Topics

Bloodwork Help - PPID and IR


Rebecca and Joe
 

New here, currently working on putting together a case study. I do not have a firm diagnosis of anything at this point and looking for help to know if I should be continuing to suspect PPID, IR, or laminitis and what if any futher testing I should do. Have had trouble finding vets in my area who can help me so if anyone knows of someone local to my area to work with that would also be appreciated. 

My guy is a 17 y/o OTTB, in good weight when it started and currently is good weight now. I had my horse tested for PPID in the Spring after becoming suspicious when he shed slow this spring. Everything else seemed normal until after a trim he became sore behind on cement and footy in general on hard ground. He was barefoot working with a good specialized barefoot trimmer. Over this summer he has had a variety of symptoms (hives/allergies, intermittent stocking up behind, suspected cellulitis, strong digital pulse all around, periods of listlessness, lethargy, sore footed on hard ground standing with all legs more under himself) X-rays showed thin soles all around as well, no signs of laminitis on x-rays. Currently he is on sparse grass paddock, free choice hay from slow feed net, low NSC feed with mineral balancer and doing well except for some days with a strong dp (maybe 1-2 out of 0-5 scale) and footsore at times especially behind when barefoot on hard ground. Trying to figure out if I'm even looking in the right place and if I should be worried about his dp and footsoreness or if it's all tied to thin soles (he got dp still some days even when in glue on easycare performance shoes and formahoof behind). 

Bloodwork so far:
5/7/20 (during height of symptoms, pulled in field when he was on full unrestricted pasture turnout) He had just started SMZs the day before and I believe had 1g of bute the day before- 

 

ACTH 15.6 pg/mL 9.08 – 45.4 

Cortisol 2.91 ug/dL 1.9 – 9.2 

Insulin 8.1 uU/mL 5.0 – 36 

T4 24.0 ng/dL 9.0 – 36 

 

Glucose 99 mg/dL 64-150 

 6/20 - Lyme from Cornell - negative

6/30 - Insulin 2.1 - after being in stall with hay (not sure if he had hay available the whole day) since 7am, blood pulled at 3pm

7/23 - Insulin 4.3 uU/mL after turnout from 7:30am-12:00pm then put in a stall with hay. Blood pulled at 4:00 appx
--
Rebecca Evans,  Lexington KY,  2020


Sherry Morse
 

Hi Rebecca,

You'll get a full welcome shortly, but some quick questions:

1- what lab was used for the bloodwork?
2 - Were ACTH and glucose checked with either of the follow-up blood tests?
3 - Did you get actual results for the Lyme test or were you just told that it was negative because while I was reading your message Lyme was one of the things that crossed my mind.

TBs don't typically present with IR unless it's an offshoot of PPID but they are somewhat notorious for having thin soles and the accompanying issues can present as something else but in that case the solution may be as simple as getting his feet in order.




Trisha DePietro
 

Hi Rebecca. Hello 

Welcome to the group! 

The ECIR Group provides the best, most up to date information on Cushing's (PPID) and 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 Insulin Resistance (IR). These are two separate issues that share some overlapping symptoms. An equine may be either PPID or 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 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: IR 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 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. 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 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 IR/PPID individuals.

We do not recommend feeding alfalfa hay to IR/PPID 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 https://ecir.groups.io/g/CaseHistory/files/Trisha%20and%20Dolly%20-%20Hope
Dolly's Photos 
Hope's Photos 
Primary Responder


Rebecca and Joe
 

Sherry:

Lab for everything but Lime was Park Equine Hospital Laboratory. No ACTH or glucose run with the second and third insulin tests. Lyme results were : OSPA: 308 Negative OSPC: 92 Negative OSPF: 136 Negative

We are in the process of rehabbing his feet and he is making slow but steady progress, I'm wanting to put him back out on grass again, but not sure if that's part of the strong dp I still get periodically. I don't want to keep him off pasture if it's not necessary. He was dry lotted for two weeks before being moved to a paddock and pulse did not really improve in that time. It has been at its best once we put shoes and formahoof on, but he has had days here and there with shoes where it's stronger than I'd like, but maybe that's just his normal? All other symptoms have vastly improved at this point (worse swelling, lethargy and allergy days seem to coincide with poor air quality). From the website info he did check a lot of boxes on symptoms for early PPID even though his ACTH was normal in May. Was wondering if I should worry about looking into that more or not.   
--
Rebecca,  Lexington KY,  2020


Kirsten Rasmussen
 

Rebecca, September-October is the time to check if he has early PPID.  All horses have higher ACTH at this time of year, but horses with PPID will have a relatively exaggerated ACTH rise.  Even if he was normal in May, he could actually be elevated now and then you would know he needs meds to get him through this time of year.  Usually fall laminitis is the first sign of PPID.  Also, issues with allergies or other immune-related problems can resolve once PPID is being treated, so it's possible there us a connection there.  The other typical signs of PPID, most notably a curly or long coat that doesn't shed, are very late signs when the disease us in a flow blown state.

I also think you should make a photo album and post some hoof photos and xrays (instructions in your welcome letter).  If it's not PPID-related laminitis, then re-evaluating his trim will be the next major line of investigation.  You'd be surprised at how many horses have trims that are not physiologically correct.

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


Rebecca and Joe
 

Kristen,

Thank you. I will look into getting him re-tested in the next month. This may be a stupid question, but if he is not PPID, IR, or EMS does that rule out some kind of subclinical laminitis from sugar in grass or hay? Or do I still potentially need to be wary of turning him out on pasture full time? So far the only symptom he's having now is a slightly strong dp. His symptoms were worse in spring and beginning of summer. I will work on getting photos uploaded as well.
--
Rebecca Evans,  Lexington KY, Aug 2020


Eleanor Kellon, VMD
 

Rebecca,

His insulins are all normal. I wouldn't bother checking that again but an ACTH in September might tell you if he's at risk for PPID.

The sugars in pasture are not an issue except for EMS horses. Pulses do not automatically mean laminitis.  They can mean inflammation but also are elevated after more movement,  hard ground, hot ground, standing in the sun or after getting up  from the ground when the legs had been folded underneath.  "Thin soles" often means underrun heels and potential negative palmar angle and that = chronic deep digital flexor tendon and navicular strain. The underrun hoof also loses much of the shock absorbing capacity of the frog and digital cushion.
--
Eleanor in PA

www.drkellon.com 
EC Owner 2001


Kirsten Rasmussen
 

I'll just add to your question about pasture: if he is actually positive for early PPID, his ACTH will need to be well-controlled by medication for him to be safely back on pasture at this time of year.  That means ACTH should be kept near the middle of the normal range, year-round, with meds as needed to be considered well-controlled.

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


Rebecca and Joe
 

Is it okay to test ACTH now,  or is it better to wait a few weeks? Also what range on results would be considered an indication of early PPID?
--
Rebecca Evans,  Lexington KY, Aug 2020


Kirsten Rasmussen
 
Edited

Hi Rebecca, if you test now there's still time to get pergolide on board if he comes back as positive, although it might not be as effective as starting pergolide earlier in July would have been.  Testing anytime before the end of October should be ok.  Normal ACTH generally doesn't go above 55 pg/mL even at the peak of the seasonal rise, so anything above that is likely a positive (subject to Dr Kellon's opinion of course).

I was looking for the week-by-week Liphook chart for normal ACTH in the northern hemisphere in our files but couldn't find it (I know we have it, WHERE is it??).  However, the link below does have a transposed week-by-week chart for the southern hemisphere, as well another file on diagnosing PPID with using baseline ACTH on the first page with a chart showing the general annual variation for normal and full-blown PPID horses in the northern hemisphere.  In both files you'll still see that ~55 pg/mL is the max ACTH in a normal horse.
https://ecir.groups.io/g/main/filessearch?o=0&q=Liphook

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


Kirsten Rasmussen
 

This might help a bit, too.  I just saw this advice from Dr Kellon to another member, who's horse came back with an ACTH of 62 at the beginning of September and has signs of increased urination/drinking:

https://ecir.groups.io/g/main/message/254365

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


 

The chart is at this link, showing ACTH by week of the year in the northern hemisphere:
https://liphookequinehospital.co.uk/wp-content/uploads/Seasonal-Changes-in-ACTH-Secretion2.pdf

--
Cass, Sonoma Co., CA 2012
ECIR Group Moderator
Cayuse and Diamond Case History Folder                
Cayuse Photos                Diamond Photos 


Rebecca and Joe
 

Thanks everyone! I got him scheduled for the blood pull Monday, but when I was talking to the vet she suggested running TRH stim instead. She said it's more accurate than ACTH in early PPID detection. I don't know anything about this test, is it safe? Is it worth the extra money to run that instead of ACTH?
--
Rebecca,  Lexington KY, 2020


Sherry Morse
 

Hi Rebecca,

This isn't the right time of year to do a TRH Stim test and the initial draw is the same as a baseline ACTH.  If the regular ACTH comes back equivocal then you might look into doing the TRH in December.  As per this message from Dr. Kellon (https://ecir.groups.io/g/main/message/254270) TRH Stim should not be done between mid-July and mid-November.




Kirsten Rasmussen
 

TRH stim is not needed during the seasonal rise because baseline ACTH will be abnormally high already if he has early PPID.  Dr Kellon recommends waiting until January before doing a TRH stim, after the seasonsl rise in ACTH is over, at which time it is an excellent test for diagnosing early PPID.  It is safe, just more expensive and unnecessary right now.

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


Rebecca and Joe
 

Joe's test results came back as 34.3 pg/mL which as I'm understanding from what everyone said means I should not be concerned about early Cushings for him. Is that correct? If then according to bloodwork he is not IR, PPID, or EMS then he's safe to build back up to full time turnout again? Is it possible that some of his symptoms are coming from an overload of allergies and backed up lymph system? He is doing well right now with the cooler temps and better air quality (other than decreased topline, and continuing to rehab his feet which do have underrun heels). Looking to avoid another train wreck next summer, but not sure where to look now. 
--
Rebecca and Joe,  Lexington KY, 2020

Case History: https://ecir.groups.io/g/CaseHistory/files/Rebecca%20and%20Joe


Kirsten Rasmussen
 

That's great news Rebecca!  Except that now you still don't know what was wrong!  My next line of investigation would be the trim.  If you want an honest opinion of it, you can post pictures here.

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


Sherry Morse
 

Hi Rebecca,

Was that test sent to Cornell?  34.3 would be at the high end of normal most of the year, but as we're at the height of the fall rise and it's below average for a normal horse without PPID I would suspect a handling issue.  

Were he mine, I'd want the test redone with shipping to Cornell and confirm that the blood is processed and sent according to their guidelines.  There are too many other things going on that point to early PPID for me to be comfortable with that number, especially this time of year when the average normal horse will show an ACTH of 50.




Rebecca and Joe
 

It was not processed by Cornell, it was processed by Park Equine Hospital's lab, but it was put on ice and spun down within 30 minutes by the lab. Does feeding before the blood pull affect the way the test comes out?
--
Rebecca and Joe,  Lexington KY, 2020

Case History: https://ecir.groups.io/g/CaseHistory/files/Rebecca%20and%20Joe


Rebecca and Joe
 

Also in case it's relevant we took radiographs of his feet beforehand and he had to be sedated. Blood was pulled at the end of the visit so that they could get it straight to the lab. I was told it would not affect ACTH but was that incorrect?
--
Rebecca and Joe,  Lexington KY, 2020

Case History: https://ecir.groups.io/g/CaseHistory/files/Rebecca%20and%20Joe