Australian testing help for vet tomorrow


fvanruth@...
 

Hi,
For Australian testing. 
Vet is coming to test tomorrow. 
Has anyone successfully used IDEXX for endogenous ACTH and accurate insulin and glucose?
 
Vet has glucometer but wondering if I should push to send and test glucose with insulin for the sake of accuracy and ECIR has not mentioned or recommended testing with IDEXX??
 
Also any suggestions for other tests that could be relevant for 12 year old mare for hormone / minerals or anything else for health check while the vet is here??
 
Thank you. 
--
Freya, NSW Australia, temperate climate, joined 2021.


Maxine McArthur
 

Freya, most vets here have an account with either Idexx or Vetnostics. No problem with either. These labs are probably not appearing in posts on the group here as the majority t of our members are in North America. You should do ACTH, insulin and glucose. Make sure the vet knows the protocol for the blood draw for ACTH as it is not the same as the others (vets are usually familiar with the protocols for insulin and glucose). The vet should use a purple-topped EDTA plasma tube for the ACTH. The blood should be kept chilled and spun (with a centrifuge) within four hours of the blood draw. Usually the vet will take it back to their clinic to do this. If your vet is on the road all day and won't return to their office/clinic until evening, you might like to volunteer to take the blood to the clinic so that it can be spun down in time--this is what I often do. Usually the vet will freeze the spun sample overnight and send it off to the laboratory the next day via courier. Some vet practices have daily collections so they may not need to freeze and send the next day. 

Unless you have a particular concern with this mare, I'd just do the above tests. But you could consult your vet if you think there may be other issues. 
--
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

 


Kirsten Rasmussen
 

I'd push to have the glucose done by the lab.  If you get glucometer and lab results it will be interesting to compare 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


fvanruth@...
 

Thank you for the info Maxine, this is very helpful.  Yes, lots of great information for USA!!  We have only had a cattle vet in the area until recently. He will be here this afternoon so hopefully he should be able to spin it within 4 hours.  I am very concerned because her fat deposits are not shifting after being on low sugar teff, minerals and the protocol so hopefully the testing can be done accurately so I can help her better. 

--
Freya, NSW Australia, temperate climate, joined 2021.


fvanruth@...
 

I definitely will. Thank you for highlighting this as it’s what I have read for best accuracy. I really need it to be accurate as I think there is something else going on that is preventing her from losing the fat deposits. 
--
Freya, NSW Australia, temperate climate, joined 2021.


Maxine McArthur
 

Just a thought, Freya—is she sound enough to exercise? Exercise is the best insulin-buster, provided the horse is not actively laminitic. 


Would you have a friend or family member who could assist you to get a case history done? If we had more details we might be able to offer more useful suggestions. 
--
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

 


Kirsten Rasmussen
 

Make sure the vet keeps the blood draw on ice until they can spin and freeze/refrigerate it.  You can have ice packs and a cooler ready for them to use, just in case.

--
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


fvanruth@...
 

Thank you Maxine, I completely agree. I have been riding up until a week ago. Her pain, fat pads and lumps are increasing. She is in more pain every day over the past 10 days so exercise is much more limited now. I definitely would get help if I could but very isolated unfortunately and not good with technology. I would need to do it for 13 horses.

The vet refused to test for ACTH despite me asking to test 3 of them one still hasn’t shed his winter coat. He did not have ice despite me asking (it is now very warm here) and me sending him the link to the ecir recommendations and he said that it is incorrect. I feel like I am living in a third world country with this. He also did not want to do the glucose but I said I need to know the glucose otherwise it’s not worth doing and he did NOT like that at all.  

He just sent through the results of the horses that were tested. I don’t know why some do not show a number, I don’t think that it is accurate or worth the money time and effort not to do it properly, it just doesn’t make any sense to me. I am extremely frustrated and upset about it. I am not asking for it to be done correctly for the fun of it lol -



--
Freya, NSW Australia, temperate climate, joined 2021.


fvanruth@...
 

I did not see this until now.  That would have been the thing to do, however he was not happy about me asking him to do it at all and did not believe in any of this so even if I had the ice I honestly don’t think he would have used it. 
--
Freya, NSW Australia, temperate climate, joined 2021.


Kirsten Rasmussen
 

Sounds like it would have been a wasted effort, unfortunately.  Are there any other vets you can get out?  Can you post your testing results?

I re-read your previous posts and it sounds like 13 horses are overwhelming....it would be for anyone.  I doubt ALL of them have metabolic issues but if some need special care, like your Spanish mare, they might do better where they can be on a dry lot and fed soaked hay.  I'm afraid it will be very very hard on all of you if you can't keep her, and any other metabolic horses, off the grass.  Maybe if you could condition her up as if she was going to be endurance racing she could handle grass, but she needs to be sound for that so it's a catch-22.

--
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


fvanruth@...
 

Thank you Kirsten,

How do I post the test results?
I copied any pasted the results that the vet wrote on scrap paper above but it pasting the photo above didn’t work…. I am guessing copying photos in here does not work. I will write the 5 test results out below. I have asked him to email me the actual lab reports as some do not have numbers next to them - does this mean that the sample was not good / not handled properly?. 

They are all metabolic to varying degrees, except for the youngest one (who is #1 in the test below and was eating high sugar grass with a greenguard grazing muzzle prior to the test).  

It’s in their genetics (Portugese and Spanish). They are all related and cresty. It was much easier before I moved and then it started raining 12-18 months ago and hasn’t stopped. This grass is super high in sugar.

The calculator for Marcella’s results with the higher glucose looks concerning. (If it is accurate)??? She is struggling with increasing foot pain, obese, fat pads, cresty neck - 
G/I Ratio - 5.67 
RISQI Calculaton - 0.22
MIRG Calculation - 6.4

G/I Ratio
RISQI Calculaton
MIRG Calculation
 

 

Insulin and Glucose Mmol/ L

1 - Insulin <20  Glucose Low (the first one tested an the longest in the heat)

2 - Insulin 23.4 Glucose 3.4

3 - Insulin 21.3 Glucose 3.5

4 -Insulin 37.5 Glucose 2.6

5 - Insulin <20 Glucose 6.3 

(#5 - Marcella Spanish mare foundered 1 year ago)


--
Freya, NSW Australia, temperate climate, joined 2021.


Kirsten Rasmussen
 

Ok, I would not trust any of those results.  Glucose is too low in all of them except Marcella.  Anything below 4.7'ish is very suspicious.  Definitely get the original copies.  Hers is probably only higher because it is extremely high already (ie, above the upper lab reference range, in the diabetic zone).  Did your vet use the glucometre?   Then you could compare the data to confirm Marcella's glucose number. 

You can't be sure without reliable numbers, but you can largely go by the physical signs you're seeing.  If Marcella is eating soaked low sugar hay already(?), then you may need to consider medication.  You need to find a supportive vet to help you get reliable testing done (insulin, glucose, ACTH) and who is willing to prescribe meds that help lower insulin for the horses where diet isn't working (Metformin, and if that doesn't work then Stelgatro).

--
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


fvanruth@...
 

Hi Kirsten,

I completely agree and that is what I was thinking and concerned about. 

Despite asking multiple times for the pathology results I was ignored.  Have you heard of in house insulin testing??  This is what I learned he did   

Do you know how  accurate are in-house insulin tests done by the vet?  Some do not have numbers. 
 
I was under the impression that the insulin, glucose and ATCH was being sent to idexx and had asked for the glucose to be sent with the insulin for testing (as well as the glucluometer reading) so that I could do the formulation and ECIR recommendations for 5 of the 13 horses. I originally asked to use gribbles to do the leptin as well and he said he uses idexx not gribbles and idexx don’t don’t do leptin……. 
 
It has been 2 weeks and insulin results do not all have numbers see photo of results from vet below.  I also definitely don’t trust these results as some of the tubes sat in the sun for an hour. 
 
It cost over $1000 and I am feeling very upset about this and extremely frustrated and think it was a complete waste of money and time and I I can’t make informed decisions about the horses. 
 
I have requested the pathology result forms a few times with no response.  I pushed it with their office today and found out that it was “in house results”, so no result forms.

where to from here?  I am finding it really hard to write to the vet that this is not what I was expecting and try to ask for a retest through the lab that I thought it was being done through.  

Does ECIR recommend in house insulin testing if it has been handled correctly? 

i have not heard of this before. 

I feel like am talking in a foreign language that the vet doesn’t want to understand. 

he is the only vet in the rural area unfortunately. 
--
Freya, NSW Australia, temperate climate, joined 2021.


Kirsten Rasmussen
 

We do not recommend in-house testing.  If it's your only option it's better than no testing, but the samples MUST be handled correctly each time for the results to be useful.

Photos and attachments don't come through in messages.  You have to start a photo album in our Case History sub-Group and provide the link to it if you want us to look at it.

You already know your mare is having problems.  You can probably identify other horses in your herd that are going to have problems based on physical signs (crest, tender on gravel, fat pads).  My focus now would be to set up your management practices so you can keep those horses off grass and feed soaked hay, or low sugar tested hay.  This might mean bringing them into a grass-free paddock or barnyard for hay meals, then turning them out with a closed muzzle for exercise.  Maybe you can modify the Greenguards by adding a heavy duty mesh barrier to them.   Once you have this, or another, system in place, you could revisit testing to see how they are doing.

--
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


fvanruth@...
 


Hello Kirsten,

Than you a million for your dedicated, informative and awesome help. My horses and I really appreciate it. 

I have a lot of questions, I apologize. This is really really hard.

I wish I wasn’t having so much trouble with the vet and the testing.  What is the difference between an in-house insulin test and the lab test and have they been validated tested to be comparable (if handled correctly). it would be difficult if there are many different brands and therefore much variability I would presume.


I am going to be getting computer so I can download the histories, details  and photos. 

If the horses were eating high sugar grass for 9 hours before the glucose/insulin test would you expect their glucose levels to be higher than these results are like with people eating sugar?  Are there any studies showing this?  


These in-house tests cost over $1000 and I need to somehow politely try to get the vet to understand this so that I can have them retested and I take the blood myself.   

Could Marcella have diabetes?  Is it true that testing glucose is meaningless as the vet said below unless doing a fasting glucose test? I pushed for it to be sent solely for the purpose of accuracy (thinking it was being sent to IDEXX) and I am glad that I did but he did not say that he was not sending it off or doing this in-house test.

is there any research showing that the insulin is highly likely to be inaccurate if the glucose is low below 4.7ish??

Yes, unfortunately they all have lots of signs of crests, fat pads, strong pedal pulses and pain.  I had been following the ECIR protocol with strictly soaked and low sugar teff in slow feeder nets, minerals, trim. It is no longer possible to continue to sustain this slow feeding in yards with so many horses and I need accurate information and help to make some major decisions with management and letting go of some who are in pain and that I can not help. It is cruel I can’t keep them suffering it’s not right.  and It is emotionally, physically and financially heartbreaking and devastating. They are my life, family, love and passion  

They are suffering with thrush and separation from the extreme prolonged mud conditions so have been recently letting them out with greenguard muzzles for the first 1/2 to 3/4 day. I don’t have any dry area, barn or shelter at all it is either mud yards or sodden sugar grass paddock. it is a Noah’s arc Groundhog Day here for 2 years and much extreme flooding. The drought was better for them. 


Hay comes from Melbourne 18 hours away and is very expensive. 

Below is the first reply I have received from the vet this whole time after many requests for the pathology reports. This is after I finally contacted
 his secretary/wife (E) because he was not responding and they learning about the in house test.


I understand he has different opinions. Is there anything research wise I could send regarding usefulness of testing glucose (for accuracy)/leptin (I’m sure it would be high but would be further confirmation and give a level) and help me to decide who needs to be managed at a higher level.

I’m sure that others have experienced this difficulty also.  Please let me know if there are any suggestions or information/research I can forward to the vet or how I could respond. I am really stuck and need help with what to say and how to say it. High functioning autism is challenging for me also and I need some guidance. 

I was under the impression he was using IDEXX from our discussion not an in-house test that I have never heard of before. 


Dear Freya,


I have been speaking to E regarding your correspondence with her. 
Unfortunately something has gone wrong with the ACTH sample and it did not reach the lab, this has happened in the past due to issues with the courier. This will need to be resubmitted. Unfortunately this is the nature of relying on courier services to send samples interstate.  
As E told you, the insulin and glucose was processed in house as is routine. This is much cheaper than sending them to an external lab and has been well validated. The results were sent to you as soon as we processed the samples.
Glucose is quite meaningless in this context. In the many dozens of EMS horses that I manage every year we do not measure glucose unless we are performing an oral glucose tolerance test. The literature suggests that in a non fasted sample, insulin is the most sensitive and reliable screening test for EMS. 

If you have any further questions regarding the pathology results and how to manage your horses according to these results please reply to this email.


Regards,
C

Dear (E),
When I called the vet I specifically asked to test for leptin, insulin , glucose and ACTH through Gribbles pathology as per the ECIR protocol.  The vet said he only uses idexx and they don’t do leptin after I had asked to use gribbles to include the leptin as per the EVIR recommendation that I am following. 

 

When the vet was here I asked for the glucose to be sent away with the insulin to check for accuracy and compare it with the glucometer test to determine any differences for future reference.  At no stage did I hear anything about an in house insulin test.  I would not have gone ahead with the testing had I known this prior to looking into it first.  I have now checked and it is recommended for what I need it for as per the ECIR protocol I am following. 

 

For the testing to be accurate it needs to be handled correctly according to the protocol. This was not done.  



Freya, NSW Australia, temperate climate, joined 2021.


Kirsten Rasmussen
 

Generally, we rely on labs that have statistically determined reference ranges for their results.  For glucose, leptin and ACTH the reference ranges are a good measure of 'normal'.  There is variability in the insulin assays used, so insulin reference ranges can also vary.  For insulin, normal results are highly dependent on what the horse has recently eaten, so when we recommend a horse be fed forage only (grass or hay) prior to pulling blood, we expect insulin to be less than approx 15 uIU/ml in a horse that does not have EMS.  Insulin is less sensitive than glucose to degradation from incorrect handling, but is affected, too.  If your samples had been handled differently (kept on ice), the in-house values would give you some idea of your horses' metabolic status.  You could point out that some of the glucose numbers are too low to sustain life, and ask to have the blood redone in-house for free with the guarantee that the samples will not be allowed to degrade before testing.  That might be an acceptable compromise, especially if you do the blood draws yourself and drop them off.

Keep in mind that pasture is not always sugar-laden and it's possible that insulin could be low even after 9 hours of grazing.  It depends on weather, time of day, stresses, etc.  If you're doing turnout, the best time is very early in the morning and after a warm night.  Rainy or cloudy days are also safer.  As soon as sun hits the grass, it starts to photosynthesize and make sugars.  Late afternoon/early evening on a hot sunny day will be when sugars peak.

A normal glucose on forage, regardless of whether its pasture/hay, is approx 5.6 pmol/L, and anything less than 5 starts to become questionable unless the horse is fasted.  It can be higher if the diet is inappropriate, even reaching the diabetic range, but if diet is corrected it should still normalize.  If the horse truly has diabetes, it likely has very advanced PPID, very low insulin, and glucose will not normalize.  You should see other signs indicative of advanced PPID (loss of topline and other muscle mass, polyuria/polydypsia, immune system issues like skin issues, soft tissue injuries/breakdown) if that's the case.  And an ACTH test would be in order.

Leptin is not needed, save your money.  We know now it is more closely related to being overweight.  It will not help with diagnosis.  As your vet said, insulin is the best parameter used for diagnosis.  As you know, we recommend glucose alongside insulin and ACTH primarily to monitor sample degradation.  Even a relatively small decrease in insulin or ACTH can result in a false negative result.  For example, if your horse's insulin is actually 20 uIU/ml after eating only pasture for 9 hours, that horse likely has EMS.  If glucose is low,  you can bet that their actual insulin was higher (we don't know how much higher).  You have 3 positive results despite the low glucose.  If it's 15 uIU/ml, that horse is in an equivocal zone where knowing the glucose-insulin ratio can help with diagnosis, as per the Diagnosis page on our website.  If it's 10 uIU/ml, the horse likely does not have EMS, but if glucose is low the actual insulin would be higher, making this a false negative.  Glucose can also help detect diabetes if that's a possibility (very rare, but a possibility for Marcella).  Refer him to the Diagnosis page on our website.

Try to find some common ground on which you and your vet can agree and work outwards from there.  You both agree insulin is crucial in a non-fasting test, and you want the most accurate insulin results possible.  You may have to ask him to "humour you", put the sample on ice, keep it refrigerated at the office, and do glucose "just to see".  He's not wrong, he's just not following what we recommend to get the most reliable results, and because of that your first round of blood tests cannot be trusted beyond showing that horses 2-4 are positive for EMS.

--
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


Kirsten Rasmussen
 

Hi Freya, just want to make sure you see this new post with a link to research on insulin degradation at room temp:
https://ecir.groups.io/g/main/message/285092

Specifically:

"Insulin was stable at room temperature for 24 hours in both centrifuged and whole blood collected in K+-EDTA tubes. In contrast insulin levels decreased in serum gel tubes both centrifuged and whole blood (66% of baseline, p = 0.01 and 76% of baseline p = 0.01, by 24 hours respectively). C-peptide and insulin remained stable after 6 freeze-thaw cycles.

Conclusions

The stability of C-peptide and insulin in whole blood K+-EDTA tubes negates the need to conform to strict sample handling procedures for these assays, greatly increasing their clinical utility."


--
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