Introduction: Cinnamon :)


Hi all, new here, our mostly retired large pony (22 ish) was just diagnosed with Cushing’s. She was tested in Spring and was IR (so put on Thyro-L) but negative for Cushing’s at that time. She was a bit heavy in Spring and had some fat pads; I’ve since changed up her diet and she looks good. She has a heavy coat (always has), seems a little depressed this fall (new), and see below for lameness. Have dealt with EPM and chronic Lyme in the past 8 months. 

she currently gets:
3-4 TC Timothy Balancer cubes, soaked (literally a small handful)
handful TC Balancer Gold
hanful Purina Outlast
3T VT Blend Pro
Cosequin ASU
thyro L
MVP Eclipse
1/2 c Omega E (Custom Equine Nutrition)
3 squirts Emcelle

handful TC Balancer Gold
handful purina outlast 
Sprinkle flax

She has mostly Timothy first cut NY hay in a Porta grazer or small hole net available 90% of the time. Can’t soak because of freezing temps. 

she used to get field time all day but horse dynamics have forced us to do only 1.5-3 hours per day, on very poor straggly pasture (the whole property is air plants so no one wants rich grass). She has not been in the field since the below lameness started.

about a month ago she turned up with one very sore front hoof. Developed a little heat, then the next day the other was a little warm. Spent a few days icing both, bute AM and PM. Wrapped and closed in very deep stall overnight (usually she has her walk out paddock - dry lot - access). I have kept her off the field since then. The situation cleared up within 2 days but I continued treatment for 5. 

vet came and tested on the 11th. I didn’t know she was going to test for Cushing’s (it was a chronic Lyme recheck and a look at that laminitis (?) lameness episode, so she was not fasting. Results are as follows:


TRH Stimulation Test for PPID

 Endogenous ACTH 41 pg/mL

  Endogenous ACTH post (10 min)

483 pg/mL

 Mid-November to Mid-July (Non-Fall Months): 10 min after TRH ACTH value:

<110 pg/ml is considered negative for PPID 110-200 pg/ml is considered equivocal for PPID >200 pg/ml is considered supportive of PPID

Mid-July to Mid-November (Fall Months):

There are no published values to interpret TRH stimulation in the fall. However:

values <110 pg/ml would exclude a diagnosis of PPID

values > 500 pg/ml are generally considered diagnostic for disease.

 Insulin (Equine)

 Insulin 61 0-42 uU/mL HIGH

Result Verified

Insulin dysregulation (ID) is characterized by elevated resting

insulin and/or an abnormal response to consumed oral sugars. Elevated basal insulin can also occur in horses with Pituitary Pars Intermedia Dysfunction (PPID).

Suggested Reference Ranges (Equine Endocrinology Group 2020):

Testing after hay and no grain within 4 hours(resting insulin):

< 20 uU/mL - non-diagnostic. Consider dynamic testing if insulin dysregulation (ID) is suspected

20-50 uU/mL- suspect for ID if consistent with clinical signs > 50 -uU/mL- Insulin dysregulation

Testing while on pasture (to assess current diet and management): 20-50 uU/mL- dynamic testing (Oral Sugar Test) recommended (see test codes L545

or L550)

> 50 uU/mL - Insulin Dysregulation

Evidence is mounting that insulin concentrations are affected by season with higher concentrations detected in December, January, and February in the Northern hemisphere, suggesting a winter-associated exacerbation of ID.


  Glucose 57 70-120 mg/d

im not sure how to attach an image or PDF to this message, sorry!

Cinnamon was head bobbing lame on her right front at the walk again Sunday, same deal but definitely a warm front foot and the other slightly warm as well. Iced 2 days, heat gone, now still on bute and seeming comfortable. She has never stood “rocked back” but that foot was sore for sure.

I have received a box of Prascend but I haven’t started her on it yet. I’d love to hear folks’ thoughts. Cinnamon is my daughter’s first pony (she’s a large, 14.1 3/4) and her very best friend. She has been an outstanding member of our family for the past 8 years and I want to be sure we do right by her 100%.

thanks so much for listening to this long story!!!
Mary Glickman

Candice Piraino

HI Mary!

Welcome to the group! 

Ok this is going to be a lot but you are in the right place! Please complete a case history as soon as you are able. Below you will find directions on how to upload it and photos, as well as lab results. 

I would go ahead and do another overhaul on her diet. Remove her from all grass. Soak the hay- you can search this group for tips and tricks for those who come into freezing temperatures. The hay could be very dangerous for her since you do not have a hay analysis on it. 

Before starting the pergolide I would go ahead and start her on APF (adaptogens) a few days before and then start slowly with pergolide with 1/4 tab of Prascend. Once on a full tab for 3 weeks, you should retest her to ensure she has the proper dosage of pergolide. 

I love that you have already implemented some good stuff for her diet: Emcelle, Vermont Blend, TC Naturals Balanced Cubes! That is wonderful!

You can also put her in boots and pads to help ease her pain as well. 

Others will chime in, I am sure.

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. 


Candice Piraino

Primary Response Team

September 2018, Summerfield, FL

Shark's Case History

Shark's Photo Album 

PHCP Barefoot Trimmer


Kirsten Rasmussen

Hi Mary,

Hoof pain clearing up after 2 days off grass sounds very typical for laminitis.  I agree with Candice about keeping her off pasture.  Since her turnout is only a few hours a day, she could go out with a closed off muzzle to exercise, as long as she doesn't exceed 4-6 hrs without food.

Also recommend testing her hay.  If it doesn't need to be soaked, then you'll want to know that.  We recommend the 603 Trainer package at Equi-Analytical.  It us the most accurate and will also give you major and trace minerals so you can check that her mineral needs are being met.

If she was mine, I would wait until mid-December or later, and redo the TRH Stim test, since your results were borderline for positive.  Make sure you take her off the Prascend at least 3 weeks before the retest.

You will get more feedback once you fill out a Case History, where you can fill in all her past bloodwork results and other relevant info.  You can upload pdf documents in the same folder you upload your Case History to, in our Case History subgroup.  You can also make a Photo Album there to upload hoof and body photos.  You have received instructions on joining our Case History sub-Group and downloading the form; at the end of the form are instructions on getting it uploaded.  Let us know if you get stuck along the way, and check out our "Wiki" to learn more about how this online platform will answer questions you didn't know you had!

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