Cutting the hay with a lower protein hay is something you could think about trying.  But they need to be mixed very thoroughly and then ideally fed in a small hole hay net, so he doesn't high grade the good stuff and leave behind the less appealing hay.

Don't forget to try soaking his hay, then redo his insulin and glucose bloodwork.  Even though your teff hay is nice and low in ESC and starch, soaking it can still make a big difference and that might be all you need to do.  If some of the high protein is actually due to high nitrates, soaking will also lower those, which is a good thing.  Mustangs seem to be some of the harder cases to manage. 

I agree that your estimated weight of 1100 lbs is too high for a 15HH horse, unless they're a heavily muscled QH or a draft cross.  I have a 15.1 Paso Fino and his ideal weight is ~900 lbs, at which he maintains a BCS of 4.5 on 15.5 lbs hay/day (1.7% of BW) and 1 cup beet pulp (dry measure), with no exercise.

The fat pads are the last to go and they are more closely tied to insulin than they are to body fat.  They'll probably never fully disappear, but you might be able to reduce them to the point where only you can see them.

--
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

Thank you everyone who has chimed in. 

I really appreciate the sources that I can share with my vet to support the metformin dose increase. I am optimistic that we can get that increase approved and hopefully it will help us get a better handle on his IR.

Kirsten, you are absolutely right that the ACTH test was pre and post TRH, with the lower number being pre and higher post. I wasn't certain of how to notate that on the case history but I'll try to go back in and update it soon.

Regarding the hay protein: I feel like I'm between a rock and a hard place to some extent. Aurelio gets fecal water when he is on any other forage aside from teff (I've tried every gut supplement known to Man and teff as primary forage is the only thing that keeps the FWS at bay). It is hard enough to find teff hay, and almost impossible to find any local hay with low protein and appropriate sugar/starch. I could try cutting the teff with beet pulp or a lower protein hay or beet pulp?

Aurelio's ribs are very easily felt and can be seen as he moves (hard to see in the photos given his winter coat), however he does still seem to have the unhealthy fat deposits around his crest and tail head which has made me worry. The unhealthy fat pads are definitely smaller since the acute laminitis. It seems like he's lost most of the more "normal" fat that he can but still sort of holding onto those unhealthy fat pads -- possibly because the insulin has been staying stubbornly high? I can't really reduce his hay any more right?

I'll see about trying to change up the hoof trimming/care a bit more. I've been pestering our farrier and sharing ECIR resources but he's been very reluctant to put a bigger bevel on or make other significant changes. Fortunately Aurelio has appeared comfortable while moving for the past few weeks. The Duplo composite shoes do make use of his whole hoof (sole, frog, bars) and we've been hand walking about 30 mins and trotting up 10 mins 5-7 days per week. We'll likely pull the composite shoes soon and switch back to boots for a while.

I do still feel like he's a ticking time bomb which really scares me. I agree that he's currently more of a "simmering" sub-clinical laminitis case and not acute.

--
- Emily W
2022 King County, WA State, USA
Case History: CaseHistory@ECIR.groups.io | Files
Aurelio's Photo Album: CaseHistory@ECIR.groups.io | Album

Hi Emily,
I agree with the others about his metformin dose and the possibility of a constantly simmering laminitis.  An insufficient dose of metformin is a very common issue and it doesn’t seem that half of the correct metformin dose will do half the job of decreasing insulin.  You need an adequate dose to have an effect.  I also think he still looks overweight.  I don’t think any 15h horse should weigh 1100 pounds, and he most likely doesn’t, but you’re feeding him an amount appropriate for bringing an overweight horse down to 1100 pounds.  Decreasing his weight will not affect his insulin but it will decrease the prybar effect of using hooves suitable for a smaller horse to carry the weight of a larger one.
We have other active members with mustangs and reading through their issues might give you some guidance.  Try doing a search on the messages for “mustang” to see what that brings up.
--

Hi Emily, 

The timing of this and the insulin remaining high despite your changes had me wondering if early PPID is a factor.   But I don't understand your blood test results because you gave 2 ACTH values.  Is one a baseline and the other a post TRH Stimulation value?  If that's right, then it's safe to rule out PPID, but perhaps you could clarify on your Case History with "pre-TRH" and "post-TRH" next to the number the next time you update it.

I would also recommend getting hoof markups done.  The breakover on the RF is getting farther and farther forward with time, which you do not want.  You've probably been here long enough to know we do not recommend any shoes during the recovery period because the hooves need trimming more frequent than shoe resets are done.  Plus putting that much more stress on already damaged lamellae is not recommended; you need the sole, frog and bars to take most of the load.  Hoof boots with pads in them are more comfortable and take the strain off the hoof walls. 

I agree the new growth is consistent with persistently elevated insulin, but not necessarily acute laminitis as sub-clinical laminitis with only moderately elevated insulin can produce growth rings.  Are you soaking his hay?  That WILL help lower his insulin.  His hay is also quite high in protein.  Sometimes high protein hay is problematic for EMS horses and we don't know why (unless the hay is high in nitrates, which shows up as high protein....you need to request a nitrate test separately).  You want to try to feed grass hay that is between 8-10% protein.

The EEG Guidelines specify the correct Metformin dose of 30mg/kg 2x/day.  They even suggest going higher or dosing up to 3x/day.  We do NOT agree with everything they put out, but your vet will probably be ok with following their guidelines on Metformin. 

--
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 Emily
Re the metformin dose—in the Files there is a folder titled “metformin” which contains studies that support our recommendation of an effective dose of 30mg per kg of body weight twice daily. Aurelio is getting half that.  main@ECIR.groups.io | Files
You can search the Files using the Search function. 
I've personally seen two ponies who improved in soundness and insulin levels when their low dose of metformin was raised to the recommended 30mg/kg twice daily, and we have a number of members who have experienced the same. The vet who attended those two ponies is now prescribing the correct dose, so maybe your vet would be willing to look at the study and change Aurelio's prescription too. 


nav

--
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

 

Thank you Sherry and Trisha.

I have just taken some new photos of his hooves and added them to the album. He's currently wearing Duplo composite shoes. The new growth on his front hooves doesn't look good, right? :( I think his hind hooves look fairly decent though.

The most recent January blood test was taken around noon and it was about 45 degrees out. There weren't any other procedures. I'm less certain of the July test however I believe that it was early afternoon and likely in the 70s or 80s.

I'll double check the metformin dose. I'm pretty sure I read it right -- he gets 8 tabs AM and PM, and I think each tab is 1000 mg. I'm a bit leery of questioning the dose that my vet prescribed. Is there a specific study or something that defines the "correct" dose?

--
- Emily W
2022 King County, WA State, USA
Case History: CaseHistory@ECIR.groups.io | Files
Aurelio's Photo Album: CaseHistory@ECIR.groups.io | Album

Hi Emily. I am here to officially welcome you to the group.  I reviewed your case history ( nice job and thank you for doing it!)  If  you are only giving 16 grams of metformin per day...that is too low for your horses bodyweight. If  we use the 1100 pounds as his current weight, he should be getting 30 grams per day. Metformin is dosed by weight at 60 mg/kg/day...or 30 mg/kg 2 x day.     Here is a link for you to review about metformin and its dosing, etc. https://ecir.groups.io/g/main/files/4%20Insulin%20Resistance/Metformin/Metformin%2008.08.20%20FINAL.pdf    Also, something else to think about, is cold induced hoof pain "winter laminitis". We do know that horses who have had laminitis events, can get very sensitive to the cold and hoof pain can start up. Also, we know that insulin goes up in the colder weather. I'm not sure what your temps are in Washington right now, but if you are consistently below 40-45 degrees...you may want to warm his hooves with wool socks and boots and then some leg wraps or fleece lined shipping boots.  I see that he is already on j-herb. You may want to add AAKG here is a link to read more on that topic:  https://ecir.groups.io/g/main/files/Pain%20Medication%20and%20Alternatives/Jiaogulan,%20Nitric%20Oxide%20Support,%20AAKG%20and%20Supps/AAKG%20Guidelines.pdf  

 I know you are an experienced reader with us, but this is a nice concise version of the protocol to keep handy as things arise. I am sure others will be chiming in to assist. 

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.  --

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     

Hello everyone, this is my first time posting so you'll have to forgive me if I've done something incorrectly with the case history form and photos. I've tried my best.

I'm feeling really defeated. My gelding Aurelio suffered acute laminitis in July 2022 and was subsequently diagnosed as IR. Since that time I have carefully implemented every instruction from our vet and the extensive ECIR resources (yes, up until now I have been a silent ECIR lurker). Our vet is pleased with Aurelio's current weight, he's on a strict ECIR diet (no pasture), he's getting metformin and a low dose of Thyro-L, he appears comfortable in his current composite shoes, and we are gradually increasing his daily activity.

Despite all of this, we just received new bloodwork indicating that his insulin is still out of control. In fact, his insulin is higher now than it was during his acute laminitis.  Also, his new hoof growth since the acute laminitis has been slow and uneven (there still appear to be event lines). Over the past 2-3 months he has had occasional days where he appears footsore again, although it has typically been short term.

I'm feeling very discouraged that we're doing everything "right" but still aren't able to control his IR. I am also really scared that he might have another acute bout of laminitis despite my best efforts. I've done all that I can think of so I'm here now: what else is there?

Another reason that I am emotionally fragile: our mare was diagnosed with DSLD on the same day that Aurelio was diagnosed with laminitis and IR. I have been trying to cope with two devastating diagnoses and I'm running short on hope.

--
- Emily W
2022 King County, WA State, USA
Case History: CaseHistory@ECIR.groups.io | Files
Aurelio's Photo Album: CaseHistory@ECIR.groups.io | Album