Diagnosed PPID 2 wks ago - Severe muscle spasms?
18 yo 13h welsh pony - Diagnosed PPID 11/10 - Began 1/2 tab Prascend 11/11. ACTH 230-something. Does not look like insulin or thyroid were checked. Glucose very mildly elevated. All other labs WNL. Diet changed to Hygain Zero and slow feed mixed grass hay (started Triple Crown Safe Forage today to replace mixed grass hay). Moderate lameness noted 11/10 and has continued to get worse. Ruled out laminitis. No heat/bounding pulse/neg. hoof test per vet. Unstable on feet/very careful when placing feet and walking/only moves when absolutely forced/toe walking/rocking back and forth and front to back. Vet says severe muscle spasms that will get better in a few weeks. His recommendation: Banamine 8cc daily for two weeks, continue stall rest, 50ft walk twice daily (which is significant struggle). Now, bleeding from left nostril (day 4 of Banamine - we were previously doing Equioxx daily). NSAID related or something else? We're at a loss. We do not want her to continue to suffer, but we don't want to give up on her if these symptoms will pass. Any recommendations/suggestions/help is greatly appreciated!
Your first post here triggers our lengthy welcome letter, containing all sorts of ECIR related information. Keep it in mind as you work your way through the care details. What might not seem important now may well be later.
It appears that your Welsh pony has been diagnosed PPID with a high ACTH value of 230. We would like to see your actual lab results posted either as a pdf in your case history files or a photo in your photo album. Files cannot be attached to your posts. In order to correctly diagnose insulin resistance, you would need to have checked the insulin and glucose from the same blood draw. You probably won’t need to test the thyroid as any altered results are generally the result of being PPID/IR. The previous tests done by your vet are not conclusive, especially in a small pony.
Welsh ponies, especially the smaller ones, have a genetic predisposition to become IR. I would assume that is the case and begin treating her as such. No harm will be done if she’s not. Our emergency diet is described in the welcome I’ll include. That includes soaking her hay for an hour in cold water and then rinsing well to decrease the ESC (ethanol soluble carbohydrates) in her hay until you test and determine that her hay is appropriately low in ESC+starch. The hay products you’re feeding may or may not be low enough for her as they generally aren’t tested for every batch. A better option might be Triple Crown timothy balance cubes, in which every batch is tested and mineral balanced.
I would not force any unnecessary movement on her. When she’s comfortable, she will offer it herself. Doing so before she’s ready will likely further damage the connectivity the already damaged lamina provide.
Metabolic laminitis is not an inflammatory event and does not benefit from the administration of banamine, bute or any other NSAIDs such as Equioxx. They can definitely cause unwarranted damage, as you may be seeing. If she’s been on NSAIDs for awhile, you’ll need to slowly taper them down by increasing the time between doses. Go from once daily to every other day for 3-4 days and then to every third day for the same. If you decrease it too quickly she might experience rebound pain and you would need to begin the weaning process over again.
Half a tab of Prascend is unlikely to have brought her ACTH down from that high value to a normal range. You can test again three weeks after starting Prascend or increasing it to see where you are. I would be likely to increase the dose to 1mg and then wait three weeks to test. The appropriate dose is what it takes to normalize the ACTH and has nothing to do with the size of the horse.
I would also recommend X-rays and appropriate photos of the hooves so that she can be trimmed to keep her comfortable. Before you do more blood tests, make sure that you understand how to follow our feeding instructions prior to the blood draw.
We will be here to further answer your questions and to clarify our answers. Don’t hesitate to ask. And now for the group welcome I promised which should generate a few questions.
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.
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.--
Martha in Vermont
ECIR Group Primary Response
Logo (dec. 7/20/19), Tobit(EC) and Pumpkin, Handy and Silver (EC/IR)
Martha and Logo
Eleanor Kellon, VMD
If your weather has cooled off (below 40F) it's entirely possible this is cold induced hoof pain, aka "winter laminitis" which does now show heat or increased pulses https://drkhorsesense.wordpress.com/2019/11/30/winter-foot-pain-in-metabolic-horses/ . I would also stop the TC Safe Starch and substitute Triple Crown Naturals Timothy Balance Cubes which are already mineral balanced and each batch tested for safety. Also stop the Hygain Zero. It's safe from an insulin standpoi9nt but high in omega-6 fatty acids.
P.S. The "muscle spasms" are muscles tensing/bracing against the pain.
Eleanor in PA
So sorry you and Shorty are going through this. It is painful to watch, but with the right care, Shorty can recover. I went through this myself starting in May. My horse is now cantering around at liberty. I highly recommend downloading the document entitled "Acute Care For Endocrinopathic Laminitis" at this link (it's free).
I had to ignore almost all the advice given by veterinarians. What works is outlined in your welcome letters and as described by Dr Kellon. Take all these steps ASAP:
-Get the right labs, including ACTH, insulin and glucose, handled in the very fussy and specific ways required by Cornell Veterinary Lab.
-Treat existing metabolic conditions aggressively to gain control of PPID and high insulin.
-Get radiographs ASAP to check for rotation and sole depth. Post images in your Photo Album.
-Get a great trim in place after seeing mark-ups. Resist advice to use fancy appliances on the feet. They can work in the right hands, but far too many are tacked on top of a bad trim and don't improve comfort.
-Use hoof boots and pads for hoof comfort ASAP. You can tape on pads in while you wait for boots to arrive. You may need to change sizes as the trim progresses. There is no one magic hoof boot. Measure the front hooves carefully and order to size.
-Bed in deep shavings and keep the stall available 24/7. A place to lie down and rest is critical.
-Feed only safe, tested hay or Triple Crown Timothy Natural Balance Cubes. Make sure Shorty has the building blocks to build new hooves.
This forum can provide you with the support you'll need.
Cass, Sonoma Co., CA 2012
ECIR Group Moderator
Cayuse and Diamond Case History Folder
Cayuse Photos Diamond Photos