Topics

Bloodwork, PPID, EMS Invokana and Pergolide


Nancy & Vinnie & Summer
 

Hi Dr K and all, I have been thinking a lot trying to figure out what the root cause of Vinnie's latest foot soreness that began on Feb 8th. 

I am a little confused because I honestly thought I had his metabolics managed after about 22 days on Invokana with the remarkable response he showed.

A little background:
-Vinnie started to get sore again off and on around mid to late  November. At that time I thought my hay that was supposed to be only blue grass; and I found alfalfa.  This hay I did retest and it came back at 9.3 esc+starch. I started soaking hay and looking for a replacement.

Around Dec. 19 the footsoreness got worse so managed to get an appt for bloodwork and Radiography. Started metformin.

- dec  21 we did bloodwork and rads and things looked ok..no new rotation etc..
12/26 bloodwork came back with insulin out of control at 198.37, acth 20.2.  Vinnie was on prascend .50 mg at this time.

We went the route of trying invokana

Started inovkana jan 8th , stopped prascend the same day. And stopped metformin.

Based on his test results we didn't think PPID, and he was still exhibiting symptoms of the veil even after being on pergolide for months.

Retested insulin on 1/12 and got some new rads. Planned on doing a trh stim but wasn't sure if needed based in the 1/16 result. we did not test acth since he was normal on 12/21.

1/16 got the results that Vinnies insulin had dropped to 40.94, leptin and glucose had improved dramatically too. Great news.
 
Vinnie had improved every day from 1/16 thru 1/31 having some great walk days up
through 2/8. 

1/30 and 2/4 administered adequan IM injections for  beginning loading dose 

2/7 pm noted pulses returned in the front.

2/8 am pulse noted by Shockwave therapist and we did some Shockwave on hips si, neck and hocks.

2/8 he was moving fantastic all day moving like he was feeling back to normal. Did a little free trotting in the arena.

2/9 very sore looked laminitic with pulses in fronts.

He has been sore since 2/9.

2/17 noted alf in the tested new grass hay that i had only fed about 20% of total  forage beginning about 2/4. This hay also has yellow foxtail

Vinnies diet is dialed in, I weigh and test everything. Even the hay that I ended up finding trace amts of alfalfa and foxtail tested at about 4.8 wet chem esc starch with the latest test at 6.8. I retested iron several times on all the hays to determine the baseline and then the shaken and sifted. Vinnie is eating the finta orchard right now and no more getting the new Vaca hay as of last night.

The thing that this seems to point to is possibly stopping prascend was not the best idea.

So, my question is, as I look at him being EMS and presumptive ppid, why was his insulin so high on the test where his acth was normal and diet balanced and..then after stopping prascend why was his insulin able to drop so dramatically on invokana without prascend on board for 3 days?

Does prascend have a half life where it remains in the system so 3 days after stopping it was still able to control acth enough to enable the insulin to come down so fast?

Body condition wise he has lost his crest, puffy eyes, fat pads..I mean he looks amazing.  I am perplexed.

Can adequan cause an insulin response?

I am going to put him back on .25 prascend tonight titrating up to .50. I had stopped APF so hoping starting apf and prascend in the same day still controls the veil.

Thanks in advance.

--
Nancy and Vinnie and Summer
Oakley, Ca
Joined Nov 2018
https://ecir.groups.io/g/CaseHistory/files/Nancy%20and%20Vinnie 
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Summer
https://ecir.groups.io/g/CaseHistory/files/Nancy%20and%20Vinnie/Summer 
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Kirsten Rasmussen
 

See this post from Dr Kellon on how long pergolide stays in the system:

https://ecir.groups.io/g/main/message/215025

There are probably no clear-cut answers as to why Vinnie is sore again...the best thing you can do is make note of these events and all possible factors leading up to them, and look for patterns.  And try different things to alleviate the pain, which could be mechanical or circulatory, not necessarily laminitis.  You also put a sneaker on his left front at some point in there, could that be related?  Maybe the boot was working better for him.

Setbacks are so frustrating, but they still seem to occur even when [we think] we are doing everything right.

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


Nancy & Vinnie & Summer
 

Hi Kristen, thanks for the response.  He was much worse in a boot because of heel rubs.on the left. So I don't think that is it. 

I definitely think it is metabolic response, I am just trying to understand the bw numbers in context to physical symptoms.

My farrier agrees it is not mechanical in the sense that adjusting breakover etc would not have made a difference. 

He is sore on hard ground, not as much on soft.. LF is better than RF

We didn't rule out collections but he has moderate pulses (including the hinds which is not been usual for him)  which implies not circulatory or mechanical and more metabolic laminitis.
--
Nancy and Vinnie and Summer
Oakley, Ca
Joined Nov 2018
https://ecir.groups.io/g/CaseHistory/files/Nancy%20and%20Vinnie 
https://ecir.groups.io/g/CaseHistory/album?id=245855

Summer
https://ecir.groups.io/g/CaseHistory/files/Nancy%20and%20Vinnie/Summer 
https://ecir.groups.io/g/CaseHistory/album?id=249104


Nancy & Vinnie & Summer
 

So this does help make sense of  what I am seeing after stopping Vinnie's prascend... do he probably has the early PPID and after stopping prascend was a cascading effect invokana helping insulin but as acth continued to rise through and after day 21 that he got foot sore on about day 32.
"McFarlane's study on ACTH and pergolide in PPID horses found that by 10 days after the last dose there is no detectable pergolide in any horse.  At five days, half the horses still had low levels of pergolide but 2/3 were showing ACTH on the rise.  At 2 days after the last dose, ACTH had increased by 50% in half the horses and there was a significant rise in all the horses by 14 days after stopping pergolide and this continued to rise to the 21 day mark."
I just really hope I can get him past the veil.  

Can I do TRH stim while on prascend to see if prascend is working? Or would I just test standard acth?  I started him on a .25 dose last night because I don't want the laminitic episode to progress.

--
Nancy and Vinnie and Summer
Oakley, Ca
Joined Nov 2018
https://ecir.groups.io/g/CaseHistory/files/Nancy%20and%20Vinnie 
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Summer
https://ecir.groups.io/g/CaseHistory/files/Nancy%20and%20Vinnie/Summer 
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Hi Nancy,
My understanding is that you should take him off pergolide for three weeks before doing a TRH stim test.  There are no normals associated with the post TRH stim test results while on pergolide.  I won’t comment on you hypothesis except to say it sounds good to me.

Is it possible that the trace amount of alfalfa you’ve noticed in your hay is enough to set him off?  I’ve never had an alfalfa sensitive horse but my understanding is that the cause is unknown and there is no way to modify the hay to counteract its presence.  Alfalfa itself tends to have low s/s.
--
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


 
 


Nancy & Vinnie & Summer
 

Thanks Martha, the alfalfa is certainly a variable, but honestly it would have been so little in terms of the amount he would have ingested it seems unlikely as the root cause.

As a test because I didn't have time to pull put the foxtail, I switched for two days in the middle  of the soreness to the finta orchard only and that didn't provide any improvement.  And the pulses behind seem to indicate more metabolic systematic response. My gut tells me he is early PPID without positive acth.
--
Nancy and Vinnie and Summer
Oakley, Ca
Joined Nov 2018
https://ecir.groups.io/g/CaseHistory/files/Nancy%20and%20Vinnie 
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Summer
https://ecir.groups.io/g/CaseHistory/files/Nancy%20and%20Vinnie/Summer 
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Nancy Kitchen
 

Just adding my two cents worth from our history, my horse seems to be sore when off the Prascend altho his blood work indicates that he is not PPID.  I did not have the stim test done but I have chosen to leave him on the .50 mg of Prascend.  The convincing factor was Alicia Harlov's podcast with Dr Debra Taylor titled Not All Laminitis is Created Equal.  It is well worth the listen for anyone dealing with laminitis.  She describes a horse she treated for multiple bouts of laminitis with no known cause...  upon necropsy they found a pituitary tumor indicating PPID but yet his tests never showed any trace of PPID.
Altho my horse's insulin is up right now, and I am working diligently to get it down, he is on Invokana and Prascend and very comfortable in Clouds...
I hope that helps you in some small way....  
--
Nancy K
Smoke and Tucky
November 2018, Southeast, MA

Smoke Case History:  https://ecir.groups.io/g/CaseHistory/files/Nancy%20and%20Smoke
Smoke Photo Album:    https://ecir.groups.io/g/CaseHistory/album?id=94122
Tucky Case History:  https://ecir.groups.io/g/CaseHistory/files/Nancy%20and%20Tuck 
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Nancy & Vinnie & Summer
 


Nancy & Vinnie & Summer
 


Nancy & Vinnie & Summer
 

Just in 2 doses of pergolide .25 and upped my Jherb there is much improvement in Vinnies foot soreness.  I think he may have a collection on the lateral rf. We shall see...
--
Nancy and Vinnie and Summer
Oakley, Ca
Joined Nov 2018
https://ecir.groups.io/g/CaseHistory/files/Nancy%20and%20Vinnie 
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Summer
https://ecir.groups.io/g/CaseHistory/files/Nancy%20and%20Vinnie/Summer 
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Nancy & Vinnie & Summer
 

I am hoping maybe someone can shed some thoughts on why before we started invokana that his insulin jumped so high to 198.37, but acth 20.2 making be thubk that it wasn't the acth causing the insulin rise.

I have listened to 3 different podcasts to try and understand the mechanisms that cause insulin rise, and this is important to me because I want to prevent any more set backs.

Are there other hormones in geldings that can cause insulin to rise? I was looking back at pictures and only of u knew then what inknow now... even 8 years ago Vinnie fit the Ems model to a T.. added an image to my folder. 

I am also going to test iron on the next bloodwork we do.  
--
Nancy and Vinnie and Summer
Oakley, Ca
Joined Nov 2018
https://ecir.groups.io/g/CaseHistory/files/Nancy%20and%20Vinnie 
https://ecir.groups.io/g/CaseHistory/album?id=245855

Summer
https://ecir.groups.io/g/CaseHistory/files/Nancy%20and%20Vinnie/Summer 
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Nancy & Vinnie & Summer
 

Hi, again.. a little crisis mode today trying not to panic. Vinnie is pretty sore, farrier coming back to see if we can figure out of there is a collection. We opted to hold on doing anything to see if starting prascend helped.  It seemed to help a bit, but of course I am titrating up.

So being as Vinnie is as sore as he is with pulses in all four.. should I throw caution to.the wind and up his dose of prascend now to .50? Today is day 3.  He on in APF 10mls am.
--
Nancy and Vinnie and Summer
Oakley, Ca
Joined Nov 2018
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Summer
https://ecir.groups.io/g/CaseHistory/files/Nancy%20and%20Vinnie/Summer 
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Sherry Morse
 

Hi Nancy,

We usually recommend titrating up 3 days at a time so you can up the dose now.




Nancy & Vinnie & Summer
 


 

I’d give maximum dose APF twice a day whenever possible. If it’s not possible every day, do it when you can. 
--
Cass, Sonoma Co., CA 2012
ECIR Group Moderator
Cayuse and Diamond Case History Folder                
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Kirsten Rasmussen
 

Thanks Nancy K for sharing your experience and that podcast post...I had listened to it last summer and really got a lot out of it, but had forgotten her story about that one horse...  This helped me finally decide that I need to do a pergolide trial with Shaku.  No more if, ands, or buts!

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


Nancy & Vinnie & Summer
 

Cass, would you do 10ml twice per day?  I am doing 1 time rn and did increase jherb too as gums are a little less pink. 

Kirsten, I too got soooo much out of that podcast. And then I went in to listen to the two others Alicia noted in the beginning of the podcast.  So enlightening and inspiring and of course daunting.  But, it is so relieving to know we are not alone.  I think the comrades here and the support provided is what keeps me going.
--
Nancy and Vinnie and Summer
Oakley, Ca
Joined Nov 2018
https://ecir.groups.io/g/CaseHistory/files/Nancy%20and%20Vinnie 
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Summer
https://ecir.groups.io/g/CaseHistory/files/Nancy%20and%20Vinnie/Summer 
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Nancy & Vinnie & Summer
 

I thought I should also note Vinnie is slightly improved from yday so we are making progress ever it be small.  I was expecting more soreness today too so that was a nice gift.. 

I think prascend is working.. knock wood.  Next time follow gut.. that nagging feeling is probably right. 
--
Nancy and Vinnie and Summer
Oakley, Ca
Joined Nov 2018
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Summer
https://ecir.groups.io/g/CaseHistory/files/Nancy%20and%20Vinnie/Summer 
https://ecir.groups.io/g/CaseHistory/album?id=249104


 

Nancy, I'd give what you need to see an effect, up to roughly double the labeled dose. Maybe 6 ml twice a day, or 10 once and a second dose of 4-6 ml. My experience with APF was that double the labeled dose really helped when one horse experienced a serious pergolide veil (non-PPID horse ate the PPID horse's full 5 mg pergolide dose). I'm not being cavalier with herbal dosing, but my experience is that starting doses are fairly conservative. While starting doses may work for some herbals for some horses, especially with Cayuse, failures with strong and effective herbals  (CTB, J-Herb, Devil's Claw, Canadian Ginseng, Spirulina, Mov-Ease) have all been cured by increasing dose and doing it fairly quickly after I notice a failure of effectiveness. 

Also, I'll just put this out there again (forgive me for repeating myself-it's my age) as a possibility. Failure to eat a mash isn't something I'd initially blame on the pergolide veil. Does he seem spacey and distracted? You know Vinnie the best, and I take your word for it when you say you think it's from the veil. Just remember that the veil rarely lasts for weeks. Refusal to eat the usual bucket meal can be a result of pain, an early warning when your horse still wants to eat hay. I get serious fast about the pergolide veil (and about pain!) when my horse won't eat hay. 
--
Cass, Sonoma Co., CA 2012
ECIR Group Moderator
Cayuse and Diamond Case History Folder                
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Nancy & Vinnie & Summer
 

Thanks Cass, knock wood right now he js eating heartily..no changes.  Today will.be day 2 on .50, last time I noticed a change right away. It seems like Vinnie is like Cayuse where he needs higher doses of the herbals to get the optimal effects 
--
Nancy and Vinnie and Summer
Oakley, Ca
Joined Nov 2018
https://ecir.groups.io/g/CaseHistory/files/Nancy%20and%20Vinnie 
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Summer
https://ecir.groups.io/g/CaseHistory/files/Nancy%20and%20Vinnie/Summer 
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