When we did bloodwork on 10/17 Mouse was Glucose 88 Insulin 92.73 Ryn was Glucose 99 Insulin 93.56 on unsoaked hay tested at ESC 6.0 Starch .4 with wet chemistry.  Starting on 10-19, I began to soak this hay and it has been soaked since then until blood draw on 11/15.  Both of them had Glucose of 108, Mouse's insulin was 136.07 and Ryn's was 50.13.  They are not on Metformin.  We have also done a HTMA to see if something else is amiss.  Ryn is in work, Mouse is not due to thin sole on RF and is in boots, being hand-walked 10-15 minutes a day.  He is trimmed every three weeks.  I will update case history asap.  Any thoughts as to why a hay this low in ESC and starch and soaked would spike Mouse's insulin?  Weather was 45 degrees about 1230 pm and they had been eating this hay since 7 am, soaked.  
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Kimberly joined 7.17.2018 Virginia
https://ecir.groups.io/g/CaseHistory/files/Kimberly%20and%20Mouse
https://ecir.groups.io/g/CaseHistory/album?id=275222

Hi Kimberly.I took a look at your case history and based on the information that is available there, I think you might want to draw an ACTH level. The last one I could see in your CH was June of 2022. And it looked fine. I don't see one that was drawn with your 10/17 Blood draw or 11/15 blood draw. Do you have ACTH's from those two draws?  During the seasonal rise, ALL horses get a spike in their ACTH levels. In the PPID horse, the ATCH can drive the insulin up. Sometimes we add more Prascend before the seasonal rise starts to ensure the ACTH levels remain mid teens to low 20's year round. It looks like Mouse only gets 1 mg prascend according to your CH....

Ryn, seems to be trending down in his insulin levels definitely going in the right direction. If he is comfortable, increasing his exercise will continue to bring that insulin down. 

As far as your hay- are you soaking for one hour in cold water or 30 minutes in hot water? Are you rinsing thoroughly before feeding? is there any way Ryn/Mouse can access the rinse water? If you are following these guidelines-  I don't think its your hay that is the problem. I think it might be the seasonal rise and your horse needs more Prascend during that time frame. 

I'm sorry, I don't understand the initials of HTMA- What type of testing does that stand for? 
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Trisha DePietro
Aug 2018
NH
Primary Responder
Dolly and Hope's Case Histories
Dolly's Photos 
Hope's Photos 
HOW TO SEARCH THE ARCHIVES: https://ecir.groups.io/g/main/wiki/1993     

Hi Kimberly. I found some information about Hair analysis that might be helpful to review. Here is the link....    Hair Mineral Excerpt.pdf (groups.io)     
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Trisha DePietro
Aug 2018
NH
Primary Responder
Dolly and Hope's Case Histories
Dolly's Photos 
Hope's Photos 
HOW TO SEARCH THE ARCHIVES: https://ecir.groups.io/g/main/wiki/1993     

Hi Trisha and thanks for the response.  You are correct in that we only did the ACTH baseline in May of this year.  Yes, Mouse is on 1mg of Prascend but,,,,,Mouse has never been diagnosed with PPID.  He had his first bout of laminitis in 2017 and was overweight.  The vet immediately put him on 1mg of Prascend without blood testing assuming he was IR, no mention of PPID and at his age then, unlikely.  Two to three weeks later he was blood tested.  His insulin was 30.85, ACTH 18.2, Leptin 17.52, Glucose 93.  It was December 2017 so probably very cold and in the am.  As I understood things then (not now), his numbers looked within the reference ranges and and although he had DPs in all four feet, he never presented lame or gave any of the classic laminitis stance signs.  He was kept up for 2 weeks, put on a vigorous exercise program, put on Thyro-L and dropped alot of weight. My belief is that the vet put him on Prascend to control his insulin numbers and we did no futher blood work until March of 2018 and ACTH was 19.8, Insulin 21.87 Leptin 19.98.  In May of 2018 I called another vet to test only insulin and it was 50.66.  He has been in a muzzle since 2018 with 2-3 hours out but has had no grass since May of this year.  Further testing was not done until this year when he presented lame and I insisted.  He has not had an epidsode since 2018 until this year.   So, my question would be that since he has never been diagnosed as PPID could a spike in his ACTH during this seasonal rise have caused the huge spike in insulin even on such low ESC/Starch hay?  Would it be more prudent at this point to put him on another 1/2 tab or wait until the vet comes again on 12/2 and test ACTH and insulin/glucose to see if the 1 mg is still working although he has never been DX with PPID?  Yes the hay is being soaked in hot water and if cold water at least an hour and neither of them has access to any of the water.  I throughly drain and try to dry but do not rinse but  I do not think hay is the problem either so the only answer seems to be that he is PPID and needs more Prascend.  I appreciate your insight and will look at the HTMA info as I think that will lead no where.  Kimberly 
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Kimberly joined 7.17.2018 Virginia
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https://ecir.groups.io/g/CaseHistory/album?id=275222

From your case history it looks like he had an insulin of 169.57 in May 2022. May is before the seasonal rise. If he is a true mustang he is  genetically prone to EMS although PPID complicating it, or just seasonal rise with no PPID, is certainly possible.

Pergolide does not control insulin unless the insulin resistance is caused by PPID. Exercise is the other big piece of the picture with EMS and horses that are not being exercised, or can't be, may need medication to control the insulin. If he's still sore you should start Jiaogulan (hope he's not on any NSAIDs). If that doesn't work, go to metformin. I would stop his pergolide at this point and do a TRH response at the end of December.
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Eleanor in PA

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

Dr. Kellon, yes his insulin numbers were improving so not sure what would cause such a spike if our safest hay was being soaked after being determined to be safe.  That is why I posed the question as this makes no sense to me as to what would cause his insulin to still be so elevated.  We did try Metformin for several weeks this summer to no avail so my vet is not convinced that we should go that route again.  As I understand it, Metformin may work for a few weeks but her question is then what?  If we did get insulin into a normal range, what would prevent it from going back up if I cannot find anything safe for him to eat?  I cannot find any hay that is lower than the 6.4% esc/starch combined that I am feeding them.  I am sort of at a loss at what to do as he can be hand walked only for 10-15 minutes a day.  His RF is a work in progress with my farrier.  
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Kimberly joined 7.17.2018 Virginia
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https://ecir.groups.io/g/CaseHistory/album?id=275222

Kimberly,

Send me a private e-mail, and your vet's e-mail as well. I have something you can try that may help.
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Eleanor in PA

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

Hi Kimberly,

When you have time could you please fix the names on the August xrays you uploaded?   It's a bit tricky to see them all in the proper sequence date wise.   Please use this format:
https://ecir.groups.io/g/main/wiki/Hoof-Related-Photo-Instructions
Your farrier isn't removing any sole is he?  I'd be very worried about the RF even if he is only scraping the sole clean.  It needs as much protection as it can get.

Sorry to hear Mouse is worsening.  Definitely time to try Invokana, which Dr Kellon will advise you and your vet on.  Hang in there!

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Kirsten and Shaku (EMS + PPID) and Snickers (EMS) - 2019
Kitimat, BC, Canada
ECIR Group Moderator
Shaku's Case History
Shaku's Photo Album

Snickers' Case History
Snickers' Photo Album

Thanks Kirsten, I appreciate it.  The farrier is not working on his sole, just trying to bring the heels down to take pressure off of his toe as he is still not landing heel first.  I know Mouse has a circulation problem and no sole is growing because of that.  Xrays done on the 15th of this month show no change in over 3 months of trying with trims every three weeks.  I am at my wit's end.  When I try to load photos or xrays they will not load.  The come up black.  I have tried numerous times and it is the same.  I would love to have Lavinia do a mark-up for me but I cannot get anything to load in the photo album so I have stopped trying.  If someone has any tips on how to explain to my farrier what needs to be done that would be great although I am having little to no success with vet or farrier at this point.  Vet comes Friday and farrier next Thurs so we keep at it.  I will look into Invokana as I am pretty sure Dr. Kellon since this information to my vet months ago to no avail.  The good news is that Mouse continues to be in good spirits and is a super boy so I am not giving up just yet.  Kimberly
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Kimberly joined 7.17.2018 Virginia
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https://ecir.groups.io/g/CaseHistory/album?id=275222

Hi Kimberly,

You can send the photos directly to me as attachments:  shilohmom "at" outlook.com

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

Thank you.  Sorry for so many.  
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Kimberly joined 7.17.2018 Virginia
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