Hey team.  My 20 year old gelding Kat was diagnosed with Cushing early sept. Suspect he is also IR but that was not explicitly texted.  I will do that next week.  He did have the swollen sheath and neck but unfortunately I didn’t know those were signs of a bigger issue at the time I originally tested.   Not knowing enough personally, and getting some conflicting vet information I misdiagnosed a hoof issue as a “possible high abscess”.  Clearly it wasn’t and Kat came down with laminitis oct 10th.  Kat has had 3 sets of ex rays.  The first set (sept 14th)  was done when I thought we were dealing with an absess and they were good.  The second set was done after oct 21st and showed some rotation (see his photos) but the third set (oct 27th) indicated it has not gotten any worse.  Kat’s next vet check is next week (nov 10th) and I am trying to arm myself with some info.  I’ve spent hours on this site and its been super helpful.  I plan to do another set of xrays to see where we are at as well as test his levels (acth, glucose, insulin) now that he has been on prascend for 2 months.  Kat is now walking better and I am reducing his bute dosage (been on in some fashion since 0ct 10th) and hope to have him off it completely this coming week.  I know I have had him on it longer then I should but coupled with ulcerguard each morning he seems to be tolerating it well and its helped him with the pain to where he is walking well.   Now I am starting to look forward and hoping to have you guys point me in the right direction for additional information.  My questions primarily focus on pain meds/ feeding/clipping/trimming thoughts.

•  I have been reading about devils claw.  Is it just the pellets that people use in place of bute?  Is it used in a laminitis emergency?  Looks like a supplement so I can see it helping keep him “happy” but not sure when things are bad (hopefully with all the information I am learning it won’t get to that again).  So question is daily supplement or emergency use only?
• He has been on prascend since early sept and we are going to test his levels again next week to see where we are at. We will also test for IR as I suspect he has that as well.    I will post his original test to his case history today and fingers crossed that his levels are in a better place.  When i have the new results we can talk dosage changes if required.  He is getting one pill a day right now.
• Kat has only been getting soaked/rinsed beet pump (no molasses kind) and soaked hay since he came down with laminitis Oct 10th.  While he is now walking well He is lethargic but otherwise seems happy.  He is 20 years old and has been retired for 12 years so he will not need to be ridden. He is more like a big brown Labrador dog then a horse.  We are lucky to have dry lots so he has been turned out in one of them and not been out in his usual pasture now that he is more comfortable.     I would like to see his energy back to his post laminitis level and not sure what the cause of it is.  Any thoughts?  Concerned he is Mopey?
• I have not tested his hay yet as our Barn Owner had covid and is only back at the barn today.  Our hay fields didn’t do so well this year so we have bought a couple of loads of hay.  I want to confirm how many bales we have of the current lot left so I know if I am testing something that we will be using for a while or its almost gone.  I have enough info from the site to go through that process.  Should I wait to get that done before considering giving him something other then beet pulp.  Do you think its a good idea to give him something like stabul 1 or Timothy balance cubes.  Struggling a bit with the whole “what to feed a recovering laminitic horse” and wondering if beet pulp only is why he is lethargic.
• we have had a weird fall here in SC.  The temp has been in the low 30 F and monday will be 80F.  Kat has quite a think coat already and wondering if a trace clip would be good.  Given he isn’t in work I haven’t clipped him since moving him to SC in 2019. He also has always shed his coat nicely in the spring but that was only pre cushings.   He  tends to run hot so wondering with Cushing if I am better to get ahead of this and give a trace clip monday.  
• The farrier is also coming next week.  He is the one who put me onto this site after listening to your pod cast.  We had two horses come down with laminitis in the barn this fall and he is trying to figure out how to help them.  We have not trimmed kat since the laminitis flare oct 10th as he wasn’t comfortable.  He can now stand for the farrier and is due for a trim.  I will look at the trim protocol.  I see many folks trim more regularly.  Kat was on a 5 week cycle.   Should it be more regular to try to align the hoof better with the new rotation?  What’s the views on barefoot?  He was barefoot since he retired until he came down to SC in 2019.  Its much wetter here and he was having troubles with his hoofs up front and shoes seemed to help.  Now that I suspect he will be off pasture (TBC when testing done next week) should I consider shoeless or maybe with boots?

I have a second 20 year old Belgium warmblood gelding who I just recently retired.  I will run tests on his next week as well so I have a baseline and don’t run into the same issues with him.  He isn’t showing any signs of either cushings or IR but better safe then sorry.  

sorry for the long note.  There is just so much info here.  Wondering if a phone call with someone might help as well.
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Carolyn, SC, oct 2022

https://ecir.groups.io/g/CaseHistory/files/kat%20case%20history

Hi Carolyn

I often refer back to DDT+E as a road map

Diagnosis - Good that you are checking blood work again. This should help answer a lot of your questions. Make sure you load your past and current results into your Case History. Also, we please need exact dose amounts of medications.

The use of omeprazole with Bute is not recommended. It can increase the risk of colitis ulcers. Dr Kellon speaks about it here with reference to study. https://ecir.groups.io/g/main/message/265099

Use of Devil's Claw would ideally see you through the time you are working on his feet unless you have other underlying conditions like bone remodeling. Laminox might help you through the rehab period.

Diet - Beet pulp is most likely not the reason for his lethargy. Moving from the emergency diet to tested and balanced hay can make huge difference in his demeanor overall if pain or other diagnosed issues are not on board. Make sure he is getting adequate salt. One ounce by weight daily minimum. Two ounces if he is sweating in the crazy weather.

Trim:  Once your diagnosis is addressed, addressing the trim is what is needed for comfort and best pain relief. IME, this can be done quickly. For majority of cases a more regular trim cycle is needed. Depending on rads and current condition of the feet, it could be minimum of two weeks, IME, or  even periods of every several days. The horse will tell you. This would require the horse to remain barefoot. Boots if needed.

The results from a realigning trim, as addressed by Dr Bowker in this website quote are amazing: Hoof pathologist Robert M. Bowker, VMD, PhD, has found that in a horse with painful acute or chronic laminitis and founder, nerves are stimulated from the new displacement of bone within the foot: "To alleviate the pain, the horse must be made as comfortable as possible, as quickly as possible, via corrective trim and conformable surfaces."

Here's the full article
https://www.ecirhorse.org/DDT+E-trim.php

Here's more info you may have already seen.
https://www.ecirhorse.org/realigning-trim.php

Exercise: If he can do short hand walks, that may help his demeanor. I'd wait for rads and next trim to approach this area, but here is a recommended approach. https://www.ecirhorse.org/DDT+E-exercise.php

I'll have to leave clipping question to others.

Best to Kat.
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Nancy C in NH
ECIR Moderator 2003
ECIR Group Inc. President 2021-2022

HOW TO SEARCH THE ARCHIVES: https://ecir.groups.io/g/main/wiki/1993

Hi Carolyn,
Could you please spend some time getting a photo album set up and your radiographs in it?  That would help us a lot!  Not all WB’s are subject to insulin resistance so it would be important for us to review his insulin and ACTH testing results as they come in as well.  My 15.3h Trakehner was never IR and she appeared to have a lot of Arab blood.  Being much taller, Kat may be more TB, which would tend to protect him.  However, any horse can be driven to be IR by uncontrolled PPID so it’s important that the pergolide dose be adjusted to keep his ACTH in the upper teens to low 20’s year round, with no allowance for the rise.  

It’s important to get him off bute by starting to wean him soon.  I understand the logic of protecting his gut with omeprazole but recent research has found that that’s not a safe compromise and the lining of the hind gut is affected.  Bute would not help with laminitis pain as it is not due to inflammation.  It may help with pain resulting from the stress of trying to protect his sore feet but so can Devils Claw.  If you search for Devil’s Claw in the messages, it should bring up lots of suggestions.  I use Uckele PhytoQuench pellets, which contain DC but not the frequently included yucca which is not recommended for an IR horse.

Balancing the hay adds minerals in the correct amount to give him the optimal diet.  It’s important for every horse but more so for one that is metabolically challenged.  Soaking the hay in the meantime is what we recommend doing until you know that the ESC+starch of the hay is safe for him.  You could have the hay analyzed (603 Trainer from Equi-Analytical ) which will allow you to determine the need for soaking and have someone balance the hay at your “leisure” and their availability.  The balance cubes are a good option as they are already balanced (and contain beet pulp).

Clip him as needed to keep him comfortable.  Prascend does not generally address the heavy coat.  

Good that your farrier has an open mind about trying to figure out the laminitis cases.  We can make that much easier if you post the radiographs and hoof photos as we describe.  Many people here keep their horses barefoot, using boots if needed for their comfort.  It allows for a much more frequent trim schedule.

Oops.  I accidentally posted this before I intended to but I think this may be long enough for now.
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Carolyn, SC, oct 2022

https://ecir.groups.io/g/CaseHistory/files/kat%20case%20history

Hello Carolyn,

Use PQ with DC pellets as needed. Gabapentin does not need to be weaned.

Fescue is a big potential problem for hoof comfort. https://pubmed.ncbi.nlm.nih.gov/22585825/ , https://pubmed.ncbi.nlm.nih.gov/23449860/ , https://pubmed.ncbi.nlm.nih.gov/7695144/ .  Since your horse's breed is not normally prone to endocrinopathic laminitis, I would take that seriously.  Read about testing here http://equine.ca.uky.edu/news-story/tall-fescue-testing-understanding-numbers .

--
Eleanor in PA

www.drkellon.com 
EC Owner 2001
The first step to wisdom is "I don't know."