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Dewi - latest blood test results - high resting insulin - what to do next?


jenny.comish@...
 

Hi there,

as recommended by this group I had fresh blood tests done on Dewi for insulin, glucose and my vet decided to test ACTH again too as he wondered if the samples had been incorrectly handled previously. I've updated my case history form with the new results (the line dated 12th Feb 2021) and have added some comments in the comments section at the end. I've not discussed the results with my vet yet, but the lab in the UK that tested the samples recommended the following:

ACTH probably OK. Poor resting insulin though.
It would be useful to know how quickly this insulin falls after withholding
feed to give an idea of how much this is due to inappropriate diet (eg.
high-sugar hay) versus inherent metabolic disease (eg. slow insulin
clearance). If you could collect a further baseline resting insulin followed
by 2 further insulin samples collected at 2 and 6 hours after witholding
feed, then this would help inform the further management of the case and we
would test these free of charge as part of an investigation into this area.
This approach frequently provides compelling evidence of inappropriate
dietary management.~

Please can you let me know what you think about this advice? I did not fast Dewi before the blood was taken (even though my vet wanted me to), but from the lab's comments they seem to have assumed I did not fast any way. However despite not fasting Dewi, when I arrived at the yard at 08:30am, Dewi had run out of hay, so I can't be certain when he'd last eaten. I gave him soaked hay as soon as I arrived but the vet was early and arrived at 9am, so Dewi only had a chance to eat for 20 - 30 mins before I had to whip the hay away so the vet didn't see it! The vet did the x-rays first and was talking a lot and was very slow, so blood was not taken until about 11am, so actually inadvertently Dewi was fasted for 2 hours. I'm wondering if his results could be skewed by the fact he had not eaten much before the blood was taken (especially seeing as he'd run out of hay when I arrived and only got a chance to eat for a short while before the vet turned up)? 

Thanks very much.

Jenny
--
Jenny Comish
England, UK
Dewi Case History: https://ecir.groups.io/g/CaseHistory/files/Jenny%20Dewi
Dewi Photos: https://ecir.groups.io/g/CaseHistory/album?id=257833


Lorna Cane
 

Hi Jenny,

Dewi is a sweetheart !
I'll leave the testing questions to others, but I  do think his trim is in need of correction, and his comfort level will improve when that has been looked after .
I think you were going to add x-rays to his album,for Lavinia.
Has the vet sent them to you yet?
Maybe let Lavinia know here when you have been able to post them?

--

Lorna  in Eastern  Ontario
2002
Check out FAQ : https://www.ecirhorse.org/FAQ.php


 

Hi Jenny,
I would probably plan on repeating the tests.  Doing it later in the day might be easier to organize.  I, too, have one of those ponies who finishes her hay at who knows when.  I was directed to the Liphook Equine Hospital page on IR testing.  It states quite plainly that fasting tests are no longer recommended.  Perhaps, armed with this information, you can open a discussion with your vet about avoiding the fasting.

Also, I would not be so quick to say that ACTH test result is normal.  When your vet is out for his next ‘repeat’ you might think about having a TRH stimulation test done.  It’s more sensitive than the regular test but is only used for diagnosis, not monitoring pergolide effectiveness.
--
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


 
 


Sherry Morse
 

Hi Jenny,

I agree with Martha, since Liphook is offering to do the insulin test free of charge for their research I would take them up on it.  The way I read their directions is that the baseline would be non-fasting (at least 4 hours after any concentrates were fed and with hay in front until the blood draw) and then the other 2 samples would be done at 2 and 6 hours after that (no hay allowed after the first blood draw).  That would mean the first test would need to be later in the day.  I would obviously confirm with them exactly what conditions they want for that first blood draw.  I would still expect Dewi's insulin to be elevated even under ideal conditions which could make him a candidate to try metformin to see if that will help get his insulin level down.

For the ACTH -it's not terribly high, but since he tested high on the TRH previously and has had other elevated results it may be time to start him on pergolide and see if that helps bring his ACTH level firmly down into the 'normal' range. It may have a knock on effect on his insulin level as well as elevated ACTH can drive insulin up, although obviously he's not that far out of normal range. 

As far as the diet suggestion from the vet...if Dewi is 263kg and you think that's a good weight for him, he should be eating 5.25kg per day (hay plus concentrate) which is 2% of that weight.  Even that is less than you're currently feeding so reducing his intake to a more appropriate amount may help with his insulin level. 

Just to run some numbers -  6kg would be an appropriate amount for a 300kg pony and at 11.3 that would mean Dewi would be quite fat.  I would expect a pony at that height to be about 225 - 250kg so if you were to take the 250kg as his ideal we recommend 1.5% of current weight (the 4kg the vet recommended) or 2% of ideal (5kg) - whichever is larger.  For Dew that would be the 5kg.  Again that's a significant reduction from his current amount and one that would probably benefit his insulin level.

Getting his trim in order will also help with the pain level I expect, as there's quite a bit of room for improvement there. If you can get the x-rays from the vet to post to your album that will help Lavinia with trim recommendations.




Kirsten Rasmussen
 

Hi Jenny, sounds like a bit of a kerfuffle.  Fasting will lower the result, and pulling blood within 4 hours of the first meal of the day will raise the result.  But not THAT much, so with an insulin that high we know the diet is not controlling it (it sounds like the additional bloodwork would provide interesting information, as well as a chance for you to retest non-fasting, but you probably still have to pay the vet call out fees and it may not be worth it for 3 more blood pulls spread out over several hours).  A fasted insulin in a non-IR horse would be closer to 5 uIU/ml, and a non-fasted insulin in a non-IR horse would be no higher than 13.  Non-fasted insulin in an IR horse that is well controlled would be around 12-20.  So you can see how out of range Dewey's insulin is.  Anything above ~80 is in the range for acute laminitis and if there is nothing more you can do diet-wise to lower it below this number, Dewey should be put on medication.  I can't see anything you can do to tighten up his diet so I think the next step is trialing meds.

You could start with Metformin, which has been used successfully and safely to help many horses initially (although it gets less effective with time, and some horses don't respond to it).  Martha did up a wonderful information sheet on why and how to give it, but there are some other documents in our files to review too:  https://ecir.groups.io/g/main/filessearch?q=Metformin
I would also advise asking Dr Kellon to email you and your vet the protocol for trying Invokana.

Also, his ACTH is out of range at the time it near it should be near it's lowest.  Fasted ACTH will be artificially low, too, so the real ACTH could even be a little higher.  You could redo with the TRH Stim test; last time was equivocal, but if it was done fasting or was mishandled (?) then it is not reliable.  With his baseline ACTH I think it is very likely Dewey is in the early stages of PPID as well.  You might not choose to treat it yet but next July-August before the seasonal rise is in full swing you should test his baseline ACTH and start him on pergolide as PPID may have been related to his crippling lameness last November.

It's kind of hard to tell with his winter coat but I don't think losing weight is needed.  Can you easily feel his ribs?  With IR horses we suggest you aim for a BCS of 4.5/9...you should be able to just barely see his ribs and very easily feel them.

He is such a sweetie he looks like a mini version of my Shaku!

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


Eleanor Kellon, VMD
 

Hi Jenny,

Two hours after eating a meal is when peak insulin would occur and if that meal was given after a fast the insulin response would be exaggerated.  That said, even if he had eaten grain for those 20 minutes you wouldn't get an insulin of 173 uIU!  If he had been out of hay for less than 2 hours when you arrived, the results are probably valid for nonfasting despite the smaller meal and 2 hour delay.

From the trend in your glucose and insulin numbers you are getting an improvement with the soaked hay but it's probably not going to get any better.

I disagree the ACTH is "OK". It's elevated.  The abnormal insulin and glucose was existing long before this though.
--
Eleanor in PA

www.drkellon.com 
EC Owner 2001


jenny.comish@...
 

Thank you all so much for your massively helpful responses. It is such a comfort having this group - I finally feel I am starting to make small steps in seeing if there is light at the end of the tunnel for Dewi. And the vet I’m using seems much more motivated to try to help Dewi than my last vet practice who had no interest in taking more bloods and made no further suggestions for what could be done for him. 


My vet is not sure he sees much benefit in following the advice from Liphook to take blood after a 2 hour fast and then a 6 hour fast. He has said he will call Andy Durham at Liphook on Monday to discuss it. But of course my vet thinks I had already fasted! But in a sense Dewi had blood taken after a 2 hour fast due to slowness of vet so the 6 hour fast would be the only thing that had not been done.

Dr Kellon - thank you for confirming that you think my blood tests are ok to be counted as non-fasting. I imagine it was less than 2 hours before I arrived that Dewi had run out of hay as usually he does have a little left and I was a bit late that morning. Do you think Liphook’s advice is worth following with the 6 hr fast? The way I see it Dewi has a massive problem and his insulin is going to be abnormal no matter what test we do.  But would appreciate your thoughts on this.

My vet agrees Metformin in worth another go. But if it only works short term it’s where I go from there?

I got my hay analysis results back today - ESC is 6.3%, starch is 1.60%, WSC 14.5%. Protein is better than past hay - 9.10%. Do you think it could be worth me sending another hay sample off for analysis that has been soaked for an hour to see how much it brings down the ESC? I was just thinking that maybe 7.9% combined ESC and starch could be borderline for Dewi? But I already always soak it for a min of one hour before feeding. 


Thanks for the advice on diet Sherry. I find it so hard cutting his hay ration as I hate to think of him stood for long periods with no food. But if you think it could further help his insulin I will do it. I can feel his ribs easily.  But my vet still thinks losing a bit more weight would be helpful. I will do anything to get him out of this mess! 


As regards his ACTH, my vet agrees this is elevated. I do wonder if past samples have not been handled correctly by my previous vet.... My new vet has suggested I put Dewi on a product called Equilife Vitex. But I’ve looked up chasteberry on here and it doesn’t sound like it will do much for Dewi as I have only read that it helps with shedding and Dewi doesn’t have an issue with that. And thanks for the tip about trying pergolide before the seasonal rise. 


Dr Kellon - do you think Dewi ought to be on pergolide now? Also would it be possible to send me/my vet information on Invokana? If so, my email address is jenny.comish@...

And as for the x-rays, I’m still waiting on those - my vet has been busy lambing and calving all week. Bit frustrating as I want to get them on here. But I am VERY lucky as Sarah Braithwaite from Forage Plus has offered to come and take a look at Dewi’s feet next Wednesday for me. We’ve been corresponding about Dewi for sometime. I’m not local to Sarah but she is making a special trip 😊.

Once again, thank you all so much for the huge support. It’s heart warming to think there are people the other side of the globe all trying to help get Dewi better 😊.

Jenny (oh and I will add my hay analysis to my files and also I forgot to add my TRH stimulation test results to my case history! Post TRH he was 123). 
--
Jenny Comish
England, UK
Dewi Case History: https://ecir.groups.io/g/CaseHistory/files/Jenny%20Dewi
Dewi Photos: https://ecir.groups.io/g/CaseHistory/album?id=257833


Eleanor Kellon, VMD
 

This new study from AU has some good information on seasonal TRH results (table 2) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7848300/ . I would  start him on Prascend but he clearly had EMS long before this.

If you can already easily feel his ribs I wouldn't recommend further weight loss. Definitely retest your hay for ESC and DE. DE can lower substantially so you need to feed more.

I don't think you need any further insulin testing.

As far as I know, Invokana is available in UK. If you want to try metformin again first, Begin with a short trial and retest in 6 days. If it's not doing a good job then it never will. However, after reading your last experience with it I would probably go directly to Invokana. I will need to send directly to your vet so please send me his e-mail at drkellon @ gmail.com.
--
Eleanor in PA

www.drkellon.com 
EC Owner 2001


Kirsten Rasmussen
 

Almost certainly 7.9% ESC+starch is too high for Dewey unsoaked.  Maybe after starting pergolide and invokana you will find he can manage that hay without soaking, but definitely for now keep soaking it and don't stop until you have bloodwork proving his insulin has normalized.

I'm glad you are building a more local support team because that is critical, but yes we are all here for you, too!  :)

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


jenny.comish@...
 

Dr Kellon thanks very much for your advice. I will be speaking with my vet today so I will mention about the Invokana and will get his permission to share his email address with you (I don't want to surprise him!). I will also mention about starting Dewi on Prascend. My vet has not mentioned this so far so I hope I can persuade him to try. It's difficult acting as a go-between with this group and your own vet if they are not on board with the recommendations. 

Dewi is getting his feet trimmed on Wednesday (by Sarah Braithwaite so at least it's someone who knows what they are doing!! Sadly it's a one-off visit). My vet has suggested I give Dewi Metacam for pain relief. But the opinion on this group seems to be it won't help - I'm not sure why he has gone for Metacam over Danilon? (Dewi is now off the Danilon and is on Devil's Claw but I can't see any signs that the Devil's Claw is helping sadly). 

And I've just updated his latest X-rays from 12 Feb 2021. 

Thanks again.

Jenny
--
Jenny Comish
England, UK
Dewi Case History: https://ecir.groups.io/g/CaseHistory/files/Jenny%20Dewi
Dewi Photos: https://ecir.groups.io/g/CaseHistory/album?id=257833


Sherry Morse
 

Hi Jenny,

Much of the pain you're seeing with Dewi can be coming from the elevated insulin as well as the less than ideal trim.  Metacam is just another NSAID and will not help the situation at this point.




Kirsten Rasmussen
 

Jenny, I was reading the 2020 EEG guidelines last night (in preparation for a conversation with my own vet) and noticed that they specifically state that Invokana ("canagliflozin") can be useful in "horses with laminitis and severe ID that do not respond to recommended management changes. Smaller equids may be treated at a more reasonable cost because of their size"...this group is very well respected and your vet will almost certainly take their advice as the current gold standard of treatment for EMS.  The guidelines are updated every 2 years, or more frequently when new information becomes available.

Here is the link to the download site:
https://sites.tufts.edu/equineendogroup/
Maybe you could send your vet the pdf in case he/she has not seen the new recommendations, and ask him/her about that treatment option?  You already know Metformin is not likely to be helpful, which is the only other recommended pharmaceutical for lowering insulin, so that leaves trying the "Sodium-glucose co-transporter 2 (SGLT2) inhibitors", which includes canigliflozin (aka Invokana).

They also do up a guideline on PPID (same link), which I highly recommend you download and read given that Dewi's ACTH is abnormal.

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