Newbie to IR


cct.7745@...
 

Hello ECIR Warriors,

I am new to this site and thankful I was recommended to join!!

To spare you all the drama of the past four weeks, I'll move forward to my bestie's diagnosis. Sheena (14y/o Foundation QH) has been diagnosed with hyperinsulinemia. She has always been an "easy keeper."  She been being treated for laminitis due to the hyperinsulinemia. I have a knowledgeable farrier with laminitis and she has Sheena in cloud boots with zero pressure on her coffin bone. Sheena has improved within the last week with the cloud boots, DIM and soft sole cushion. My biggest concerns now is diet, labs and caring for her.

Currently, I am soaking 10lbs. 1st cutting Timothy hay for 12 hours. She gets this twice a day.
                Tribute Essential K - one cup twice a day. After emailing Dr. Kellon - I'm weaning her off the Tribute and getting her on Stabul 1.
                                                 How much of the Stabul does she need?
                 Beet Pulp pellets 1 cup - soaked - twice a day
                 Metformin 8,000mg twice a day until Feb.13 then will discontinue
                 Insulin Wise - one scoop daily.  Today, I stopped this due to she will not eat her feed with this sprinkled on it. It does have a                             strong smell that I don't think she likes.
                 Bute powder - one scoop twice a day.
                 Horse Guard vitamin/mineral/Selenium pellet supplement once a day

Labs:         Fasting Insulin (RIA)  33.7  H
                  Fasting Glucose         97
                  CK 973   H
                  AST 465  H
                  Sodium  140  H
                  Chloride  102  H
                  Osmolarity Calc.  292  H
All other lab results were normal.

I think I understand Sheena needs low carbohydrates  and low starch diet...but how much?
I'm concerned, she's been getting Bute for 4 weeks twice a day...does she need some kind of gut supplement?
Any help or direction is greatly appreciated.

Kindly,
Cindy C
MI 2023

                  



--
Cindy C. MI 2023


 

Hi Cindy ,

Welcome to the ECIR group!  Your first post here triggers our formal welcome message with a great deal of reading material relative to your being the partner of an IR and/or PPID horse.  Some of it will be very familiar to you and other ideas might be new to you.  Don’t forget to explore the links as well.

I believe Cass has given you information for putting together a Case History on Sheena as well as a photo album where you can load photos and radiographs to share with us.  All of this information is invaluable to us in sorting out her needs.

Soaking her hay is a perfect first step until you can get the hay analyzed.  You only need to soak it for half an hour in warm water or an hour in cold and then rinse before hanging it to drain.  With respect to the Stabul 1, you only need to use enough as a carrier to get any supplements down.  It’s not meant to be a source of calories but you will need to incorporate the amount of Stabul into the amount you calculate you need to feed her.  How much she gets fed depends a bit on her present body score, generally 1.5 to 2% of her body weight.  We like to see a body score of about 4.5/9.  If she’s overweight, we recommend 1.5% of her current weight or 2% of her ideal weight, whichever amount of feed is higher.

The dose for metformin is 30mg/kg twice daily.  Have you calculated to make sure that her dose is correct?  Why are you planning to discontinue it next week?  Instead I would test again after a week to see if it’s working.  If so, don’t discontinue it as it needs to be given regularly to do it’s job.

In the future, there is a insulin blood testing protocol which should be followed which is addressed in one of the links in the welcome material.  We want the test to show the insulin level under normal circumstances, rather than fasting.  Did you test her ACTH?  She’s on the young side for PPID but I would do  it anyway.  QHs aren’t known to be genetically predisposed to be IR (although we have run across a number which are) and uncontrolled PPID can elevate insulin as well.  I don’t know what it means to be a “Foundation” QH which might well affect her likelihood of being IR.

We haven’t found InsulinWise very useful.  They have a money back guarantee if you want to take advantage of that.

Bute isn’t likely to help the laminitis as, in spite of the name, laminitis is not an inflammatory process.  I would discontinue it by slowly weaning her off.  As you know, it has difficult to manage side effects.  Recent research indicates that giving omeprazole to diminish the effects of the bute she is getting will adversely affect the hind gut.  

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
 


Eleanor Kellon, VMD
 

Cindy,

Metformin 8000 mg would be the dose for a 586 pound horse so  I  suspect you are underdosing her. She should be getting 14 mg/lb twice a day. I would fix that dose and keep her on it.

We really need to see hoof photos (directions in the Wiki) and copies of radiographs.

If ACTH has not been tested, that needs to be done, preferably by TRH stimulation test. It's virtually unheard of  for a QH to have metabolic syndrome/abnormal insulin unless they have PPID/Cushing's disease. She is young but it's not unusual for laminitis to be the first sign, long before abnormal coat, etc..

She only needs as much Stabul 1 as needed to get her supplements into her. Supplements should be based on a hay analysis. Follow the emergency diet for now.

I would get her off the bute ASAP. She will need to be weaned because she has been on it so long. Substitute LaminOx. Start the LaminOx at the same time as you begin to taper. How much bute is she getting?

--
Eleanor in PA

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


cct.7745@...
 

Thank you for all the information!

Sheena weighs 1081 lbs and is getting 16,000mg  of Metformin daily. (8,000mg am & pm).  My vet here ordered the Metformin for two weeks then discontinue.

The ACTH was 8.73 pg/ml and T4 Immulite was .889 ug/dl.

I’ve ordered the LaminOx and will start to wean her off the Bute.  She’s been receiving Bute powder 1gm am & pm.

I'm working on my case study to get everything uploaded. It’s slow going.  Thank you sooo much for your help!!
--
Cindy C. MI 2023


Eleanor Kellon, VMD
 

That should be 16,000 mg twice daily, not total daily.

On the bute, cut it to 1 g once a  day for 3 days, then stop.
--
Eleanor in PA

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


Sherry Morse
 

Hi Cindy,

The dose of Metformin is 30mg/kg 2x a day.  For a 1081lb horse that would be a dose of 14,710mg twice a day.  At 8000mg 2x a day you're giving about half an effective dose.  Also, metformin can be used long term if needed, although it may stop working for some horses. 

I would suggest you have a talk with your vet about a proper dose and testing insulin again 7-10 days after starting that dose to see if it is effective or not.





cct.7745@...
 

Thank you for the information! Will do.
--
Cindy C. MI 2023


cct.7745@...
 

Sherry, 
Thank you for the clarification on the Metformin. I’ll give my vet a call on Monday to discuss & get more labs soon. Since the diet change and cloud easy boots she is improving. I’ve been taking her on short walks and she’s loving loving it. Have a peaceful weekend.
--
Cindy C. MI 2023