Margo Case History

Sherry Morse

Hi Ducka,

As Margo is IR she should not be on pasture at all.  Your current bloodwork shows that neither her IR or PPID are controlled and adding grass to that could be enough to push her over the edge into laminitis.

As noted in your welcome message we do not recommend alfalfa for IR/PPID horses as many can have issues from it.  If you can source Triple Crown Timothy Balance Cubes those are a much safer feed option for her. 

2 - 3 flakes means nothing - how much is that by weight? Which Timothy cubes are you using?  Triple Crown or something else? 


Thank you for your help. once Margo was diagnosed I did cut her pasture time back greatly in hopes of weight loss and decreasing chance of laminitis. She is all forage fed. She has malocclusion with her molars so eating hay does not work for her. She can eat Standlee alfalfa, she gets about 2-3 flakes a day, she gets 4 cups well soaked Timothy cubes and 2 cups chopped alfalfa mixed in for flavor 4 times a day. She love the alfalfa, Timothy not so much. She does get to graze in the arena for an hour, not much grass and she walks quite a bath while grazing.

Thank you,

Sent from my awesome iPad.

Ducka in Central NY 2022

Trisha DePietro

Hi Ducka. Your first post triggers a welcome message which incorporates the cornerstones of the protocol that we follow. I see Dr. K and Sherry have already given you some insights. As you read through the protocol, you will find blue highlights that will take you deeper into the subject matter. There is a lot to learn here and there is alot to unlearn, as some things you may have already read about  on other websites, are not accurate. So, take your time and if you have more questions we are here to help answer them for you.  As Sherry mentioned the most important thing for you to understand is that PPID is a disease process. It is not curable. BUT it is manageable and we can slow the rate of progression by using Prascend/pergolide. If you decide to use Chasteberry- do NOT use it with prascend as it competes and interferes with prascend efficacy. The other pearl of information is that the protocol is designed to be used together. Diagnosis, diet, trim and exercise are the keys to success. It sounds like you have caught Margo's PPID early prior to getting laminitis...and that is the whole point of this group is to avoid laminitic events for your horse. 

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

Eleanor Kellon, VMD


I understand your reluctance but pergolide is not related to impaction and impactions can't occur after only 6 days, presuming she did continue to drink just not as much.

How much was she drinking after starting Prascend?

Heiro has nothing to do with PPID/Cushying's control and there are no herbals that can do it either. I did the original research on Chasteberry back in the early 1990s and even then knew it only controlled early symptoms. Subsequent research has shown it does not control the hormone levels/pituitary growth.
Eleanor in PA 
EC Owner 2001
The first step to wisdom is "I don't know."

Sherry Morse

Hi Ducka,

You'll be getting a full welcome message shortly but by test results your girl is definitely both IR and PPID.  Whether the elevated ACTH is driving the elevated insulin level is hard to say but you need to realize that PPID is a progressive disease that needs to be managed by medication. Using herbal remedies can treat symptoms but will not stop the disease progression. 

With that said - Heiro is a very expensive supplement that many of our members have found to be worthless as even Dr. Reilly admits on the site that it must be accompanied by management changes which match our recommendations.  

Whether the colic was related to starting Prascend or just a coincidence there is no way to say.  If this were my horse I wouldn't hesitate to start her on Prascend again, perhaps adding APF in to help with any veil effects as she starts the medication and it's titrated up to a full mg dosage.

Excessive drinking (and accompanying urination output) is a sign of PPID.  So are muscle loss and loss of top line.  Her current insulin level is very close to where we see obvious laminitis occur but there can be sub-clinical changes happening even now so getting her on a limited ESC+starch diet, on a weight loss plan (if needed) and getting her back on meds are all going to be key to keeping her non-laminitic and happy.



Hi, my Name is Ducka Kelly, I am hoping I can get some IR/PPID recommendations from you?  I have a sweet Haflinger in her 20’s. On 8/30/2022 I received results on Insulin and ACTH tests on her from Cornell lab. Insulin  75.11 high normal 40. ACTH 71 high normal 30. On 0/72022 I started 0.25 mg Prescend SID, AM 4 days, then 2 days 0.5mg. On the 6th day of treatment in the  evening she was very colicky.  She ended up going to. Cornell Vet School for medical management, of a large colon impaction. As well as nephrosplenic entrapment that may. Have resolved during the 40 minute trailer ride. Hospitalized for 3 days 2 nights.  Discharge on Sept 16. Thankfully she is doing well at home now.


 I am in a real quandary about restarting Prescend. I do feel she had been a horse who drank and urinated a lot and after starting the Prescend she decreased drinking and urinating. My error was thinking it was a good sign. Obviously I was wrong. 


I have been researching your website. Thank you for it. So very helpful. I have also been looking at Dr Riely’s herbal website and know of horses who have done well on Heiro for IR. Also Dr. Margo Depalo’ website. He has Chastree. 


Questions, as long as Margo’s levels are relatively low, no history of laminitis, only real symptom is some muscle loss, top line and possibly PU/PD. She she even be treated with Prescend and can I try herbal management now and repeat BW to see when her levels are since we will be coming out of the high level season anyway. 


Thank you so much,

Ducka Kelly



687 Dawson Hill Rd

Spencer NY, 14883