Bonnie is a 9 year old Missouri Foxtrotter who is a pasture pet. She has had a ravenous appetite since I got her in 2020. She had an episode of laminitis in May 2022 that did not last long and vet said it was probably due to recent trim. She had another episode in late September. She was diagnosed with PPID in Oct. ACTH 5x normal range, Insulin 2x normal range, Leptin 4x normal range. Xrays revealed she also had some rotation of both front feet. She has been started on Pergolide 1 mg q d. She is also on Thyro L 1 scoop since Oct 10. I give her Equioxx QOD. Trying to wean her from this. She still seems as sluggish as ever. Feet better with new egg bar shoes with injectable padding; but still tender. She has free choice coastal hay. Gets 1/2 pound grain to mix meds in daily. I am having trouble getting her to eat low starch pellets to mix her meds with. Loose salt in grain. Salt lick available. She weighs about 1400 pounds and has lost about 100 as best I can tell. I am here to learn how to take care of her. 
--
Debbie
Santo, Texas
2022

Hi Debbie and welcome to the group
It sounds like you have made a good start in managing Bonnie so that she has no more laminitis episodes. We can certainly assist you in fine-tuning her management. You will have received an email giving you instructions on how to create a case history so that we have more details. Just as an example of why we ask for a case history: when you put the actual test result numbers into your case history plus the lab range in numbers, that gives us an idea where Bonnie stands on the spectrum of IR--which is a metabolic type and is managed with diet and exercise (and medication when diet and exercise are insufficient to control insulin)--and her ACTH result gives you a baseline from which to correlate her symptoms with her pergolide dosage. Different labs may have different ranges, and use different units of measurement, so we need the actual numbers, units and range. Also please see this page on the need for caution with insulin test results as "laboratory range" does not mean "normal". Fasting Insulin – Lab Ref Ranges | ECIR Group, Inc. (ecirhorse.org)

The purpose of this reply is to give you our long welcome message for new members. It contains a lot of information, broken up into sections "Diagnosis", "Diet", "Trim" and "Exercise". It also contains clickable links to further information within each section. Please read through the message and the links carefully, and let us know if you have more questions. 

Taking the points you make in your message in order, you have a diagnosis of both IR and PPID. Was she fasted for the blood tests? Was the test for PPID just one blood draw or two? Have you retested her after 3-4 weeks on pergolide to get an idea of whether the pergolide is controlling her ACTH levels? It's possible that your vet is waiting until after the seasonal rise to retest. See this page for more on seasonal rise: Seasonal Rise | ECIR Group, Inc. (ecirhorse.org)
Thyrol L may assist with weight loss but will not help her insulin. What is her ideal weight? See this section in the Wiki on body condition scoring and ideal weights. Body Condition Scoring Guide.pdf (groups.io)
You can also create a photo album in the Case History sub-group so we can see what she's looking like at the moment. 
Equioxx is unlikely to be helping and yes, we would suggest weaning her off it. 

Diet-wise, there are a number of things you can do that should make a difference in her comfort, and probably quite quickly. You need to test your hay--both to make sure it is actually safe in terms of sugar and starch, but also so that you can give her minerals balanced to the hay. There's much more in the "Diet" section below. For now, weigh her hay and give her only 2% of her ideal weight or 1.5% of her current weight, whichever is larger. Free-choice hay is not recommended for EMS horses with high leptin because they have no "off" switch. You can put the hay in small-mesh haynets so that it lasts longer. Until you test it, you should soak the hay (one hour in cold water or 30 min in hot, drain well). Some owners report tender feet resolving after a few days of soaking hay. 
Cut the grain. Also be careful of feeds marketed as "low starch" or "low sugar", as many of them are unsuitable. We aim for under 10% ESC (simple sugars) and starch combined, with starch ideally under 2% and fat under 4%. The safest carrier for supplements is rinsed/soaked/rinsed beet pulp. The smallest amount possible to get the supplements eaten. There is a safe feeds list in our Files. 
Many members, myself included, do not give pergolide or other medications in the feed. You can conceal it in a safe treat, or dissolve in a tiny amount of water and syringe it in the corner of the mouth. I syringe, then give a safe treat after. If you have to give it in the feed, you can put it into a gelatine capsule, which conceals the taste. 

Trim is often the missing link once you have diagnosis and diet dialled in. You can post hoof photos to your album in the Case History sub-group if you'd like advice on the trim. How-to instructions for hoof photos are in the Wiki here: main@ECIR.groups.io | Wiki

I know this is all a lot of information to take in at once.
 Chunking it down for you: 1. get an accurate current weight on her, weigh her hay, stop the free choice feeding 2. soak the hay--I find it easier to stuff my haynets then submerge the nets in a big tub of water with a heavy object on top, but whatever works for you 2a. get your hay tested as you may not need to soak it if it's low enough in sugar/starch--but as she is currently still sore, you need to soak it until you're sure
3. read through the welcome message below and note any more questions you have 4. get your case history (photos if you wish) done and let us know when it's ready for comment 

And here's the welcome message: 

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:

• 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.

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. 

 

--
Maxine and Indy (PPID) and Dangles (PPID)

Canberra, Australia 2010
ECIR Primary Response

https://ecir.groups.io/g/CaseHistory/files/Maxine%20and%20Indy%20and%20Dangles 
https://ecir.groups.io/g/CaseHistory/album?id=933

 

Maxine,

I have posted Bonnie’s lab and X-rays and made a case history. I am very much overwhelmed and still going through all the information. 

I think Bonnie is too young for her diagnosis of PPID. Is it safe to stop pergolide and test in spring. I have not seen any change in her since she started pergolide. She was not fasting for the test and had only one test. 

Many thanks!

--
Debbie
Santo, Texas
2022

She is on the young side but not too young for PPID and her level on 10/1 was outside the normal seasonal rise. Once you get her trim and  diet straightened out and she is comfortable you could consider taking her off and retesting but regardless of those results she should be on in starting in August to protect her from laminitis during the seasonal rise. The later in life onset, and fall timing, points to early PPID.
--
Eleanor in PA

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

Hi Debbie, 

Thanks for getting your info uploaded.  Her ACTH is high enough for a positive diagnosis and treatment with pergolide is warranted.  If you want to retest her, the safest time to stop pergolide is in March-May.  Make sure she's been off pergolide at least 3 weeks first, and ask for a TRH Stimulation test.

A few things I noticed.  Her trim needs to be adjusted to shorten those long toes.  If you're not sure what that means, you can request a free set of hoof markups once you post a full round of hoof photos, as described here:
https://ecir.groups.io/g/main/wiki#Photos-and-Hoof-Evaluation-Help

And given that she's needs to lose a lot of weight, her hay needs to be weighed and fed at either 2% of ideal body weight (24 lbs) or 1.5% of current body weight (21 lbs), whichever is higher.  If she's not losing weight on 24 lbs a day, you can reduce it by 0.5-1 lb until you see an effect, but don't go below 1.5% of current weight.  Her obesity is mainly why her leptin is through the roof, so losing weight will bring that down and help her feel less ravenous all the time.

If you can feed 4 equal meals every 6 hrs, or use slow feed nets that make her meals last longer, that will prevent her stomach from fully emptying and will reduce insulin spikes that occur when breaking a fast (>6 hrs without feed).  The oats need to be stopped ASAP,  and she should be on the Emergency Diet detailed in Maxine's welcome letter, including soaked hay to bring her insulin down to a safe range.  Getting her diet under control is just as important as treating the PPID with pergolide.  It is very likely that even without PPID she has EMS at baseline, given her breed and her obesity, so diet will always be critical.

If you're having trouble getting pergolide into her, rather than try to hide it in food I strongly recommend dissolving it in water in a syringe and giving it orally, followed with a small treat.  That way you know she's getting it and it doesn't put her off her feed.  You can put her Thyro-L on rinsed-soaked-rinsed beet pulp, along with the other supplements detailed in the Emergency Diet.  The Thyro-L will help with the weight loss but it's a temporary solution and you still need to reduce her intake for her since she cannot do it herself.  We don't recommend NSAIDS like Equiox but you are trying to wean her off so that's good.  It's probably not doing much her her hoof pain, and long term is likely to do more harm than good.

If you can implement these things, you will see her doing a lot better.  You're in the right place!

After 3 weeks on her prescribed dose of pergolide, ACTH, insulin and glucose should be retested.

Can you add these links to your auto-signature:
https://ecir.groups.io/g/CaseHistory/files/Debbie%20&%20Bonnie
https://ecir.groups.io/g/CaseHistory/album?id=281967

Here's the instructions for amending your auto-signature:

1) Go to this link to amend your auto-signature: https://ecir.groups.io/g/main/editsub

2) Look at the bottom of that page for the window with your signature and paste the links to your Case History folder and your Photo Album below your name.

NOTE: If/when you are adding a link to your Case History or photos, make sure you make it "live". Adding a space after your link or hitting enter on your keyboard will turn it blue.

3) Make sure you check the 2 boxes saying "Use Signature for Web Posting" and "Use Signature for Email Posting”.

4) IMPORTANT: Scroll to the bottom and hit SAVE!

--
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