Laminitis Spike


Robin
 

Hogan, my mini is in a spike that is quite bad. Looking for advice on how I can help to bring him out of it and also ease his pain. I got him as a rescue about 6 yrs. He is IR and has Cushings. Since I've had him, this is his 3rd flare up. This one started in late December with just one hoof. At that time we also relocated from NY to SC so a lot of change and stress for this poor little guy. He had a bad trim (didn't know anyone here asked for recommendations and it was a disaster). He took off from his already thin sole. This caused his condition to worsen. Over time his other foot started to become painful and his pain level has increased. He is now so painful that he can hardly walk and often leans back to take the weight off his toes. Due to him being so painful, we didn't trim for a bit and his toes got quite long. I am now getting a farrier in tomorrow with a vet to block his hoof so we can trim. Then I'm going to have his hoofs trimmed every 2 weeks to get them back to where they were.

He wears softride boots on all 4.

He is currently on:
- Prascend 1/4 pill daily
- was on bute 2 gr daily, just switch to banamine 3 gr daily
- 2 gabapentin 2x daily
- 5 tylenol 2x daily
- 1/4 ulcergard once daily
- just started 1/2 gr Ace IM twice daily
- isoxsuprine
- Insulinwise
- Feed: Tested hay 9.6 NSC, soaked, Triple Crown lite balancer, Triple Crown Safe Starch Forage
- Supplements: Natural Vitamin E, Arenus Assure Guard for gut, electrolyte, chinese herbs for laminitis

What else can I do? What different approach should I take?
--
Robin Aiken, SC 2022


Sherry Morse
 

Hi Robin,

You'll be getting a full welcome message shortly but just some things that jumped out at me from your note:

IR - do you have actual insulin and glucose numbers?  When was he last tested?
PPID - do you have recent ACTH numbers?  
Laminitis in an IR or PPID horse is almost always caused by elevated insulin so that points to ACTH not being well controlled and driving up insulin or diet not being as tight as it could be and driving up insulin.  

He could also be in pain from toes being too long/soles to thin so you need to figure out the cause of the current pain and remove the trigger.  That could mean a rather extensive trim to get his feet to where they should be and then boots 24/7 until he's had a chance to regrow his hoof (which takes 9 - 12 months on average). 

If the pain is due to laminitis from elevated insulin NSAIDs (bute or banamine) will do nothing for it.  We would recommend weaning off of those as soon as possible.  Gabapentin and Isox have both not been found to be useful in most horses and Tylenol has mixed reviews.  Tramadol would be a better option for pain control or you can switch to Devil's Claw.  


You also should not be giving NSAIDs with Ulcerguard: Re: URGENT: Laminitis suspected, possible abscess too? Already on ER diet ... what next? (groups.io) explains why not.  Why are you using Ace?

In the experience of this group Insulinwise is a waste of money, but luckily they offer a money back guarantee. 

We look at ESC+starch and want that to be under 10%.  If your hay is not tested you need to start soaking it.  Neither of the Triple Crown products is recommended for an IR horse as they are not guaranteed to be under our 10% goal number for ESC+starch.  If you can source Triple Crown Naturals Timothy Balance Cubes you can feed those as a complete feed and only will need to add salt, vitamin E and flax to them.  They are fed at a 3:4 ratio to hay as they are more calorie dense than hay.  Is there a reason you're giving electrolytes and not just plain white salt?





 

Good morning Robin,

Welcome to the ECIR group!  I’m sending you this welcome from the group as a response to your first post here.  There is a lot to read about our group and how it can help you and your gelding.  And there are more worthwhile links to follow.

You have come to the right place to get help with Hogan’s IR and Cushings (PPID).

I want to caution you against giving both NSAID and omeprazole to Hogan.  Recent research has shown that it can cause more issues than it’s meant to prevent.  They don’t work well together.  We actually don’t recommend any NSAIDs after the first few days of a laminitis attack as laminitis is not an inflammatory condition.  When you decide to discontinue them, there needs to be a tapering off.  

We as a group have not found Insulinwise to be effective.  They have a money back guarantee.  Same with isoxsuprine, without the guarantee.  Gabapentin works well on my dog but ai don’t think it’s well enough absorbed by the horse.  Not sure the reason you’re giving Ace but I suspect it’s because your not getting relief from the NSAIDs?  The relief will come when the laminitis trigger is removed, not before.

We look for hay to be below 10% for ESC + starch when tested by wet chemistry methods.  You’re presently soaking it so that should be good.  Electrolytes are often filled with sugar.  Our diet, described in the welcome letter below, calls for loose iodized salt, vitamin E in oil, and flax.  We also recommend magnesium unless your hay has been found to contain adequate Mg.  Tell me more about the Chinese herbs.  None of the lite or low starch products are suitable for our horses unless they have been tested by our group and marked as safe to use.  They aren’t guaranteed to be consistently low.

Hogan has PPID and you are giving him 1/4 tablet of Prascend .  Has he had his ACTH tested after 3 weeks on that dose.  The correct pergolide (Prascend) dose is the one that controls the ACTH.  PPID is a progressive disease and often needs increases in pergolide doses.  Prascend is scored to be split in half but wasn’t designed to be regularly dosed as a quarter tablet.  He may be getting different doses each day.  The generally recommended starting dose (after slowly titrating up) is a full tablet, regardless of the size of horse.

We can advise on his trim if you post photos and radiographs.  I believe Cass sent you instructions on setting up a case history for Hogan, which will allow you to post photos to your own album.

If you haven’t already, I’m sure you will receive lots more advice from others.  What follows is our welcoming letter.

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. 

 
--
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


 
 


Robin
 
Edited

This is his case history and his xrays are here as well.
--
Robin Aiken, SC 2022
https://ecir.groups.io/g/CaseHistory/files/Hogan%20Case%20History


Sherry Morse
 

Hi Robin,

Please add the link to your photo album: https://ecir.groups.io/g/CaseHistory/album?id=275012 to your signature when you have a moment. 

The x-rays show his toes are much too long which can cause pain and he also has ski tips on his coffin bones on both fronts which means that there have been long term issues with his feet.  He does appear to have a good amount of sole depth.  I would get his toes brought back ASAP to help his comfort level.  If you can take and upload photos of the current trim and post a message to Lavinia (who is our markup guru) she can explain exactly what needs to be done to get the trim in order now.


As far as the CH - do you know Hogan's current weight?  How much is he being fed now?  Is it being weighed so you know exactly how much he's eating?  As his ACTH in January was in the normal range I would concentrate on getting his diet much tighter and getting his trim in order to help with his comfort level now.  I would also consider bumping his pergolide dose up to 1mg as he's higher than we'd like to see a PPID pony and he likely will go higher than you want during the seasonal rise as he's at the upper end of the reference range now. 




 

Hi Robin,
Your link did not take me to you case history.  Try this instead.  

 
You’ve set up a folder which opens to a case history but the link didn’t go there.  Also, I changed the link presently in your signature to make it active.  Be sure to press return and then save, if that’s an option, when your done.  It should become blue.

Also, reviewing your case history, as you probably know your insulin is quite high and may need medication to bring it down.  For discussion later as you can’t expect control from the meds without a tight diet..   Next time you do an insulin, ask your vet to let them know that the value may well be over 200 so please test appropriately to obtain a more accurate number.   The ACTH is too high so his Prascend needs to be increased.  We like to see ACTH in the upper teens to low 20’s.  The comparison values are a reference range and not meant to indicate what normal is.
--
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


 
 


Lavinia Fiscaletti
 

Hi Robin,

Thanks for adding Hogan's radiographs. I've added mark-ups to help guide the trim for tomorrow:

https://ecir.groups.io/g/CaseHistory/album?id=275012

This can all be done at tomorrow's trim, then all you need to do is maintain it going forward.

Both feet have toes that are way too far forward, which has been a problem for some time as both also show demineralization and remodeling of the coffin bones (ski tips). Toes need to be backed up, esp. at ground level so that the breakover gets aligned with where the bony column needs it to be. The LF appears to have a slightly better breakover location already in place, with a bevel that may be lifting some of that excess toe out of ground contact. Still need to remove all that excess toe beyond that point, however. There are some shadows within both toes that may be abscess collections, or just gas pockets, that the trim will cut thru if it is aggressive enough in removing the unnecessary toe length. Although that may spew some seepage that could be startling, it's not a reason to stop trimming back to the appropriate place. Due to the length of time he has been on NSAIDs, there may also be hidden abscess collections waiting to exit and correcting the trim would mobilize them. That could affect his soundness until they have a chance to drain but do NOT be tempted to restart the NSAIDs at that time, as that will only prolong the problem. Soaking and poulticing with Numotizine would be a better choice if this issue arises.

There is significant sinking, which may or may not resolve to some degree over time if the laminitis is stopped, the trim is corrected and his diet is revamped and kept tight. Both fronts are laterally high to some degree, with a bit of wall flaring. Sole depth is now adequate - so NOTHING should be removed from the soles behind where the breakover gets set. There is a slight amount of bony column rotation, which means the heels need to be lowered while leaving the remainder of the bottom of the foot untouched.

LF DP: This is looking at the foot from front to back. Blue areas on both walls are where the flares need to be removed, more on the medial wall. Lateral wall also needs to be lowered a bit as it's too tall.Red arrows show where the joint spaces on the lateral side of the pastern bones are compressed due to the lateral wall being taller. Yellow line runs thru the centers of the foramen while the pink line shows how they should align- again, laterally slightly higher.

LF lateral: Pink line shows how the bony column should align, while the purple line show how it does. The slight bulging forward of the purple line indicates there is some bony rotation of the coffin bone. Pink line hits the ground where the breakover should be - there should be NO hoof capsule touching the ground beyond this point. Green line shows where the dorsal wall should be - this isn't a trim line, just a visual marker. Blue line is where the toe needs to brought back to, with the blue X being all the excess toe length that needs to be removed. Blue line from mid-foot back to the heels indicates where to lower ONLY the back half of the foot to correct the bony rotation. Red line from mid-foot forward indicates NOT to trim the bottom of the foot here at all. Yellow line #1 runs thru the coronary band, #2 points to the extensor process. The distance between them indicates the amount of sinking.

RF DP: Same general discussion as the for the LF.

RF lateral: Follow the guidelines for the LF.

It is likely his hind feet have many of the same issues. Pay particular attention to the medio-lateral balance as many minis have medially tall/flaring walls and toes that are miles too long on their hind feet.

The pads in his Soft Ride boots should have the frog support cut off and the pads themselves should be cut flat, rather than being a wedge.

If you implement the suggested trim, diet and med changes, Hogan should start to feel better within days.

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


Robin
 

On Thu, May 12, 2022 at 12:25 PM, Sherry Morse wrote:
As far as the CH - do you know Hogan's current weight?  How much is he being fed now?  Is it being weighed so you know exactly how much he's eating? 
He is about 250 lbs. He gets 1/4 lb Triple Crown Lite twice daily, soaked hay (4x daily) - I fill a mini slow feed hay bag (don't weigh it). He's a hard keeper, always been lean, so I feed as much hay as he'll eat which isn't a lot.

 
--
Robin Aiken, SC 2022
https://ecir.groups.io/g/CaseHistory/files/Robin%20and%20Hogan


Robin
 

My vet thinks his pain is coming from the coffin bone. There is remodeling on the tip where it is flared up like a ski jump. Bearing this in mind, should I still take him off the NSAIDs?
--
Robin Aiken, SC 2022
https://ecir.groups.io/g/CaseHistory/files/Robin%20and%20Hogan 
https://ecir.groups.io/g/CaseHistory/album?id=275012


Robin
 


Robin
 

Thank you for the xray mock ups for the trim. Should we do this in one go or slowly over time?
--
Robin Aiken, SC 2022
https://ecir.groups.io/g/CaseHistory/files/Robin%20and%20Hogan 
https://ecir.groups.io/g/CaseHistory/album?id=275012


Robin
 

On Thu, May 12, 2022 at 02:10 PM, Lavinia Fiscaletti wrote:
The pads in his Soft Ride boots should have the frog support cut off and the pads themselves should be cut flat, rather than being a wedge.

If you implement the suggested trim, diet and med changes, Hogan should start to feel better within days.
Wow and Wow! Thank you so much! Very surprised to hear the pads in the soft rides should be flat and not have frog support!
 
--
Robin Aiken, SC 2022
https://ecir.groups.io/g/CaseHistory/files/Robin%20and%20Hogan 
https://ecir.groups.io/g/CaseHistory/album?id=275012


Robin
 

He doesn't lick his salt block. That is why I feed electrolytes.
If I switch to iodized salt, how much do I feed?
--
Robin Aiken, SC 2022
https://ecir.groups.io/g/CaseHistory/files/Robin%20and%20Hogan 
https://ecir.groups.io/g/CaseHistory/album?id=275012


Robin
 

Is beet pulp required to be fed as part of the emergency diet? Or can I put salt, Vit E, Flax and Magnesium on top of the soaked hay? So, is there a specific benefit to beet pulp or is it just a carrier for the supplements?
--
Robin Aiken, SC 2022
https://ecir.groups.io/g/CaseHistory/files/Robin%20and%20Hogan 
https://ecir.groups.io/g/CaseHistory/album?id=275012


Robin
 

For the emergency diet, do I need to discontinue his Arenus Assure Guard (gut supplement)? Or can I continue to give him that?
--
Robin Aiken, SC 2022
https://ecir.groups.io/g/CaseHistory/files/Robin%20and%20Hogan 
https://ecir.groups.io/g/CaseHistory/album?id=275012


Lavinia Fiscaletti
 

Hi Robin,

Definitely get him off the NSAIDs, gabapentin, isoxsuprine (doesn't work orally in equines). The pain is from the laminitis due to the insulin being sky-high. The laminitis and the trim mechanics are the underlying causes of his pain. If you don't remove the causes, you are only trying to apply band-aids and hide the symptoms. If fixing his diet doesn't lower the insulin quickly, then ask the vet to start him on Metformin as that will actually address the high insulin. Dosing is 30mg/kg, twice daily. More on Metformin here::

https://ecir.groups.io/g/main/filessearch?p=name%2C%2C%2C20%2C1%2C0%2C0&q=metformin

Definitely taper him off the NSAIDs - don't stop all at once as he will likely experience NSAID rebound pain, which can happen when an individual is on long-term pain meds which are stopped too quickly:

https://ecir.groups.io/g/main/files/Pain%20Medication%20and%20Alternatives/How%20to%20Taper%20Off%20NSAIDs.pdf

Being a mini makes it highly likely he'll be quite sound and happy as soon as you get the diet, trim and meds optimized. Keeping him on the lean side (4-4.5 BCS) is also a very good thing.

Definitely fix the trim completely tomorrow - no reason not to set it up properly in one trim based on his rads.

Enforced frog supports can make a horse (mini) lame all by themselves just from the constant, unrelenting pressure on the frogs. The wedge shaped pads are contra-indicated when there is bony column rotation because that makes the bony column rotation worse - the opposite of what you want to do.

For a mini, about 1/2 oz of iodized salt mixed into his food until you can get his diet better balanced.The Apple a Day electrolytes have a lot of sugar - not helpful for a laminitic animal.

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


Robin
 

My pony has been on bute and gastrogard and see here it's not a good idea.
So, making up action plan needs to be to stop gastrogard immediately, wean off bute and if needed for pain, add devils claw or tramadol. Do I need ulcergard with those meds? Was really giving gastrogard due to ill effects of bute.
--
Robin Aiken, SC 2022
https://ecir.groups.io/g/CaseHistory/files/Robin%20and%20Hogan 
https://ecir.groups.io/g/CaseHistory/album?id=275012


 
Edited

Hi Robin,
Our emergency diet calls for 1-2 ounces per horse or 2-4 heaping Tablespoons.  He most likely won’t eat whatever you dump that much salt into so I spread it around.  Some in feed and the rest sprinkled on damp hay.  Or you can dissolve the salt in water and squirt it on dry hay.  I put a feed bucket underneath to catch the drips and it’s generally all eaten.  They like salt but it needs to be introduced gradually or it will turn them off.

Oops.  I see that Lavinia has answered you about the amount of salt.  The above dose is for an average size horse and so it should be adjusted according to weight for a mini.  Use her dose suggestion.
--
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


 
 


Eleanor Kellon, VMD
 

Hi Robin,

I see our wonderful team has been all over helping you already! Nothing much to add. Salt for your mini would be 1 tablespoon and it's best to sprinkle it on the soaked hay if he doesn't eat it willingly. I agree with all the suggested changes, and the trim especially might give him considerable immediate relief. No reason to go slow with those changes, as Lavinia said. I would also get him on LaminOX ASAP https://uckele.com/laminox-3lbs.html, 1/2 scoop twice a day for two weeks then once a day. If he has abscess collections, this will make them drain. You can use it with Phyto-Quench pellets, which contain Devil's Claw, 1/4 scoop twice a day for two weeks. Use coupon code UHNWELCOME for 10% off. It's very important to get your hay completely analyzed, including for minerals. Use beet pulp as the carrier for supplements because it is by far the safest and also will provide extra calcium, which most of your local hays need.With insulin that high, it's likely he will need medication at some point. We start with metformin (and pergolide dose adjustments) but there are further options too.
--
Eleanor in PA

www.drkellon.com 
EC Owner 2001


Lavinia Fiscaletti
 

The Assure Guard contains dextrose (sugar). Given Hogan's super high insulin, I would remove it as you need to make his diet super tight right now.

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