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Help with New Acute Laminitis


lorraine.dearnley@...
 

Hi,
I am new on here and really hoping for some help. My pony was diagnosed with laminitis a couple of weeks ago and had x-rays and realigning trim on Wednesday. 

Her history is that she is 12 years old and a New Forest pony cross. She has been out of work for over a year as she damaged her right fore check ligament and although healed, she was not landing level with the right hoof but sound in all paces. A month ago she had a slight swelling on the lateral right fore cannon bone so I kept her in yard/ stable for this to improve, whilst taking her out for hand walks. Again she was sound. About four days later, the swelling had gone but the left hind had swollen up. A couple of days after that she was in so much pain and couldn’t move so I called out the vet. She diagnosed laminitis and put her on two Danilon a day. After a week she was a lot better but had fluid build up under the abdomen. Bloods were normal but she was moved onto paracetamol. After another 6 days she was in a lot of pain again so back on Danilon. 

I haven’t got a copy of the x-rays yet but the right fore showed 15° palmar angle and the left wasn’t too bad. Hind feet are ok. Sole depth at the fronts are about 0.8mm. 

She is barefoot and has had a realigning trim on Wednesday but I can’t take her any lower than two Danilon and 38 paracetamol a day as she is in too much pain. She is currently in boots and pads with a chunk cut out of the pad on the right fore. 

She has a history of stomach ulcers and I am worried about the use of Danilon. 

She is on 8kg of soaked hay over 24 hours and just a vitamin and mineral supplement. 

Will it take time for the right fore to settle after the trim? My podiatrist is back in a couple of weeks and he did say that I might need some softer pads in the boots. 
--
Lorraine D in UK 2020


Maxine McArthur
 

Hi Lorraine
Sorry to hear your pony is going through this, but it's good that you found the group. I'm sending you our welcome message that all new members receive. In this message you will read about the group's protocol of Diagnosis, Diet, Trim and (once the horse is comfortable) Exercise. There are lots of links to follow for further information in the message (just click on the links in blue). Please keep posting questions if you still have them after you've read the message. 

We'll have a few questions for you before we can offer any suggestions, and you will have received a message about creating a case history for your mare so that all her information is in one place, and volunteers can refer to it rather than going back through many messages. There are also links in the welcome message below about creating a case history folder and also a photos folder to upload copies of x-rays and hoof photos. Let us know if you get stuck at all. Once you've got your information collated, you can add to this message thread or start another one at any time. 

A couple of questions spring to mind. The answers should go in your case history and will help us work out the best way to get your mare comfortable. 
Firstly, were any blood tests done to determine whether she is EMS/IR or possibly early PPID? It would be a good idea to at least test insulin and glucose (more on how to do that in the welcome message below). 
Second, do you have a nutrient (particularly starch and simple sugars) analysis for her hay or are you soaking what you have? How long are you soaking and in how much water?
Was she on pasture when she was diagnosed with laminitis? What is her current and ideal weights?
Have you spoken to your vet about ulcer medication while she is on the NSAIDs? There is more about pain relief in the welcome message, but if her pain is from endocrine-related (EMS/IR or PPID) laminitis, NSAIDs are unlikely to help. What does help is to eliminate the trigger for the laminitis--hence all our questions about diet, blood tests etc. 

Absolutely agree it's a good idea to experiment with pads to find a combination that makes her comfortable. Members have used a variety of pads, from styrofoam to nappies to felt to yoga mats/pads. Her preference may change from day to day, so keep an eye on how she goes. If the cutout she has in her current pad doesn't help, try no cutout, or a slightly different cutout etc. Is she on soft bedding in her stall?
If you can add copies of her xrays and any photos you have (all these instructions are below) to a photo album, our trimming guru can give you some helpful comments to take to your trimmer. 

Here is the welcome message. It's long and full of information, so take your time and do ask any further questions you may have. 

Hello 

Welcome to the group! 

The ECIR Group 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 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: 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 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. 

 



--
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

 


lorraine.dearnley@...
 

Hi Maxine,

Thanks for all the information. I have added a brief case history but will add to it as I get a bit more time and get the x-rays sent to me.

In answer to your questions:

My vet is assuming EMS/IR but didn't think there was any point taking bloods for it as I don't want to use Metformin. She said that you couldn't test for PPID yet until the acute laminitis stage has passed as that can give a false result.

I am currently soaking the hay for 5 hours and rinsing afterwards and she has lost weight with this according to a weightage, although we have a felling that some of that is fluid loss as her crusty neck immediately softened and she wasn't as bloated.

She was off pasture for 6 days before this happened which is a bit strange, unless my hay was high sugar (I am looking into testing it).

She is currently getting a couple of handfuls of St Hippolyt Equigard musli so I can add any herbs, vitamins and medication. I am using a herbal ulcer supplement, but I think it is just the pain in her right fore that I can't quite manage. I am using 7lb pads in the boots but will get some softer 4lb ones. She has plenty of soft bedding although that doesn't seem to make much difference.

Has anyone used sheep's wool in boots to help pad them? I do think that it is the padding that is key to comfort.
--
https://ecir.groups.io/g/CaseHistory/files/Lorraine%20and%20Evie

Lorraine D in UK 2020


 

Lorraine
Here is a link to a helpful document about hay soaking. There is no need to soak hay (cold water) for HOURS. A soak in cold water of 1 hour should be sufficient, 30 minutes if soaked in warm-hot water. 

https://ecir.groups.io/g/main/files/9b%20Pulling%20it%20Together/Hay%20Soaking%20Tips.pdf

If you do a search about hay soaking you'll find many articles from various sources that agree with the 30/60 minutes soaks.
--
Bonnie Snodgrass 07-2016

ECIR Group Primary Response 

White Cloud, Michigan, USA

Mouse Case History, Photo Album


lorraine.dearnley@...
 

Bonnie,

Thanks for that on soaking hay. My vet said to soak for 8 hours but I didn't think that was right either!! It is much easier to soak for an hour so will do that instead. Lots of great knowledge on this group!
--
https://ecir.groups.io/g/CaseHistory/files/Lorraine%20and%20Evie

Lorraine D in UK 2020


Sherry Morse
 

Hi Lorraine,

IMO your vet is wrong in saying there's no point in doing bloodwork at this stage.  Doing bloodwork will give you a positive diagnosis of EMS/IR/PPID (she's a bit young for PPID but it wouldn't be unheard of in a 13 year old) and provide you a baseline to work with so you can tell on follow up if your changes in diet and management are helping or not.  Not every EMS/IR horse needs metformin as most do respond well to diet changes, but if the insulin levels stay high then it may be considered to help with that.

Bonnie's already advised you on hay soaking.  Fluid loss doesn't necessarily show up in a softer crest, that's more likely to be the result of your changes in diet.