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Advice on New Blood Work, Please


lindsaykrauland@...
 

I received the interim report for Audi’s new blood work from Cornell:

ACTH 31.1 pg/ml
Insulin 5.39 uIU/ml
Leptin pending

Audi has been on 3mg CP since 9/18 and has continued to be symptomatic.  Since we’re coming out of the seasonal rise now, should I increase his pergolide or hold at 3mg and see what happens?

His prior blood work was from 7/28.  His ACTH was 33.7 at that time, and he was on 1mg pergolide.  So, he’s had a really modest decrease in ACTH since then, despite now being on 3X more medication.  What are you thoughts on this?  Is it most likely due to the rise?

Finally, what do you make of his insulin?  He did have hay overnight and a small amount left in his feeder in the morning when I went to draw the blood, but I’m wondering if maybe he hadn’t actually eaten for a few hours?  

--
Lindsay in TX 2020

Audi Case History:  https://ecir.groups.io/g/CaseHistory/files/Lindsay%20and%20Audi

Audi Photo Album:
https://ecir.groups.io/g/CaseHistory/album?id=248156 


Eleanor Kellon, VMD
 

Lindsey,

I would wait until end December then retest.
--
Eleanor in PA

www.drkellon.com 
EC Owner 2001


lindsaykrauland@...
 

Thanks, Dr. Kellon! That's what I'll do.

Regarding the insulin, is that anything I should concern myself with?

The back and forth good days & bad days are driving me batty. (Today is a bad day. He looks depressed and is just hanging out near the barn.)  And his ACTH isn't exactly through the roof. Is it really plausible that a horse with ACTH in the low 30s is struggling so hard with PPID? Or is it more likely that something else is confounding things? 

--
Lindsay in TX 2020

Audi Case History:  https://ecir.groups.io/g/CaseHistory/files/Lindsay%20and%20Audi

Audi Photo Album:
https://ecir.groups.io/g/CaseHistory/album?id=248156 


Eleanor Kellon, VMD
 

The insulin is normal even if he hadn't eaten for a while.

 I can't really put any odds of whether his behavior is PPID/pergolide related or not but it's always a good idea with these horses to remember there can be many things going on which are unrelated. Take his temp and pulse, monitor food and water intake, manure production. See how he responds to grooming or going for a walk. Get your vet out if concerned.
--
Eleanor in PA

www.drkellon.com 
EC Owner 2001


lindsaykrauland@...
 

Thanks again! 

I suppose I was just looking for some general trends along the lines of whether it's typical or very rare for a PPID horse to struggle when his ACTH is as close to "good" as Audi's seems to be. If it's very unlikely this is all PPID, then I can justify the trouble and expense of running down other causes. On the other hand, I know I have heard from other members here that their horses really needed ACTH levels to be controlled lower than Audi's currently are, but I don't recall specifics of how minor or severe those horses' PPID signs were when the ACTH was only modestly elevated. If other horses have looked like Audi but improved when their ACTH levels came down into the 20s or so, then I feel more comfortable sitting tight and just giving Audi more time.

Audi was in to the vet on Wednesday this week. Temp normal, heart sounds good (in fact, the vet couldn't appreciate Audi's mild heart murmur, which had been present in two previous appointments), clean fecal. Manure output is normal. EPM was the only other thing that came to mind for the vet, given Audi's muscle atrophy and his habit of occasionally dragging his back feet. EPM test is pending. Audi eats well, and I've been separating him from his buddy for almost every meal so that I can monitor Audi's intake. He does eat very slowly. A 5 lb meal can take 3+ hours. Walks are hit or miss. Sometimes he goes out well and sometimes (yesterday), he just plants his feet and refuses to move on. He seems to enjoy all grooming. He has a scheduled 6mo dental appointment next week.

I am trying hard to consider all possibilities, and to be honest it's really exhausting my resources. And it's maddeningly frustrating because I'm not seeing any big improvements yet, and I'm going on a year of trying to turn this horse around. It constantly feels like I'm missing that final piece of the puzzle or something.

--
Lindsay in TX 2020

Audi Case History:  https://ecir.groups.io/g/CaseHistory/files/Lindsay%20and%20Audi

Audi Photo Album:
https://ecir.groups.io/g/CaseHistory/album?id=248156 


Lorna Cane
 

Hi Lindsay,

If Audi were here I would be, considering everything else that has been done, focus on his trim. I'm by no means an expert, but I would like to see if a tighter trim would make him more comfortable. He doesn't have to be obviously  'unsound' ( I know you know this) to be hurting. This could show up in his on again/off again behaviour.
You said, "Walks are hit or miss. Sometimes he goes out well and sometimes (yesterday), he just plants his feet and refuses to move on."
And it maybe could even account to some extent,for his weight issues....low grade pain interfering here?
Just brainstorming. I know how frustrating this can be.

--

Lorna  in Eastern  Ontario
2002
Check out FAQ : https://www.ecirhorse.org/FAQ.php


 

Lindsay, a number of us mentioned his feet in this thread so I would take to heart Lorna’s suggestion on that issue.  My experience with caring for my own collection of PPID horses is that they’ve all been different in terms of how the PPID symptoms respond to pergolide.  I spent a lot of brain power trying to make correlations and my frustration seemed to be the primary result.
--
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


 
 


lindsaykrauland@...
 

Thank you, Lorna & Martha.

I am taking the foot suggestions to heart.  I’ll share everything said here with my trimmer, and I think I’ll also crowd source some additional opinions on a hoof rehab site I’m on, just for good measure.

Still, although there may well be room for improvement in Audi’s trim, I don’t think they appear shockingly bad, and they’ve come A LONG way from when we purchased him.  I just don’t feel like the current state of his feet should be making him feel so poorly that he’s unable to gain weight, is intermittently lame, so uncomfortable that he doesn’t want to walk, etc.  At the very least, considering that his feet ARE far better than they had been, shouldn’t he have had some improvements in proportion to the improvement in his feet, if the feet were significantly contributing to his woes?  

I don’t doubt he’s painful in his lower body, but I wonder whether it’s all hoof related or perhaps more attributable to arthritis?  When we purchased him, he was on daily Previcox for arthritis in his hocks.  He’s been off that since Feb, and at that same time, we were making so many other changes to his management that I can’t say what effect stopping the NSAID might have had.  Also, I don’t know how the hock arthritis was diagnosed; I don’t have any vet records related to that, and he was clearly suffering from long-term sub clinical laminitis, so I don’t know whether any pain his previous owners noted would have been caused by the arthritis or the laminitis.  He does have some ringbone that showed up in his hoof radiographs in June.  I have him on 3 gm Mov-Ease as a joint supplement (had been 6 gm/day for months, but I didn’t notice a difference with the higher dose), plus 1 tbsp jiaogulan.  Should I consider switching to some other supplement(s) for potential joint pain?

And Martha, thanks for sharing your experience with your horses.  Have you personally witnessed any of your horses continuing to be very symptomatic with relatively normal blood labs?

--
Lindsay in TX 2020

Audi Case History:  https://ecir.groups.io/g/CaseHistory/files/Lindsay%20and%20Audi

Audi Photo Album:
https://ecir.groups.io/g/CaseHistory/album?id=248156 


Lorna Cane
 

On Fri, Nov 6, 2020 at 12:33 PM, <lindsaykrauland@...> wrote:
At the very least, considering that his feet ARE far better than they had been, shouldn’t he have had some improvements in proportion to the improvement in his feet, if the feet were significantly contributing to his woes?  
Possibly, but not necessarily. Especially if the trim still has issues.

But I defer to Lavinia.
 
--

Lorna  in Eastern  Ontario
2002
Check out FAQ : https://www.ecirhorse.org/FAQ.php


 

Lindsay, I have a large pony who has never shown an elevated ACTH, although he is undoubtedly PPID as he responds to pergolide appropriately.  At the time I first had him tested, because of his hair coat, my vet suggested I put him on pergolide even though his ACTH was in the mid 30’s.  His ACTH seems to remain about the same and I adjust his pergolide based on what I see in him.   I did not know about the TRH stim test at the time.  I could take him off pergolide for awhile and do the stim test but I feel like I have a good handle on him and don’t know what I’d do if it came back negative.  Not great science but that’s where I’m at.  

This is not to suggest there is a large number of horses out there like Handy but there are definitely some.  Handy is at least 35 now and he looks great. I put him on Phyto Quench this spring, knowing he has some arthritis, and he seems very comfortable and eager to move around.  I cannot maintain him well on hay alone but he gets a weighed amount of ODTBCubes (soaked) and a small amount of soaked hay to give him more chew time.

--

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


 
 


lindsaykrauland@...
 

Again, thank you!

My trimmer and I had some discussion this afternoon.  She’s seen this thread as well as my previous one.  She and I agree that repeat xrays would be lovely.  Perhaps we could even arrange for her to come out to my vet’s office to be present for those.  Definitely something to consider, though we’re going to kick that can just a bit down the road, as my budget only allows so many for vet bills each month.  We may also move back to a 2-week trim cycle.  He had been on a 2 week cycle for several months, but we moved to every 4 weeks a few cycles ago. 

She did bring up an excellent point, which I was totally overlooking.  Around Aug/Sept, Audi was in two full trim cycles (about 8 weeks) of first hoof casts/DIM and then a cycle of casted-on composite shoes/DIM.  He did look particularly comfortable in the shoes, and he made some progress in growing his heels and soles in that time.  However, he never gained weight, and though he looked pretty happy, he wasn’t exactly cantering everywhere.  In actuality, I witnessed a few trots at liberty and maybe 1 canter in that whole time.  It just wasn’t a night and day difference.  I am absolutely not trying to be argumentative— and believe me, I want the best for Audi more than anyone else does!  But I do feel like our experience with different footwear for Audi suggests that maybe the problem is not quite in his feet.  Thoughts?

Martha, PhytoQuench might be worth a shot, thanks!  It’s entered my radar a time or two, but I put it off for one reason or another.  I have may more questions about that later.  Thank you also for sharing more about your pony.

I may be totally off base, but I can’t get the possibility Audi has EPM out of my mind.  I wonder if his “foot soreness” and lethargy could actually be at least in part to his feeling dizzy/wobbly/weak due to neuro issues?  The sweating, though fairly nonspecific and also possibly due to PPID, could also be a sign of EPM.  Granted, that wouldn’t explain his laminitis from May nor the subsequent abscesses, skin gunk, etc— that’s all PPID, most likely— but I am really on pins and needles waiting to see the results of the EPM test next week.  If he’s negative, then I think I’ll go down the trim rabbit hole a bit more, starting with repeat rads.  But if it’s positive, I think my resources are better spent on that taking a front seat and only reassessing PPID control and feet/trim post- EPM treatment.  What do you all think?

Darn horses!

--
Lindsay in TX 2020

Audi Case History:  https://ecir.groups.io/g/CaseHistory/files/Lindsay%20and%20Audi

Audi Photo Album:
https://ecir.groups.io/g/CaseHistory/album?id=248156 


Lorna Cane
 

On Fri, Nov 6, 2020 at 04:18 PM, <lindsaykrauland@...> wrote:
However, he never gained weight, and though he looked pretty happy, he wasn’t exactly cantering everywhere.  In actuality, I witnessed a few trots at liberty and maybe 1 canter in that whole time.  It just wasn’t a night and day difference.  I am absolutely not trying to be argumentative— and believe me, I want the best for Audi more than anyone else does!  But I do feel like our experience with different footwear for Audi suggests that maybe the problem is not quite in his feet.  Thoughts?
I think the fact remains that his trim needs to be addressed. 
Now I promise, I  definitely  defer to Laviia.
I wish you would ask her,Lindsay. (if I'm off base you win. If I'm not off base , Audi wins. :-) )
 
--

Lorna  in Eastern  Ontario
2002
Check out FAQ : https://www.ecirhorse.org/FAQ.php


lindsaykrauland@...
 

Just to be clear, I don’t look at any of this as a competition, and I’m not out to “win” anything.  As far as anyone in particular offering advice, I welcome anyone to chime in.  Do I need to actually tag Lavinia in order for her to see this?

--
Lindsay in TX 2020

Audi Case History:  https://ecir.groups.io/g/CaseHistory/files/Lindsay%20and%20Audi

Audi Photo Album:
https://ecir.groups.io/g/CaseHistory/album?id=248156 


Lorna Cane
 



Sorry, Lindsay, it was a figure of speech,said in fun. No competition here at all.

I know Lavinia is always busy, so I'm not sure how often she is able to read. If I wanted to get her attention,I'd put her name in the Subject line.

--

Lorna  in Eastern  Ontario
2002
Check out FAQ : https://www.ecirhorse.org/FAQ.php


Eleanor Kellon, VMD
 

 Hi Lindsay,

There's a very simple and foolproof way to tell how much discomfort he has in his feet - nerve blocks. Blood antibody levels can't definitively tell you if he has EPM - only if he has been exposed.  CSF antibodies are the gold standard - and clear abnormalities on a neurological exam.  EPM may start out vague sometimes but it always progresses.  Sweating per se isn't a symptom, just patchy asymmetrical sweating.

His hoof form is certainly better than it was in March, but may be worse than in May. He still has severe flaring. Mineral balancing will help with the cracks and chipping but you won't resolve the flaring and sinking without a trim that unloads the walls and gets his breakover back to where it should be. That divot out of the toe on the RF is a good landmark. All hoof wall in front of the point of that triangle should be rasped back.  The 6-10 radiographs don't show any evidence of laminitis - just hoof flaring away from the bone.
--
Eleanor in PA

www.drkellon.com 
EC Owner 2001


lindsaykrauland@...
 

Thanks, Lorna, for clarifying.  I must admit, I was slightly offended at first!  I’m good now.  :)

As always, Dr. Kellon, thank you!  

Geeze, I am so confused.  If what we saw in late May- uncomfortable stance, heat in feet, subsequent hoof rings & abscesses, and worse foot health ongoing- then what on earth was it??  Also, as you noted, he did have sinking.  I thought the laminae were strong enough to hold the bony column in place unless they were stressed by inflammation?  Please understand, I’m a first time horse owner and absolutely learning via trial by fire with this guy!  I have already shared your thoughts on the RF crack as a landmark with my trimmer and am awaiting her reply.  I know she greatly respects your opinion.  As for mineral balancing, he has been on a balanced diet since April, and I feel very strongly that the cracks correlate with the hoof rings that popped up around the time of his “episode” (whatever it was) that began on 5/29.

I do realize the EPM serum test is just an antibody titer test and that it requires interpretation, similar to the ACTH tests.  That was one reason I held off on testing him when my vet first mentioned it back in June— From what I have seen, Audi doesn’t fit the typical clinical picture, and false positives can be high.  PPID certainly seemed to be a more logical explanation for what we were seeing in him.  My vet told me this past visit that he would expect the test interpretation to be fairly straightforward in Audi’s case, as he would expect levels to be quite high (as opposed to a more equivocal range) if EPM were causing Audi’s woes, given the severity of Audi’s symptoms.  He also said one of his own horses had EPM, presented similarly to Audi, and greatly improved with treatment.  Admittedly, I’m grasping at straws here, but again, I just want to help my horse, and I certainly don’t have any prior experience with any of this.

I have to admit, it was the “laminitis” that really pushed me to test for PPID.  Prior to that, I was blaming my management for Audi’s troubles.  Dr. Kellon, in your opinion, is Audi clearly a PPID case regardless of the “laminitis?”  I ask because his ACTH has never been above the particular lab’s equivocal range; he’s not showing a great response to the medication (and I did get assurance, in the form of potency testing from the pharmacy, that the pergolide I’m using is good); and his symptoms are somewhat non-specific (in my opinion).  I just feel like I’m in over my head with all this, and my horse is struggling in the meanwhile.  

--
Lindsay in TX 2020

Audi Case History:  https://ecir.groups.io/g/CaseHistory/files/Lindsay%20and%20Audi

Audi Photo Album:
https://ecir.groups.io/g/CaseHistory/album?id=248156 


Eleanor Kellon, VMD
 

Lindsay,

Let me try to explain a little more. The strength of the hoof and the laminar connections is partially genetic and partially nutritional. We can't do anything about the genetics except maximize nutrition and trim to support good health as much as we can. Sinking is caused by things other than laminitis. Horses can, and do, sink because of poor nutrition and poor trim, especially when in shoes https://hoofrehab.com/DistalDescent.htm . Every horse with "flat" feet has sinking. Poor connections and flared hooves also predispose to abscesses.

We can't say if metabolic laminitis was a part of the picture in May because we don't have an insulin level from then. I can say with the poor sole clearance he had it wasn't necessarily a factor. Just moving around or playing too much could do it. Rings don't only mean laminitis. Many things cause rings - change in diet, change in exercise. metabolic events like giving birth, any inflammation or injury anywhere in the hoof can cause a ring. Only rings wider at the heel than toe are characteristic for laminitis because they indicate rotation.

As for PPID, Yes, I would call him positive. The upper ranges on tests are determined by statistics, not medical fact. They represent odds. Unexplained loss of weight/muscle is a common sign of PPID. If you compare these two pictures, there is clear improvement:

https://ecir.groups.io/g/CaseHistory/photo/248156/16?p=Name,,,20,1,0,0

https://ecir.groups.io/g/CaseHistory/photo/248156/44?p=Name,,,20,1,40,0

Muscle at the withers has filled in.  Abdominal tone is better. Muscle at forearm and triceps is better.  Croup is more filled in and sacrum less prominent. More to go for sure, but better. Once you confirm ACTH is well controlled, generous calories and protein with regular deworming should bring his condition back.

All of that said, he certainly could have EPM or something else. I'm just saying it's not necessary to explain what you have seen.

--
Eleanor in PA

www.drkellon.com 
EC Owner 2001


Kirsten Rasmussen
 

Hi Lindsay,

I think we've implied that radiographs are needed, but you actually don't need radiographs to improve the trim.  You just need a good rasp.  I think you should start now rather than wait.  Dr Kellon has already given you your starting point: file the toe back on the right to remove the crack.  Then file the same amount from the toe on the left so both fronts look the same lengthwise.  Dragging toes can also mean the toes are just too long, so try shortening them a bit on his hinds, too.  After the toes are shorter, the sidewall flares can be reduced similarly so that the hoof appears rounded again from the sole view.  Lavinia could provide you with much more detailed advice if you retake your photos to spec, and request markups.  But she is busy and it might take a while, whereas you can start now with a file while you wait.

Not saying that trim is the cause of his weight issues, but certainly it is important in how he moves, how his feet feel, and how eager he is for any exercise.  It is soooo important to how he feels and it's so easy to start making positive changes there for little to no cost (a 40$ rasp and some gloves).

I'm glad to hear Dr Kellon's assessment that Audi is looking better.  He is a tough case but it sounds like you are making progress.  He's lucky to have such a dedicated new owner.

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


lmittler@...
 

Hello,

I'm Audi's hoof trimmer. I am working on photo comparison collages for Lindsay to post but in the meantime, I'd like to mention that Audi was extremely sore the morning after his trim on Tuesday. I don't agree with taking his toes back anymore at this time, which she and I have discussed, at least until someone gives us a good reason to risk making him even more sore. This was the first time he was sore after my trim and I have no doubt it's because I took his toes back too far this time. He was sound before the trim. He still has a sole ridge to protect his flat soles so taking more toe (and therefore, sole ridge) will put him further down on his thin soles. I'd also like to point out that you're looking at a 2D picture of a 3D form so dimensions are lost in translation. His walls are rolled off the ground, similar to but not as aggressive as a founder trim, and his breakover is further back than the end of the toe you see. Audi has been very uncomfortable during the last five trims so I do what I can while Lindsay convinces him to stand on three legs for as long as he can. I am not being defensive or argumentative about your suggestions thus far, I just wanted to add these important pieces of info so we can continue to work together to help Audi.

Lindsay is an amazing owner, the kind of owner trimmers wish they had in droves! She deserves a huge pat on the back for her efforts!! And thank you all for the information you've shared thus far. We're determined to get Audi feeling 100% and your efforts are helping us get him there.
--
Lisa Mittler
Barefoot Hoof Practitioner
South and Central Texas
January 2019


Lavinia Fiscaletti
 

Hi Lisa,

Thanks so much for joining in on this discussion regarding Audi. It's really helpful to have first hand input from his trimmer.

Sorry to hear that he has been having a tough time after his most recent trim. Some other possibilities to consider regarding the soreness is that it may be due to the changes in his mechanics that are engaging other structures that aren't used to functioning - sort of like when you start to work out and muscles you didn't even know you had start yelling at you the morning after. This can be across his entire body, not just limited to his feet and lower leg. The changes in mechanics can also cause mobilization of trapped collections of material that are now making their way out as the hoof functions differently. While this is an overall good thing, the process itself isn't always pretty. Is he currently in padded boots at all times to both help with protecting those thin, flat soles and to assist him in building stronger overall structures?

We are definitely aware of the limitations of photos vs. seeing the feet in person so ask for specific views of each hoof to help in assessing things in a more 3D perspective. Thank-you for preparing more hoof photos for Lindsay to upload - it's much appreciated. If possible, would you be able to provide the following view:

https://ecir.groups.io/g/CaseHistory/photo/243358/30?p=Created,,,20,2,20,0

This one would help in seeing more of what you are seeing regarding the sole ridge.

I can relate to how difficult it can be to work on a horse who is not able to hold up his feet to be worked on. Sometimes, it can be a downright dangerous situation.

Audi is lucky to have you and Lindsay as his advocates.

--
Lavinia, George Too, Calvin (PPID) and Dinky (PPID/IR)
Nappi, George and Dante Over the Bridge
Jan 05, RI
Moderator ECIR