Dr Kellon what are your thoughts on using pergolide for elevated insulin?
My 16 year old horse is now on 1 mg of pergolide and her insulin level came down from 170 to 50 ulU/mL.
She had been on .5mg pergolide and her insulin level was in the 70s. 
Took her off the pergolide as I wasnt sure .5 mg was doing anything and then the retest had her back up at 170 ulU/mL.
(at the time I took her off the .5 mg dose I could not get her up to 1 mg without sustained horrible veil even on APF)

Since her insulin level seems to have came down with the increased pergolide (there were 2 other changes, see below),
should I see if the insulin values would improve even more on an increased dose of pergolide?
Her ACTH has not been drawn again but even if ACTH is currently in the "normal" value range would there still be advantage to trying to bring insulin down with it given there are other hormones the pergolide affects?
The only symptom I can say she could have of PPID is excessive urination which is also symptom of IR.
The only other change I made around the same time is soaking and then also rising the hay before feeding
(newer hay is considered safe but is higher in starch and esc than last batch was) and I increased spirulina from 10 g to 20 g a day
and will now be giving her 20 g twice a day.

Her ACTH was slightly over the normal zone for the period of the rise and was only 1 unit over the "normal"--with a reading of equivicoal 
in late June of this year. 

Thank you,

Lesley Bludworth 
Phoenix, AZ   7/2022
Sophie TWH mare IR/EMS, PPID?
https://ecir.groups.io/g/CaseHistory/files/SophieB%20Case%20History
https://ecir.groups.io/g/CaseHistory/album?id=277749

Hi Lesley, 

I think to get a prompt answer you should put all your blood testing results in your Case History (most of what you describe in your post is missing), and clarify which hay you were feeding at which times, the date you changed hay, and when you were soaking hay, as well as when you increased the spirulina.

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

Snickers' Case History
Snickers' Photo Album

FWIW, my IR mare (non-PPID) responded wonderfully to 1mg Pergolide during the seasonal rise. 

Her insulin now tested at her **BEST EVER** 21 uU/mL (0-42 ref), glucose 93 mg/dL (70-120 ref), and ACTH 13 pp/mL (<15 ref), tested four weeks off the Pergolide.  She never tested this well last summer, even while on Steglatro, with more exercise and soaked hay.  Peaches' ACTH did not warrant Pergolide, but we decided to give it a try during the seasonal rise, because she had to quit the Steglatro because of elevated GGT.

My understanding is that there is no harm in giving Pergolide if she doesn't need it.  And it certainly seemed to help Peaches this year.  I am interested in the replies to your situation, in light of Peaches' recent experience.      
--
Sheri P in IL 2021
Peaches Case History & files:  https://ecir.groups.io/g/CaseHistory/files/Sheri%20and%20Peaches
Blood results summary:  https://ecir.groups.io/g/CaseHistory/files/Sheri%20and%20Peaches/Peaches%20-%20Triglycerides%20Study
Peaches photos:  https://ecir.groups.io/g/CaseHistory/photosearch?p=title%2C%2C%2C20%2C1%2C0%2C0&q=sheri+and+peaches

Sheri,
Thank you, your experience is exactly the information i was hoping to hear!
--
Lesley Bludworth 
Phoenix, AZ   7/2022
Sophie TWH mare IR/EMS, PPID?
https://ecir.groups.io/g/CaseHistory/files/SophieB%20Case%20History
https://ecir.groups.io/g/CaseHistory/album?id=277749

I'll add my 2 cents, too.  Shaku has EMS and it was getting harder to keep him sound as every year passed.  ACTH always tested normal.  When we finally got a somewhat abnormal result during the seasonal rise and started pergolide, his EMS/insulin became way easier to manage.  In hindsight I think he had early undetected PPID and I could have started medicating with pergolide 5 years earlier, after his first and only founder.

It could be that horses with insulin that responds to pergolide but don't have elevated ACTH are actually early cases of PPID, or cases where other PPID hormones are elevated but ACTH remains normal.  The other hormones also cause insulin to rise, and they are also treated with pergolide.  Maybe one day we'll have a PPID panel blood test that looks at more than 1 hormone. 

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

Snickers' Case History
Snickers' Photo Album

Kirsten,
I will work on Sophies CH and thank you for sharing your experinece with Shaku!  
 --
Lesley Bludworth 
Phoenix, AZ   7/2022
Sophie TWH mare IR/EMS, PPID?
https://ecir.groups.io/g/CaseHistory/files/SophieB%20Case%20History
https://ecir.groups.io/g/CaseHistory/album?id=277749

The ideal approach in equivocal or borderline cases is the TRH response test. Both of the changes you made could have had some effect but it was probably the pergolide too. You will have to get approval for dosage increase from your vet.
--
Eleanor in PA

www.drkellon.com  BOGO 2 for 1 Course Sale Through End of January
EC Owner 2001
The first step to wisdom is "I don't know."

Dr. Kellon,
I upped her pergolide 1/4 tab last night and will let my vet know.
Since it seems the recommended dose of pergolide is based on symptom management and not totally on ACTH numbers, will the TRH stim test tell me more than what can be determined with repeat insulin testing with the incrased pergolide dose? 
--
Lesley Bludworth 
Phoenix, AZ   7/2022
Sophie TWH mare IR/EMS, PPID?
https://ecir.groups.io/g/CaseHistory/files/SophieB%20Case%20History
https://ecir.groups.io/g/CaseHistory/album?id=277749

Insulin numbers are multifactorial, including by time of year and all the other things we talk about. Your mare was already high risk for EMS because of her breed so you can't blame it all on PPID.
--
Eleanor in PA

www.drkellon.com  BOGO 2 for 1 Course Sale Through End of January
EC Owner 2001
The first step to wisdom is "I don't know."

I am not blaming PPID for her insulin dysregulation.  I am trying to help regulate her insulin levels however best I can.
PPID can affect insulin regulation seperate from EMS/IR, correct?   So insulin dysregulation can also be seen as a symptom of PPID?
 If we increase pergolide dose and it improves insulin values further, wouldnt it just be helping to control a symptom of PPID, seperate from her IR/EMS. 
I know she has IR (cresty neck) and will continue to manage her as such but so far diet control has not done much to bring insulin down  to better levels (below 80) certainly not as much as giving the pergolide at this point.
my plan is to take her up to 1.25 for 2 weeks and retest insulin, if improved again, I will take her up to 1.5 mg pergolide and retest in 2 weeks.
Will do the stim test in March. 
--
Lesley Bludworth 
Phoenix, AZ   7/2022
Sophie TWH mare IR/EMS, PPID?
https://ecir.groups.io/g/CaseHistory/files/SophieB%20Case%20History
https://ecir.groups.io/g/CaseHistory/album?id=277749

Hi, Sherry.  I did not do a TRH Stim test on Peaches.  She does not exhibit any signs of PPID, though her July 21, 2022 ACTH was 24 pg/mL (ref:15-50 = Equivocal).  Peaches is turning 12 this Spring, is sound, and has no issues with shedding, belly, or laminitis.  To date, her symptoms have been classic IR, only.

Do you feel that a TRH Stim test is warranted? 

Thanks,
Sheri

Sheri P in IL 2021
Peaches Case History & files:  https://ecir.groups.io/g/CaseHistory/files/Sheri%20and%20Peaches
Blood results summary:  https://ecir.groups.io/g/CaseHistory/files/Sheri%20and%20Peaches/Peaches%20-%20Triglycerides%20Study
Peaches photos:  https://ecir.groups.io/g/CaseHistory/photosearch?p=title%2C%2C%2C20%2C1%2C0%2C0&q=sheri+and+peaches

Sherry,
How long does a horse need to be off pergolide before doing the TRH test for accurate results?
--
Lesley Bludworth 
Phoenix, AZ   7/2022
Sophie TWH mare IR/EMS, PPID?
https://ecir.groups.io/g/CaseHistory/files/SophieB%20Case%20History
https://ecir.groups.io/g/CaseHistory/album?id=277749

Hi Lesley, doing the TRH STIM test will hopefully answer your question.  If she's positive, then the pergolide probably helped.  If not, it's possible you're seeing the effects of your other dietary changes plus external conditions (time of day, weather, stress, a bale of hay that is higher or lower in ESC+starch at the time of testing, mare hormone variations, and endless other factors).  It's easy to know in hindsight, like my case.  I would never have even done the TRH STIM test back then because I didn't see any signs of PPID, his EMS masked them and he "always" had a dropped topline even when he was young.  It's only looking back that it all comes together.

Her ACTH was slightly over the normal zone for the period of the rise 

What was her ACTH during the rise?  It's not in your Case History.  I think there are a few test results missing?  According to your Case History her insulin was 25 uIU / ml before you started the 0.5mg pergolide.  There are no results reported for after starting pergolide. 

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

Snickers' Case History
Snickers' Photo Album

Kirsten,
Her ACHT was 66 pg/ml September 12th. I was told that was abnormal for the time of year.
She was on Metformin up til around the end of september or so but discontinued as it stoped working at some point.
I do think her insulin may have gone up in reaction to being trimmed and painful at somepoint as well.
She is peeing MUCH less on the pergolide however. 
She used to pee everytime I came out to feed and would pee 1 or 2 times on a 1/2 hour walk even when her insulin was much lower.
I did not think much of it before because I used to give her a treat for peeing.... Dont ask ;)
Now she does not pee on her walks or when I go out to feed.
--
Lesley Bludworth 
Phoenix, AZ   7/2022
Sophie TWH mare IR/EMS, PPID?
https://ecir.groups.io/g/CaseHistory/files/SophieB%20Case%20History
https://ecir.groups.io/g/CaseHistory/album?id=277749

Yes, 66 pg/ml is just a bit above normal at peak rise.  The reduction in peeing on pergolide is another sign.  I would agree she should be on a low dose of pergolide, ideally so her ACTH doesn't go above the low 20s, YEARROUND.  You can try a TRH stimulated test in the spring, off pergolide, to confirm her diagnosis though.

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

Snickers' Case History
Snickers' Photo Album

Kirsten,
Is 1 mg considered low dose?
She is at 1.25mg right now.
Vet didn't want to go up to 1.5mg.
Looking to do another insulin test next week. 
Can do ACTH on the current dose also.  
Can pergolide be stopped quickly for TRH test or does it need to be cut back slowly?
--
Lesley Bludworth 
Phoenix, AZ   7/2022
Sophie TWH mare IR/EMS, PPID?
https://ecir.groups.io/g/CaseHistory/files/SophieB%20Case%20History
https://ecir.groups.io/g/CaseHistory/album?id=277749

Hi Lesley,
1 mg pergolide is considered a “starting” dose.  Some do fine on less but most will need more.
If you’re doing insulin/glucose, I would check the ACTH as well.  
Pergolide can be stopped abruptly but you should wait three weeks after stopping before doing the TRH stim test.  When you restart the pergolide, you should probably taper on, unless you have reason to believe that’s unnecessary.

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