Just diagnosed PPID


Dawn Hernandez
 

My pony has just been diagnosed PPID,(through Cornell).

I have tried a few times to complete the case history form but unfortunately was unsuccessful and a bit lost to be honest. I do have rads and pics that I wanted to include. 

Dalli is a 9 yr old Shetland Pony, 330lbs. I’ve had him for a little over a month now and no episodes of laminitis.

current diet:
1st cut analyzed hay,(6 lbs).
TC Naturals Tim Balancer Cubes
Vermont Blend
Loose Wht Salt
Omega E

Test Results:
Glucose = 92 mg/dl. (71-122)
Insulin Baseline = 18.32 uIU/ml. (10-40)
Leptin Baseline = 3.99 ng/ml. (1-10)
Pre ACTH = 15.6 pg/ml. (2-35)
Post ACTH-TRH Response = 967 pg/ml (2-110)
T4 = 1.07 ug/dl (1-3)

Plan: Prascend Tabs: 1/4 tablet daily for 2 weeks, increased to 1/2 tablet after initial 2 weeks. I have not started him on the tabs yet. Will do so by end of the week.

Im feeling a bit overwhelmed by the numbers and still not too clear on reading the results.

Thanks


--
Dawn Marie & Dalli
Eliot, ME


Bobbie Day
 

Welcome Dawn, 

I am here to send you your official welcome message, I'm sorry you're in this position but take a big breath we are here to help, I understand that Kirsten is trying to help you with getting your case history up so thank you for following up with that. Hopefully you will get it sorted out so we can better comment on your questions. We've all been where you are right now, and your absolutely right, it can be overwhelming for sure, but your here now and we will do our best to guide you. There is a whole LOT of information in the following message so please take your time and keep it handy to refer to when needed. 
I will let our more experienced mods comment on your blood work. Let us know if you have any additional questions. 


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 Desi (over the rainbow bridge 7/21) 
Utah, Nov 2018
NRC Plus 2020, NAT, C&IR March 2021
ECIR Group Primary Response 


https://ecir.groups.io/g/CaseHistory/files/Bobbie%20and%20Desi 

https://ecir.groups.io/g/CaseHistory/album?id=78821


Sherry Morse
 

Hi Dawn,

I'd like Dr. Kellon to chime in on those results as 9 is a bit young for a PPID diagnosis, although it's not unheard of.  Is there a reason you decided to test him for PPID?  Was the testing done fasting or non-fasting?  How tall is Dalli? Is he overweight? Fat pockets? How much of the Balancer cubes is he eating per day?  Is he on pasture? 






Dawn Hernandez
 

I was able to submit Dalli’s case history and photo album.--
Dawn Marie Hernandez, Mgr/Instructor
Bartlett Homestead Stables - (303)502-6205
Mgr hours: 8:00am - 4:00pm



--
Dawn Marie & Dalli
Eliot, ME


Sherry Morse
 

Hi Dawn,

Please add the links to your signature:

1) Go to this link to amend your auto-signature: https://ecir.groups.io/g/main/editsub

2) Look at the bottom of that page for the window where you typed your name and location in.

3) Add the links below your current signature line:
4)make sure you make the links "live". Adding a space after it or hitting enter on your keyboard will turn them blue.

5) IMPORTANT: Scroll to the bottom and hit SAVE!




Sherry Morse
 

Hi Dawn,

Please see https://ecir.groups.io/g/main/wiki#Photos-and-Hoof-Evaluation-Help for information on taking useful hoof pictures.  The one hoof picture you posted isn't really useful but the x-rays shows excessive toe length and something we don't often see here - too much sole.  It also shows a ski tip on the coffin bone which shows that the hoof issues have been ongoing for quite a while.

We really do need to know if the bloodwork was done fasting or not and also if you know for sure that Dalli is 9 or if that was a guesstimate on his age.




Dawn Hernandez
 

Hi Sherry,

Dalli is a rescue that I adopted 11/29/2021. He is ‘presumed’ to be 9 years old. I do have the vet coming again to take new X-rays this Friday. I will have her look at his teeth to see if she is in agreement with the 9 year estimate.

The X-rays were taken soon after he was bailed out of the kill pen.

When the blood work was taken, I did not fast him. He had access to hay only.
--
Dawn Marie & Dalli
Eliot, ME

https://ecir.groups.io/g/CaseHistory/album?id=271623



Dawn Hernandez
 

Hi Sherry,

I wanted to have the Metabolic panel done due to his laminitis. He was also excessively drinking when I first brought him home.
He is 40” tall, slightly overweight, no fat pockets. He gets just a handful of cubes. My best guess is that he gets 1lb daily. I just purchased a scale and will get an accurate weight on his feed. He is not on pasture.

thanks, Dawn 
--
Dawn Marie & Dalli
Eliot, ME

https://ecir.groups.io/g/CaseHistory/files/Dawn%20and%20Dalli

https://ecir.groups.io/g/CaseHistory/album?id=271623



Sherry Morse
 

Hi Dawn,

Ok, now that we know he wasn't fasted for testing his results are indicative of IR but not terrible (if he'd been fasted 18 would be a high result for insulin).  An insulin level of 80+ is the danger zone for acute laminitis. 

At 10 hands I'd want to see him at no more than 300 - 325 pounds so your assessment of him being slightly overweight goes along with that.  You do want to keep his diet at no more than 6lbs a day unless he starts to lose too much weight on that amount so that means you do need to know how much the hay and cubes really weigh.  Cubes are usually fed at a 3:4 ratio to hay as they're more calorie dense so that's just something to keep in mind as well.   

Very curious to hear what your vet says about age.




Dawn Hernandez
 

Thank you so much!

I’m curious about such a high number in the post ACTH-TRH Response. Isn’t 967 really high? 



--
Dawn Marie & Dalli
Eliot, ME

https://ecir.groups.io/g/CaseHistory/files/Dawn%20and%20Dalli

https://ecir.groups.io/g/CaseHistory/album?id=271623



Dawn Hernandez
 

I recorded all my feed weights and measurements today. Along with the 6lbs of hay,(analysis in photo album), Dalli receives:

TBC - 12.2 oz ‘split’
1 tsp loose wht salt ‘split’
1.5 oz Vermont Blend ‘split’
1/2 cup Omega E ‘split’



--
Dawn Marie & Dalli
Eliot, ME

https://ecir.groups.io/g/CaseHistory/files/Dawn%20and%20Dalli

https://ecir.groups.io/g/CaseHistory/album?id=271623



 

Thanks, Dawn!  Don’t forget to update your case history accordingly.  With effectively a pound of cubes plus 6 pounds of hay, you may well still be over feeding him.  

Why are you waiting until next week to start Prascend?  Is it just a matter of availability?  

I think we still need to know what test was used for the hay analysis.  Can you please tell us a little more about how the hay test got done?

Yes, the post TRH stim was high but that doesn’t always seem to dictate how much Prascend you will need to manage it.  Prascend dosing isn’t done by weight, although vets tend to start little guys on less Prascend.   A high ACTH after stimulation with normal before is often seen in the early stages of PPID.
--

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


 
 


Dawn Hernandez
 

Hi Martha,

Yes, I’m just waiting for the Prascend to be delivered. 

I had a feeling I may be overdoing the cubes and going over my daily requirements for him. I’ll definitely adjust!

The hay analysis was performed by Equi-Analytical.
I do not have a hay core, so I broke open 10 various bales and took a small sample from the middle of each one. I mixed those samples together and sent it off in the plastic bag that was provided in the kit.
--
Dawn Marie & Dalli
Eliot, ME

https://ecir.groups.io/g/CaseHistory/files/Dawn%20and%20Dalli

https://ecir.groups.io/g/CaseHistory/album?id=271623



Lavinia Fiscaletti
 

Looks like the hay analysis is the #601 Equi-Tech, done via NIR testing. That means the ESC+starch values can be off by as much as 30% in either direction.

The hay analysis shows high calcium and manganese, so mineral balancing needs to provide extra phosphorus and magnesium, as well as added copper and zinc.

--
Lavinia, George Too, Calvin (PPID) and Dinky (PPID/IR)
Nappi, George and Dante Over the Bridge
Jan 05, RI
Moderator ECIR


 
Edited

As Lavinia points out, the particular hay analysis package you have doesn't reliably determine ESC+starch for equines with EMS. If the analysis is recent, you can contact Equi-Analytical to ask if the sample is still on hand in the lab. If so, the lab can add analyses for ESC and Starch by wet chemistry.  You need your sample number. 
Email: https://equi-analytical.com/contact/ 
Phone: 1-877-819-4110

If ESC+Starch turns out to be safe, the mineral analysis you have is fine for balancing the diet. 
--
Cass, Sonoma Co., CA 2012
ECIR Group Moderator
Cayuse and Diamond Case History Folder                
Cayuse Photos                Diamond Photos


Dawn Hernandez
 

Thank you so much for this information! I wasn’t aware of the differences in testing. Unfortunately, the sample was received by Equi-Analytical on 9/13. I can contact them but I’m thinking it may be too old.

For the next sample - what should I do different with submitting my samples? I have a hay supply from 3 different fields and will be testing each one accordingly.

Thanks again.
--
Dawn Marie & Dalli
Eliot, ME

https://ecir.groups.io/g/CaseHistory/files/Dawn%20and%20Dalli

https://ecir.groups.io/g/CaseHistory/album?id=271623



 
Edited

That most likely has been too long but if you find out what their holding period is, please let us know, Dawn.  Below is a link to the E-A testing page.  The test we recommend is the 603 Trainer.  Some people use the 644 Carb Pack if they have several hays under consideration but sugar/starch is their prime consideration.  They then follow up with the 603 Trainer on the one that fits with their sugar/starch requirements.


--
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