergolide dosage right before, however to be safe I was thinking of increasing him by another 0.25mg prascend to at least bump him back up to the 3mg equivalent. Does the group have any thoughts on this?

Thank you, as always. This one could technically be just "the perfect storm", as I suspect it is, but given the potential for it to escalate quickly at this time of year I don't want to take any chances.

(P.S. Zahr's CH file is a little out of date with some of the recent changes, so I will be sure to get back to that and update asap).
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Mikaela Tapuska in Calgary AB, 2021

Case History: https://ecir.groups.io/g/CaseHistory/files/Mikaela%20and%20Zahr

Photo Album : https://ecir.groups.io/g/CaseHistory/album?id=274255

Hi Sherry,

The May hay analysis is the current one, yes, and Zahr's hay is soaked for his feedings at bring in and night check but not for the AM or midday feedings. I'll get current trim photos up right away.

My thoughts were similar in that it is such a small amount and very close to the 3mg prascend he was on prior. Given that, I suppose what I am trying to figure out is if such a small increase likely would not improve much, would such a small decrease be enough to cause a problem? I know there won't be a solid answer on that since every horse is different, but I thought I'd run it past the group. The timing of everything together for Zahr is suspicious, but with him being sensitive I don't want to overlook any possibilities. 

The hope was to get him tested before August and I do expect, given how high his ACTH was in late May, that he will need to go up probably another 0.5mg at least for the rise.

Thank you!
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Mikaela Tapuska in Calgary AB, 2021

Case History: https://ecir.groups.io/g/CaseHistory/files/Mikaela%20and%20Zahr

Photo Album : https://ecir.groups.io/g/CaseHistory/album?id=274255

Photos are up - they are the ones from July 22.
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Mikaela Tapuska in Calgary AB, 2021

Case History: https://ecir.groups.io/g/CaseHistory/files/Mikaela%20and%20Zahr

Photo Album : https://ecir.groups.io/g/CaseHistory/album?id=274255

Hi Mikela,

Thanks for getting the photos up.

Unfortunately, part of Zahr's issue is that his trim needs a lot of work. His toes are still way too far out ahead of where they need to be. His HPA is broken back, soles are thin. Although the trim after the rads were done improved things some, it hasn't been nearly enough.

--
Lavinia, George Too, Calvin (PPID) and Dinky (PPID/IR)
Nappi, George and Dante Over the Bridge
Jan 05, RI
Moderator ECIR

Is there any way you can have the hay soaked for all feedings? It can be done ahead and then allowed to dry. In addition to getting the trim addressed that's one thing I would change ASAP.

Keep in mind hind end stiffness could be because his front feet are bothering him so also keeping him in boots may help him all around if that's not already being done.
--

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/Scutch%20Case%20History.pdf

https://ecir.groups.io/g/CaseHistory/album?id=78891

I agree that tiny amount is not likely to have much influence, good or bad.  Please get your case history updated so everything is in one place. You are going to need to address all aspects of drugs, diet and trim to get this under control. I would be very surprised if 3 mg is going to be enough.
--
Eleanor in PA

www.drkellon.com 
EC Owner 2001

Shoot. I thought that we had made some good improvements, but now that they have been pointed out I can see the problems... and his RF out of the two seems to be the one getting away on us this time. I will talk to my farrier and see if she's open to it, but I think I would like to get some mark ups done before his next trim. We need help with this and I don't want to continue on the track of dragging this on and on for poor Zahr. But he is indeed wearing his boots full time right now to give him extra support.

Soaking his hay for the other feedings will be difficult, but I'll see what I can do. He's still presenting like the soreness is stemming from higher up in his hind end, and he warms out of it with some in-hand work. 

Based on what you said Dr. Kellon, I think it makes the most sense to stay the course with his meds until the vet is out to do bloodwork so as not to throw any numbers off. And I have a good amount of prascend on hand to increase his dose asap as needed based on the results.

Thank you all for your advice, I have some re-figuring out to do. And I will post the updated CH right now (mainly the ACTH values that were needed).

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Mikaela Tapuska in Calgary AB, 2021

Case History: https://ecir.groups.io/g/CaseHistory/files/Mikaela%20and%20Zahr

Photo Album : https://ecir.groups.io/g/CaseHistory/album?id=274255

Hi Mikaela, 

You could increase the pergolide dose the same day, after the blood pull, since results seem to take a while.  If you're at 3 mg, consider moving up to 4 mg for the rise.  You can come back down to 3 mg in December.

Also, your current pergolide dose is not listed in your updated CH.

I would also get insulin and glucose done with this next blood pull.  His insulin will help you make decisions.

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

Hi Sherry, 

That is something that concerns me with Zahr, for sure, because he similarly is an extremely stoic horse. What you and other group members have described with the hind end stiffness has happened before with him (I think, based on the timeline, that's what happened in fall 2021), although generally his pattern seems to be that he gradually gets stiffer and then suddenly turns and the lameness gets really bad. This time was different in that he went from feeling really good (he was really bright and perky the week leading up to this, even the day before, the closest I've seen him to his old self in a long time) to suddenly very sore on his right hind. The head bob on the front end didn't start until a couple of days later.

This may sound weird, but I can tell how heavily he's been leaning on his forehand because I can feel his sternum poking out more than normal. Ordinarily it is palpable under his muscles if I feel for it, but it doesn't feel like it's jutting out. Since he pulled up lame this time it feels like it's been jutting out, so in our in-hand I try to get him to lift and that seems to help him. 

Given the chance that he is having an episode (even if it is a mechanical one triggered by over-compensation) I am trying to carefully walk the line between not overdoing it but equally not doing too little with him. I've tried only rest when he's been uncomfortable before and he gets so sore so much faster that way, it worries me that maybe neither forehand or hind-end will not be able to handle any compensation if I allow that to happen. Unfortunately he presents so similarly for both I can't easily tell them apart, and the longer it goes on I do start second-guessing myself. I hope that on Wednesday the vet can look at him with fresh eyes and help me figure this one out.

Kirsten, that is a good plan and will get him started on his increased dose as soon as the blood is pulled. Apologies I totally missed that part in his CH when I was updating it last night, I'll get that fixed and reuploaded right away.

Ideally insulin would be great, but given the expense I really want to make sure that his ACTH is controlled before I do that one again. I don't mean to be tight, the bills for his meds have just been adding up as of late with him having to be on such a high dose of prascend for longer than planned and the issues with getting the correct dose of CP. His recent WBC counts have been low, so the vet will be pulling blood for hematology too this time to see if there will be any difference after having stopped the NSAIDs.

We'll probably have to do ACTH again after we've adjusted for the rise to confirm it's controlled. I'm thinking maybe that would be a better time to do insulin to at least offset the costs somewhat and hopefully have a more accurate result than we might get if we test now. 

Thank you for all the suggestions, it gives me a lot to think about. (And I hope none of my replies come across as argumentative over the computer, I really appreciate the feedback and it helps me to be able to brainstorm with the group).
--
Mikaela Tapuska in Calgary AB, 2021

Case History: https://ecir.groups.io/g/CaseHistory/files/Mikaela%20and%20Zahr

Photo Album : https://ecir.groups.io/g/CaseHistory/album?id=274255

I totally understand the need for budgeting as Prascend is ridiculously expensive.  I just think insulin now would help you decide if you need to make the extra effort of soaking all Zahr's hay or not.  But you have to prioritize based on what you can and can't do.

You don't sound argumentative at all, and hopefully you understand volunteers aren't trying to boss you around...we just advise on what we think would be ideal, whether or not it's possible is up to you.  :)

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

Thanks Kirsten! I'm glad, and likewise I know your advice is not meant in a bossy way. Even if some of it may not be doable now, it provides good ideas that I can put in the toolbox for later.

My thoughts are to check ACTH today and if results come back high I will presume his insulin is also high (given the last test results), which I think then would be a reasonable time to ask the barn owner if we can soak his hay for all of his feedings. I am looking at coolers on Kijiji just in case, I liked Nancy's idea for soaking and I hope that would make the barn owner's life a little bit easier if we could do his day's worth of hay all in one go. And additionally we will start increasing meds for the rise asap first thing tomorrow morning.

Reading in the forum, someone mentioned testing ACTH at the end of October to see if the adjustments for the rise were adequate (I think it was Sherry?) but I can't remember which thread it was in. Depending on where his results today come back at, maybe then would be a good time to retest and do insulin as well once he is on the additional 1mg.

On a side note, Zahr's overall lameness did slowly improve somewhat over the week. However yesterday things changed and his right front seemed to be the one that was most uncomfortable. I took him for just an easy 10 minute walk to keep his joints moving and feeling okay, and afterwards the pulse in his LF was down (nearly undetectable) but felt like it had shot up in his RF. He has never shown that before, usually if his pulses are mildly up they will come down after walking but in both feet. Not opposite results in each foot! So I am suspicious now that he may have an abscess brewing in his RF (grasping at straws perhaps? But I think that would be the only thing that could cause that kind of unilateral response, and may explain why his symptoms have seemed quite random over the week).

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Mikaela Tapuska in Calgary AB, 2021

Case History: https://ecir.groups.io/g/CaseHistory/files/Mikaela%20and%20Zahr

Photo Album : https://ecir.groups.io/g/CaseHistory/album?id=274255

Soaking all the hay in 1 go does make things so much easier.  In Calgary, being so hot and dry, I don't think you even need a cooler, just a place it can sit and continue to drain.  This is what I use to drain and transport the soaked hay: https://www.canadiantire.ca/en/pdp/yardworks-steel-garden-cart-600-lb-0601329p.0601329.html?ds_rl=1283573&ds_rl=1283573&gclid=EAIaIQobChMIvbTj2fub-QIVlBx9Ch3D7wDSEAQYAiABEgJJL_D_BwE&gclsrc=aw.ds#store=486
Here in Kitimat the only time hay has smelled really off was on warm humid/muggy overcast days.  Hot + dry, or cool + wet days it seems to be fine. The hay at the bottom of the net where the water pools, even when it's sitting on a drain board, always smells a bit fermented after 12 hrs (even in a cooler) but its not moldy.

Testing ACTH at the end of September will give you the peak of the rise.

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

That's brilliant!! I thought I needed a full fledged drying rack for that, which is why I was hesitant to try, but the owner of the barn is on board with that plan and is lending me a similar wagon that she has to see if it works first (I'll go pick up that one from Canadian Tire if it does, thank you for the link!). So far the hay is actually draining and smelling nicer than when it was soaked and drained in a bucket right before feeding, and he seems to still be eating it quite well. 

A little bit of a good and bad update from the vet's visit. On the bright side, she doesn't think it is a full blown acute episode. On the downside, she thinks that Zahr is at the point where he is stuck in a cycle of chronic flare ups, especially since they seem to have been happening more frequently as of late (albeit most of them milder than this one). Given the other underlying conditions that he has to contend with, she gently suggested I start keeping track of how many good and bad days he is having so that, should he continue on this route, I can make a decision on where his quality of life is at before winter. I am going to continue to fix up every gap in his DD&T in the meantime, because I cannot make that decision unless I know every base has been covered, which they have not yet been. The vet did seem open to continuing to try what we can, so I am hopeful in that regard as well.

Drugs: Zahr officially started on his increased pergolide dose this morning (we'll gradually titrate up by 0.25mg prascend at a time again until we reach 4mg). The one thing the vet recommended was to wait on increasing his dose until we get his blood results back, which I don't think Zahr has time for so I'm going ahead and increasing it anyways as the group has advised, but she said she'd do some reading on it when I explained why I wanted to do so.

Are there any good papers or articles on medicating to prevent the rise in PPID horses and its benefits? I will keep researching, just if anyone has something off the top of their head I'll send that to her so at least I can give her a good, scientific reason for doing this. As I said, I think she's open to it.

Diet: We started soaking his hay (1hr in cold water) and drying on a wagon for all meals as of yesterday, so all S&S should now be at a safe level of below 10%.
Something, however, I had missed earlier but realized may be a problem is that he has fescue in his hay (along with timothy and orchard grass) and from actually looking through it the fescue makes up a large amount of the mix.

I was looking at Dr. Kellon's replies to other members about fescue, along with the 2 papers that have been done on its effect on foot pain in horses. He has been on this hay since mid-April, and again hard to say with all of the other confounding factors for why he may be having more of these chronic flare ups, but I wonder if that may be an underlying reason he's recently been having so much trouble... It could very well be a coincidence, but fingers crossed the new hay (back to the brome mix he was on before, same field) will all be in this week so hopefully can get him switched on to that asap and will continue to soak all of it until tested. 

Trim: Zahr's farrier is on board for getting mark ups, so I will get some new pictures since those last ones posted were from July 22 and will upload them tonight.

Is there anything else that I overlooked in my plan? I want to make sure I haven't missed anything, since Zahr's is such a tricky case.

Thank you!

--
Mikaela Tapuska in Calgary AB, 2021

Case History: https://ecir.groups.io/g/CaseHistory/files/Mikaela%20and%20Zahr

Photo Album : https://ecir.groups.io/g/CaseHistory/album?id=274255

Keep in mind that Zahr's ACTH has never been well-controlled and once he gets on a high enough dose of pergolide you might see the chronic flareups disappear.  The fescue could definitely be a problem, too.

There is research showing that increases of 1-2 mg DURING the seasonal rise are ineffective at bringing down
elevated ACTH, which is why you want to start increasing the dose now.  As per Dr Kellon:

McFarlane's 2016 study. Those horses (positive PPID) did not respond to 1 or 2 mg doses for several months but treatment started during the seasonal rise and there was an abrupt drop once that was over.

As for keeping ACTH in the reference range, even through the rise (ie, <10 pmol/L year-round), I believe that is based on the collective experience of the ECIR Group members finding their horses just do better.  In fact we like to keep it below the middle of the reference range, which would be <5 pmol/L.

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

Good point re: his ACTH never truly being under control... Every time we'd get it to the high end of the reference range and think "Okay, that's good enough", which considering his history was never actually the case. And that is a great paper, thank you for sharing it! I'll be sure to email that one on to my vet.

Zahr's eyes started getting runny again over the past couple of days, so I am happy that he is back on his increasing dose and hopeful that we caught it right as the seasonal rise was starting to drive his levels up again. Speaking of, last time his dosage increased I upped it by 0.5mg right away and then went up by 0.25mg each time after that, with approx. one week in between each increase. He didn't have any problems with the pergolide veil. Would it be ill-advised to shorten that adaptation period to 4 days for each 0.25mg increase? Given the time of year I don't want to risk taking a full 4 weeks to fully adjust his dose and then have to wait another 3 weeks to test ACTH, as any changes after that point probably won't have any effect.

His fecal water seems to be back with a vengeance with this increase in meds. That, along with high heat and thunderstorms (barometric pressure drop?) - both of which we are experiencing -  seem to be the recurring factors when it flares. I ordered some bovine colostrum to try with him as it sounds like some group members have had good luck with it for similar issues. 

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Mikaela Tapuska in Calgary AB, 2021

Case History: https://ecir.groups.io/g/CaseHistory/files/Mikaela%20and%20Zahr

Photo Album : https://ecir.groups.io/g/CaseHistory/album?id=274255

I would wait no longer than 4 days between increases unless you see an issue.
--

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/Scutch%20Case%20History.pdf

https://ecir.groups.io/g/CaseHistory/album?id=78891

Thank you Sherry! I will do that.
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Mikaela Tapuska in Calgary AB, 2021

Case History: https://ecir.groups.io/g/CaseHistory/files/Mikaela%20and%20Zahr

Photo Album : https://ecir.groups.io/g/CaseHistory/album?id=274255

FFW can be a side effect that flares up when you increase the pergolide.  Shaku has the same problem.  I feed extra beet pulp and ODTBC to try and counteract it with more digestible fibre, and that helps but it doesn't fully resolve.

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