Hi Everyone,
I am new to the group, and I have read through some previous threads regarding this topic, but I would like to get some opinions specific to our situation. We have a pony who is almost 14 years old, that has Cushings (controlled with one prascend daily.) His last blood sample came back with ACTH results that were “amazing” according to the vet. His blood sugar was ever so slightly high, where she wasn’t super concerned, but likes to get ahead of it, to prevent any future issues. At the time is was on a senior feed that was about 17 or 18% NSC, and hay that wasn’t being soaked. He is now on a lower starch (12.90 % NSC), soaked hay, soaked beet pulp (pretty sure no molasses), and a top line supplement that is under 10% NSC. We also added Insulin Wise, as per the vet recommendation, as well as Vitamin E with Selenium. I think this will help that ever so slightly raised insulin.

My ultimate question is pertaining to his need of injections now. I have been researching, and all is so overwhelming. Has anyone successfully done steroids, while have cushings and Slight IR under control? We have a conservative vet, who has his best interest at heart, and she feels that with everything controlled, lower end of dosing, and proper care, all will be ok. I trust her, but I also like to get some outside knowledge to educate myself. We did discuss prostride for the future, but at this point she feels he needs a more immediate relief, and that prostride is a good maintenance option. If you’ve last this long reading, I thank you!! I am new to owning a pony who needs some maintenance, and trying to educate myself! 

Hi Sherry,

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K, NY, 2022

Hi Denise. Your first post triggers an encyclopedia of information regarding IR and PPID ( Cushings). In this message,  you will read about diagnosis, diet, exercise and trim which are the cornerstones of our protocol. Within each topic you will see blue links that will take you deeper into more information. 

What type of joint problem are you trying to treat? There are other things to try first before using a steroid. If its an arthritis situation  then you could try a product called MovEase by My Best Horse. Also, hyaluronic Acid intravenous injections can also be used. Adequan like Sherry mentioned.... You can also search the files to read more about arthritis and what our members have found works and doesn't work. 

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 etiquette, what 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.

EXERCISE: The 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. 

 

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Trisha DePietro
Aug 2018
NH
Dolly and Hope's Case Histories
Dolly's Photos 
Hope's Photos 
Primary Responder

Hi Trisha,
Thanks so much for your response! I actually read up on that post beforehand, and it offered some valuable information. What I am having a hard time finding is if anybody has had success with steroids. I know the risks, but with so many telling me that the risk is low, with managed care and cushings, I am trying to research myself to see how low it really is. Does that make sense?  In all my groups I have only found one post about people who have had no issues. 

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K, NY, 2022

Hi Denise,
in your signature you have ‘K’.  Is that what you prefer to be called.  If you like being called “Denise”, put that in your signature, so we’ll know.  Thanks!

Could you be a little more specific in what you mean by “Injections”.  My guess is that you’re considering a hock injection.  Two types of risks come to mind, the risk of injecting a steroid into a metabolically challenged horse and the risk of injecting anything into your horse’s hocks.  When we see your horse’s results, we would be in a better position to assess the first risk and the second one is probably related to how frequently your vet does the procedure and your compliance with aftercare.

If you have reason to believe your horse has arthritis in the hocks, there are plenty of other options as the others have said,.  In all the horses I’ve had and ridden, I think I’ve only had one set of hock injections  done, on a pony club trooper.  That one was partially driven by peer pressure.  Adequan is injectable but you can possibly do it yourself.  

--

The plan is to inject his coffins. The vet is planning on using a steroid that is not known to cause problems. The hocks are a possibility in the future, but I think once the coffins are done, we will see improvement on the back end. I know he has had steroid injections in the past, and done fine with them, but we have never personally done them, since we only got him within the past year.  
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 Denise, NY, 2022

Denise- If it were me, I would ask my vet for the research studies that support the use of steroid injections with Insulin Resistant and PPID horses....perhaps those research studies can provide you with a risk:benefit ratio. "low" does not mean never...is it 1 out of 1 million horses? or is it 1 out of 10 horses? Defining "low" in normal horses or "low" in horses with co morbidities such as PPID and IR.  Perhaps Dr. Kellon can provide more info...
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Trisha DePietro
Aug 2018
NH
Dolly and Hope's Case Histories
Dolly's Photos 
Hope's Photos 
Primary Responder

Denise, when you say coffin bone, is the vet intending to inject the joint between P3 (coffin bone) and P2? Depending if the pony has any sinking, that joint could be inside the hoof capsule. Do you have radiographs showing arthritic changes? Is the pony lame? I guess it’s unclear to me why you are considering injections and where.
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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

 

I’m going to be completely honest, and say I don’t know. I was just told that she thinks starting with the coffins is best. Nobody has ever said he is lame, but he is dragging his back right foot a bit. He is also taking his weight off of his left front leg, which is why she suggests starting there. She did ask if she can take some x rays that day. 
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 Denise, NY, 2022

I’ve known a horse triggered into a laminitis episode just from throat spray with dex in it. For me knowing what people here have gone through and friends of mine, the risk is always too high with an IR/cushings horse to make it worth it. I would rather spend more now on what I’m choosing to use for my injections then have to go through months of recovery from a laminitis episode.

That said my horse takes a serious amount of maintenance due to multiple different soundness issues. So I have run the gauntlet of options outside of steroids. I have used Pro-Stride on my mare, Noltrex, and most recently Arthramid. All three work slightly different and she has responded in various ways to all three. They are all pretty equivalent in cost which is unfortunately not cheap. For her last coffin joint injections we did Arthramid and *knock on wood* she has responded fairly well to it. 

Besides being safer for IR/cushings horses these options are all also better on the joints. Steroids do decrease the inflammation but they also do damage to the joints as well.  So in the long term spending that extra money for one of those other three options will probably help your horse more long-term.
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- Anthie

Northern California
August 2015

Erin's case history: 
https://ecir.groups.io/g/CaseHistory/files/Anthie%20and%20Erin/

https://ecir.groups.io/g/CaseHistory/album?id=269097

Yes, I completely agree with you. I made sure the vet knew that I was not concerned about price, and all I cared about was the safety of it for him. I am going to look into Noltrex and Arthramid. Do either of those work more immediate than the pro stride?
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 Denise, NY, 2022

Hi Denise,

Sounds like you need to back up a couple of steps. Why are coffin joint injections being considered? Is your pony foot sore? You've taken some steps to help lower your pony's insulin/glucose levels but you need to know if those steps are enough. Most feeds do not guarantee that the sugar+starch is under 10% - the numbers they list are "typical" or "average" numbers, which don't tell you anything about the bag you are feeding from. What is the "top line supplement"? A feed that is listing 12.9%NSC is better than 17-18% but is still not safe for an IR individual. Soaking hay is a good precaution but it may not be needed or, if the sugar+starch is too high, it may not lower those values enough to be safe. Need to test the hay to know for sure.

Was the blood glucose elevated or the insulin? You need to get actual copies of the blood work that was done and the results. Elevated insulin is going to cause laminitis to some degree, whether it is acutely visible or at the sub-clinical level. That, in turn, is going to affect the hind end as the animal shifts more of its weight back in order to ease the discomfort in the front feet. You definitely need to make sure there is no laminitis going on before even considering steroids of any kind because they do have the potential to cause or worsen it in an IR/PPID individual.

It would be very helpful to see the radiographs and hoof pictures to assess the trim before doing something as invasive as joint injections. In most cases, it's the trim that is actually causing/compounding problems and if that's the case, injections aren't going to solve anything.

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

Thank you for your response. I just looked back in my notes, and the insulin was “just a bit high”. 

With all of this valuable information, I am going to call her in the morning, and ask about the alternatives to the steroid if prostride isn’t a good option. 

It seems like this is too risky. 

Thank you all!
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 Denise, NY, 2022

Hi Anthie,
I’m curious about the Noltrex. I spoke with the vet briefly this morning, and will speak more at length when she gets a moment sometime today. She said Noltrex is a last resort, when nothing else works because it stays in the joint for a long time. She has not used Arthramid, so she can’t speak to personally seeing the effectiveness. Is Noltrex a product that doesn’t allow for anything else to be used in the future because of the gel substance that is formed? How did you find it worked compared to Prostride?  Thanks so much. 
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 Denise, NY, 2022

I have not heard anything about that regarding the Noltrex myself because it is, and I’m going to totally flub explaining this, but the idea of Noltrex and the Arthramid  are that they integrate themselves with the tissues. It’s not like it forms a gel and sits in their joint for the rest of their life. We did the arthramid injections after the Noltrex.

In my own personal experience each one serves its own purpose. For my particular mare after her MRI on her foot that showed she had severe cartilage damage to the coffin joint we initially use Pro-Stride as it is designed not only to decrease the inflammation in the joint but it has healing properties. I can’t remember exactly but we probably did at least three different Pro-Stride injections over a period of time between 2018 and now and her first injection was a significant difference. People who see the video of her before and after, she is not completely sound in the after video but the before video is so bad people can’t fully watch the video that’s how crippled she was. They used my before and after video on their Facebook page. I’m not sure their Facebook page is still active anymore as Pro-stride was bought by another pharmaceutical company recently  but you might be able to still find it. I did notice that after her subsequent injections the improvement was less than her initial injection, so that’s when we started looking at other options. I am thinking we had reached the point of maximum recovery so to speak of that joint and that’s why we weren’t seeing any more improvement.

I only moved on to Noltrex because Arthramid  wasn’t available as an FDA approved drug in the United States yet. I was told noltrex takes 2 to 3 weeks to fully work, but in my horses case one of her problems is how dry her joint gets and having no padding in there. I kid you not right after her injection she was walking better than before we did the injection and I think it was just because she had padding in the joint. 

by the time her most recent injection was due Arthramid had been approved and I decided to try it because while I liked how she responded to the noltrex it didn’t seem to last as long so I wanted to try out the Arthramid to see what she would do. I will say in her case it did take quite some time, and it takes a really strict rehab type program, but the arthramid has by far done the best out of all of them for her soundness.

Sorry for the lengthy post, but really what you choose is going to be dependent on what’s wrong with your horse. So you really do, as everyone has been stating, need to know why you’re doing the injections to be able to pick what is going to work best. But I wouldn’t pick steroids just because it’s going to work faster because that’s not going to be in your horses long-term best interest.
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- Anthie

Northern California
August 2015

Erin's case history: 
https://ecir.groups.io/g/CaseHistory/files/Anthie%20and%20Erin/

https://ecir.groups.io/g/CaseHistory/album?id=269097