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High ACTH for two mini horses, asking input on Vet's rec to start on Prascend


lynnc66
 

Test results from Cornell for 10/6/20 show high ACTH for both mini horses, Bella and Destiny (In February they were both in normal range, although Bella was high normal.) I've updated Bella's CH and added a new CH for Destiny.  
 
Vet wants to put them both on 0.5 mg of Prascend. When I mentioned titrating up to that he was fine with that. It sounds like he does not think we need to retest anytime soon, and that the time to test is during the seasonal rise.
 
Brief summary:

Bella:
In Feb, Bella was diagnosed by vet with laminitis. Her feet are still sore, but much improved with boots, she walks around the dry lot and keeps up with the other mini's.  
Insulin  >200 in July,  135.85 in Oct. 
ACTH was 29.2 in Feb, and is now 139
 
Destiny:
The vet called Destiny obese in February. I've been exercising her at the trot, about 25 minutes 3x/week, and she has lost about 50 lbs. She is sound, no issues with laminitis.
Insulin  > 200 in July,  31.67 in Oct.  
ACTH was 19.2 in Feb, and is now 318.
 
Both of these mini's have lost about 50 lbs since February. They both develop very thick coats in the winter, but always shed out. I have not noticed any excessive drinking of water, or muscle loss.
 
I would appreciate your input and advice, especially about dosage of Prascend and when to retest ACTH.
 
Thank you,

Lynn Cox
Kern County, CA

May, 2007 

Bella Case History   https://ecir.groups.io/g/CaseHistory/files/Lynn%20and%20Bella
Destiny Case History  https://ecir.groups.io/g/CaseHistory/files/Lynn%20and%20Destiny  .
Photos, Bella, Destiny, Zoe, Pip   
https://ecir.groups.io/g/CaseHistory/album?id=247665  





Sherry Morse
 

Hi Lynn,

Prascend/pergolide dosage is based on the amount needed to control the ACTH, not the size of the equine it's being given to.  For both of them given those results I would want to get them up to 1mg and then retest 3 weeks later as even for the seasonal rise those numbers are excessive and particularly for Bella could be driving her insulin up as well.  With her number that high she's still in the danger zone for laminitis so trying to get her number down further should continue to be your goal.

For both of them continued weight loss until they get to their target weights is going to help with their insulin numbers as well - it sounds like they're doing well in that respect but still need to lose about another 25 - 30lbs.

Is there any chance that the ACTH results are reversed?  It's not that Destiny's couldn't be that high without a spike in insulin, but given Bella's history it just seems more likely that her level would be higher.




Eleanor Kellon, VMD
 

Hi Lynn,

I agree those results are positive for PPID and your vet is correct that this is the most sensitive time of year to test. Whether these early cases need pergolide all year when they test normally at other times is a
--
Eleanor in PA

www.drkellon.com 
EC Owner 2001


Eleanor Kellon, VMD
 

Sorry. I hit send somehow.

... question without a good answer at this time but most people do just continue it rather than doing multiple checks. The suggested dose is typical.

Your girls are also an example of the power of exercise when combined with an appropriate diet.
--
Eleanor in PA

www.drkellon.com 
EC Owner 2001


Kirsten Rasmussen
 

Hi Lynn, I would get them titrated up to the prescribed dose then retest after 3-4 weeks.  If their ACTH is still unusually elevated you'll have good justification for asking your vet to increase the prescription.  As Sherry said, it's true that it's not the size of the horse that determines an equine's response to pergolide, so often higher doses are needed.  But the instructions on the Prascend packet do say to dose by body weight, so it seems like most vets recommend starting off minis with half the standard starting dose.  It might be enough but you won't be sure without follow-up bloodwork.

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


lynnc66
 

Thank you Dr. Kellon, Sherry and Kirsten for your responses.
 
I was amazed at the improvement in Destiny's Insulin level since July, which is indeed such a testimony to the diet and exercise. We are continuing to work further on weight loss for both of these girls. I am hoping that the Pergolide might help bring down Bella's Insulin and help relieve the pain in her feet.
 
Just received my order of APF today, and plan to start the Prascend a few days after starting the APF. 
 
Question regarding retesting in 3 to 4 weeks after titrating up to 0.5 mg Prascend. When does the fall rise end? Just wondering if there can be a risk of overdosing if the ACTH levels decrease after the fall rise, and if that's a consideration? 

And Kirsten, I wanted to thank you for your suggestion of testing ACTH, when I wrote previously about the high Insulin levels. Given the high ACTH results now, our vet thought that was a great suggestion.
 
Thanks again,

Lynn Cox
Kern County, CA

May, 2007 

Bella Case History   https://ecir.groups.io/g/CaseHistory/files/Lynn%20and%20Bella
Destiny Case History  https://ecir.groups.io/g/CaseHistory/files/Lynn%20and%20Destiny  .
Photos, Bella, Destiny, Zoe, Pip   
https://ecir.groups.io/g/CaseHistory/album?id=247665  





Donna Coughlin
 

Lynn, in case your minis' ACTH doesn't come down sufficiently when you retest, here's some background that might help you convince your vet to increase your RX:  In 2015, my mini's ACTH shot up to 113 (see case history) after being controlled on 1 to 1.5 mg. Prascend. My vet didn't want to increase beyond the 2 mg. recommended by Boehringer in the US (despite the fact that at that time, if I remember correctly, Boehringer allowed up to a 4 mg. dose in the UK). He kept referring to Duke's size, then about 250 lbs., and I kept pointing out the sudden and scary rise in his fall ACTH numbers and the high risk of laminitis. Duke had been laminitic before. So I tested monthly in Oct., Nov. and Dec. 2015, increasing the Prascend to 3 mg. Finally, either the end of the seasonal rise OR the increased pergolide brought his ACTH down to 23.3. Thankfully, it's remained there or lower with only one .5 mg increase to 3.5 mg in 2017. I recently convinced the same vet to let me use compounded pergolide for another horse whose ACTH had increased enough to need medication this fall, something he never would concede before—and I was superstitious enough to never argue that for Duke!  

Duke is now 44 and has been on 3.5 mg. Prascend for 3 years. His ACTH during these past 3 years has tested in the high teens or occasionally in the low 20s on that same 3.5 mg dose. As I posted recently, this fall, this same vet asked how old Duke was and said, "He's the oldest horse in my practice! Just keep doing whatever you're doing."

It pays to persist. And to echo Dr. Kellon and ECIR, the correct pergolide dose is the one that works.



--
Donna Coughlin, Duke, Robin Goodfellow, Ariel Max and Obi over the Rainbow Bridge (5/17)

CT 2009

 

 


Sherry Morse
 

Hi Lynn,

Usually by the end of November the effects of the rise are no longer seen.  With those levels I doubt either mare is going to be in the normal range after the rise but you may want to do a search of the archives as I believe this has been discussed before.  You may also want to refer to the Liphook graphs here: https://liphookequinehospital.co.uk/wp-content/uploads/Seasonal-Changes-in-ACTH-Secretion2.pdf




Eleanor Kellon, VMD
 

The ACTH rise is normally gone by December but may linger in horses with PPID including  early cases. I would wait until late December or January to retest.

There is no danger of oversuppression of ACTH.   ACTH is normally produced by another area of the pituitary and is not influenced by dopamine.
--
Eleanor in PA

www.drkellon.com 
EC Owner 2001


Kirsten Rasmussen
 

Thanks Lynn!

I defer of course to Dr Kellin's advice to wait until the seasonal rise is over to retest.  :)

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