Crisis with a cushings mare


Kay
 
Edited

Hi I am in crisis with learning how to feed and manage my horses PPID. 

She is in her late teens, and her name is Cassidy.
She is thin and will not gain weight or hold body condition  

She was diagnosed in May of 2022, with a baseline ACTH of 55.

Her T3 (45) and T4 (0.6) were low. 

Her glucose was 37, also low.


She was prescribed 1 Prascend per day, it helped temporarily and now it is no longer helping and she has become dangerous and off the rails  
She was formerly a very gentle, children’s mount. 

Her appetite is good, besides leaving behind some when she seems stress but I’m really struggling to figure out how to feed her. I’m trying to do less than 12% NSC with the entire diet. 


Right now she is getting too much, she is on purina equine senior, alfalfa pellets and some beet pulp, a combination senior supplement, comega supreme, cocosoya, and pre and probiotics. 

Open access to pasture right now which is primarily fescue  

She has a 60 day retest on July 29th  

Please if anyone can help me build her a complete diet or tell me how to handle all of this. I’m so worried and stressed  

--
Kay @ K & J Ranch LLC
In the South, USA 
2022


Trisha DePietro
 

Hi Kay. welcome to the group and I'm sorry you have to be here- Its good to hear that Cassidy's appetite is good. Are her feet sore? What symptoms prompted you to test her for PPID? What was her insulin level? We will get you up to speed on the diet and will get Cassidy straightened out. We recommend that Cassidy should be fed 1.5 to 2% her "ideal" body weight. This would be for hay and any other items that are fed. also the sugar and starch in her diet should be less than 10%.  There is a lot of information here on this site and you will also be receiving a welcome letter that will highlight what to feed under the diet section. While you are waiting for the welcome letter, you could start gathering information to complete her case history. Was her insulin tested as well with the  glucose? Your lab work, current feeding measurements, ideal weight, breed, age, etc are stored in the case history so that we can best advise you. Hang in there. It does get better and there is a lot of information here to help you. 
--
Trisha DePietro
Aug 2018
NH
Dolly and Hope's Case Histories
Dolly's Photos 
Hope's Photos 
Primary Responder


Kay
 

Hi, thank you! I have already completed the case history the best that I can and uploaded it to her file.
Her feet are not sore, the farrier says she does not have any issues with laminitis etc. 
So I rescued Cassidy in 2021-03-13 with zero history, a vague description and completely emaciated. Info given was "Saddlebred mare, if you could sit in the saddle you could ride and extensively shown and trail ridden" 
From the start she has had an abnormal coat length and thickness, delayed shedding, odd shedding pattern and inability to really shed all combined.
It is odd but she has also always knocked her bucket over during feeding and peeded all over herself and everything, she seems to always be in heat and or urinating all over the place.
She always been a little insecure but was easily persuaded to leave the area and she now will not leave the area and will scream and call just extremely herdbound and barn sour when she was never like this before.
She got to be a bit spooky and unpredictable from the start of the year and it got worse starting on Prascend.
She had a hard time refeeding but in the fall put on a good bit of weight and was almost abnormally fat but then around march or so rapidly lost it all and has huge flucuations in gaining and losing. It's up and down at rapid levels. I hope I am not forgetting anything. 

Her insulin level was 26
Her glucose was 37

T3 was 45
T4 was 0.6 


I really do not know what her ideal weight would be as I'm just not really sure of her breed. She may be some sort of saddlebred cross but her dna did not hit with the registry shes a big girl at 16,2/16.3hh maybe 1000 pounds.



--
Kay @ K & J Ranch LLC
VA, USA 
2022
https://ecir.groups.io/g/CaseHistory/files/Kaylee%20and%20Cassidy


Bobbie Day
 

Hello Kay and welcome to the group!
It looks like Trisha has given you some feedback, as she also mentioned I will be sending along your welcome message. It has a lot of information; it can be a bit overwhelming we know but please give it a read through as it will address some of your initial (and future) questions.
We operate on the philosophy of DDT/E, which is short for Diagnosis, Diet, Trim and Exercise. You're not alone, and we'll do our best to get this sorted out for you. I see you did complete a case history. Do you need any help with that? The more information you can give us the better, it all matters.
My mare did the same thing when she started, symptoms can actually mean she needs a bump in her dosage. Did you start her at one gram right off? We suggest titrating up until you can see her symptoms start to resolve. What I did with my mare is take her back down to a half for a week, then bumped her up with some APF on board. I will include some links for you.
Pergolide 101.pdf (groups.io)
I do want to mention that we are going to be entering the rise very soon, so now is the time to get this under control, we want to have her ACTH at low twenties to high teens. I would get her up to that dose (slowly) again and if she isn't doing better test her again to see if she needs a bump up. I wouldn't think she would need too much with those numbers, but we have some horses on very high doses, we say this many times the best dose for your horse is the dose that controls the symptoms. PPID can be tricky, but it can be managed too, we don't want her to tip over and risk laminitis. 
As Trisha also mentioned, diet is an important component here, I would get her on the emergency diet and get your hay analyzed and balanced asap. If you're not able to balance yourself, I have included a list of balancers here that may be able to help. Or Dr.Kellon offers a free balance if you get your mix from Uckele. 
HAY BALANCING (groups.io)
I will let someone will more knowledge than I address her reproductive issues, hopefully Dr.Kellon can chime in once she sees your case history.
I do want to mention one more thing, do you have any other options than fescue hay? It can make horses footsore, if you can source other hay, I would do that, but it needs to test under 10% starch and sugar, if not we suggest rinsing, which is in more detail in the welcome message below. 
Per Dr.Kellon regarding fescue and why we don't recommend feeding it. 
https://pubmed.ncbi.nlm.nih.gov/7695144/
I hope this will give you a good start on what needs to be done to help your mare, please let us know if you have any additional questions.


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 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 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.

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. 

 










Bobbie and Maggie 
Desi (over the rainbow bridge 7/21) 
Utah, Nov 2018
NRC Plus 2020, NAT, C&IR March 2021
ECIR Group Primary Response 

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


Sherry Morse
 

Hi Kay,

We usually don't see glucose that low which makes me think that your bloodwork may have been compromised and her insulin and ACTH could both be higher than what the bloodwork says.  I would be treating her as if she's IR and PPID until you know otherwise which would include a pretty drastic diet change as we do not recommend alfalfa for either IR or PPID horses, nor any Purina products as they are too high in ESC+starch for most horses. The Renew Gold Senior is also not recommended as it has a large amount of rice bran, coconut meal and is again over our 10% ESC+starch max for an IR or PPID horse.  

Given the area you're in I would also arrange for a Lyme test to rule that out as a source of the spookiness and possibly a full repro exam to see if you can sort those issues out as well as they may or may not be related to IR or PPID.




Kay
 

Hi, thank you. I was wondering if I had done it correctly or not. 

So, I actually don’t have access to actual hay, I’ve been out for weeks and that’s why I’m feeding bagged hay and other things. 

Let alone any that has already been analyzed, and I don’t want to buy anything, analyze it myself and see that it is much too high even after soaking it multiple times and that I can’t feed it to her. 


She was started off immediately on 1 pill a day and never experienced any side effects or problems till most recently, the last few weeks is when all of the issues got worse. 

Can I get her on the emergency diet with bagged hay or pelleted hay? If so can someone help me with it. 
--
Kay @ K & J Ranch LLC
VA, USA 
2022
https://ecir.groups.io/g/CaseHistory/files/Kaylee%20and%20Cassidy


Kay
 

Hi so as far as K can remember the day her blood was drawn she hadn’t eaten anything but grass in hours. 

I was also worried about how low it all was, her vet told me that both the thyroid and glucose were extremely low and after her 60 day retest if neither improved she would need to be placed on thyro- L. 

Our next appointment is July 29th for her 60 day retest 
I will mention both to him when he comes but I have to space out my bills right now due to my 4 year old having an 1100 emergency bill and a week long horspital stay. Lol
Thank you, so so much. 
--
Kay @ K & J Ranch LLC
VA, USA 
2022
https://ecir.groups.io/g/CaseHistory/files/Kaylee%20and%20Cassidy


Kay
 

Hi so as far as K can remember the day her blood was drawn she hadn’t eaten anything but grass in hours. 

I was also worried about how low it all was, her vet told me that both the thyroid and glucose were extremely low and after her 60 day retest if neither improved she would need to be placed on thyro- L. 

Our next appointment is July 29th for her 60 day retest 
I will mention both to him when he comes but I have to space out my bills right now due to my 4 year old having an 1100 emergency bill and a week long horspital stay. Lol
Thank you, so so much. 
--
Kay @ K & J Ranch LLC
VA, USA 
2022
https://ecir.groups.io/g/CaseHistory/files/Kaylee%20and%20Cassidy


celestinefarm
 

Kay,
You can use Ontario Dehy Timothy Balance Cubes which are bagged in 40-50 lb bags. They are guaranteed to be less than 10 % starch and sugar and the starch less than 4% Any Triple Crown dealer can order them for you if they don't have them in stock. If you are feeding them exclusively, then feed the amount or just a little less as you would hay. The only thing you would need to add is salt, flax and Vit E. as the cubes have been formulated with appropriate vitamins and minerals balanced to what the timothy in them contains.  Dr. Kellon is who supervises that formulation.
--
Dawn Wagstaff and Tipperary   

Saline, MI  2003

Tipperary Case History

Juniper Case history: https://ecir.groups.io/g/CaseHistory/files/Dawn%20and%20Juniper/Case%20history%20Juniper.pdf .


Sherry Morse
 

Hi Kay,

The easiest thing to do for hay replacing is to source Triple Crown Timothy Balance Cubes (Ontario Dehy Timothy Balance Cubes) and feed them at a 3:4 ratio for hay.  In addition you can feed beet pulp (rinsed/soaked/rinsed) in larger quantities (see DDT +E – Diet | ECIR Group, Inc. (ecirhorse.org) for information on this).  That would be preferable to feeding higher ESC+starch feeds. Tractor Supply should be able to source the Triple Crown for you as they sell the TC products.  

Worse case scenario you could use the Standlee timothy pellets but they are not tested like the Timothy Balance Cubes and you would still need to add flax, vitamin E, salt and magnesium to them.  

Getting her off the inappropriate feeds may help with her feeling better as would confirming that she's on the right dose of pergolide.  It's not unusual for previously 'quiet' horses to start acting differently when they're put on medication because they're feeling better and their true personality is coming out.  From a distance it's of course difficult to tell if that's going on with Cassidy or if it's a combination of factors including "mare issues" as well as PPID and maybe Lyme.  The tumor itself can cause many of the behavior issues you've mentioned which is why getting the dose of pergolide sorted out is so important.




Kirsten Rasmussen
 
Edited

Hi Kay,

Please read the Diagnosis section of Bobbie's email to you and make a plan with your vet before he arrives.  The reason glucose was so low is because her blood was not handled correctly.  This will artificially lower the insulin and ACTH, too, although not as dramatically.  Immediately after pulling it, it needs to go on ice or in the fridge.  It must be centrifuged within 4 hrs then frozen overnight (longer is ok) and shipped to the lab with ice packs on 1-day delivery.  It needs to arrive at the lab chilled and on a weekday so it can be received.  My vet will often freeze it over the weekend and send it out on a Monday.

Thyroid hormones are often low in metabolic horses due to euthyroid sickness.   This is due to the metabolic issues, not a diseased thyroid, so the best fix is to deal with the metabolic issues.   Thyro-L will cause weight loss, which you don't want, and it will depress the natural thyroid function so it needs to be weaned off of very slowly. 

A safe bagged feed are the Triple Crown Naturals Timothy Balance cubes (aka Ontario Dehy Timothy Balance cubes), if you can source them.  They are guaranteed to be below 10% sugar+starch, are fully mineral balanced, and because they are higher in calories they are fed at a rate of 75% of the hay you are feeding, by weight.  All you need to add is 2-4 oz ground flaxseed, 2000 IU vitamin E, and salt to have a complete diet that is safe for a metabolic horse.

She was started off immediately on 1 pill a day and never experienced any side effects or problems till most recently, the last few weeks is when all of the issues got worse. 
Conjecture here, but if her behaviour changed recently on Prascend, and she was doing well before on 1 mg, it's likely that she needs a higher dose because the seasonal rise is started.  I would restart it and work on increasing the dose until her behaviour and other signs (like excessive peeing) normalize.  The abnormal fat last fall may have been the fat pads and cresty neck associated with uncontrolled PPID.

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


Kay
 

Thank you so much. I called out of work today to find these cubes for her and will be getting them asap. 


What brand or what supplement exactly do I need to use for the flax and the magnesium etc? 
--
Kay @ K & J Ranch LLC
VA, USA 
2022
https://ecir.groups.io/g/CaseHistory/files/Kaylee%20and%20Cassidy


Kay
 

Thank you so much. I will be getting those today if possible if not I will order and temporarily use the Standlee Timothy pellets. 


I have completely taken away all of the feed and supplements I was giving and stopped giving alfafa. She is only receiving pasture grass now and I will get her a muzzle as well while I’m out since I don’t have a dry lot. 


I assumed that might be the case with both. 
--
Kay @ K & J Ranch LLC
VA, USA 
2022
https://ecir.groups.io/g/CaseHistory/files/Kaylee%20and%20Cassidy


Sherry Morse
 

Flax - if you can source Triple Crown they make a flax product (Golden Ground Flax) as well.  Magnesium - you can use MgOx from a feed mill as the cheapest source or a human supplement - again, that's outlined in the emergency diet section of the website.




Kay
 

So I have access to and can pick up some triple crown flax today. 


I can’t source the cubes though so then I should replace with Standlee Timothy cubes? 
--
Kay @ K & J Ranch LLC
VA, USA 
2022
https://ecir.groups.io/g/CaseHistory/files/Kaylee%20and%20Cassidy


Sherry Morse
 

It's not ideal but yes you can use the Standee cubes.




Kay
 

I can’t find the cubes I’m supposed to use anywhere. I’ve called, looked online and can’t find them. I can get ahold of Standlee either. The only thing I can locate is Timothy grab and go bale from Standlee or pellets. 
--
Kay @ K & J Ranch LLC
VA, USA 
2022
https://ecir.groups.io/g/CaseHistory/files/Kaylee%20and%20Cassidy


Eleanor Kellon, VMD
 

Try contacting both Triple Crown and Ontario Dehy directly for help in locating the cubes locally,.
--
Eleanor in PA

www.drkellon.com 
EC Owner 2001


Kay
 

I did, we have very limited dealers of Triple Crown, no one can order it in, I can’t locate Timothy cubes either. So what do I do now? I can dry lot her later and get her off grass
--
Kay @ K & J Ranch LLC
VA, USA 
2022
https://ecir.groups.io/g/CaseHistory/files/Kaylee%20and%20Cassidy


Eleanor Kellon, VMD
 

Kay,

Did you contact Ontario Dehy?
--
Eleanor in PA

www.drkellon.com 
EC Owner 2001