Hello,

Please help me clear up some confusion about September bloodwork. I understand that ACTH can be elevated seasonally. The two main questions are:

1. how much elevation is within a normal fluctuation range for this time of year (my online "research" turned up the number 50 pg/mL as the upper bound of the "okay" range for the fall - is this accurate?), and 
2. is elevated ACTH a laminitis risk factor in itself or only via its impact on insulin/glucose metabolism?

In other words, if both glucose and insulin are within the reference range, but baseline ACTH is elevated (35.7 pg/mL one horse (10 y/o) and 49.8 pg/mL the other (13 y/o) - both are below 50 but one is pushing it) is it okay to wait until the winter to re-test baseline ACTH and/or do TRH stimulation and/or dexamethasone suppression tests, or am I playing with fire and need to put them on pergolide now?

Thank you!
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Ed P in TX 2022
https://ecir.groups.io/g/CaseHistory/files/Edward%20and%20Atticus
https://ecir.groups.io/g/CaseHistory/album?id=273196

The upper limit of the seasonal rise varies from study to study and is likely higher (80 or so) for older horses. For horses with a history of fall laminitis, no increase is OK. If you are trying to diagnose and have a horse in the grey zone like those two are, wait until December. ACTH per se will NOT cause laminitis. It's the elevated insulin.
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Eleanor in PA

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

Question regarding testing efficacy after starting pergolide.
My vet said we could retest ATCH after 2 weeks on desired dose of pergolide vs 3 weeks.
Also said Cornell does not consider Arizona as having a seasonal rise? She suggested i call Cornell regarding that which i will do but thought I'd bring it up here and call tomorrow 
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Lesley Bludworth 
Phoenix, AZ
Sophie Case History 7/2022
https://ecir.groups.io/g/CaseHistory/files/SophieB%20Case%20History
https://ecir.groups.io/g/CaseHistory/album?id=277749

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Ed P in TX 2022
https://ecir.groups.io/g/CaseHistory/files/Edward%20and%20Atticus
https://ecir.groups.io/g/CaseHistory/album?id=273196

Hi Lesley. Your vet is correct.  In Nancy's link it states that the pergolide can be tested between 2-4 weeks.  https://www.ecirhorse.org/pergolide.php    I usually use 3 weeks. As for the seasonal rise- I thought it was for the Northern Hemisphere and Arizona should still be in the Northern Hemisphere, unless somebody moved it :) 
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Trisha DePietro
Aug 2018
NH
Dolly and Hope's Case Histories
Dolly's Photos 
Hope's Photos 
Primary Responder

Hi Ed,

Atticus's bloodwork looks good.  I don't think you need to change anything. 

I agree with Sherry that Gunner's insulin is a bit high.  Likely he would do better if not on pasture, but you'll want to recheck his insulin once he's on hay and no grass.  Looking forward to seeing Gunner's Case History when you get it posted. 

I don't think either horse needs pergolide this fall.  Both results are within normal for Sept 1.  If you want to be absolutely sure, you can do an ACTH Stim test after December.

--
Kirsten and Shaku (IR + PPID) - 2019
Kitimat, BC, Canada
ECIR Group Moderator
Shaku's Case History
Shaku's Photo Album
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Kirsten and Shaku (IR + PPID) - 2019
Kitimat, BC, Canada
ECIR Group Moderator
Shaku's Case History
Shaku's Photo Album

Hi Ed,
Your post caught my attention because stallions are rarely IR.  Maybe his Andalusian genes got the upper hand here.  Your case history mentions that Atticus has winter laminitis every year.  Two things I know of to help that are keeping him warm in cold temps and making sure that the hoof capsule fits the hoof closely.  The most recent radiographs and photos you posted were earlier in the year so they may not be representative, in which case, you should post more.  What I see is a common trim issue that is not particularly easy to fix.  Many of us can vouch for that.  It was suggested that you contact Lavinia for guidance back in June but you felt that you had progressed far enough not to need that.  I would recommend that you ask for her help once she returns from her vacation in early October in an effort to avoid another winter laminitis event.  His splayed hooves and extra weight put a huge strain on the connections between the hoof wall and its innards.  It’s easy to think that because he’s big horse, he needs big feet.  I loved when my 17.2 h Holsteiner had his feet trimmed and he looked to me like he was wearing little kids’ tennis shoes, with a nice snug fit.

Another thing which would help would be to have his hay tested and balanced.  That can make a huge difference in supporting the connections between his hoof wall and hoof.  Although you aren’t treating him as an IR horse, and he may well not be, the trim and the diet are important to any horse, not just those that are IR.
--

Hi Ed,
I saw that you posted more recent photo’s of Atticus’s trim.  Thank you so much!  It looks to me like you are doing a superb job with getting those feet stacked up how they should be.

Don’t forget the nutrition aspect.  You’ll need that to hold things together.
--

First of all, a huge thank you to everyone who responded. Dr. Kellon, Sherry, Kristen, Martha, Lesley, thank you! This group is the most caring and supportive place!

I mentioned the grass not to be cavalier about it but just to give a frame of reference to the blood test. I second-guess myself every day with these two, trying to balance the risks with the quality of life. Gunner went from 67.47 insulin in May to 36.42 insulin in September and down one BSC level on the summer pasture 24/7 with a grazing muzzle on 24/7. He is now another BCS level down, a bit "ribby" BCS4. This horse goes stir crazy in confinement. I finally put together his case history. Will re-test insulin, ACTH, and do TRH stim in January. He has no history of lameness of any kind, never had an abscess or any foot distortion, ridges or rings. Still need to upload pictures of his trim. His September radiographs (uploaded to his album) show ossification of collateral cartilages, and I don't know how to help him with that, but nothing else appears to be alarming. I did lower his heels a little to improve the angles.

With Atticus, after his founder in February, he made a very rapid recovery from all but complete immobility to trotting around like nothing happened in less than two weeks. That was after 3 months of not being able to walk and hardly even stand. I slowly re-introduced him to pasture with a grazing muzzle on and he seemed to be doing well: insulin levels within the range, slow but steady weight loss (he lost ~350 lb), no fat pads, smaller and much softer crest, BCS7-8 in February down to BCS4-5 now. His feet are improving but very slowly - he's still growing out thick bloody wedges and the new growth still has some rings, not nearly as pronounced as before but still not smooth. This worries me. If his metabolic profile is okay now, with considerably decreased adiposity (and hopefully increased insulin sensitivity as a result), what would be causing the rings on the new growth? There's a trigger there that has not been eliminated. I rasp down his feet every one to two weeks keeping the wall completely off the ground, other than the heels and heel/bar junctures. The whole foot moved backwards and appears almost abnormally compact. I realize that this is what it probably should have been all along and it was a long toe, the flares and the stretched forward sole/frog that was giving it a much larger appearance before. We still have ways to go with his feet (pictures uploaded in his album). He walks, trots, and gallops comfortably, showing no signs of sensitivity. That is, of course, wearing boots (EasyCare Stratus with Cloud pads) 24/7 since his founder. I still need to update his case history with all of this new info. I fell behind on regular updates and now need to go back and search for dates to reconstruct what happened when. Atticus too will be re-tested in January for ACTH and insulin, plus TRH stim to see if there's any early PPID.

I also got new, low carb, hay for the winter, so I wouldn't have to soak their hay all winter long, and tested both the hay and the pasture (October sample). The test results for both are here: https://ecir.groups.io/g/CaseHistory/files/Edward%20and%20Atticus/EQ153958.pdf. The pasture (at least this time of year) appears low-carb as well. The next step is balance the minerals based on these two tests. They are still eating the pasture during the day (grazing muzzles on), but at night I put out one-inch-mesh feeding nets with this new hay and they mostly work on that.

Thank you again for your comments and support! 
--
Ed P in TX 2022
Atticus's Case History
Atticus's album
Gunner's Case History
Gunner's album

Hi Ed,

Sounds like things are really coming along.

Just want to comment on the growth rings Atticus still has.  My horse has them, too, despite a couple years now of safe insulin, regular trimming and mineral balancing.  He did not have them before his original founder event in 2017, and since then they've never gone away.  They are not as pronounced as Atticus's.  I don't know if it's because of permanent damage to the quality of hoof growth, or if he has insulin fluctuations that haven't shown up in a blood test yet.  He has not had a laminitis flareup for exactly 2 years.  For Atticus, maybe his insulin is really up and down on pasture.  We do know sugars in grass can very widely in a single day.  I also suspect part of it is the mineral balancing piece that you need to implement as well.

--
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 Kristen,

Thank you for sharing details about your horse. It really helps to know that these rings could potentially be an aftermath of laminitis and not an ongoing problem. Hopefully this will improve overtime for the both of our guys. I sent the hay analysis to Dr. Kellon, and her response was that what I'm doing now (Uckele U-Balance Foundation plus added magnesium) is adequate. So, no changes in the nutrition piece. This is both good and bad. Good because they are getting what they need, but also concerning because this isn't something I can improve and hope to fix the situation. They have been on the Foundation pellets for years now and Atticus foundered while on them. So inadequate nutrition isn't a specific trigger that I can eliminate and have more peace of mind.

With Atticus, I'm keeping my fingers crossed that this might just have been that I let him get too fat and didn't properly address his foot distortions. Obesity messed up his metabolism and extra weight combined with gradually progressing distal descent and too much leverage on the hoof walls might have resulted in a crisis. If that's the case, then just keeping him thin and properly trimmed, and monitoring his insulin levels with seasonally changing diet (hay to pasture (spring, summer, fall) back to hay) should be enough to keep him healthy. This, of course, can be just wishful thinking on my part. But other than testing him for PPID in January, I don't know what else I can change. 

With Gunner, it's a newer concern - I only noticed that he started dangerously gaining weight this spring, got him tested, and lo and behold his insulin was high. I immediately put a grazing muzzle on him, and started him on LaminOx and PQ-DC. He started losing weight and by now got to close to his ideal weight, I think. His latest bloodwork wasn't great, but markedly better than in the spring. I will re-test him again in a couple of months (and also do TRH stim) to see if this can help with the diagnosis. With decreased adiposity I'm also hoping that his insulin sensitivity might improve. 

The hay I got (analysis in Atticus's case history) appears low-carb so this should hopefully keep their insulin low. I will, of course, not leave anything to chance, and retest their levels. I do have a question about LaminOx and PQ, but I'll start another thread for that so this one stays more on-topic.

Thank you so, so much for following our journey and helping.

--
Ed P in TX 2022
Atticus's Case History
Atticus's album
Gunner's Case History
Gunner's album

Ed,

It sounds like you may be putting too much blame on adiposity and not enough on grass access. Neither of these horses can safely be allowed grass access at this time. The simple carb levels in grass are a moving target.
--
Eleanor in PA

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

I understand your concerns, Ed, but it's a mistake to think quality of life is tied to grazing. Do they enjoy it? Of course - but in this case it is analagous to really enjoying chocolate when you're diabetic. I'm not saying a horse with metabolic syndrome can never graze.  I am saying you are playing with fire when you let them. It may not be the first year but eventually you're going to be dealing with laminitis. The only way to break out of this is to get the horse sound enough to go into a significant work program. When that happens, you can start to allow some grazing. The reason for this is that the sugar and starch in a pasture are always changing. There is  the effect of weather, time of day, and also time of year/dominant species combined with those. We don't know enough to predict accurately when any given pasture will be safe.

Your safest approach is a dry lot or track system. If you have considerable pasture acreage, you can lease it to a farmer to use for hay. If you want to treat your horses, cut fresh grass then let it sit/dry on screens for at least 24 hours before feeding.

P.S. You are NOT a drag on my time!
--
Eleanor in PA

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