Sarah, I would suggest asking your vet if she would consider a pergolide trial.  That way you’ll know if it’s helpful.  You should definitely get the insulin/glucose tested.  That’s the only way you will know if your management is appropriate.  What’s adequately low s/s for one horse may not work for another.
Martha in Vermont
ECIR Group Primary Response
July 2012 
Logo (dec. 7/20/19), Tobit(EC) and Pumpkin, Handy and Silver (EC/IR)

Martha and Logo

Lesley Fraser

Hi Sarah

Apologies if I missed it in your posts, but do you happen to know if the ACTH test was carried out at the Liphook lab?  I found they were very reliable, and they offer the TRH Stimulation test that Martha mentioned -

US members have access to all sorts of suitable feeds that unfortunately we can’t get in the UK.  However, Dr Kellon’s article 'Steps to Evaluate Safe Feeds for IR and Cushings Horses’ is a great introduction to what to look for and why - you can find it in the ECIR Files section under 'No. 2 Safe Feeds’.  It also has a check list that’s useful to keep handy when you’re ringing up a feed company to ask for more information.  Many bagged feeds that are advertised as ‘low starch/low sugar’ are not low enough in starch or sugar for IR ponies, and it’s important to delve into the detail to make sure they are actually safe.  Speedi-Beet, or any other unmolassed beet pulp with no additives, is fine, though.  It needs to be rinsed, soaked, and then rinsed again before feeding.

One of the most useful things you can do is get your hay tested.  I used a hay corer attached to a standard DIY drill to get the samples and then sent them off to Equi-Analytical in the US  for the Trainer 603 test.  After you get your hay analysis results back you can ask one of the ECIR volunteers trained in mineral balancing to balance specific minerals to fit your hay.

Regarding the swollen sheath issue, Omar suffered from that before his PPID was controlled.

It’s all a lot to take in at first, but you’ve come to the right place and it does get easier as you go along.  We’re all here to help in any way we can! 

Lesley and over the bridge Omar,
ECIR Group Primary Response,
Highland, UK

Omar - Case History

Kirsten Rasmussen

Hi Sarah,

You have an equivocal value in an equivocal month, so it's hard to be certain.  However, we do suggest keeping ACTH in the mid teens to low 20s AFTER a diagnosis of PPID, so even without a definitive diagnosis I don't think you are in a risky zone.  If you can have a TRH/TSH test done between January and May you will better be able to determine if this pony needs medication to get through the next seasonal rise.  Now that we are out of the seasonal rise, have all the issues cleared up?  He's also had some big changes since coming to live with you, notably a new home and living on a track, possibly exposing him to be stresses and allergens. 

We do like to see a baseline for insulin and glucose because it lets us know how the equine is doing under the current management.  Some horses will come back with surprisingly high values and might need further steps taken to minimize sub-clinical laminitis and avoid acute laminitis.

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

Sarah Ince

ACTH was 23.6 pg/ml on 18th November

Report states July and November, PPID unlikely <15pg/ml, Equivocal 15-50pg/ml, PPID likely >50pg/ml 

Tested at home, very relaxed normal day.
Sarah I in UK 2022

Sarah Ince

I did ask the vet about testing for IR and she said even if it came back positive it wouldn't change anything be as he is managed with a low sugar/starch diet anyway. I'm thinking of trying a different vet practice.
Sarah I in UK 2022

Sherry Morse

Hi Sarah,

Just wanted to add to the advice Martha's already given you that if you have not had this pony's insulin level checked all signs point to him being IR moreso than PPID for me.  Getting that confirmed, under control and getting him back to a better weight are going to be key.  Is he currently muzzled?  If not, and he's living out on a track, he may well need to be.


Hi Sarah,

Welcome to the ECIR group!  With your first post here we send a formal welcome with all sorts of information on metabolic laminitis, PPID and managing horses with those conditions.

We tend to focus on DDT/E, which stands for Diagnosis, Diet (and appropriate drugs), Trim and Exercise, if suitable.

I would say we are at the diagnosis state of your son’s pony’s issues.  We would like to see a case history with his blood test values but I think it would be appropriate to post the ACTH values here, with some explanation about whether he was tested at home or trucked, did he have any veterinary work done immediately prior to having the ACTH blood sample drawn.  Anything out of the ordinary from his regular day.  What was the date of the test, the value returned and the “normals” posted for that analysis lab?  You can’t post attachments here but we would love to see them with the case history.

There are some cases of horses having PPID without having a particularly elevated ACTH.  You can test for that as well as early cases of PPID with a TRH stim test.  It may be called something else there but someone will come along and help us out.  You don’t want to do that during the fall rise but we are exiting that now.  PPID horses may have an extended rise so maybe wait until mid January to test.

Some of the symptoms you’ve noticed sound like they might be PPID related, others suggest insulin resistance and some might be related to the habronema, which I have never knowingly experienced.

Did you have insulin and glucose tested at the same time?   Being overweight does not cause insulin resistance and ensuing laminitis but the extra weight on the feet certainly doesn’t help when laminitis does occur.  If he is gaining weight and on a track, you should be able to help regulate his weight with an appropriate amount of hay, which is 2% of his ideal weight or 1.5% of his current weight, whichever amount of hay is greater.

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 etiquettewhat 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.

EXERCISEThe 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. 

Martha in Vermont
ECIR Group Primary Response
July 2012 
Logo (dec. 7/20/19), Tobit(EC) and Pumpkin, Handy and Silver (EC/IR)

Martha and Logo

Sarah Ince

I'm here because I'm trying to determine if my son's pony has the start of PPID. The pony is 13 years old and we bought him in April. He came from a home where he was stabled unless being ridden and that was less than an hour a day. He was lean but not thin. The seller said he'd had an incident of laminitis a couple of years ago when he was away on loan and allowed to become overweight. This resolved quickly upon returning to her and having diet controlled.  As he was coming to live on a track with my EMS cob this wasn't a huge concern for me.  Since arriving he's rubbed his mane out, been diagnosed and treated for ulcers, suffered with habronema on his face and sheath and just become generally very unhappy and grumpy. His sheath did sell when he had the habronema but went back to normal once that was treated. A couple of months ago his sheath became very swollen again and rock hard. Had vet who ran a general blood screen and ACTH test. Vet reported both tests were normal. They sedated the pony and checked all was well with his penis.  Gave a week of antibiotics as they were baffled. No improvement. They then offered steroids or antihistamines which I declined. A vet nurse friend looked at the blood results and feels the liver enzymes are higher than they should be and PPID was borderline. The pony has gained quite a bit of weight since we got him. I'm not sure where to go now. We just want him to be happy.
Thank you for reading.  Any advice much appreciated.
Sarah I in UK 2022