Complicated Laminitis episode
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My 21 yr old Hanoverian who has been IR for about 6 or 7 years, but managed successfully previously, developed lamintis in both front feet after a cold snap, a rear leg injury and subsequent injections (not steroids). He presented normal in front (for him) until the day after injections. Attending vets were not my regular vet and viewed the front end lameness (multiple times) as a reaction to the injection or soreness from the farrier. I can provide a lot more information. There is a lot!! He is currently improving but so many things have happened I have a lot of questions since I don't believe in coincidences. Please tell me the best way to document this journey. I am attempting to document a case history if that is the correct way to proceed.
Thanks -- -- Debi V 1/2023 Boulder, CO |
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Bobbie Day
Hello Debi and welcome!
Your first post here signals a welcome message to help you understand our protocols which are DDT/E, Diagnosis, Diet, Trim, and Exercise, the last only when and if the equine is able to move about on their own, we don't want forced movement as it can damage already fragile feet. I understand you will be getting your case history up and that's great, the more information you can provide the better we can advise you. We understand this is a lengthy process and appreciate your efforts in getting it done. In the meantime, I will include your message below, and notice that there are hyperlinks that will take you even further into the subject. We also suggest that you keep it handy to refer back to as it answers many questions that come up here. And you can also do a search in the messages (upper right of your screen) to find answers to many questions. Please let us know if you have any questions or trouble with your case history so we can help. Again welcome. Hello 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 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:
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.
Bobbie and Maggie Desi (over the rainbow bridge 7/21) Utah, Nov 2018 ECIR Group Primary Response Horsekeeping Moderator https://ecir.groups.io/g/CaseHistory/files/Bobbie%20and%20Maggie https://ecir.groups.io/g/CaseHistory/album?id=271156 https://ecir.groups.io/g/CaseHistory/files/Bobbie%20and%20Desi https://ecir.groups.io/g/CaseHistory/album?id=78821 |
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I am adding additional information because I cannot find a documented link to the injections my horse received and laminitis. Currently working on case history. In a nutshell, my IR gelding sustained a serious injury to his left hind. I did later find video of him rolling in his run, banging his leg against the steel bars of the run. He would not walk. Vet checked for laminitis but all radiographs normal and no pulses or heat. At this point clearly just a bad hind end injury. Called different vets for chiro and they did a lameness exam, concluded that he had injured his proximal suspensory ligament. They injected with Renovo and since he was sedated decided to inject left front pastern with Arthramid since his ring bone had gotten much worse so thought Arthramid would last longer than IRAP. This injection was radiographically guided. The next day he seemed comfortable but the following day he was very uncomfortable in both front but mainly left front. Not a true joint flare but pretty sore. Attending vets returned to check and finally do chiro a week later. Still very lame in front but almost normal in left hind. They felt he was just stiff since he has high and low ringbone both front. They also felt he was just sore from the injection and perhaps the farrier had trimmed him too short ( he was fine for a week until the injection). They told me to tack walk him. He felt very bad in front but ok behind. Next day even worse so I did not ride him. They wanted to come back and block him but I was not ok with that. Finally called my regular vet after 4 days of declining movement. He immediately diagnosed laminitis and slight rotation in left front. His insulin came back at 8 times the normal value and he came back Cushing’s positive. I test yearly for Cushing’s, insulin and cbc and he was normal last Feb. I will add all this to my case history but has anyone experienced laminitis after an Arthramid injection? I was assured it is safe for both IR and Cushing’s horses. What about Renova? Or were there just too many things that happened to push him over the edge into a laminitic event. This really is a brief synopsis, believe it or not, of what happened to him in a 10 day span. The day before he was happy, energetic, felt wonderful. He is on the mend now and is walking normally in softride boots and even looks good without them for the short stroll down the barn aisle. Any experiences with Arthramid or Renovo and laminitis would be appreciated.
Thanks -- Debi V 1/2023 Boulder, CO |
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Lavinia Fiscaletti
Hi Debi,
Renovo has been discussed here: https://ecir.groups.io/g/main/topic/81127575#262211 Arthramid as well: https://ecir.groups.io/g/main/topic/95544159#286179 Neither would be prone to induce laminitis. Seeing all of the info in a case history is going to really help with parsing out the particulars here. It is more likely that there was a "perfect storm" of underlying factors that coincided with the timing of the injections. We need to know the dates of when all of this occurred; what his actual ACTH, insulin and glucose numbers were/are; was he in work and then needed to stop due to the suspensory injury? what is his diet? what were the temps like around the time that all of this happened? Good to hear he is improving now. -- Lavinia, George Too, Calvin (PPID) and Dinky (PPID/IR) Nappi, George and Dante Over the Bridge Jan 05, RI Moderator ECIR |
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If you know, the sedation used is also good information.
-- Cass, Sonoma Co., CA 2012 ECIR Group Moderator Cayuse and Diamond Case History Folder Cayuse Photos Diamond Photos |
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This is probably irrelevant assuming you were there for all the exams, but is it possible one of the chiro/vets used treats during the exam?
For multiple years I assumed my horse’s soreness after shoeing was due to the shoeing, but it turned out to be the treat reward given after by the shoer. It was a small thing but it used to throw everything out of whack for him for several days. -- Chris H in CA 2021 https://ecir.groups.io/g/CaseHistory/files/Woody%20and%20Chris |
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