Banamine/Gabapentin/Pentoxifylline


Alysoun Mahoney
 

My ~1,200 lb 13 yo TB Charlie was diagnosed with laminitis/founder on Tue June 7. No history of founder though there is some in his lineage; he has other racing related damage to his legs and thin soles. My vet team prescribed twice daily doses of 10 cc Banamine and 11 400-mg tablets Pentoxifylline, plus thrice daily doses of three 600 mg Gabapentin tablets. They want to taper down slowly because they are afraid he will flare back up, but are we tapering too slowly? The only med reduction they have authorized so far, beginning yesterday June 14, is from three to two of the daily three 600-mg tablet doses of Gabapentin. He has been on continuous stall rest, and the vet recommends that the next step tomorrow should be to give him access to the barn aisle in addition to his stall (equivalent to a total of about 4 stalls), and hold off on further med reduction a bit longer. I see in your literature that Banamine is not recommended for more than five days, but Charlie is now on day 9 and I am concerned. How do I reconcile the different recommendations?
--
Alysoun M in PA 2022


Eleanor Kellon, VMD
 

We focus on finding and removing the cause rather than masking the results.  These medications don't actually treat anything. Pentoxifylline doesn't work https://pubmed.ncbi.nlm.nih.gov/10338160/  although he is getting a much higher dose than used there.

What do they suggest is the cause of this? Could you post a picture of him (body) in our case history subgroup? This group deals with endocrine related laminitis and that would be extremely rare in a TB unless he has Cushing's disease.
--
Eleanor in PA

www.drkellon.com 
EC Owner 2001


Alysoun Mahoney
 

Thank you for the quick reply, Dr. Kellon. 

I can post Charlie’s photo and case history later today per your recommendation. He is stocky for a TB but not overweight. 

He has Secretariat in his lineage — is it known what caused the liaminitis that intimately led to Secretariat being euthanized?

My vet team does plan to do labs, but recommended waiting until Charlie tapers his meds. I understand that they are assuming insulin resistance until we can prove otherwise, and have directed diet changes. This seemed reasonable to me since endocrine factors are overwhelmingly the cause of laminitis in equines generally, and the other common causes of laminitis don’t seem to make sense in his case. 

I initially thought his lameness stemmed from having work done on my barn aisle — which exposed coarse gravel for a week, and necessitated keeping my horses in the pasture for 48 hours straight (with water and a run-in). My vet thinks this was purely coincidence.

Alysoun

--
Alysoun M in PA 2022


Alysoun Mahoney
 

Thank you again! I just set up a photo album in the case history subgroup, and posted left and right body shots of Charlie in his stall an hour ago, together with left and right fore lateral x-rays from last Friday June 10.

I will work on the full case history as soon as I am done caring for him and my other animals later today!
--
Alysoun M in PA 2022


Sherry Morse
 

Hi Alysoun,

Please add the photo link to your signature https://ecir.groups.io/g/CaseHistory/album?id=275965 

To do that:

1) Go to this link to amend your auto-signature: https://ecir.groups.io/g/main/editsub

2) Look at the bottom of that page for the with your name, general location, and year of joining.

3) Paste the link to the photo album (and case history folder once you have it) below your current signature and add a space to make the link live.

4) IMPORTANT: Scroll to the bottom and hit SAVE!




Trisha DePietro
 

Hi Alysoun and welcome to the group! This is your official welcome letter and it is full of information regarding Insulin Resistance, laminitis, as well as PPID ( formerly Cushings Disease). I see you already loaded some photos and xrays- Sherry gave you instructions on how to make them part of your signature for ease of reference. When you complete your case history form you will see how to add that as a link to your signature as well. The diagnosis for any horse is the key to treatment. As you read through the welcome information, you'll see how it all fits together and what you can do to help Charlie feel better quickly. 

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. --
Trisha DePietro
Aug 2018
NH
Dolly and Hope's Case Histories
Dolly's Photos 
Hope's Photos 
Primary Responder


Eleanor Kellon, VMD
 

With older TBs, or older stallions in general, it's almost always PPID causing the metabolic issues.
--
Eleanor in PA

www.drkellon.com 
EC Owner 2001


Alysoun Mahoney
 

I’m getting Charlie tested for Cushings and IR on Friday. But he is 13 - not really old.

I’m scared of Pergolide after a bad experience with my other TB former racehorse, who I just had to euthanize on Tuesday at age 24. Vet prescribed the drug last April after one elevated ACTH level and some top line muscle loss. His appetite tanked from that point on — and he was a hard keeper to begin with. After four months and two normal ACTH levels, we took him off the Prascend last August. His appetite improved but never recovered — and vet found from blood and ultrasound that he had irreversible liver damage. 

So I’m wondering if Pergolide triggers something in horses who were given performance enhancing drugs while racing. Charlie is known to have been given thyroxine powder; other drugs are not well documented.

--
Alysoun M in PA 2022
https://ecir.groups.io/g/CaseHistory/album?id=275965 


 

Pergolide is metabolized by the liver and I can imagine that it might be an issue in a horse with compromised liver function.  Tylenol and some NSAIDS are toxic to the liver and I think those drugs might get used in the racing industry.  I don’t know what the rules are on racing while medicated but it could be used a lot between races.  If your vet tested for liver function before Charlie is started on pergolide, would that ease your concerns? 
--
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
 

Alysoun,

I don't doubt the pergolide was affecting appetite but liver issues are more likely from previous damage. Anabolics for example. That said, I think you are correct that pergolide on top of pre-existing liver damage may be a perfect storm scenario https://www.ncbi.nlm.nih.gov/books/NBK548593/ .
--
Eleanor in PA

www.drkellon.com 
EC Owner 2001


Alicia Harlov
 

I agree PPID would be helpful. You mentioned on Instagram that the ECIR folks said this was mechanical founder. I don't see that anywhere, can you link those comments and/or rads? 

If the sole is thin and there are long toes and hoof capsule rotation, the health of the foot is compromised. It is a symptom, not a cause. We want to find the root cause and remove it. 

--
-Alicia Harlov in South Hamilton, MA 
PHCP hoofcare provider, The Humble Hoof podcast
Member since 2017 (previous email address)


Eleanor Kellon, VMD
 

Alicia,

Long toes and hoof capsule rotation (bones in normal alignment, hoof capsule overly forward) are not effects. They are a cause.   That doesn't mean there isn't something else going on too but those are trimming errors.
--
Eleanor in PA

www.drkellon.com 
EC Owner 2001


Alysoun Mahoney
 


Lavinia Fiscaletti
 

Hi Alyson,

Thanks for adding the radiographs:

https://ecir.groups.io/g/CaseHistory/album?id=275965

Based on the rads, there are definite mechanical issues that are at the very least contributing to Charlie's lameness issues.  His trim is definitely problematic. His toes are too long horizontally - more so on the LF. Walls are flaring all around and his heels are underrun. Soles are thin. There is a dark area at the tip of the coffin bone on the LF that may be an abscess or gas pocket. RF appears to have some of the dorsal edge of the coffin bone missing, with a detached, opaque area ahead of it that might be the "missing piece". The RF also has numerous areas of inflammation/calcification along the back of the pastern bones.

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


Alicia Harlov
 

I understand what you're saying in regards to the trim not allowing for correct hoof capsule alignment with P3. I meant the endocrinopathic cases I trim tend to overgrow toe which needs a lot of correction, and lack laminae integrity resulting in hoof capsule rotation. 

I have also trimmed neglect cases where long toes did not result in rotation. I have only seen one case of mine where it's possible long toes caused hoof capsule rotation, but the foot overall was weak, and the horse actually wasn't painful. In my experience, a weak hoof capsule is more apt to distort or rotate with an improper trim than a strong hoof capsule. Trimming for a breeder who doesn't touch the feet until the horses are sometimes 3 or 4 years old was pretty interesting - long toes didn't mean they were all laminitic. That's the only point I was expressing. 

--
-Alicia Harlov in South Hamilton, MA 
PHCP hoofcare provider, The Humble Hoof podcast


Alicia Harlov
 

Thanks for the rads Lavinia! Looks like there's a lot of P3 remodeling and distal periphery bone loss? Is there a keratoma in the RF, or are you saying it's just a sequestrum?

Both feet look fairly unhealthy to me, so while adjusting trim I'd continue to pursue root cause. 
--
-Alicia Harlov in South Hamilton, MA 
PHCP hoofcare provider, The Humble Hoof podcast


Eleanor Kellon, VMD
 

In addition to the long toes and very thin soles, this looks like white line disease to me rather than laminitis.
--
Eleanor in PA

www.drkellon.com 
EC Owner 2001


Eleanor Kellon, VMD
 

There are also soft tissue calcifications behind the sesamoids and behind the proximal pastern. Can't tell what structures they are in. You would need an ultrasound. Bone quality of the coffin bone is not good. Can't diagnose it from these films but pedal osteitis is almost guaranteed.
--
Eleanor in PA

www.drkellon.com 
EC Owner 2001


Alysoun Mahoney
 

Thank you so much for the feedback, everyone. I did move from MD to PA last year, and struggled to find a new farrier who was taking new clients — even when my vet made a referral, that farrier declined. After months of searching, I had every reason to believe the farrier I ultimately found last April was doing the right things — until seeing some of the comments here. Charlie last had X-rays that same month and the vet had no major concerns at the time. Rotation is all in the last year. My vet said nothing about bone loss, so your comments on that have me concerned as well. Maybe I need to find a new farrier with more expertise in difficult cases? I see there are other PA folks in this group. Do any of you have farrier recommendations for the South Central PA region?
--
Alysoun M in PA 2022
https://ecir.groups.io/g/CaseHistory/album?id=275965 


Eleanor Kellon, VMD
 

Understood, Alicia. That's also why the walls should not be weightbearing in laminitics - or horses with poor connections for other reasons.

Capsular rotation is a bad term and confusing. Capsular displacement would be better and would apply to conditions other than laminitis.
--
Eleanor in PA

www.drkellon.com 
EC Owner 2001