First Post: Ribbon
Hello everyone, I hope I am doing this first post correctly. My 26 year old QH/Arabian mare (AKA Ribbon) has Cushings/IR. One blood test was taken in early May and it was 158, I was advised by my vet to put her on Prascend, no other precautionary steps were taken as I had never dealt with a horse with Cushings/IR and did not receive any other information/treatment guidance at that time. Ribbon began to display progressive soreness with head bobbing when she was walking around her paddock, we pulled her off her field and had blood tests retaken on June 8th and her ACTH was 71 and Insulin 42.7, it had dropped, but she was very sore in her feet. She was permanently pulled off her dry lot which does not get irrigated (which very obviously was not as dry as I had thought, weeds have sugar too) and put on stall rest with grass hay being soaked. Her radiographs were taken June 8th and displayed 5 degree rotation in L and 6 degree rotation in R of the coffin bone. I was recommended to have glue-on shoes put on or to use an easy boot by my vet. My vet stated the glue-on shoes would stay in place and not need to be taken on and off and thought this would be better. Ribbon did not do well with glue-on shoes, her lameness became more progressive while on stall rest and she was very sore, those were taken off and the "Cloud" easy boots were applied. I had no idea about how often she would need to be trimmed, my vet did not inform me of this, otherwise the glue-on shoes would have never been put on. She was walking better for a few days and now has shown progressive lameness again for the last four or so days. She is in a stall with a run and is resting in her stall for most of the time and occasionally goes out into her run with the cloud boots on. I just had radiographs retaken and unfortunately, she has rotated more aggressively in her R front (I do not have the new radiographs yet to show exactly what her numbers are. I feel like I have been quite in the dark before finding this group, I wish I knew this information even a month ago. At this point, I am not sure the prognosis for her is a good one due to the amount of rotation she has developed. She is getting everything recommended in her diet by the ECIR diet. She is on prascend, hay getting soaked (it just got tested, I am waiting for the results). My vet recommended bute for her inflammation as she is quite lame not being on something, I have been told to try Devils Claw. Despite the amount of rotation, she is still standing fine and not shifting her weight back on her hind end thus far, eating and drinking and overall does not seem to be in too much distress at this time.
Questions I have: Stall rest vs having access to a 12x24 run? (she is very quiet and does not move around much, but is still walking- is this harmful right now?
Devils Claw vs NSAIDS - why do some vets not recommend trying Devils Claw? The vets I have spoken to thus far stated because there is no scientific research behind the Devils Claw, they do not endorse.
Please excuse me if there is information that does not make sense in this post or I have worded things incorrectly, this is all still very new to me and I have been extremely stressed and emotional due to my thinking right now that my horse does not have a good prognosis at the moment. I have scoured the posts on the ECIR website and have found answers to some of my questions, it has been really helpful. If anything, I have learned of a good resource to seek out for the future.
Courtney F. in OR 2022
You're doing great--lots of research done, blood tests done, diet dialled in. I'm now going to paste below my comments our welcome message for new members--you may have read this before, but please go through it again, following the links, as there may be information you are not yet aware of.
Well done to keep her off all grass (and weeds). Please post your hay test results to your case history folder--Lavinia has sent you the links for creating the folder and uploading documents. You can also find instructions in the Wiki. Balancing her supplements to your hay test will be the next step in her diet, and we have a list of people who can do this for you in the Files.
Her ACTH result is higher than we like--most PPID horses do best when their levels are kept low throughout the year (in the low or mid-20s pg/mL)--so you will probably need to increase her Prascend dose, particularly as we are going into the seasonal rise when the levels increase. We usually suggest re-testing ACTH 3 weeks after a dose increase to make sure it is effective. You may find that as her ACTH drops, her insulin will also drop more and if her hoof pain is from the insulin, her hoof pain should decrease too. Please also post photos and xrays for us to look at her trim. A less than optimal trim may be a part of her soreness. The Cloud boots are an excellent choice, but make sure you keep her feet dry and watch out for rubs. Some horses prefer a different pad in their boots, so be prepared to experiment if that should be the case.
Regarding your questions, if Ribbon is not on the NSAIDs now, she can have access to a run provided any movement is her choice and she's not being forced to walk in any way (including by other horses). If she doesn't want to move, or she wants to lie down, that's fine too. If she does spend time lying down to rest her feet, you can move her hay and water within reach. It's excellent that she does not seem to be badly distressed.
Many veterinarians in my neck of the woods also refuse to consider anything other than NSAIDs for pain relief. They do have a point--herbals are not regulated nor do they have a set dosage, which means sometimes we need to dose to effect rather than a particular number/amount. The best you can do is research the relative side effects, consider why we don't recommend NSAIDs for laminitis pain, and make your decision. There is a document in our Files about pain relief alternatives: Pain Relief Alternatives to Bute and Banamine (groups.io)
These presentations by Dr Kellon on why endocrinopathic laminitis is not inflammatory may also be of interest: main@ECIR.groups.io | Files
Let us know if you have further questions, and here is the long but very important welcome message.
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.
Maxine and Indy (PPID) and Dangles (PPID)
Canberra, Australia 2010