Help Decipher New Bloodwork Results /New Symptoms


 
Edited

Hello…I decided to re test my 11yr old Wb mare Schimpie last week because she has been very low energy to ride and just blah in general lately..also sort of irritable too at times…so far this is what has come back : Metabolic panel sent to Cornell (non fasted) 
Glucose -96 mg/dl ( 71-122)
lipemia - 7
leptin still pending 
Insuin - 27.62ulU/mL (10-40)
T4 - 1.44ug/dL (1-3)
acth - 77.4pg/mL (2-30)  
lyme - all negative 
epm - still pending 
Vitamin E level still pending 

looks like last time I tested her was April 2021…numbers weren’t much different - Glucose -98, Insulin-37, Acth pre stim 14.4/ post 55.3, Lyme negative..and also not much difference from the initial onset of actute laminitis 6/2020 triggered by steroids - Cortisol 3.89 (2-6) , Insulin 63.15, acth 34.6, Lyme negative 

Anyhow she had been doing very well for quite some time …I’ve just been noticing lately her energy level is super low and she’s just not herself when being ridden 

..I’m a bit puzzled because her diet is pretty good -or so I thought …she gets a small amount of Ontario Dehy Timothy Balance Cubes/Vermont Blend/Flax/Vitamin E capsules with a handful of usually Nuzu Stabul One (unless chewy is out of it ..in which case she gets a handful of Hygain Zero)this is to cover her supplements which are Uckele Laminox, Phytoquench Pellets, Spirulina, GUT and Insulin Wise , Tractguard, and Sucralfate…i recently added APF Pro in hopes of it helping her energy…I normally feed her a tested low sugar Timothy hay but my supplier has run out and hasn’t been able to find any for couple months now …since then we have been soaking our local hay guys Timothy /orchard mix, and also found an alfalfa/orchard mix that surprisingly tested low sugar -so I give her a little of that as well …that is really the only difference in her diet -which I understand possibly a big difference…however her bloodwork results to me don’t seem that much different from previous..yet her energy and demeanor have declined again. Her weight and body condition is pretty good all things considered.

My vet has recommended to try Metformin and Thyro L

--
Michele Goldberg 
Bernville, Pa
joined 2015


Sherry Morse
 

Looks like she needs a bump on her Prascend dosage at the very least right now.  Her insulin is nowhere near high enough to warrant Metformin and unless she needs to lose weight there's no need to put her on Thyro-L.  




 

She’s not on Prascend …never has been …my vet said she didn’t have Cushings and is too young (she’s 11) ?? This is where I’m confused with the results ..I understand fall seasonal rise takes consideration…vet said the results can be up to 3 times higher for a normal horse during seasonal rise?? 
--
Michele Goldberg 
Bernville, Pa
joined 2015


Sherry Morse
 


 

Hi Sherry… I will send this over to the vet… However based off of these blood results does this indicate that she does have Cushing’s?
--
Michele Goldberg 
Bernville, Pa
joined 2015


Bobbie Day
 

Hello Michele welcome back!
I see you have already received some great feedback from Sherry, however although you have been a member or some time, I am going to send along a welcome message. We want to be sure new (and old) members have all the information at their fingertips needed for questions that may come up.
I would like to remind you though it would be really helpful to have a case history on your mare. 

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
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


 

Hi Michelle,
You stated that your recent results were not very different from last April’s.  In April, you did a TRH stim test but you do not specify having done that recently, so you’re comparing April’s 14.4 with September’s 77.4.  You can wait a few months and test again if you want to make a more accurate comparison.  Some early PPID cases only need pergolide during the rise.  We have seen horses even younger than yours diagnosed positive.
I totally agree with Sherry that metformin isn’t warranted and Thyro-L only if she needs to lose weight.

--

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
 


 

Hi Martha… Yes that is correct we did not do a TRH stim this time as it was my understanding that if you’ve done a TRH stim once that is all you need and then further testing in the future does not warrant repeating the stim test? Also my vet is telling me that during this time of year the seasonal rise normal horses can have three times the reference range and still being considered normal?… My head is spinning there’s so much conflicting info
--
Michele Goldberg 
Bernville, Pa
joined 2015


 

Michelle, I’m just suggesting that 77.4 is more than five times the value you found when you tested in April so I’m not sure what’s conflicting here, except for your vet’s understanding that 11 is not necessarily too young for PPID.  You should not need to do a TRH stim once diagnosed positive and started on pergolide, neither of which apply to your horse.  You should also not do a TRH stim during the rise at this point because there are no published standards to which you can compare your results.  It’s fine that you didn’t do one but you need to be sure to compare the correct numbers.
--

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
 


Nancy C
 

Hi Michelle.

Agree with all that has been said. I would add, "energy and demeanor" are non-specific signs and could range from diagnosis ,to diet,  to trim, to work issues.  DDT+E.
 
Again, case history please.
--
Nancy C in NH
ECIR Moderator 2003
ECIR Group Inc. President/Treasurer  2021-2022



Kirsten Rasmussen
 

Michele, an ACTH of 77 in a young horse is indicative of early PPID at the peak of the seasonal rise.  That number would be more normal for an elderly horse, not an 11 year old.  Our understanding of what is normal this time of year is evolving and the 3x rule doesn't hold anymore with new research.  The Liphook charts that Sherry shared the link to show a max of about 55 (normal) at the peak of the rise.  If you want to leave her untreated this fall and redo the TRH Stim in the late winter or spring to confirm the early PPID, that's fine as we are coming out the other end of the rise and Schimpy's insulin is not overly elevated.  But next by July you should have her started on pergolide and then retest her baseline ACTH to make sure it's staying low. 

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


 

Martha …I guess what’s conflicting in my mind is my vet telling me that her acth of 77 is acceptable/normal beings that it’s during the fall rise ?? I understand that it’s considerably higher than April 2021 …..but isn’t that to be expected during fall rise?? Her stim results both pre and post put her in the normal /not Cushings category …that’s why we didn’t stim her again ..and also like mentioned you generally don’t stim during fall rise if I’m understanding correctly….the other conflicts is vet saying she’s far too young to have Cushings and also the other conflict is vet saying she should have Metformin??
--
Michele Goldberg 
Bernville, Pa
joined 2015


 

Hi Kirsten …thank you …that makes sense 
--
Michele Goldberg 
Bernville, Pa
joined 2015


Sherry Morse
 

Hi Michelle,

The short answer is that your vet probably doesn't have the experience that this group does and as indicated in the 2 files I shared earlier 77 is outside the expected range in a normal horse this time of year.  If she is early PPID she would experience and exaggerated rise and you may only need to medicate during the rise.  As far as age of onset - PPID has been diagnosed in some horses at ages in the single digits.  It's unusual but not unheard of.

Have you asked your vet why he/she believes that Metformin is needed now?




 

Hi Sherry ..thank you for your response and helpful info …my vet said something about the glucose to insulin ratio put her in the “at risk” category I believe and that’s why he suggested Metformin…I’m guessing her insulin might be what it is due to the elevated acth or vice versa??if I were to go ahead and start her on Prascend what dose would be appropriate? Would that be the best treatment plan ? Or like someone else mentioned would you hold off treating since we’re coming towards the end of the fall rise , and re test with a stim come winter ??
I want to do whatever the best thing is for Schimpie and get her feeling like her usual self. 
--
Michele Goldberg 
Bernville, Pa
joined 2015


Eleanor Kellon, VMD
 

 Michele,

How much work is she doing? I wouldn't put her on pergolide, Metformin or Thyro-L. Her diet may be too low in available carbs to replenish her glycogen.  Try giving her 1.5 lbs of high quality oats (aka racehorse oats) or oat groats immediately after exercise - no other time.

A negative TRH stim test trumps a seasonal ACTH elevation every time. You can repeat that test later though. They can change from negative to positive. It wouldn't be high on my list at her age.
--
Eleanor in PA

www.drkellon.com 
EC Owner 2001
The first step to wisdom is "I don't know."


 

Hi Dr Kellon…she is in light consistent work ..anywhere from 3-5 days /week usually around 20-30 minutes of mostly flat work in the arena and occasional trail riding and flat work out in the fields….I was wondering if this could be diet related to the low energy and that she needs a boost …I can certainly give this a try.
--
Michele Goldberg 
Bernville, Pa
joined 2015


Eleanor Kellon, VMD
 

I would definitely give the post work oats a try. Let us know how it goes.
--
Eleanor in PA

www.drkellon.com 
EC Owner 2001
The first step to wisdom is "I don't know."


 

Ok will do ! Does steam crimped versus whole oats make a difference?…Triple crown sells both types
--
Michele Goldberg 
Bernville, Pa
joined 2015


Eleanor Kellon, VMD
 

Michele,

Unless the horse is known to have trouble chewing, whole oats are fine.
--
Eleanor in PA

www.drkellon.com 
EC Owner 2001
The first step to wisdom is "I don't know."