Topics

Labs and Radiographs

Melissa Mathurin
 
Edited

Hi. I have a terrible time with the case history uploading and linking thing. Hope it works. We recently moved from MI to ME and my horse, Cooper, developed his second bout of laminitis. The new vet on 7/9/2020  increased his Prescend from 1 1/2 pills to 2 pills, increased his Thyro-L from 3 teaspoons to 4, had me continue his Metformin and then had me add InsulinWise. She drew insulin only and then did radiographs and had the farrier trim his front feet. She initially wanted to check insulin and ACTH in four weeks along with doing more radiographs and having the farrier trim again. I declined the second set of radiographs and the farrier visit. His trim left Cooper way worse then he started. So now she wants to wait until Sept 1st to retest ACTH (during the rise) and insulin. If Cooper's insulin is lower, how do I go about figuring out if the metformin or InsulinWise is working? Also how often do most people get radiographs? My MI vets rechecked his feet in 3 months, not four weeks. Thanks so much,
--
Melissa and Cooper 07/2019
Montville, ME
https://ecir.groups.io/g/CaseHistory/files/Melissa%20and%20Cooper

Trisha DePietro
 

Hi Melissa. Welcome to the group. There is alot of information here to read and hopefully, we can help you sort out this second bout of laminitis. You are in the right place. I'm not sure how much change you will see in radiographs if the trim is not correct to begin with. When you can, could you upload the radiographs and get some shots of Coopers feet for the photo album? 

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 quickly understand the main things you need to know to start helping your horse. Also open any of the links (in blue font) below for more information/instructions that will save you time.

In order to help you and your equine quickly and effectively, we need you to explain your equine's situation by following the instructions you were sent upon joining. Your completed case history form and ECIR Signature will save days of back and forth questions. If you haven't done so yet, please join our case history sub-group. Follow the uploading instructions so your folder is properly set up and then upload your case history. If you have any trouble, just post a message or email the case history group explaining specifically 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 APFThe 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 groundflax 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 spikeMake 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 aproper 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.

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 recommendtapering 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.

 

 Like
 
 
 
--
Trisha DePietro
Aug 2018
NH
Dolly and Hope's Case Histories https://ecir.groups.io/g/CaseHistory/files/Trisha%20and%20Dolly%20-%20Hope
Dolly's Photos 
Hope's Photos 
Primary Responder

 
Edited

Hi Melissa,

I wanted to add that for some reason I had trouble posting this, resulting in lots of copying and pasting.  So, if something doesn’t make sense, let me know.  It’s quite possible entire paragraphs were removed and/or inserted.

Thank you for moving your case history into our Case History group.  Sorry about the confusion there.  The option to post from your Dropbox, Google, etc. is a new one apparently, one that we just became aware of with your post, and we have yet to explore.  I’m not sure if they can be accessed by someone who does not have the appropriate account, whereas the files in the Case History group are available to all of us.

 

It sounds like you are not particularly satisfied with your experiences with the new vet and farrier.  Maybe, since you’re new to the area, this would be a good time to try to expand your options a bit.  I looked on the map to see where you are located.  We attended a llama conference at a summer camp in Freedom, ME some years ago.  I remember it as quite rural but not like some parts of Maine, further north.  Maybe call a few, explain you are new to the area and interested in getting better acquainted.  A new ACTH test before we get too far into the rise might be a good opportunity.

 

I looked over Cooper’s case history and see a number of ways we could help you, from working to tighten up the diet and assessing the trim to providing more details on the supplements and meds you are giving.  Lots of this information is addressed in the ECIR welcome. The metformin dose this group recommends is 30mg/kg, twice daily.  It appears you might have your units incorrect so you might want to compare what you’re actually giving to our recommendation.  Most people here have not found Insulinwise to be useful.  If you find that it is not giving you the results you desire, I believe they will refund your purchase cost.  Something to keep in mind.

 

As Trisha stated, new Xrays won’t really serve any purpose over the short term.  Your goal should be to modify his diet ASAP to prevent further changes.  The Xrays you have will help the farrier to trim him to be more comfortable and continue to improve.  The goal is to provide a tight hoof capsule for the foot.  You have suggested that you have radiographs posted but I’m not sure where they are.  Providing us with a look at the Xrays, as well as properly taken corresponding hoof photos would help us to help you and Cooper.
-- 

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


 
 

Sherry Morse
 

Hi Melissa,

Sorry you had such an issue with the CH - it looks like you were the (un)lucky first person to find a new way of doing the upload and linking to somewhere else but since I found your folder in the CH files I think you have that all fixed now.

With that cleared up (and thank you for perservering!) you can do a search on Insulinwise in our messages to see other's experiences with it but I think for most people they haven't seen any difference with it.

Now I have a bunch of questions for you which will hopefully help us help you and Cooper.

Is there a reason the vet had you increase the Thyro-L?  It may help with weight loss, but it has not been shown to decrease insulin so if that was her reasoning you may want to discuss that with her.  Same question for the Prascend as Cooper's level from January showed he was well controlled at that point.  Without running another ACTH it's just a guess at if increasing ACTH is driving his insulin up.

As far as the metformin - is that a once a day dose or 2x a day?  The recommended dose is 30mg/kg 2x a day so by my calculations for Cooper's current weight that comes out to 14,940mg/2x a day. 

It's hard to say why the trim made Cooper worse - was this a new farrier or one you have been using?  Did he trim to the radiographs?  If you could start an album on the Case History group with the radiographs and trim pictures that will help us assess the trim. Directions on that https://ecir.groups.io/g/main/wiki/1482#Photos-and-Hoof-Evaluation-Help.  What did the x-rays show?

For redoing bloodwork - ideally you'll be able to have the vet test insulin, glucose as well as ACTH at the same time to get a better overall view of all of Cooper's numbers.  Testing during the rise would let you know if the current dose of Prascend is keeping his ACTH level where it should be and help eliminate that from causing an insulin increase (if it's within the range for seasonal rise in a normal horse) or you could wait until after the rise to have everything checked, but ultimately that decision is something you need to discuss with your vet.

And one last question - you say in the CH that you were feeding free choice hay to 3 horses and now you're doing 18lbs. per horse per day.  Are they still all being fed together?  That makes it very hard - as you probably already know - to assess who's actually eating what amount of hay.  If it isn't possible to separate them you may need to consider muzzling Cooper to help restrict his intake.


Melissa Mathurin
 

Hi! The llama farm shares our property line on the other side of the mountain. How funny! 

Yes, I may need to find another vet. I would like to see his ACTH level. I was only trying the InsulinWise to follow the vet's advice. I did see on here that it was not really a miracle worker. 

My current dose of Metformin is 16,000 mg twice a day.

I just uploaded my current radiographs to the photo section but have not labeled them or linked them to my signature. Cooper's toes were way too long. I had a hard time finding a farrier in MI. The one I used didn't know why the vet wanted him to see the set of radiographs when Cooper was first diagnosed. He just trimmed him without looking at them.



--
Melissa and Cooper 07/2019
Montville, ME
https://ecir.groups.io/g/CaseHistory/files/Melissa%20and%20Cooper

Melissa Mathurin
 

Sherry, 
The vet increased his Thyro-L to help with weight loss. I'm not exactly sure why she increased his Prascend since I had provided her with Cooper's ACTH level that had been done in May of this year. She did not want to check his glucose, even though I asked about it. 

The vet only works with one farrier for founder. He charges $100 per foot, which I didn't know until it was time to pay him. He only did the front feet and said he'd do the all the feet when he returned in 4 weeks. They were planning on using plastic shoes for him. Cooper went from moving around slowly in his Cloud boots to not being able to move more than a step or two at a time. I called her and she had me increase his bute to 4g/day. She said that his soreness was to be expected. Cooper did slowly improve over a week or so and I weaned him off the Bute.

Cooper has now lost 51 pounds since I stopped feeding free choice and began soaking the hay.  I'm feeding out of the 1 inch hay nets. It's been so hot during the day that he spends a lot of time in the shed, once it gets hotter. I was concerned that they were leaving hay in both the day and evening bags but now they're eating most of it. My old horse, Harley, can't chew hay anymore. He just takes a few bites of it here and there. I'm feeding him soaked hay cubes 4x/day. 

I had considered using a grazing muzzle on him but since he's been losing weight (and my other horse's weight has remained the same), I've been waiting to see if he really needs one at this time.

Thanks for the help!


--
Melissa and Cooper 07/2019
Montville, ME
https://ecir.groups.io/g/CaseHistory/files/Melissa%20and%20Cooper

Sherry Morse
 

Hi Melissa,

Overall his feet post-trim are in much better shape than they were prior to the trim but it also looks like there might be more pressure on his toes post-trim which could explain why he was reluctant to move at all.  Lavinia can probably explain that better than I can but having a set of hoof pictures to go with the xrays is really helpful as well.



Lavinia Fiscaletti
 

Hi Melissa,

Thanks for adding the radiographs and photos. Here's the link to the album:

https://ecir.groups.io/g/CaseHistory/album?id=251365&p=Created,,,20,2,0,0

When you have a moment, you can add that to your signature as well.

Sorry to hear Cooper had such a hard time after his trim. Glad he is feeling better and off the bute now. The trim removed all of the laminar wedge on both fronts and brought the breakover back considerably, which was needed.  LF toe was actually brought back a bit too far. Unfortunately, the trim also thinned Copper's soles, which were at just an adequate depth before the trim, so had nothing extra to remove. That is likely the biggest source of his post-trim discomfort. I can't tell if the frogs were trimmed but they don't appear to be even close to making ground contact and look as if they were also trimmed. If they were, that could be another source of the soreness and why he appears to be wanting to stand more on his toes right now.

His heels are underrun and significantly flared. That needs to be addressed but without losing any of the vertical height. That means they can't just be cut back further as that would result in his coffin bones becoming ground parallel (NOT what is needed).

The Cloud boots are a perfectly good way to manage him at this point and I don't see any reason to put any type of shoes on.

It would be helpful to see a full set of hoof photos, of all four feet. Here's the link to what's needed:

https://ecir.groups.io/g/main/wiki/1472

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