ACTH and Insulin Still High - Updated Case History


Jamie Miller
 

Hello. 

Walker's ACTH and Insulin Levels are still well over the reference interval indicated by Cornell. Below is a chart that shows his longitudinal progression. His ACTCH and Insulin levels went up when Prascend dose was increased.  His best levels for both ACTH and Insulin were when I split his dose between an AM and PM administration. He has always had high insulin levels, but it's only been since February that he's been tentative to walk.  His daily diet is 18 pounds soaked Timothy Balance Forage Cubes with supplements and about 1 pound of soaked non-molasses beet pulp.  He gets no hay and no grass.  I started Metformin this past Wednesday June 22nd and will have bloodwork drawn next Thursday or Friday which is about a week after starting the medication.  Other than that, I am at a loss on what else can be done to help bring his levels down and help him feel more comfortable.  

Thank you in advance for any guidance you are able to offer. 

Date
Prascend During This Reading
  ACTH pg/mL Insulin ulU/mL Glucose Leptin
12/13/2021 2 1x/day   72 >200 104 (normal) 9.86 (normal)
3/17/2022 2 1/4 2x/day split dose between AM and PM   49.3 68.59    
4/27/2022 3 1x/day   66.8 165.99    
5/20/22 3 1x/day   45.9 125.7    
6/17/2022 4 1x/day 1 scoop InsulinWise 124 131.34    
7/1/2022 (pending) 4 1x/day Metformin started 6/22/22        
           
 
--
Jamie Miller
Louisville, Kentucky, USA
July 2019
Horse: Hiram Walker
Walker Case History: https://ecir.groups.io/g/CaseHistory/files/Jamie%20and%20Walker
Photo Album: https://ecir.groups.io/g/CaseHistory/album?id=93084
Link to Profile for Hiram Walker


Eleanor Kellon, VMD
 

Jamie,

I know I just said this isn't the time of year to experiment but Walker is not responding to pergolide. I would switch him to cabergoline ASAP.  The other option would be go back to twice a day in case he metabolizes it differently, at least 3 twice a day, preferably 4. Personally, I'd go with cabergoline.
--
Eleanor in PA

www.drkellon.com 
EC Owner 2001


Jamie Miller
 

Thank you, Dr. Kellon, and I apologize for the chart looking a bit wonky in the post.  Looked alright on my end, but apparently I didn't think that one through. 

Cabergoline is a new thought for me.  Does the vet prescribe this medication? What is the best administration?  Will it help ACTH and insulin levels? And, do I continue with the Metformin while on the Cabergoline?

I appreciate your guidance. 
--
Jamie Miller
Louisville, Kentucky, USA
July 2019
Horse: Hiram Walker
Walker Case History: https://ecir.groups.io/g/CaseHistory/files/Jamie%20and%20Walker
Photo Album: https://ecir.groups.io/g/CaseHistory/album?id=93084
Link to Profile for Hiram Walker


Eleanor Kellon, VMD
 

Yes, your vet has to prescribe it. It is given as an intramuscular injection every 10 to 14 days (usually 10). Your vet can teach you how to do it. It is addressing ACTH which in turn will lower insulin. Walker is a breed prone to metabolic syndrome but since his laminitis was relatively late in life it is likely the PPID has played a major role. Metformin won't help with insulin related to uncontrolled PPID but it could help with any baseline EMS he may have had.
--
Eleanor in PA

www.drkellon.com 
EC Owner 2001


Jamie Miller
 

It sounds like keeping him on metformin would help the EMS, but giving the Cabergoline to address the PPID might bring the insulin down too. What would be optimal? Stop Prascend and metformin, start Cabergoline? Or, switch Prascend for Cabergoline and continue Metformin? Also, when should he be retested after starting Cabergoline?

Additionally, his knees are puffy. Fronts worse than back ones. I've iced them, but it's not really helping. Any suggestions to address that? I'm not 100% sure it's really good/laminitis related. 
--
Jamie Miller
Louisville, Kentucky, USA
July 2019
Horse: Hiram Walker
Walker Case History: https://ecir.groups.io/g/CaseHistory/files/Jamie%20and%20Walker
Photo Album: https://ecir.groups.io/g/CaseHistory/album?id=93084
Link to Profile for Hiram Walker


Eleanor Kellon, VMD
 
Edited

I would stop Prascend and start cabergoline, continue metformin for now. There is no published research on cabergoline in PPID but there is on cabergoline and prolactin, which is controlled by the same dopaminergic neurons that control ACTH. Here are some references for your vet

http://www.j-evs.com/article/S0737-0806%2812%2900910-0/abstract

 

http://etd.lsu.edu/docs/available/etd-04162012-095021/unrestricted/Hebert_thesis.pdf

 

http://www.j-evs.com/article/S0737-0806%2813%2900964-7/abstract


Do you mean knees and hocks? That wouldn't be laminitis related. It could just be arthritis but I would definitely test for Lyme disease at Cornell with the Lyme Multiplex. Lyme can also worsen laminitis.
--
Eleanor in PA

www.drkellon.com 
EC Owner 2001


Eleanor Kellon, VMD
 

There is only one source of cabergoline, BET Pharmacy.  See the cabergoline intro document in our files https://ecir.groups.io/g/main/files/3%20Cushings%20Disease%20-%20PPID/Cushings%20Disease%20Treatments/Cabergoline .
--
Eleanor in PA

www.drkellon.com 
EC Owner 2001


 

Jamie, if you decide to switch to cabergoline, I highly recommend putting him on APF a few days before, if he’s not already.
--
Martha in Vermont
ECIR Group Primary Response
July 2012 
 
Logo (dec. 7/20/19), Tobit(EC) and Pumpkin, Handy and Silver (EC/IR)

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