Can sedation for minor procedures affect ACTH levels?
Boomer, my 13 yr old Canadian x gelding recently had a metabolic panel done. He had a laminitic episode 3 yrs ago and was diagnosed with uncompensated IR. ACTH was within normal limits. Panel was done Jan 10, 2020. He has been managed as an EMS horse since that time with a balanced diet. This summer and fall I noticed weight loss and muscle wasting, reduced appetite and lethargy. He had his yearly dental done in October, 2022. It was unremarkable. His appetite and lethargy did not seem to change. He had a dental recheck done under sedation Nov 8th, 2022. Mouth exam was normal. We also ran a CBC/Chem at the same time. All values within normal range. At that time I decided to have another metabolic panel done. Blood was drawn will he was recovering from light sedation. Glucose and insulin were within normal limits. ACTH came back at 224pg/ml. Very high. My vet has written a prescription to start him on Prascend, 1mg tablet once daily. My question is it possible the sedation may have affected the ACTH levels? At what point should we retest ACTH? My cost for the ACTH is app $160.00 so hopefully wont have to do it to many times.
Holly K 29/10/22 Northern AB, Canada
Hi Holly. Welcome to the group. Your first message here generates a welcome letter for you to review. It is based on the ECIR protocol of diagnosis, diet, trim and exercise. These are the cornerstones of care. Your Case History will give us more information, but for now, begin to read through our welcome letter and if you have questions, just let us know.
I did a quick search here on the site and didn't find any reference to sedation affecting ACTH levels.
However, stress from exercise, trailering, and procedures can increase the insulin and glucose testing. So, drawing those first, prior to any other interventions, is best.
Starting Prascend- we recommend starting it at a lower dose- like a 1/4 tablet and increasing to a full dose within about 7 -10 days. After being on the full dose of 1 mg for 3 weeks, it would be time to retest. There is more information on testing, etc in our welcome letter. As you read through, you will find blue links that will take you deeper into the subject matter. You can also do your own searches using the window at the top of this forum. You can chose searches from messages and files. If you look at my signature it has a link of "how to search" for the most concise information. I think this welcome letter will answer alot of your questions and also provide you with information going forward.
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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.
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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.
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.
No hay is "safe" until proven so by chemical analysis. The diet that works for IR is:
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.If you have any technical difficulties, please let us know so we can help you. --
Dolly and Hope's Case Histories
HOW TO SEARCH THE ARCHIVES: https://ecir.groups.io/g/main/wiki/1993
I had a similar experience with my horse Logo before I knew better. He had a mild sedation and a dental float before we remembered we hadn't drawn blood for ACTH testing. It came back higher than expected and when I rechecked it 3 weeks later it was fine. Logo's ACTH value after the dental was in the mid 70's, definitely high but only alarming because it had been low and I was a frequent tester.
"Within normal limits" does not necessarily mean normal so it would be good for us to know those numbers. Please post the reports with your case history. The beginning of the November is still within the rise so his ACTH would be elevated by that, although not normally that much. As Boomer is fairly young for PPID, he may well be in the early stages, where ACTH is only elevated during the rise but excessively so. He may just need pergolide during the rise.
In terms of how much testing you will need to do, I would suggest that you will need to do enough to find the right dose and then probably twice a year - late spring before the rise begins and winter, after it's done. PPID is a progressive disease. The thought is that the better it's controlled, the more slowly it will progress. At least you will notice it less if you keep up with it. This varies from horse to horse and with experience you will have a better idea what to expect from Boomer. You may be able to save some money by finding a vet tech to draw the blood and take it to the vet yourself for shipping to the testing site. There are stringent precautions for the testing protocol. If these aren't met, the ACTH may well be artificially low. Testing during the rise is fine. It gives you a picture of how high things might get but starting or increasing pergolide during the rise is unlikely to be effective.
You can test three weeks after starting or adjusting the pergolide dose. If you decide to stop pergolide before testing for a baseline, pick a time outside the rise and stop the pergolide 3 weeks before testing.
A lot to sort out here but you're heading the right direction and we're here to guide you
Martha in Vermont
ECIR Group Primary Response
Logo (dec. 7/20/19), Tobit(EC) and Pumpkin, Handy and Silver (EC/IR)
Martha and Logo
There is evidence that sedation can affect insulin, glucose and ACTH, and the effect varies DEPENDING on the sedative used. It is summarized here:
The best practice is to have the vet pull blood before anything else is done as even procedures without sedation can affect ACTH.
Kirsten and Shaku (EMS + PPID) and Snickers (EMS) - 2019
Kitimat, BC, Canada
ECIR Group Moderator
Shaku's Photo Album
Snickers' Case History
Snickers' Photo Album
Thanks everyone for their input. I have started him on the reduced dose of pergolide and will slowly increase to recommended dose. We will look at retesting in a couple of months. Im working on uploading his case history. He has had several on and off episode of mild lameness in right front and right hind over the past 2 years for which radiographs and flexions have not produced a definitive diagnosis. Very frustrating. His diet is balanced through Mad Barn and I will upload that info as well. We have some challenges here in northern Alberta with finding low sugar/starch hay and straight timothy cubes are no longer available here, only the timothy/alfalfa cubes can be purchased now.
Holly K 29/10/22 Northern AB, Canada