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help with deciding how to move forward - new PPID diagnosis

Lucinda Vette
 

I hope I am doing this message correctly. Please advise if I am not. Thank you for this group.

My 26 year old Swedish warmblood mare, Juilliard, recently diagnosed with probable PPID. Her ACTH ( I am still waiting for the vet to send me her lab results) is 186, vet said normal would be under 35. She also has iron deficient anemia, the vet thinks due to an ulcer. Juilliard has always been sensitive to touch around her flanks. I have consistently had blood panels done over the years and her blood work has always been normal. So anemia is something relatively new. I am not sure why or how she would have developed an ulcer.

Facts:
26 year old mare
On IR diet since 9/2019
mineral balancing done by Dr. Kellon
lethargic for past few months
ACTH tested 2/5/2020 and was 186 (below 35 considered normal)
vet suggested the injection cabergoline (we haven't discussed dosage)
vet suggested we treat for ulcers (I can't remember the medication she suggested)
I have a call into the vet but have not heard back from her, to get answers to some of my questions
symptoms include large belly and diminishing topline, some ataxia recently, pretty severe lethargic affect

MY QUESTIONS - I am feeling a bit lost and could use some input and information to decide how to move forward
1) Cabergoline vs pergolide/prascend pills - is there an advantage to at least starting with the pills to be able to titrate the medication or can I co that with the injection?
2) Is there an ECIR recommended protocol for beginning treatment for Cabergoline?
3) Should I test her for IR and / or anything else? I think we did a full blood panel
4) Is it ok that the vet used Idex lab instead of Cornell? (They don't have an account with Cornell)
5) Could there be another reason for the anemia other than an ulcer?
6) Could the anemia cause an elevated ACTH?

Thank you for any help you can give. I will upload her case history with lab tests and that information as soon as I get it from the vet.

--
Lucinda, Pharrah (IR), Juilliard (PPID), and Cimarron- Amado, AZ, 2019

Eleanor Kellon, VMD
 

On Sat, Feb 8, 2020 at 11:07 AM, Lucinda Vette wrote:
1) Cabergoline vs pergolide/prascend pills - is there an advantage to at least starting with the pills to be able to titrate the medication or can I co that with the injection?
You can, and should, do it with the injection too.  Using a tuberculin syringe it's possible to accurately give dosages less than usual 1 mL target starting dose.

2) Is there an ECIR recommended protocol for beginning treatment for Cabergoline?
As above. It's not an ECIR protocol but most start with half the recommended dose for 1 or 2 injections.
3) Should I test her for IR and / or anything else? I think we did a full blood panel
Yes, you should. A  chemistry panel does not include insulin.
4) Is it ok that the vet used Idex lab instead of Cornell? (They don't have an account with Cornell)
With ACTH that high any lab is likely to pick it up. We like to stick with Cornell for insulin too just so it's easier to make comparisons.
5) Could there be another reason for the anemia other than an ulcer?
Not only possible - it's likely. Ulcers can only be diagnosed by endoscopy. They don't cause flank pain. Even bleeding ulcers won't cause iron deficiency because of the huge amounts of iron horses store. Before even considering treating for iron deficiency insist on a full iron panel of ferritin,TIBC and serum iron from KSU http://www.ksvdl.org/laboratories/comparative-hematology/ . Only ferritin gives a true assessment of iron stores https://ecir.groups.io/g/main/files/Iron,%20Iron%20Testing,%20Iron%20Overload/SMITH.pdf . Iron deficiency is virtually nonexistent in adult horses and iron excess can be very detrimental https://ecir.groups.io/g/main/filessearch?q=ferritin .
6) Could the anemia cause an elevated ACTH?
No, but chronic diseases like PPID can cause anemia. Mild anemia is also very common in horses her age where it is more a natural physiological consequence of a slowed metabolism than a true disease state.

 
--
Eleanor in PA

www.drkellon.com  2 for 1 course sale until January 31, 2020
EC Owner 2001

Maxine McArthur
 

Hi Lucinda
Welcome to the group! Thank you for getting your signature set up, and thank you in advance for putting your horses' details into case histories, as it saves the volunteers so much time to have the relevant details of diet and management in one place rather than having to trawl back through multiple messages. 
Dr Kellon has answered your specific questions about Juilliard, and what follows below is our welcome message to new members, detailing the group's philosophy and the protocols we have found to bring the greatest success in keeping our IR/PPID equids healthy and happy. Just on a personal note, my mare's blood tests showed some anaemia on a basic blood panel (not the KSU tests) before she was diagnosed with PPID, but since she has been treated, her bloods have come back within normal range. 

If you have any further questions after reading through the welcome message, ask away!

Hello 

Welcome to the group! 

The ECIR provides the best, most up to date information on Cushing's (PPID) and 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 Insulin Resistance (IR). These are two separate issues that share some overlapping symptoms. An equine may be either PPID or 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 IR is diagnosed by testing non-fasting insulin, glucose and Leptin. Leptin is the hormone that says "stop eating". Knowing this helps to differentiate if a horse is IR "at baseline" or if an elevated ACTH is "driving" the insulin up. In Europe, substitute adiponectin for the leptin test.

*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: IR 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 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. 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 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 IR/PPID individuals.

We do not recommend feeding alfalfa hay to IR/PPID 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 exercisecan 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. 

 

--
Maxine and Indy (PPID) and Dangles (PPID)

Canberra, Australia 2010
ECIR Primary Response

https://ecir.groups.io/g/CaseHistory/files/Maxine%20and%20Indy%20and%20Dangles 
https://ecir.groups.io/g/CaseHistory/album?id=933

 

 

Hi Lucinda,
I maybe stepping out of bounds a bit with my single experience with cabergoline but here is what I would suggest.  First, look over the finances because cabergoline will be more expensive than compounded pergolide and even Prascend at ‘normal’ doses.  If you still decide to pursue cabergoline, I would start Juilliard on pergolide at a low dose and titrate her dosage up until her ACTH is satisfactory and then switch over to cabergoline at the dose Dr. Kellon suggests.  I would also pretreat for a few days with APF before starting pergolide, making significant dosage increases and switching to cabergoline or just keep her on it the entire time.  My horse had a whopping veil when I switched him from pergolide to cabergoline and it can be a little frightening, knowing he’s stuck with cabergoline on board for days.  As my horse made significant positive changes while on cabergoline, my thoughts are that he wasn’t as controlled on pergolide as I was hoping and even the half dose of cabergoline was a whopping change for him.  He might have been fine had I remembered the APF.
If, on the other hand, Dr. Kellon responds to say that’s a ridiculous notion, remember my experience was unique.

--
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


 
 

LJ Friedman
 

nice that your vet knows of cabergoline.  i wonder how?  my view;
  cabergoline is ideal when your horse will not swallow a tablet of prascend or a capsule of compiunded pergolide
  you dont give the meds because you bosrd and bsrn staff is not reliable 
you show your horse and travel often
  otherwise i d start with comoiunded pergolide and consider cabergoline if not successful  

--
LJ Friedman  Nov 2014 Vista,   Northern  San Diego, CA

Jesse and majestic ‘s Case History 
Jesse's Photos

 

Lucinda Vette
 

Hi Dr. Kellon,

Thank you for your reply. I have a couple more questions as a result of your answers, and some of the other responses to my questions.

1) Someone suggested starting with compounded pergolide until she is through any pergolide veil, and also until her acth levels are down. Do you have a preference or recommendation regarding that? I am inclined to start that way because it seems like a more cautious approach, and that is how I'm feeling right now. But it would be helpful to have your insight. Also, my mare HATES injections.

2) When I get her tested for insulin, is it correct that I should do insulin, glucose, and leptin? 
3) When testing for insulin, should I use a vet that can use Cornell for the lab? ACTH was tested by Idexx.

4) Money is not unlimited, and I have potentially two other horses in need of additional blood work. With that in mind, how important is it that I get her iron levels tested at, I believe you said, KSU. Or even at all. Could I treat her for the PPID and then look at iron levels when I retest her ATCH levels?

5) Since the lab work was done at Idexx, do I need to stay with that lab for any further testing?

6) I have another horse, Cimarron, who tested positive for PPID in the fall. He was also anhidrotic at the time. The recommendation was to hold off on meds and retest him. He has been retested and was in the normal range (25 with less than 35 being normal). Should he be rested using Cornell? Should I test his insulin, glucose, and leptin and try to determine of PPID is an issue even though he tested in the normal range last week? The biggest symptom I see with him is the same I saw in Juilliard, that being lethargy. Something is not quite right or normal, it is the lethargy, and the previous anhidrosis, and then just a feeling that something subtle has changed in him. 

I would like to get her started on medication asap and will be talking with my vet today. Any additional information from you that can help me sort through this would be very appreciated.

Thanks,
--
Lucinda, Pharrah (IR), Juilliard (PPID), and Cimarron- Amado, AZ, 2019
https://ecir.groups.io/g/CaseHistory/files/Lucinda%20and%20Juilliard

Lucinda Vette
 

Thanks for the information Martha. If I understand you correctly, you are suggesting I start with pergolide at low dose, gradually bringing it to a level where her ACTH falls within a normal range. Then switch over to cabergolide (if affordable) because you had better results with cabergolide than with anything else. Is that right? I like your suggestions and have asked Dr. Kellon to weigh in a bit more. One more question, what is APF?
--
Lucinda, Pharrah (IR), Juilliard (PPID), and Cimarron- Amado, AZ, 2019
https://ecir.groups.io/g/CaseHistory/files/Lucinda%20and%20Juilliard

Lorna in Ontario
 

Hi Lucinda,

Here are a couple of helpful pages, talking about abbreviations we use frequently.

Go to our Files, click on the first item, Start Here, and scroll down 5 , to Commonly Used Abbreviations.
Also click on the next item EC Glossary, which offers more description for each.

--

Lorna  in Eastern  Ontario
2002


 

 
Edited

Pretty much, Lucinda, although I need to clarify a point.  I would not want to suggest that cabergoline gives better results.  When I switched Logo from pergolide to cabergoline, he was on a very high dose of pergolide and what I saw upon giving cabergoline leads me to believe he had become ‘resistant’ to pergolide.  That was not something I had considered before reading an ECIR post.  The very same thing might have happened with cabergoline had I started with it.
Unless you have a specific need for an injectable version, I would stick with pergolide and reevaluate as you go along..  LJ detailed some of those reasons here.  When I researched it, most of the discussion came up on the Chronicle of the Horse where owners found it more convenient when boarding.  I don’t think there is a ‘better’ choice, just whatever fits your needs better.
APF is Advanced Protection Formula, something I had never heard of until after Logo started pergolide.  It’s a collection of adaptogens, something else I had not heard of before, so I may not be the best one to try to answer that.  The thought is that it helps the body deal with stress, among other things, and helps to balance out the changes which come about when treating with pergolide or cabergoline, drugs which affect stress hormones.  Giving it for a few days before starting or increasing the dose of that type of drug seems to help them tolerate it better.  Keep giving it as long as you’re playing around with dosages.  My barn helpers call it my magic potion.
--
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


 
 

Eleanor Kellon, VMD
 

On Tue, Feb 11, 2020 at 05:22 PM, Lucinda Vette wrote:
1) Someone suggested starting with compounded pergolide until she is through any pergolide veil, and also until her acth levels are down. Do you have a preference or recommendation regarding that? I am inclined to start that way because it seems like a more cautious approach, and that is how I'm feeling right now. But it would be helpful to have your insight. Also, my mare HATES injections.
IME, cabergoline and pergolide side effects are very similar.  Some horses react more to pergolide, some react more to cabergoline. It's not predictable. If you get your horse on an effective dose of pergolide with side effects controlled, you may have to start all over again if you switch to cabergoline - and vice versa. You can taper up slowly with either one.
2) When I get her tested for insulin, is it correct that I should do insulin, glucose, and leptin? 
Leptin is optional.
3) When testing for insulin, should I use a vet that can use Cornell for the lab? ACTH was tested by Idexx.
My personal preference is for Cornell.
4) Money is not unlimited, and I have potentially two other horses in need of additional blood work. With that in mind, how important is it that I get her iron levels tested at, I believe you said, KSU. Or even at all. Could I treat her for the PPID and then look at iron levels when I retest her ATCH levels?
  Yes, you can check iron levels at any time - but don't delay balancing the minerals.
5) Since the lab work was done at Idexx, do I need to stay with that lab for any further testing?
I would switch.
6) I have another horse, Cimarron, who tested positive for PPID in the fall. He was also anhidrotic at the time. The recommendation was to hold off on meds and retest him. He has been retested and was in the normal range (25 with less than 35 being normal). Should he be rested using Cornell?
I would do TRH stimulation or domperidone response if his ACTH was borderline in the fall. Otherwise, it's not at all unusual for early cases to test negative outside the seasonal rise period.
Should I test his insulin, glucose, and leptin and try to determine of PPID is an issue even though he tested in the normal range last week? The biggest symptom I see with him is the same I saw in Juilliard, that being lethargy. Something is not quite right or normal, it is the lethargy, and the previous anhidrosis, and then just a feeling that something subtle has changed in him. 
It  doesn't sound like there's any pressing need to do those tests right now but without details that's hard to tell. Definitely pin down that PPID diagnosis since the history is highly suspicious.

 
--
Eleanor in PA

www.drkellon.com 
EC Owner 2001

Lucinda Vette
 

Thanks Dr Kellon, for your response.

when you say don’t delay mineral balancing - are you talking about hay analysis and supplements? Or some other test /labs for Juilliard? Hay analysis and mineral balancing was done in September and she’s been on the IR diet with balanced supplements since then.

Many thanks!
--
Lucinda, Pharrah (IR), Juilliard (PPID), and Cimarron- Amado, AZ, 2019
https://ecir.groups.io/g/CaseHistory/files/Lucinda%20and%20Juilliard

Eleanor Kellon, VMD
 

Lucinda,

I meant hay balancing. You're set.
--
Eleanor in PA

www.drkellon.com 
EC Owner 2001