Hi Dr. Kellon,

I sent you an email with my vet's email for the Steglatro precautions/management info.
This will set us up to use it should the immediate need arise.

For now, I've decided to carry on with Rico's current management and exercise - increasing his exercise whenever I can (I really do my best with this!) and closely watching him for hoof tenderness.  He is a body score of 5.  I watch this closely, trying not to allow it to go up.  And he has a cresty neck and pretty big fat pad above the base of his tail.  The crest and fat pad are difficult to "monitor" in that I haven't perceived any changes in them in a couple years.

Thanks for all of your support and advice!
--
Jenny Heishman and Rico  
Bainbridge Island, WA   June 2018
https://ecir.groups.io/g/CaseHistory/files/Jenny%20and%20Rico
https://ecir.groups.io/g/CaseHistory/album?id=60437

Endocrinopathic/insulin-related "laminitis" isn't itis either because it's not inflammatory.

Excellent information on inflammation and Endocrinopathic/insulin-related "laminitis" here:
https://www.ecirhorse.org/proceedings-2017.php

Inflammation in Equine Metabolic Syndrome (EMS)
Eleanor M. Kellon, VMD
An extensive body of research in human and laboratory animal insulin resistance has linked obesity, inflammation, and insulin resistance. The picture in equines is less clear. We will review published findings and the implications with regard to etiology, management, and complications of Equine Metabolic Syndrome (EMS) in horses.

Download is free.
--
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

Endocrinopathic/insulin-related "laminitis" isn't itis either because it's not inflammatory. Inflammation is only part of the picture if there is actual tissue damage. The bounding pulses are because the hoof is vasoconstricted on the venous side - backed up. With inflammatory types of laminitis, flow is also restricted but because of tissue edema. The difference in winter is that you have cold induced vascular shunting on top of already impaired circulation and possibly actual vascular damage
--
Eleanor in PA

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

Hi Jenny, I have a pet peeve with the term "winter laminitis", which we use for cold-induced hoof paid due to reduced circulation with no evidence for elevated insulin.  Its really not an "itis" (aka inflammation) being more of a circulation issue and hooves will likely feel cold and lack bounding pulses, but its confusing to everyone that it is also called laminitis.  There can ALSO be an increase in insulin related to cold temps (Nancy saw an effect in her very sensitive horse Beau starting at 50 deg F), and that can cause bona fide laminitis, with elevated insulin and the rest of the classical signs (which may or may not include warm/hot hooves, bounding pulses, etc).  Its confusing, and to make it worse, both could be occurring at the same time!  Warming up the horse and checking insulin are the best ways to see what you're dealing with, and then you can go from there.

I'm thinking of altering my approach from one of aiming to get perfect bloodtest values to keeping him on the 1/2 tab of Prascend daily and then watching for any signs/expression of hoof tenderness.  Otherwise, carrying on with the same daily management and exercise.  I have Metformin on hand, that I could administer if I notice him being hoof sore. 

I think your approach is reasonable as long as Rico stays sound.  There are horses in full work that still have elevated insulin (40s-50s) but no signs of laminitis.  If you see him getting sore, you can start Metformin right away and know that if that doesn't work within a few days you can always move to Stelgatro/Invokana.  When you send your vet's email to Dr. Kellon, you can ask to be cc'd so you get the care and management information, too.  I'd do this now so you have the information on hand if/when you need it as it is a lot more complicated moving to this medication and you'll want to know what's required.  But if you are managing well as is, you can wait until the next level of meds are necessary (its also very expensive and needs more veterinary monitoring).

--
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

Hi  Jenny,

We first heard of insulin readings being erratic in the cold from a researcher at the Gluck Center in Kentucky. There are occasional mentions of it in articles but no formal studies as far as I know. I agree you may not have to have perfect insulin but I wouldn't let ACTH get out of control because that risks multiple problems. If you have a management system that works for him, no reason to change it - until it doesn't ! Also watch for weight gain and crest changes. No such thing  as too much exercise.
--
Eleanor in PA

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

Hi Dr. Kellon,

Can you please direct me to information about the temperature effecting insulin numbers?  I have read on the forum, many messages about cold induced laminitis...I thought that was due to physical damage in the internal hoof structures and reduction of blood flow due to constricting blood vessels in the cold - but can't recall info in general about cold temperature raising insulin values.

Thank you for offering to email my vet about the Steglatro.
I would also like to know the precautions - is that info somewhere on the ECIR pages?

Honestly, my brain is wrestling with the lack of correlation between his insulin values and what I observe in his behavior/movement.  I do all of his care myself, and he lives right outside my house windows on a small track - and so I am observing him all the time.  Right now, he is moving great.  He has the exact same composite glue-on shoes on all four hooves that he had back in early August when he was obviously hoof tender.  His insulin value came back at 56 then.  Now it came back at 70, and he doesn't appear sore at all.

I'm thinking of altering my approach from one of aiming to get perfect bloodtest values to keeping him on the 1/2 tab of Prascend daily and then watching for any signs/expression of hoof tenderness.  Otherwise, carrying on with the same daily management and exercise.  I have Metformin on hand, that I could administer if I notice him being hoof sore. 
What do you think of this approach?  Is it playing with fire?  Or is it reasonable, considering his case?

thanks so much,
Jenny

--
Jenny Heishman and Rico  
Bainbridge Island, WA   June 2018
https://ecir.groups.io/g/CaseHistory/files/Jenny%20and%20Rico
https://ecir.groups.io/g/CaseHistory/album?id=60437

Hi Sherry,

I stopped the Metformin for a few reasons....one was that his insulin only came down from 56 to 48
two was that it was getting increasingly difficult to get the drug into him.  He started out eating it in his mash for ten days, then eating it in mash with special additions, then not eating his mash at all and having to syringe it in am/pm.
three was that his demeanor became lethargic
and finally, I wanted to see what the Pergolide was doing on its own, so decided to stop the Metformin well before the blood draw on 11/29.

-Jenny

--
Jenny Heishman and Rico  
Bainbridge Island, WA   June 2018
https://ecir.groups.io/g/CaseHistory/files/Jenny%20and%20Rico
https://ecir.groups.io/g/CaseHistory/album?id=60437

The weather cooling may have more to do with this than his ACTH. If you are going to start Steglatro please send me your vet's e-mail address.  I am finding many don't know about precautions.
--
Eleanor in PA

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

I had Rico's bloodwork drawn on 11/29 at 1:30pm, temperature was 40 degrees F.

Numbers came back:
ACTH - 12.3 (lowest, best number in all of his bloodwork history, he is on 1/2 tab Prascend since 10/19/22)
Insulin - 70.10 (one of the highest values we have seen - was this high back in July 2021)
Glucose - 72 (lowest value in bloodwork history)

Vet advises Steglatro - one 15mg tab by mouth once daily.

Please send advice....I was hoping for the controlled ACTH to bring insulin down.  Feeling bummed out.
Rico does not appear foot sore at the moment - moving out very well on our exercise rides and handwork, not searching for softer ground like he has in other times

thanks,
Jenny
--
Jenny Heishman and Rico  
Bainbridge Island, WA   June 2018
https://ecir.groups.io/g/CaseHistory/files/Jenny%20and%20Rico
https://ecir.groups.io/g/CaseHistory/album?id=60437