Hello,  My 19 year old morgan mare, Abbey, was diagnosed with Cushing's disease and EMS about a month ago.  Many years ago she was tested for EMS and we knew she had it, but had her managed well with limited turn out, but it has definitely gotten worse.  The results came back showing her Pre TRH Response at 25 pg/mL and post at 305.  Her Insulin was at 115.59 uIU/mL.   As I read through some of the information on the site I saw that the test should be done after 4 hours of not eating, however, I did not know that at the time and that was not mentioned to me, so she had been out in the pasture for a few hours before the vet did the test.  I definitely think she has Cushing's either way as she did shed her winter coat, but it grew back in.  She definitely seemed more overweight this spring than normal and I noticed her getting a bit tender on gravel and harder ground, but she still seemed quite fine on soft ground.  Somehow I didn't piece together that she was laminitic and only realized it after she was tested.  Per vets instructions I did soak her feet in ice water and/or the stream 5-6 times a day for about a week, then went to 2-3 times a day, now down to once per day.  She was taken off pasture and given soaked hay instead, prescribed  "a heaping scoop" of "Cushings Powder" (the label says 1- 5ml level scoop contains Pergolide 1mg and Cyproheptadine 180mg), 1 scoop of Thyro-L, Metformin - 10-1000mg tablets twice a day, she was on bute for approx. 3 weeks (over which time the amount decreased every week or so, she is no longer on it) and 1 scoop of InsulinWise.   

After reading information about Metformin, I decided not to continue with that after the 500 count bottle ran out.  I purchased some easy boot Clouds with pads for her, which definitely make her feel better, almost too much as she will sometimes get irritated with not being able to go in the pasture with her friends and will run and buck.  Without the boots I feel as though she actually seems worse than she did to start with and wonder if her running and bucking sets it all off again?  Is it normal for them not to seem better after 4 weeks?  She has definitely lost weight.  Vet said to soak her feet in the morning and leave the boots off during the day, put them on at night to avoid having her feet get too soft.   Trimmer said feet do not get soft from wearing boots and if they help her to feel more comfortable to keep them on.  I don't know what to do and wonder if her feet are soft and that may be why she is seemingly worse?   In my dry lot I have pea gravel, so it's not exactly soft footing which may also contribute to her being ouchy and is why I leave her in the boots around 20 hours a day.

She is getting magnesium, copper & zinc, salt, California Trace (all of these things she has been on for years), garlic (I use in the spring/summer/fall to help with bugs) and I had been giving her chaste berry until she was put on the cushings powder.   I had been giving her Alfalfa/Timothy pellets (1 cup) and Crypto Aero (1/2 cup) soaked with all of that to get her to eat it.  I saw Alfalfa is not recommended, so I purchased the Stabul feed and started her on that yesterday, giving her 1 1/2 cups twice a day.   The soaked hay is fescue, first cut from last year.  I just purchased a few bales of first cut from this year that I need to have tested, I don't know if fescue is generally high in NSC?

She will be having x-rays taken tomorrow morning.  Given that I will be seeing my vet, I am wondering if I should ask about switching the cushings powder for just pergolide?  Could the mix with the Cyproheptadine be having adverse effects on her?   And, the note the vet wrote me with instructions states the Thyro-L is for IR, which I saw reading through the site that it really is for thyroid issues where horse are having trouble losing weight.  I don't know if she has that issue and wonder if I should ask about reducing that and eventually getting her off from it?    

I know that is a ton to read, I thank you for your time and appreciate any advice you are able to provide.  Desperate to have my pony feeling better.

--
Lori J in NC 2022

Hi Lori,

You will be getting a formal welcome message soon but I want to hit a few high points.

- There is ZERO evidence that cypropeptadine does anything to help with PPID. This was established years ago. It won't hurt anything but it's worthless. The loose powder pergolide also has poor shelf life. You should go with capsules.
- Thyro-L can enhance weight loss but does nothing for insulin resistance.
- Metformin effects are very individual. Without repeating insulin testing you can't tell whether to discontinue.
- Do a search here for InsulinWise
- Fescue is a bad idea.https://pubmed.ncbi.nlm.nih.gov/22585825/ , https://pubmed.ncbi.nlm.nih.gov/7695144/

--
Eleanor in PA

www.drkellon.com 
EC Owner 2001

Thank you so much for your quick reply Dr. Kellon.   I did receive the welcome message and read through the information, question on feeding, I have her on the Stabul feed now and not on beet pulp, is there any reason I should feed her beet pulp instead?    I believe I can find Timothy or Orchard grass to feed her instead of fescue.  I had only heard about pregnant mares having issues with fescue, had no idea about it being related to laminitis.  She has been on fescue pastures and eating fescue hay for 13 years, that's pretty much all that grows well in the area we are in.  

I did find the information on InsulinWise, thank you for mentioning that.

--
Lori J in NC 2022

Hello Lori

Welcome to the group! Glad Dr Kellon gave you some important information upfront. It may be you read the standard welcome letter we send to every new member but for good order, I am providing this below in your thread for your easy reference. As you know, there is lots of information in there and I myself go back to read it now and then.

1) Stabul 1 is ok for vast majority of horses instead of beet pulp. Only if you have a very sensitive horse then it might not work and in that case rinse soaked rinsed beet pulp would be even lower in ESC and starch. I think your first step would be to switch your hay to Timothy or Orchard. You also mentioned replacing the alfalfa and I think that means you took out the Cryto Aero as well (both their whole food and wild forage versions have alfalfa and one even has oats).

2) Dr Kellon already highlighted the loose powder pergolide has poor shelf life.

3) The boots may make her feet soft if she's sweating in them over long hours and retaining moisture. Many members manage this using generous amounts off foot powder/gold bond powder and giving about 2 hours daily with boots off to get the boots to dry out completely. I also find hoof armor if applied when the feet are clean and dry will help against moisture related softening (it's just another option, if powder works for you that's good). I'm not sure why you are soaking still and frequent soaking definitely I have found to soften feet. If you are't soaking due to treating whiteline/thrush issues (using cleantrax, white lightning or oxine) I would stop the soaking for now. Frequent soaking also seems to accelerate sole shedding/exfoliating in my experience so this could be counterproductive causing you to lose the precious sole you are trying to build up/retain.

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 etiquette, what 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.

EXERCISE: The 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. 

--

Thank you so much Cindy & Sherry for the information you sent.   I did stop both the alfalfa/timothy pellets and the CryptoAero and have her just on the Stabul-1 now.  Just had x-rays done this morning, she definitely has rotated, I have started my case history, will try to upload the photos.  I can say the distance from the coffin bone to the sole is 1.1cm on both front feet, so very concerning.   My vet did say her heels need trimming and that her toe is basically as far back as it can go right now.   She suggested clogs and stated she has seen them work very well.  She also wants me to put her back on the metformin.  I did get the capsule version of pergolide, so I will be switching her over to that over the next couple of weeks from the combination powder.  I am overwhelmed and not sure what to do about the clogs, since I have seen contradictory information.  Any suggestions?

Thanks again!
Lori & Abbey  
--
Lori J in NC 2022

"Fescue foot" is a well known problem in cattle. These are the studies with horses: https://pubmed.ncbi.nlm.nih.gov/22585825/ , https://pubmed.ncbi.nlm.nih.gov/7695144/ . It makes sense that horses with elevated insulin would be at higher risk since reduced tissue perfusion is a component of metabolic laminitis.

Take advantage of that money back guarantee on InsulinWise.
--
Eleanor in PA

www.drkellon.com 
EC Owner 2001

I find its best to find ways to accommodate and compromise with your vet when you disagree on some things.  For example, "yes, we'll go back on Metformin but instead of clogs I really want to try and support the hoof using boots with pads so we can trim less off more frequently, and adjust for comfort as needed".

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

Thank you Sherry and Kirsten,  I truly appreciate the support, my gut is telling me not to do the clogs (so is my trimmer), but they were very convincing and I really just want to help her.   I'll get pictures of her trim this afternoon and post those along with the x-ray pictures.  
--
Lori J in NC 2022

I'm not sure if you all are notified when photos are uploaded, but I was able to post the x-rays and trim photos in a new album named Lori J and Abbey.  Looking forward to your thoughts.  Thank you!
--
Lori J in NC 2022

Hi Lori

I took a look and the good news is her coffin bones seem to be in fairly good shape. I would not do clogs but work on her often as Kirsten suggested, with boots and pads. Heels and yes "toe" as in break-over. Nothing off the sole. She will tell you if you have it right.

Have a look here
https://www.ecirhorse.org/DDT+E-trim.php
and here
https://www.ecirhorse.org/realigning-trim.php

--
Nancy C in NH
ECIR Moderator 2003
ECIR Group Inc. President/Treasurer  2021-2022

Hi Lori,

I took a look at the radiographs and photos - thanks for adding them:

https://ecir.groups.io/g/CaseHistory/album?id=276850

Trim is pretty good - just needs a few tweaks to tighten it up. There is distal descent (aka sinking), which is contributing to her thin soles but NO bony column rotation. There is a slight amount of capsular rotation. Capsular rotation is when the distance between the hoof wall and the dorsal surface of the coffin bone widens as you move from the coronary band toward the ground. Easily fixed, esp. in Abbey's case as it is so mild. She needs to have her toes backed up at ground level, to move the breakover point in closer to the tip of the frog. Trims need to not touch her soles at all, for any reason.

As has been mentioned, attaching clogs (or any appliance) will make it impossible to make frequent trim adjustments as needed, which is why we recommend boots and pads instead. Plus, the pressure-and-release action of padded boots is also therapy as it stimulates circulation, which helps increase sole depth. Any boots you se should have aggressive bevels added to the treads at both the toes and across the heels, even if the boot has some beveling already incorporated by the manufacturer.

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

Thank you all for your responses, I appreciate your help so much.  I am not sure I understand everything you wrote Lavinia, but my trimmer does and she will be here tomorrow or Friday to make the tweaks you mentioned.  I have decided not to have the clogs put on and will give the proper trimming and boot adjustments time to work.  

Also, I uploaded a hay analysis from a supplier near me, I am not sure how to read it to determine if this is appropriate hay or not.  Can anyone help me decipher this?

https://ecir.groups.io/g/CaseHistory/files/Lori%20J%20and%20Abbey

--
Lori J in NC 2022

Abbey's Photo Album:  https://ecir.groups.io/g/CaseHistory/album?id=276850 

Hi Lori,

saw that the test should be done after 4 hours of not eating, however, I did not know that at the time and that was not mentioned to me, so she had been out in the pasture for a few hours before the vet did the test.

Actually, the test should be done non-fasting and if the horse had a break of more than 6 hrs in access to forage (ie, overnight most horses run out of hay) then they need to have started their most recent meal (ie, breakfast) at least 4 hrs before the blood draw.  After a fast, the first meal causes an insulin spike in the first 4 hrs, and we want to avoid testing insulin when it is anomalously high.  If Abbey was on pasture gir at least 4 hrs prior to the blood draw,  her results are valid.  Even if it was less than 4 hrs and we are seeing the spike from the first meal of the day, her insulin is still too high to be normal.  So high in fact that I would not put her back on pasture again, unless you can put a closed muzzle on her to prevent grazing.

The cold soaking does not help with metabolic laminitis since inflammation is minimal, although you might see a little pain relief from it.

The running and bucking could definitely exacerbate hoof pain.  If you're seeing that she's sore after that, you might want to find a way to prevent it.  However, if she's not sore after, and as her trim looks pretty good, it might not be an issue. 

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

Thank you for confirming Sherry, I am pretty sure it was also, but will double check with the supplier.

Thank you as well Kirsten, everything you mentioned makes complete sense.  Appreciate the info. - I had stopped soaking her feet, then felt like I should be since my vet had said to do so once a day, so did again over the last weekend, but have since stopped completely.  She doesn't tend to do the running and bucking much thankfully, but yes, I agree I need to make sure she doesn't do that at all.

My trimmer was here today, made the tweaks and also applied hoof armor,  I have her in the Cloud boots with gold bond powder to hopefully keep them as dry as possible.  

I did tell my vet today that I won't be having clogs applied, the response I got was very disheartening and made me feel terrible.  She said that Abbey needs to grow hoof and that we cannot improve her break over that will stop the laminae from continuing to tear going the trimming and boot route.  She said her coffin bone is being traumatized as it's only protected by one centimeter of sole and if we take her heels down to where they should be she will be even closer and her fulcrum point longer.  And, continually trimming her can do more harm than good, in her opinion the longer I delay having clogs put on her the less likely she is to have a full recovery.  

Of course I sent that on to my trimmer who eased my mind by explaining why some of that is not true and the parts that are true she explained what we are doing to fix and protect.  
Any additional confirmation to help further ease my mind are very welcome.  This is hard!
--
Lori J in NC 2022

Abbey's Photo Album:  https://ecir.groups.io/g/CaseHistory/album?id=276850 

Hi Lori

It is indeed hard work.

I would agree with your trimmer. You can fix and you can protect, and IME, you can do it more rapidly with out the clogs. I would encourage you to start taking photos of the foot to see how it changes between trims. Great way to expand your knowledge.

Hang in.
--
Nancy C in NH
ECIR Moderator 2003
ECIR Group Inc. President/Treasurer  2021-2022