I have a 5 yr old quarter horse gelding named Banjo. He has had recurring bouts of laminitis since Dec 2020. The first bout was diagnosed by a vet and was treated with bute, pentoxifylline and proper trimming, which seemed to work. 

In October of 2021, he had another bout that was diagnosed by a vet as "winter laminitis" triggered by the cold weather. We kept his feet warm with boots and legs wraps which helped a little bit. When the temperatures got warmer he was less sore. In the extreme cold -25 Celsius and colder, he would be so sore that he didn't want to walk. The vet suggested large doses of bute and cromolin sodium to rub into his coronary band. The farrier put on new balance shoes which seemed to help a little bit but not very much. In March 2022, the farrier added pads to the shoes but Banjo was still pretty sore. 

In April 2022, he got an injection of laminile into his digital arteries and that didn't work. 

In May 2022, we switched farriers, he took the pads off and found an abscess in the fright front, he also pulled the toes back and left the heels alone. Keeping the horse in soft ride boots seems to keep him more comfortable. Some days he is pretty sore and other days he's not sore at all. 

In the end of September, we moved him to a stable where he can be stalled at night and turned out to a dirt pen during the day. We also got him trimmed at the end of September and we found an abscess in the left front. It was a week since that trim and it seem like he's getting worse so at this point I'm not really sure what to do. Its was 7 days post trim on October 19th and he was still pretty sore, on the 21st and 22nd he was doing pretty good, didnt seem sore at all and now today he was really sore. I'm not really sure what to do because I haven't changed anything.

All of his picture and the case history form are in the Case History group. 

Any suggestions would be much appreciated.
--
Kay Humphreys
Edmonton, AB, Canada, 2022

https://ecir.groups.io/g/CaseHistory/files/Banjo%20and%20Kay

Hello Kay

Welcome to the group! 

1) To add your photo album, you can goto https://ecir.groups.io/g/main/editsub and add your this to the box which says SIGNATURE:
Photo Album: https://ecir.groups.io/g/CaseHistory/album?id=279517 (be sure to hit a space or enter/return after the link to make it go live/clickable)

2) You don't seem to have info in your CH on his weight and body condition. Useful to body condition score your horse and estimate his weight using the calculation method, information on both found here: https://tomstests.groups.io/g/main/files/ECIR%20Files%20Copies/Body%20Weight
If he is overweight, reducing his weight can help lower in his insulin as well.

3) Putting Banjo on the Emergency Diet asap will usually help lower insulin. Emergency Diet can be found on the lower part of this page: https://www.ecirhorse.com/DDT+E-diet.php and more details on Diet can be found in the DIET section of our welcome letter below (including the same link to the Emergency Diet). I would remove the Hoffman Hay Saver - can't find information on the ESC or starch on their site but the ingredient "mill run" would usually increase starch and appears to be the 2nd ingredient on the list. 

Your CH mentions Hoffman ration balancer 1/2 cup. Do you mean Hoffman's BalancIR? This is relatively safe as a carrier but is not actually designed as a ration balancer and is not a replacement for mineral balancing as described in our Diet recommendations. https://ecir.groups.io/g/main/topic/32462923

The list of acceptable balancers and advisable carriers are also in the Diet section below.

4) Some of our members in Canada use Timothy Balance Cubes or beet pulp (rinsed, soaked and rinsed till the water is pretty clear) https://ecir.groups.io/g/main/message/274589 (This link also talks about Mad Barn who carries one of our acceptable mineral balancers and is a source that can help with custom mineral mixes in Canada).

5) Not sure what Laminile is that you mentioned was given by infusion. In any event, if this is a case of winter laminitis, Dr Kellon has written a useful article here: https://drkhorsesense.wordpress.com/2017/02/06/winter-laminitis/

There's a lot of information below in our welcome letter so please take the time to go through it and ask if you have more questions.

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 etiquette, what 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.

EXERCISE: The 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. 

--

Hi Kay,

Welcome!  I, too, have a ualberta email address so your post caught my eye right away!

Agree with Sherry's suggestion to get markups done on your trim photos.  In some ways the trim has improved, in others it has degraded.

As I look thru your case history, there are a few things that jump out. 

Cut the Hoffmans.  Their minerals are adding way too much iron to Banjo's diet, and iron will worsen IR.  It's best to have your hay tested and buy a commercial product or get a custom mix to balance your hay.  This benefits all horses, but especially IR horses.  I use Nutrilytical in Calgary for hay testing.  They will mail you a hay probe if you don't have one.  They send their equine samples onwards to Equi-Analytical in New York.  Request the 603 Trainer package.  This will give you the most accurate carb testing plus the minerals you need to balance your hay.  If you can't test your hay, your best option is to feed Mad Barb's Amino Trace+ at 200g/day.

The Hoffmans hay saver can be replaced with rinsed-soaked-rinsed beet pulp, soaked soy hull pellets, or Ontario Dehy Timothy Balance cubes.  Feed Store to your Door, just outside Edmonton, sells the ODTBC, and I think they sell soy hull pellets, too.

The insulin on Sept 28 was too low for acute laminitis.  It may have risen since then, OR more likely you are dealing with abscesses, which are more painful than laminitis.  Keep giving the jiaogulan, considering Epsom soaks or dry poulticing, and cut out any NSAIDS, which only prolong the episode and may prevent it from resolving, meaning the abscessing will recur. Getting the trim adjusted can speed this up, or it can mobilize more abscess collections. 

I strongly recommend all future bloodwork be the PPID package offered by Guelph University.  It includes insulin, glucose and ACTH.  Banjo is young enough that PPID is extremely unlikely, but it might be cheaper to get that package than it is to request insulin and glucose alone.

--
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