Newly diagnosed PPID mare
This case is my 18 year old purebred Arabian mare Lulu. Lulu has a history of laminitis and rotation. First rad with rotation was around 10-11 years ago and we had her in shoes with a wedge at the time with a conventional farrier. Shoes were eventually pulled and we struggled for a years to find a good hoofcare provider. She was often trimmed flat and developed underrun heels with a long toe and was eating a grain diet (I’ve learned a lot). I then joined a hoof group several years ago which highly recommends and pushes the ECIR diet and started my own trimming journey but quickly realized this case was too much for me to learn on. I switched all my horses to a forage-based diet (about 3 years ago now) and her diet, specifically, to vermont blend, alfalfa pellets (she wouldn’t eat Timothy or even Timothy alfalfa), salt, mare magic and she gets chia seeds per my vets instructions. She gets free choice (in slow feed hay pillow) orchard mix hay that I have not yet gotten tested since it will not be a long term source. But past cuttings have tested fine according to this groups recommendations. My tested supply of three years just stopped supplying several months ago so I am now on the hunt for tested hay or long term supply. My awesome HCP Casey Sexton has been working with us over the last few years. Lulu is living in cloud boots 50% of the time. She lives in a dry paddock that stays muddy (Georgia might as well be the UK) when it’s rainy but always has a dry barn/stall so she has time to dry out. She moves really well in the clouds and sometimes I take them off to let her feet have a break (they make her super itchy) but in August she began feeling ouchy again (not in boots) which prompted me to get rads done again (exactly one year apart which further validates my PPID suspicion). She became very sore so I also finally had a metabolic panel done. Those are posted, confirmed PPID. She also has fat pockets, cresty neck, she’s extremely overweight and no matter her diet she’s still so. No problem with coat shedding or skin problems. I want to exercise her but have a hard time deciding what to do when I know she’s also in pain but I feel exercise is crucial at this point. I’ve been hand walking but fear this is not enough to make a difference. During this acute case, I pulled her off everything except soaked and rinsed 2x beet pulp with salt. I gradually started adding her supplements back in and we are now at a full dose of VB, salt, chia seeds, add magnesium and American ginseng to help with the veil. We started her on prascend 2 weeks ago and she is now on 1 tab per day (last 4 days). She was three legged lame the day before we started prascend, and was completely fine the day after we started her on 1/4 tab. I KNOW this medication does not work this fast. When I boot her I always use diapers and noticed the day after we started the meds there was a gooey spot on the diaper which prompts me to think she actually had an abscess which I thought was an acute episode of laminitis. Regardless, she does have PPID. Her radiographs do show she has rotation and she has had foot soreness in the past.
My hope for advice is:
When do I re-test?
What about her IR results?
We have a moderately grassy (lots of weeds and bare in spots -never before grazed) and half-wooded. (Basically I’m saying it’s not lush green pasture) When can I turn her out out here? If ever?
How can I exercise her even though she is in pain?
If she just had an acute laminitic episode, when will those ligaments and tissues be strong enough to begin exercise without the risk of damage?
What kind of changes (if any) do you notice on the rads, and can they be addressed?
Where do I go from here?
Meredith Lane, Atlanta, GA, joined 2021
Hello Meredith, welcome to the group!
We're sorry that Lulu is having some challenges right now, but rest assured you're at the right place for help.
I will be including your welcome message below; it includes hyper-links that will take you even deeper into the subject. We ask that you take time to read it, you will find important information and guidelines to help you and Lulu.
First thing I will ask you is to start on a case history for her as soon as your able, if you can at least start it and give us as much information as your able (weight, height, dates) and copies of ALL test results uploaded and x-rays if you have them.
The ECIR'S protocol is based on DDT/E, which is Diagnosis, Diet, Trim and Exercise.
All are very important and all need to be in place, it sounds like you've made a great start with trying to nail this down.
I just have a couple thoughts and you will be getting some great advice from our other mods and possibly Dr.K as well.
Firstly - PPID is a progressive disease which affects the pituitary, it's not curable only treatable. IR/EMS is metabolic issue, and Arabians are quite often IR. Some horses can have PPID or IR/EMS or both. Some horses do get relief very soon after starting medication as uncontrolled ACTH can contribute to laminitis.
Since she's started on Prascend, we don't suggest giving anything with chasteberry (mare magic) given together it can make the medication ineffective.
You can read more about it here.
Mixing Chastetree Berries With Pergolide in Cushing’s Horses | Dr. K's Horse Sense (wordpress.com)
I would also strongly encourage you to put her on the emergency diet for now, please get her hay tested and balanced as soon as your able. We have people in our files that can also help with that should you decide to go that way.
HAY BALANCING (groups.io)
Are you feeding molasses free BP, and rinsing/soaking/rinsing again?
We also suggest no alfalfa as it can contribute to footsoreness in some horses, have you seen our safe feeds list?
Safe Bagged Feeds.pdf (groups.io)
We suggest that you re-test in about three weeks after starting on medication, we do expect higher results since we're in the rise right now but if you can give us those results we can better advise you.
Also, you say she is overweight but how much does she weigh now? We don't recommend free choice feeding to horses, especially if they're overweight. She should be getting 1.5% of her current weight or 2% of her ideal weight, no more and all her feed needs to be included in that calculation.
I would also consider soaking her hay if she becomes foot sore again, this will (usually) give her immediate relief if the hay is the issue.
It's great that you have omitted the grain, carbohydrates are not a big problem with PPID, but it sounds like she has a metabolic issue as well, it's important that she be on a strict diet and body score of around five is recommended.
No grass unless she has a sealed muzzle, but of course since we don't know what her numbers actually are, this recommendation is only if she is IR/EMS.
As far as exercise we only want her to move if she's comfortable doing so, your right that exercise is the best thing you can do for an IR horse, but if she is reluctant to move, we suggest waiting, again if you have x-rays, please post them and our hoof experts can comment on those and the trim.
Now on to your message, please let us know if you have any additional questions or concerns.
Welcome to the group!
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.
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.
No hay is "safe" until proven so by chemical analysis. The diet that works for IR is:
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.
If you have any technical difficulties, please let us know so we can help you.
Bobbie and Maggie
Desi (over the rainbow bridge 7/21)
Utah, Nov 2018
ECIR Group Primary Response
I just want to add to Bobbie's advice about retesting: make sure you get insulin and glucose along with the ACTH. You really need the insulin number to make decisions about her diet and whether she can go on scrubby pasture or not. From what you've described so far, I think not, but the insulin will help you decide.
Also, the key to losing weight is calories in. Start with Bobbie's feeding recommendations and if she is not losing weight, reduce her forage by 1-0.5 lbs for a couple weeks then check. If she's still not losing weight, repeat. Weight loss should be slow but you'll find it usually occurs in spurts, so take your time and do not go below 1.5% of ideal body weight. Too few calories/starving actually worsens IR. Remind yourself that losing weight is going to help her feel better in the long run and stick to it until you reach a BCS of 4.5 (you can just barely see ribs).
You do not need exercise to drop pounds, so if she's sore do not force her to move. She needs 6-9 months of healthy (non-laminitic) hoof growth before she'll be ready for ridden work, but as she starts to feel better you can add ground walking/driving and eventually in-hand jogging in straight lines. There are likely some trim corrections that can be made to help her comfort, so please fo upload your trim photos and any xrays you have, as well as keep her in boots with pads. It certainly sounds like she had an abscess that coincidentally blew when you started the Prascend.
Kirsten and Shaku (IR + PPID) - 2019
Kitimat, BC, Canada
ECIR Group Moderator
Shaku's Photo Album