Hello, seriously overwhelmed new member here. Sorry, I don't have my case history file figured out yet. I'm not even sure where to start, everything seems so complicated. Sorry it's so long. --
Brittany J in Ohio 2022

Hi Brittany,

It sounds like you’re about as stressed as most of us were when we found our way here.  I think it helps to write things down so it’s good you did that.  Don’t forget to add all this to your case history details so we have all the details at hand.

Your first post triggers this welcome from the ECIR group.  I’ll address some the issues and then, before overwhelming you, I’ll add the formal group welcome letter.  There is lots of reading material there, including details for some of my suggestions and comments.  Don’t worry if I don’t  get to every detail that concerns you because others will comment where they feel appropriate.

From your description, it sounds like his hoof problems only began this past year?  When you tested the ACTH, did you test insulin as well?  It’s the high insulin resulting from uncontrolled PPID that causes hoof pain and laminitis.  You need to do everything you can to decrease his insulin, which includes diagnosis, diet (and drugs), trim and exercise if appropriate.  We use the acronym DDT/E to describe this. 

He should be managed as an insulin resistant horse.  It’s quite likely, because of his breed, that his insulin will drop out of the danger zone once his PPID is controlled but you don’t know that yet.  He should be fed the emergency diet we describe until his hay has been tested for safe feeding.  The timothy balance cubes would probably be ideal for him.  They are generally of a low enough ESC+starch; they are mineral balanced; they are easily chewed and easy to digest.  I have five horses, mostly about the age of yours and those cubes make up most to all of their diets.  We’ve found that it generally takes about 3/4 as much weight for cubes as you might need for hay.

Recent studies indicate that pergolide begun during the fall rise is unlikely to be very effective.  Once the rise abates (late Dec), it should begin to take effect.  With such a high ACTH, it’s unlikely to be controlled with 1mg of pergolide but I thought that once before and was very surprised by the results.  At any rate, the goal is to get the ACTH into the high teens to low 20’s before the rise begins again in late June.  You need to wait three weeks between adjusting a dose and retesting.  At the same time you follow his ACTH, you will want to test insulin and glucose.  I would suggest starting that process in mid January which will give the pergolide he’s getting a chance to reach its optimal effectiveness.

Post your hoof photos (there are directions in our Wiki) and radiographs in an album on our case history sub group and we can share our thoughts.  Underrun heels and long toes are our specialty here.

I can’t advise you on the boots as my experience there is limited but I’ve seen that very topic addressed so try searching the messages.

 

Now for all the details I promised.  Keep this information handy as it will continue to be useful.

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. 

--

Hi Martha,

Thank you so much for your response! Your words have already made me feel a little bit better tonight.

I will be sure to get all of the case history and pictures figured out asap. As well as going over the welcome letter in more detail.

His front feet have basically always had a tendency to go into the long toe/underrun shape, but this year is first time we've had issues as far as being sore and lame like this, yes.

His insulin and glucose was not tested at the time that his ACTH was unfortunately. But I will make sure it is next time. The vets recommended holding off on doing any further blood tests during the current laminitis pain as they said they could be falsely inflated. So I guess January it is.

I decided to hold off on those two additional medications for tonight at least. Hopefully I can get some more guidance on that.

Thank you again!
--
Brittany J in Ohio 2022

Oh, I totally forgot to address the medications!  Sorry about that.  I had isoxsuprine prescribed for one of my ponies once.  It did not appear to make a difference.  It seems that it’s not well absorbed by the horse.  It’s supposed to increase blood flow but there are better options for that.  With increased blood flow, comes increased hoof growth.  If your hooves are headed the wrong direction (not literally, of course) stimulating growth will encourage them to head that way faster.  So let’s get the trim assessed before making that recommendation.  Ace is a sedative and, not being a vet or having experience with using it, I’m not sure why it was recommended, unless he is frantic about being confined.  I’m sure someone else will fill us both in.  So, you made a wise decision there.  Your brain is still functioning well under stress!

My understanding is that QH feet have a tendency to grow “long and low”.  It may be that they are trimmed that way because it’s what’s expected.  I don’t know but Lavinia here is our hoof expert and I’m sure she will give you correct guidance.
--

Hi Brittany,

I had a couple thoughts for you.

Here's the info you need to correctly take hoof photos, name them, and upload them into a Photo Album in the Case History sub-group: https://ecir.groups.io/g/main/wiki#Photos-and-Hoof-Evaluation-Help
Lavinia, our resident hoof expert, will do a free set of trim markups for you if post a request once your photos are uploaded and correctly named.

The Bute will slow down abscess mobilization which will only prolong the pain.  Best to encourage abscesses to exit the hoof as quickly as possible with warm Epson soaks, or dry poulticing if the soles are really thin, and by giving jiaogulan (a vasodilator herb) to increase circulation to the hoof and clear out collections.  Generally we don't advise jiaogulan until the trim is in order because it does actually speed up hoof growth and shortens the trim cycle by at least 1 week, but if your trimmer is able to come more often (every 2 weeks to start, which is ideal if you are rehabbing hooves) and you have markups to guide you, you can try adding jiaogulan.  Both my horses are on a low dose of jiaogulan and I find an optimal trim cycle is 3 weeks, but I can push it to 4 if needed.

I use boots extensively and my horse has them on his fronts 24/7.  I always put a sock over his hoof inside the boot, and smooth his hair down under the sock if it gets bunched up when pulling the sock on.  Men's large athletic socks work well, but in winter I use a wool blend to help warm up his hooves.  The socks protect him from rubbing, and the thicker the sock the better that works.  I also use a liberal amount of foot powder in the boot, and the socks prevent the powder from gunking up his soles.  Socks get changed daily because they do get damp (2x a day if they get soaked), and I have a second set of dry boots I can switch him to as needed.

After he's been on pergolide for 3 weeks it's time to retest to see if the dose is enough.  You can wait until January as was suggested, but we are far enough out of the seasonal rise now that testing before Xmas would be fine, too.  Yes, acute laminitis can inflate ACTH and insulin, but usually diet adjustments will reduce the severity of the laminitis within 1-3 days to a point where bloodwork is useful again.

Now that you're here, it will get easier.  There will always be setbacks (abscesses months later being one possibility) but we've all been there and we know what works, so you're on the right track now. 

--
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

Acepromazine is not indicated in horses with PPID because it counteracts pergolide. It has no effect on insulin and is one of the few things proven to improve blood flow in the hoof but the effect does not last very long. Jiaogulan is better.
--
Eleanor in PA

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

Martha,

No problem! The vet said she was prescribing it for circulation. He's pretty content in his stall overall right now, though he was trying to follow me out of the door today wanting to be outside with my mare. My poor Bud. At least they can still see each other the whole time.

I went ahead and filled out everything in the case history document that I could for now and got it uploaded as well as the x-ray pictures that I was sent. The vet did not send any type of description or results along with the pictures though, so I really have no idea what to take from them or what the numbers on the pictures mean. I called the office to ask for more details and they said she's out of the office until Tuesday and she didn't mention that, only that I would get the results last night or today. So I'm pretty anxious and upset about that.

--
Brittany in Ohio 2022

Buddy Case History - https://ecir.groups.io/g/CaseHistory/files/Brittany%20and%20Buddy

Buddy Photo Album - https://ecir.groups.io/g/CaseHistory/album?id=282333

Sherry,

Thank you for the additional info. I have been letting him lay down as much as he wants and trying to not do anything to cause him to get up. 

He's such a crazy picky eater that it's making it really tough. I gave him the Timothy balance cubes today and he has only picked at them. Worried to add salt again and him not even touch it, trying to come up with ways to get him to eat everything. He hates wet food and hay. Trying to find a new source of hay right now. Should I withhold hay completely even if he isn't really eating anything else? I've been afraid of starving him out.
--
Brittany in Ohio 2022

Buddy Case History - https://ecir.groups.io/g/CaseHistory/files/Brittany%20and%20Buddy

Buddy Photo Album - https://ecir.groups.io/g/CaseHistory/album?id=282333

Kirsten,

Thank you for the tips! I went ahead and uploaded the x-ray pics I have at the moment and will try and get pictures of his hooves ASAP as well and do that.

I believe the abscess has completely drained at this point from what I can tell, though I don't claim to be an expert. I'm really concerned about if I'll be able to get my farrier to come more often. It's been incredibly difficult to find a farrier at all in my area over the last couple years. We're currently on a 6 week trim schedule and he is about an hour away from us but has a few clients close to me all on the same rotation. I was waiting to get the x-ray results before contacting him about all of this.

I am definitely going to have to try those tricks with the boots. I guess I will play when to retest his levels by ear for the moment and see how things go over the next few days or so.

Thank you so much again!

--
Brittany in Ohio 2022

Buddy Case History - https://ecir.groups.io/g/CaseHistory/files/Brittany%20and%20Buddy

Buddy Photo Album - https://ecir.groups.io/g/CaseHistory/album?id=282333

Thank you so much for your response Dr. Kellon! I'm glad I checked here before giving him the medication. Would it be best to start him on jiaogulan asap or wait and address the trim and trimming schedule first?

--
Brittany in Ohio 2022

Buddy Case History - https://ecir.groups.io/g/CaseHistory/files/Brittany%20and%20Buddy

Buddy Photo Album - https://ecir.groups.io/g/CaseHistory/album?id=282333

From his trying to get out of the stall it sounds like he already feels better - and no reason not to let him out as long as he can't eat grass. His radiographs show more of the long toe, underrun heel issue than laminitis. You should get mark ups and have your farrier back up his toes before starting Jiaogulan - consider getting a rasp yourself and keep those toes backed up between visits. I'm sure that shocks you but MANY here have done it. Also need to get insulin and ACTH checked ASAP because that is what is driving the hoof pain.
--
Eleanor in PA

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

Hi Brittany,
Adding all the suggested salt can be a turn off.  I would suggest putting a much smaller amount in his supplement mix and adding the rest to his forage, whether that’s hay or cubes.  If your hay is soaked, you can sprinkle the salt over the filled hay net.  Otherwise you can dissolve the salt in hot water and add that to the hay.  I have used a squeeze bottle, such as you might find for catsup or mustard, to squirt the salt water over the hay.  You might put his supplements or a little loose hay directly under the net to catch the drippings.  In time, you should be able to add all of it to the supplements.  I’d rather not take that chance so I continue to add it to the hay or cubes.
Horses like salt but they need to adapt to the appropriate amount.
--

Dr. Kellon, 

That is so reassuring to hear, I feel like I can finally breathe a little.

Not to keep asking so many questions, but I'm curious how the bounding digital pulse factors into this? Like when looking at laminitis vs pain caused by insulin and ATCH. Because the pulses and tapping the front of his feet with a hammer for a pain response were the two main diagnostics that my vet used to say he was laminitic/foundering and needed x-rays.

--
Brittany in Ohio 2022

Buddy Case History - https://ecir.groups.io/g/CaseHistory/files/Brittany%20and%20Buddy

Buddy Photo Album - https://ecir.groups.io/g/CaseHistory/album?id=282333

I didn't mean to imply he can't have laminitis, just that there are no dramatic radiographic changes like rotation or thickening of the horn lamellar zone. With an ACTH that high there's a good chance it has also elevated his insulin which can indeed cause laminitis. The bounding pulses are because insulin normally causes blood vessels to be open and counteracts the effects of a chemical called endothelin-1.When exposed to high insulin, the receptors become resistant and it no longer works to counteract constriction caused by endothelin-1 and endothelin-1 levels also increase. The result is that the blood vessels in the hoof are constricted down and the high pulses are because of the backup of blood https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4018505/ .
--
Eleanor in PA

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

Sorry, I worded that poorly. I understand what you mean. I meant I was reassured hearing there doesn't seem to be any major rotation, etc.. I guess my question is more how to differentiate between when those things are happening or not. Like for the purpose of knowing if I should allow him out of his stall for example. If that makes sense.

Brittnay,
As far as diagnostics.
My horse never had bounding pulses and she had horrible laminitis this last july.
No rotation. Initally she was limping/lame like she had an abcess and thought that is what she had.
But i am thankful the vet who was seeing my friends horse just randomly tried taping Lilly pads under her frogs which improved her walking quite a bit and that's when she said she should be tested for IR/EMS. (The Lilly pads took some pressure off the hoof wall though supporting the frog)
Her insulin was though the roof.
She didn't have pounding pulses then or ever and you could easily pick up all 4 feet and I thought they were quite hot.
Vet kept saying the laminitis wasn't bad.  But it was and got worse and worse til she couldn't walk. I finally got a new vet and found this group and have tried to follow everything they recommend.
The boots and pads are the thing that have made her the most comfortable besides changing her diet of course. 
The new vet wanted shoes with dental impression and pads (she has been barefoot her whole life) i did it just because it was so wet where she was and I couldn't check the boots enough but I took the shoes off after 5 days as she was more and more uncomfortable in them. 
She has been in boots and pads since.
--
Lesley Bludworth 
Phoenix, AZ   7/2022
Sophie TWH mare IR/EMS, PPID?
https://ecir.groups.io/g/CaseHistory/files/SophieB%20Case%20History
https://ecir.groups.io/g/CaseHistory/album?id=277749

Hi Brittany,

If he's eager to get out then let him.  As long as footing is soft, the area is too small to run around in, and the other horses can't push him around, he can't eat anything inappropriate, AND he's not on NSAIDS then it's safe to let him move as much as he wants to.  If he's getting crazy running and bucking he will have sore feet after so we advise a small area to prevent the hijinks if he's feeling fresh.  IF you can boot him to help protect his hooves, that helps a lot, but you have to be able to prevent the rubbing.

--
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

Don't get me wrong, he's still acting pretty sore and laying down a good amount. But I did decide to let him out for just a quick break from his stall since he wanted to with his boots on. Their main turnout area right now is a small limestone dry lot, so the footing isn't soft. I wonder if topping it off with some fresh screenings would be soft enough or if I need to also reconsider my dry lot plan now. Otherwise all we have right now is mud, I live in the woods so no grass (for once that's actually a positive). Are the soft ride boots enough cushion for hard ground and some rocks?

Oh and also, I'm not sure if I should start a new thread for this question or how that usually works here, but I'm trying to schedule his blood draw ASAP and 1) I read the info about not fasting before the insulin/glucose test and having access to hay the entire time before, do the Triple Crown Timothy Balance cubes count for that? Or does it have to be actual hay? Because I'm still working on finding new hay and testing it. He's still being back and forth about eating the cubes, but I'm trying not giving him any other choice for a couple days. My vet said she tells clients to fast beforehand, but I plan on following the guidelines here. When I requested an insulin and glucose test she referred to it as the endocrine panel for Cornell.

And 2) We have a major cold spell coming in a few days and it's looking like it will last until at least a couple days after Christmas. If I can't get them out here for the draw before the temperature drops, should I wait until after we get some warmer days again? Not sure exactly how long that will be. I'm eager to get it done, but I want to do whatever is best.

--
Brittany in Ohio 2022

Buddy Case History - https://ecir.groups.io/g/CaseHistory/files/Brittany%20and%20Buddy

Buddy Photo Album - https://ecir.groups.io/g/CaseHistory/album?id=282333