New Diagnosis
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Hello!
My 10yr old Arabian Gelding was just recently diagnosed with IR aftern onset of a laminitic episode. Initial presentation was soreness after a trim, but the soreness was prolonged and then the day the vet was able to see him he was the worst he had been. He had been on pasture board since March 2022 quite happily but he was to wear a grazing muzzle at least half the time. He didn't, unfortunately, and I suppose that's when things got out of control. The vet came out to see him and confirmed my suspicions. He immediately went on the emergency diet and Thyro-L. We are finishing week 2 of stall rest and all seems to be going well. His bloodwork was as follows: ACTH 38.9pg/ml Insulin 115.37 ulU/ml Leptin 18.95 ng/ml He has mild rotation in both fronts but nothing too concerning. My veterinarian was confident that shoes were not needed and he could remain barefoot. He will be getting trimmed properly tomorrow so I will begin taking him for short walks, as long as he appears comfortable. I'm starting to build my long term plan, with the help of the website and I have a few questions. We live in Pennsylvania and have had a rather warm fall so far. The grass is still very green. Where he is boarded now, I don't have a dry lot option. I will be moving him in the next month or two for an acceptable dry lot situation, but I think he will be ready for turn out again soon. Should he be muzzled any time he is outside, regardless of the time of year? For example if I'm still on this property in January and the ground is frozen? Secondly, this was a very mild (according to my vet) laminitic episode. I'm prepared to wait, but I was curious if I should still wait 2 full growth cycles before beginning ridden work again? I'm sure I'll have more questions but I think that's it for now. Thank you so much! -- Jessica J. in PA 2022 |
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Bobbie Day
Hello Jessica and welcome to the group!
We're sorry you have found yourself here, but we're here to help. Just a couple of thoughts. 1 - His ACTH is higher than we like to see, although ten is a little young for PPID we have seen it before. Typically, we like to see those numbers in the high teens to low twenties. Did you test glucose? 2 - Insulin is concerning, we suggest no pasture time for horses with high insulin, if you have no other choice, he needs a completely sealed muzzle. All grass is dangerous no matter the time of year. A dry lot would be best, but we know that our members sometimes don't have a lot of options when boarding. What is his weight? Was his diet balanced prior? 3 - Getting him on the emergency diet is a great start. I (personally) wouldn't consider any laminitis episode mild; your goal needs to be to remove the triggers that caused it in the first place. Feeding thyro-l only helps with weight loss, it will do nothing to lower his insulin. If and when you take him off of it, you will need to taper so his thyroid can learn to function again. 4 - Your welcome message includes a lot of information that will enable you to find the best way forward, it also includes blue hyperlinks that will go even deeper into the subject. When you are able, please give it a read-through and complete the case history on your boy as soon as you are able. Copies of all blood work, x-rays, and any testing you have done will be really helpful so we can advise you properly. Please let us know if you have any additional questions and again welcome. Hello 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. 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:
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. --Bobbie and Maggie Desi (over the rainbow bridge 7/21) Utah, Nov 2018 ECIR Group Primary Response https://ecir.groups.io/g/CaseHistory/files/Bobbie%20and%20Maggie https://ecir.groups.io/g/CaseHistory/album?id=271156 https://ecir.groups.io/g/CaseHistory/files/Bobbie%20and%20Desi https://ecir.groups.io/g/CaseHistory/album?id=78821 |
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Hi Jessica, that insulin is very worrying, anything could set off another laminitis episode and since he's already had 1 the second is likely to be worse. Until it comes down do not deworm, vaccinate, or allow any grass or deviations from the ER diet. His hay is being soaked? After 2 weeks on the ER diet you should be able to check his insulin and glucose again. Hopefully it's back in a safe range now, but turnout on pasture will push it back up again.
A muzzle won't stop him from eating grass unless you block off the holes. Just slowing down consumption does not prevent the high insulin that causes laminitis. Is there a sand arena that can be used for exercise turnout? Otherwise, a closed muzzle and meals in the barn every 6 hrs is your best bet. -- Kirsten and Shaku (EMS + PPID) and Snickers (EMS) - 2019 Kitimat, BC, Canada ECIR Group Moderator Shaku's Photo Album Snickers' Case History Snickers' Photo Album |
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Hello Bobbie & Maggie.
Thank you for taking the time to reply to me. 1- My vet wasn't as concerned with this ACTH level due to seasonal variations at this time. We will be repeating all bloodwork after Thanksgiving, which should also be outside of the variation window so if it's still elevated we can rule in PPID as well. 2- There is one pasture that is completely chewed down to nearly a dry lot. When he is ready to go back outside, I was going to request that he go there, with a grazing muzzle on but we don't really have any other grass free options for him where he is currently boarded. We do plan to move to a new facility in the next month or so that will have dry lot availability for us. He is around 15hh. His diet prior to the ER died was balanced, I think. He was on 24 hour access to pasture and they did provide grass hay twice daily. The I had him on a ration balancer since I had already known he was an "easy keeper" but wanted to make sure he was getting the vitamins and minerals he needed. He had been on Tribute Essential K GC Plus. 3- I think my vet's plan with the thyro-l was to help him lose weight a bit quicker, while on stall rest. He had mentioned to me that the insulin and leptin values could be high as a result of the obesity. He as hoping that some weight loss would help to get things under control while also using the emergency diet. Today is actually the last day of week 2 on the emergency diet. 4- thank you for all the information! -- Jessica J. in PA 2022 |
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Hi Kirsten!Thank you for the reply. His hay has been soaked for an hour before feeding for the last two weeks. He's still a bit sore, so I'm not sure if I should continue soaking the hay or not. I do still need to figure out how to get the hay tested that he's being fed, so maybe I should keep soaking it until I know the nutrient content of the hay. His bloodwork will be rechecked on 11/28. We do have a footed arena and round pen. I'm not sure the the barn management would be open to him going there or not. Otherwise, we are looking to move him somewhere that has a dry lot capability. -- Jessica J. in PA 2022 |
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Tribute Essential K GC Plus contains MSM and glucosamine, both of which raise insulin. Starch, ESC, and iron are also higher than ideal. Check out our list of approved ration balancers, or better yet have one of our trained diet balancers look at your hay analysis when you get it and give you a custom supplementation program. Not only will it be safer, it will be better. See our Diet Balancing folder in the Files section for more info.
I would continue soaking hay until you have it tested at least, especially if he's going to get grass access. Make sure he has enough soaked hay that he doesn't go looking for grass. Nearly dead stressed grass can be higher in sugars thst healthy lush grass. The sooner you can move him to a dry paddock with no vegetation, the better. -- Kirsten and Shaku (EMS + PPID) and Snickers (EMS) - 2019 Kitimat, BC, Canada ECIR Group Moderator Shaku's Photo Album Snickers' Case History Snickers' Photo Album |
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Kirsten,
Wow! I didn't know MSM and Glucosamine could raise insulin. I try to do something to help him and end up hurting him. 😔 I ordered California Trace Plus off the approved list. It should be here today and he will be switching to that. Thank you! -- Jessica J. in PA 2022 |
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Jessica,
MSM won't raise insulin. The concern is it might interfere with selenium, possibly copper, uptake. Glucosamine can worsen insulin resistance. -- Eleanor in PA www.drkellon.com |
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