New Member and Case HIstory


New member here, I've just (hopefully) uploaded a Case History for Max (Michelle and Max), and also uploaded xrays and photos (Michelle and Max) - but I'm not sure if its worked, if anyone can let me know please.

Max currently has laminitis - mid winter here in Australia - so we are currently trying to work out why...


Case History folder: 


Hi Michelle,

Welcome to the ECIR group.  Your first post here triggers a formal welcome from the ECIR group with lots of informational reading material  and associated links.  

I was notified by Groups that you posted your case history but, when I follow the link, it takes me to your ACTH test.  Cass is going to help you get that straightened out so watch for more messages from Cass.

You are in mid winter and we are in mid summer.  The rise began here a month ago so you are technically no longer in the rise.  From what I can see, Max’s PPID appears normal.  Have you done any insulin and glucose testing?  Welsh cobs are genetically prone to be insulin resistant.  We encourage you to test insulin in his normal state, at least 4 hours after breaking any overnight “fast” and with hay still available.  The glucose test on the same blood sample will give additional informational and also act as an indicator as to whether the sample was properly handled.  

As Max is currently experiencing issues, we encourage you to follow the emergency diet until you have implemented an appropriate low ESC and starch diet.  This is explained in our welcome but relies on soaking and rinsing Max’s hay and the addition of a few easily acquired supplements.  Once we are able to review his caste history, we will undoubtedly have more advice.  The laminitis may have been triggered by an elevated ACTH a few months ago but it could just as well be totally due to high insulin and unrelated to normal seasonal ACTH elevation.

The ECIR Group provides the best, most up to date information on Cushing's (PPID) and Equine Metabolic Syndrome (EMS)/Insulin Resistance (IR). Please explore our website where you'll find tons of great information that will help you to quickly understand the main things you need to know to start helping your horse. Also open any of the links below (in blue font) for more information/instructions that will save you time.

Have you started your Case History? If you haven't done so yet, please join our case history sub-group. We appreciate you following the uploading instructions so your folder is properly set up with the documents inside. Go to this CH message with info on how to use various devices and forms. If you have any trouble, just post a message to let us know where you are stuck. 

Orienting information, such as how the different ECIR sections relate to each other, message etiquettewhat goes where and many how-to pages are in the Wiki. There is also an FAQs on our website that will help answer the most common and important questions new members have. 

Below is a general summary of our DDT/E philosophy which is short for Diagnosis, Diet, Trim and Exercise.


DIAGNOSIS: There are two conditions dealt with here: Cushings (PPID) and Equine Metabolic Syndrome (EMS)/Insulin Resistance (IR). These are two separate issues that share some overlapping symptoms. An equine may be either PPID or EMS/IR, neither or both. While increasing age is the greatest risk factor for developing PPID, IR can appear at any age and may have a genetic component. Blood work is used for diagnosis as well as monitoring the level of control of each.

PPID is diagnosed using the Endogenous ACTH test, while EMS/IR is diagnosed by testing non-fasting insulin and glucose.

The fat-derived hormone leptin is also usually abnormally elevated in insulin resistance but because there are many other things which can lower or increase leptin ECIR is not recommending routine testing for this hormone. Leptin is the hormone that says "stop eating".

In Europe, adiponectin is tested instead of leptin. Adiponectin helps regulate glucose and fat burning, and maintain insulin sensitivity. Low levels are associated with EMS. It has come to be preferred over leptin because it is not influenced by things like weight or exercise, and also because it was the only factor other than insulin levels that predicted laminitis risk

*Before calling your vet to draw blood for tests, we suggest saving time and wasted money by reading these details and then sharing them with your vet so that everyone is on the same page regarding correct testing and protocols.

*Please remember to request copies of the results of all the tests done rather than just relying on verbal information. Your vet should be able to email these to you. If you have previous test results, please include those as well. All should go in your CH, but if you are having any trouble with the CH, just post in the messages for now. 

Treatment: EMS is a metabolic type - not a disease - that is managed with a low sugar+starch diet and exercise (as able). The super-efficient easy keeper type breeds such as minis, ponies, Morgans, Arabs, Rockies are some of the classic examples. PPID is a progressive disease that is treated with the medication pergolide. Some, but not all, individuals may experience a temporary loss of appetite, lethargy and/or depression when first starting the medication. To avoid this "pergolide veil" (scroll down for side effects), we recommend weaning onto the drug slowly and the use of the product APF. The best long term results are seen when the ACTH is maintained in the middle of the normal range at all times, including during the annual seasonal rise. To accomplish this, the amount of medication may need to increase over time. Neither condition is ever "cured", only properly controlled for the remainder of the equine's life. If your partner is both PPID and IR then both medication and diet management will be needed. 

DIET: Almost all commercial feeds are not suitable - no matter what it says on the bag. Please see the International Safe Feeds List for the safest suggestions.

No hay is "safe" until proven so by chemical analysis. The diet that works for IR is:

  • low carb (less than 10% sugar+starch)
  • low fat (4% or less) 
  • mineral balanced  

We use grass hay, tested to be under 10% ESC + starch, with minerals added to balance the excesses and deficiencies in the hay, plus salt, and to replace the fragile ingredients that are lost when grass is cured into hay, we add ground flax seed and Vitamin E. This diet is crucial for an EMS/IR horse, but also supports the delicate immune system of a PPID horse. 

*Until you can get your hay tested and balanced we recommend that you soak your hay and use the emergency diet (scroll down for it).  The emergency diet is not intended for long term use, but addresses some of the most common major deficiencies. Testing your hay and getting the minerals balanced to its excesses and deficiencies is the best way to feed any equine (look under the Hay Balancing file if you want professional help balancing). If you absolutely cannot test your hay and balance the minerals to it, or would like to use a "stop gap" product until you get your hay balanced, here's a list of "acceptable" ration balancers

There is a lot of helpful information in the start here folder so it is important you read all the documents found there. The emergency diet involves soaking your untested hay for an hour in cold water or 30 minutes in hot water. This removes up to 30% of the sugar content, but no starch. Starch is worse than sugar since it converts 100% to glucose while sugar only converts 50%, so starch causes a bigger insulin spike. Make sure you dump the soaking water where the equine(s) can't get to it. 

What you don't feed on the EMS/IR diet is every bit as, if not more important than, what you do feed! No grass. No grain. No sugary treats, including apples and carrots. No brown/red salt blocks which contain iron (and sometimes molasses) which interferes with mineral balancing, so white salt blocks only. 

No products containing molasses. No bagged feeds with a combined sugar and starch of over 10% or starch over about 4%, or fat over about 4%. Unfortunately, even bagged feeds that say they are designed for IR and/or PPID equines are usually too high in sugar, starch and/or fat. It’s really important to know the actual analysis and not be fooled by a name that says it is suitable for EMS/IR individuals.

We do not recommend feeding alfalfa hay to EMS/IR equines as it makes many of them laminitic. Although it tends to be low in sugar, many times the starch is higher and does not soak out. Additionally, protein and calcium are quite high, which can contribute to sore footedness and make mineral balancing very difficult.

TRIM: A proper trim is toes backed and heels lowered so that the hoof capsule closely hugs and supports the internal structures of the foot. Though important for all equines, it's essential for IR and/or PPID equines to have a proper trim in place since they are at increased risk for laminitis. After any potential triggers are removed from the diet, and in PPID individuals, the ACTH is under control, the realigning trim is often the missing link in getting a laminitic equine comfortable. In general, laminitic hooves require more frequent trim adjustments to maintain the proper alignment so we recommend the use of padded boots rather than fixed appliances (i.e. shoes, clogs), at least during the initial phases of treatment.

Sometimes subclinical laminitis can be misdiagnosed as arthritis, navicular, or a host of other problems as the animal attempts to compensate for sore feet. 

You are encouraged to make an album and post hoof pictures and any radiographs you might have so we can to look to see if you have an optimal trim in place. Read this section of the wiki for how to get a hoof evaluation, what photos are needed, and how to get the best hoof shots and radiographs.

EXERCISEThe best IR buster there is, but only if the equine is comfortable and non-laminitic. An individual that has had laminitis needs 6-9 months of correct realigning trims before any serious exercise can begin. Once the equine is moving around comfortably at liberty, hand walking can begin in long straight lines with no tight turns. Do not force a laminitic individual to move, or allow its other companions to do so. It will begin to move once the pain begins to subside. Resting its fragile feet is needed for healing to take place so if the animal wants to lay down, do not encourage it to get up. Place feed and water where it can be reached easily without having to move any more than necessary. Be extremely careful about movement while using NSAIDs (bute, banamine, previcox, etc.) as it masks pain and encourages more movement than these fragile feet are actually able to withstand. Additionally, NSAIDs (and icing) do not work on metabolic laminitis and long term NSAID use interferes with healing. Therefore, we recommend tapering off NSAIDs after the first week or so of use. If after a week's time your equine's comfort level has not increased, then the cause of the laminitis has not been removed and keeping up the NSAIDs isn't the answer - you need to address the underlying cause.


There is lots more information in our files and archived messages and also on our website. It is a lot of information, so take some time to go over it and feel free to ask any questions. If you are feeling overwhelmed, don't worry, you will catch on, and we are always here to help you! Once you have your case history uploaded, we can help you help your equine partner even better.

For members outside North America, there are country specific folders in the files and many international lists in the wiki to help you find local resources.

If you have any technical difficulties, please let us know so we can help you. 

Martha in Vermont
ECIR Group Primary Response
July 2012 
Logo (dec. 7/20/19), Tobit(EC) and Pumpkin, Handy and Silver (EC/IR)

Martha and Logo



Thanks so much Martha.  My vet drew bloods to test for insulin on Wednesday, he’s called me to say that the results are back, insulin is very high at 79.  Bloods were taken in the middle of the day, no fasting, just nibbling on grass hay in a slow feeder.  I’m waiting on a copy of the results which I’ll add to my case history.
Ive always managed Max as an ‘at risk’ horse, I’ve had several Cushings horses in the past, so I’m familiar with the correct management practices, most of which I gleaned from here years ago when my first horse was diagnosed with Cushings.

Ive always fed him beet pulp, Maxisoy and lucerne chaff, grass track, restricted track grazing during spring/summerand he’s done well on that for the 13 years he’s been with us.
But I suspect I made a mistake by introducing lupinpack pellets (28% protein, 8% fat) and 3/4 cup RBO after Max had dropped a bit of weight.  I thought I’d done my research to determine these were suitable for his metabolic type..unfortunately I didn’t check in here first ☹️

I removed the lupinpack and oil a week or so ago.  He’s now on the emergency diet, and I’m soaking his hay. He’s confined to a rubber floored stable and breezeway and he seems to be moving a little better today.  He’s on a reducing Bute protocol which will finish in 5 days all being well.

My vet wants to trial him on a new drug, not Metformin, it starts with an e….something like ert…….  I’ll find out the exact name.

Sorry for all the babble, I’m just so worried about my boy and feel that this is all my fault 😕

Sherry Morse

Hi Michelle,

1 - please set up your auto-signature.  To do that:

1) Go to this link to amend your auto-signature:

2) Look at the bottom of that page for the window to type in your name, general location, and year of joining. IE:

3) Make sure you check the 2 boxes saying "Use Signature for Web Posting" and "Use Signature for Email Posting”.

4) IMPORTANT: Scroll to the bottom and hit SAVE!

All posts that you write or reply to, using either the web or your email software, will then have your signature automatically added at the end.

2 - with an insulin result that high I'd stop the lucerne now and remove him from grass.  He can be out for up to 4 hours with a completely sealed muzzle as that will let him drink water but restrict him from eating any grass.  The pellets were completely unsuitable for an IR horse so good that they've been stopped.

3 - is there a reason your vet doesn't want to try Melatonin before going right to Ertugliflozin?  That's a bit like shooting a mouse with a cannon and something we only recommend if Metformin and diet/exercise do not work.



Thanks Sherry, I've hopefully fixed everything up now.  I'm so cross about the Lupinpak pellets, the label actually says "suitable for horses with laminitis".  A lesson not to let my guard down and believe anything a feed company says.  
I've cut the lucerne chaff down to a tiny handful added into the beet pulp for flavour.  He's never had an issue with lucerne before.  The rest of the diet is the Emergency Diet.  I'm using magnesium chloride dissolved into a little hot water instead of Mag ox as Max won't eat it.
I'm cautiously pleased that he seems to be moving much better today, he's brighter (trying to bust out of jail) so we'll see how he goes on reduced Bute tomorrow.  He is off grass completely, combined to a rubber-floored stable and breezeway.  He's happily eating his soaked hay in a slow feeder - he's being such a good boy.
My equine vet wants to trial the Ert... instead of Metformin as they've trialled several horses on it, with better results than Metformin both in reducing insulin and improving laminitis.  But I'm wondering if, given the improvement, I should see what happens with diet management first before medicating - what are the expert thoughts on this????
Michelle & Max
Yarra Valley, Victoria, Australia
Thank you
Joined 2022

Sherry Morse

Hi Michelle,

To get Dr. Kellon's opinion on the use of Ertugliflozin you'll want to start a new email chain with something like "Ertugliflozin vs. Metformin" in the title.  Here's my laywoman opinion though - it's a new drug for the vets to use, they don't have as much experience with it, the side effects can be dangerous and it's much more expensive than Metformin.  So to me it doesn't make sense to go to that med first when the older version might do fine.  (Vets on the other hand are much like doctors in that they get a new drug and they are all over using it vs. the old tried and true).  

So I'd go with diet first, Metformin 2nd if still needed and save the big guns for after if Metformin doesn't work or stops working.  

There are so many feeds on the market here labeled as safe for IR/PPID horses that actually are not that it bogles my mind, but the makers can make all sorts of claims so they certainly take advantage of that.


Thanks so much Sherry, I’ll start a new thread for the Ertuglifozin/Metformin.  It does seem like going straight to third base and skipping one and two though from what you are saying 
Michelle & Max
Yarra Valley, Victoria, Australia
Thank you
Joined 2022