Most recent PPID and EMS/IR lab results


a.k.a.petpalace2@...
 

Although Apollo's lab values improved from those done in April, was disappointing they weren't better as he's still very insulin resistant.  Blood samples were drawn 5 hours after first morning feedings and he received soaked hay and timothy balance cubes until blood samples done.  Cornell performed these lab tests along with TRH stim test.

Glucose 103 mg/dL; reference range 71-122.   Insulin 117.94 uIU/mL; reference range 10-40.  Leptin 13.06 ng/mL; reference range 1-10  (light draft < 15 ng/mL, Apollo is percheron/paint cross).   Previous lab values (tests done by Cornell):  glucose 113 mg/dL.  Insulin > 200 uIU/mL  and leptin 17.01 ng/mL.  Vet was not open to using metformin then and didn't say anything when I brought up subject again at time of TRH stim test. 

TRH stim test results:  ACTH pre TRH response was 11.2 pg/mL (reference range 2-30) and 10 min. post TRH response was 304 pg/mL (reference range 2-110).  Apollo has been on 1 mg of Prascend since 10/29/2021.

Regarding Thyrol-L:  Vet didn't have a problem with weaning Apollo off.  Started decreasing dose by 1/2 tsp every 2 weeks on 06/06/2022.  He is currently on 3.0 tsp/day.  Had been on 4 tsp/day starting 12/02/2021.  T4 in October 2021 was < 0.5 ug/mL and 1.3 in January 2022 but only 1.50 in April.

If I'm interpreting Apollo's lab results correctly, his high insulin in due to his uncontrolled IR not his PPID.  I'm almost out of hay for Apollo and awaiting new crop from different grower which should be much lower in iron than current hay.  This grower does wet chemistry but ESC not done by lab he uses.  Did give him info on Equi-analytical.  

Where do I go from here?  Would like to add exercise to help lower insulin but not sure how I can tell if it's safe.


--
Karen B.
Wisconsin
2022
Apollo Case History: https://ecir.groups.io/g/CaseHistory/files/Karen%20and%20Apollo
Photo album:  https://ecir.groups.io/g/CaseHistory/album?id=275817

 


Sherry Morse
 

Why is your vet not willing to try Metformin?  At that level of insulin you are still very much in the laminitis danger zone and it needs to be brought down ASAP.  As you mentioned he has lost a good deal of weight that is helping but it's obviously not enough.  I would also NOT be complacent about the post TRH number and would consider raising his dosage of Prascend to at least 2mg/day at this point.

As far as his thyroid level, that's not unusual in an IR horse and will probably level out if you can get the IR under better control.

If he's sound walking at this point you can start handwalking while you work on getting his trim in better order, but if he shows any signs of soreness you'll have to back off on that.




a.k.a.petpalace2@...
 

I don't understand why my vet doesn't object to running tests but then doesn't do much with results.  I emailed ECIR info on metformin to him in April when Dr. Kellon suggested it but he didn't respond.  When he came to do TRH stim test, I brought it up again (told him it's commonly used in managing IR horses) he didn't say anything.  I can try again but obviously can't make him give me a prescription.  Since metformin doesn't work very long in most horses, then what?  I know he is in danger of laminitis but other than exercise, there is nothing else I can do that doesn't require a vet.  Could be because he's not obviously laminitic, vet doesn't see need for any intervention.

I was pleasantly surprised Apollo didn't become laminitic when his insulin was > 200 in April.  Changing his diet, soaking his hay and starting him on Jiaogulan really made him more comfortable.  A couple of weeks ago when it was much cooler and less humid, he was acting quite frisky at times out in paddock when our younger horse would be goofing off on his side.  I've seen Apollo do things I've never seen him do before, like run around and strike out with his front hooves.  Apollo cantered a bit last night and did a little hop and buck where both back feet came off ground.  Farrier trimmed him on Friday and took back long toes and addressed some of flaring but definitely has a long way to go to have normal hooves (if that can happen).  There's about 1-1/2" of old hoof remaining.  New growth on RF looks better than on LF, but was more sore on left and had more severe white line separation.
--
Karen B.
Wisconsin
2022
Apollo Case History: https://ecir.groups.io/g/CaseHistory/files/Karen%20and%20Apollo
Photo album:  https://ecir.groups.io/g/CaseHistory/album?id=275817
 


 

Hi Karen,
I’m not sure why you think that his high insulin is due to his uncontrolled IR, rather than PPID.  Uncontrolled PPID can elevate insulin as well.  If this were my horse, I would increase the pergolide to 2 mg and retest.  It’s likely he will need more but those results will help guide 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


 
 


a.k.a.petpalace2@...
 

I thought target range for ACTH levels when using pergolide was teens/low twenties which Apollo's is.  Was I mistaken?  He is also one of those horses who had a normal endogenous ACTH level but tested positive with TRH stim test.  Isn't Dr. Kellon doing her study on these horses to help determine how to manage them?  So what I need to do is increase his Prascend dose to try and lower his insulin level even though his ACTH is not elevated? Won't increasing his Prascend lower is ACTH level too?  It was only 11.2 pg/mL when last checked.  If I increase his Prascend dose, how long do I wait to retest his insulin level?  Do I also recheck his glucose?  Does leptin level help differentiate between IR vs PPID as cause of high insulin?  If my vet would agree to metformin, would I still increase his Prascend?  
--
Karen B.
Wisconsin
2022
Apollo Case History: https://ecir.groups.io/g/CaseHistory/files/Karen%20and%20Apollo
Photo album:  https://ecir.groups.io/g/CaseHistory/album?id=275817
 


Sherry Morse
 

Karen,

You'll want to read the message Dr. Kellon posted earlier today about this: TRH Response Tests When On Pergolide (groups.io).  Are you part of the study?  At this point we can't tell you if Apollo's IR elevation is due to his PPID or not but as his insulin is still quite high trying to get it down needs to be a priority.  The way we do that is:

DIET (you're already addressing that and he's losing weight which is good, but his insulin is still elevated)
EXERCISE (you can start walking him if he's comfortable but you do need to keep an eye on him and keep working on getting his trim in order)

If insulin is still elevated with diet changes and weight loss we look at ACTH if a horse is PPID as well as IR as elevated ACTH may be driving up insulin - this is why we're suggesting increasing the dose of Prascend to see if it helps with the insulin level.

You can also try Metformin to lower the insulin but you need a script for that so need to work with your vet on that.




On Thursday, June 23, 2022, 09:04:22 PM EDT, a.k.a.petpalace2@... <a.k.a.petpalace2@...> wrote:


I thought target range for ACTH levels when using pergolide was teens/low twenties which Apollo's is.  Was I mistaken?  He is also one of those horses who had a normal endogenous ACTH level but tested positive with TRH stim test.  Isn't Dr. Kellon doing her study on these horses to help determine how to manage them?  So what I need to do is increase his Prascend dose to try and lower his insulin level even though his ACTH is not elevated? Won't increasing his Prascend lower is ACTH level too?  It was only 11.2 pg/mL when last checked.  If I increase his Prascend dose, how long do I wait to retest his insulin level?  Do I also recheck his glucose?  Does leptin level help differentiate between IR vs PPID as cause of high insulin?  If my vet would agree to metformin, would I still increase his Prascend?  
--
Karen B.
Wisconsin
2022
Apollo Case History: https://ecir.groups.io/g/CaseHistory/files/Karen%20and%20Apollo
Photo album:  https://ecir.groups.io/g/CaseHistory/album?id=275817
 


Nancy & Vinnie & Summer
 

Hi Karen
I am speaking purely from my personal experience with my horse Vinnie. His first laminitis was November 2018 ans his acth at that time was super low, if I recall 9  on the Cornell reference range.  But we had always suspected that this lamintis was driven by PPID in spite of his numbers on the bloodwork.  Fast forward to 2021 with some acute on chronic episodes of laminitis, we finally received a positive result for PPID based on a  baseline result of acth.  I wish we had the hindsight of a TRH stimulation, but what I can say is that this year we have increased from 1.8 nlmg compounded pergolide in December 2021 to a current dose of 6.6 mg compounded pergolide now.  I am finding with Vinnie that I need to consider his clinical symptoms more than looking at the acth number.  We still plan on doing  TRH stim, to use that as a marker of information, but I am finding that what his body tells me may be a better diagnostic than just the bloodwork alone.

Vinnie is also EMS and metformin didn't control him after a period of time on it, so we are using canagliflozin, but that is definitely not a first line of defense for control of insulin.

I hope your vet will work with you in metformin, but I agree with the others bases on the post stim number that could be a contributing factor go the elevated insulin based on my long arduous adventure with Vinnie.

Hope that helps, Nan
--
Nancy and Vinnie and Summer
Oakley, Ca
Joined Nov 2018
https://ecir.groups.io/g/CaseHistory/files/Nancy%20and%20Vinnie 
https://ecir.groups.io/g/CaseHistory/album?id=245855

Summer
https://ecir.groups.io/g/CaseHistory/files/Nancy%20and%20Vinnie/Summer 
https://ecir.groups.io/g/CaseHistory/album?id=249104


Kirsten Rasmussen
 
Edited

Hi Karen,

Given Apollo's high insulin despite all that you are doing diet-wise, and the fairly high post-stim ACTH number, I too would increase pergolide.  My horse is similar to Nancy's Vinnie.  Onset of very difficult to control IR in 2017 and normal baseline ACTH.  Eventually we got an abnormal ACTH result and started pergolide, but in hindsight I feel I should have started it 2-3 years earlier based on the sequence of events and physical signs of PPID.

I'm glad he's feeling good despite the high insulin.  If that changes, I would make sure your vet is prepared to write a Px for 30mg/kg 2x/day Metformin so you can treat him right away.

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


a.k.a.petpalace2@...
 

Thanks for everyone's help.  I've relayed recommendations for metformin again to my vet.  Also told him need to increase pergolide dose.  Said Dr. Kellon is concerned about Apollo's history of laminitis during last year's seasonal rise and his increased risk of laminitis now because of high insulin.  This time he didn't ignore me but texted back asking for recommended dose for metformin.   In Kristen's reply to me, she said 30 mg/kg 2x/day.  I know it should be mixed with milk of magnesia when given by syringe and his mouth rinsed after to prevent ulcers in his mouth.  How much milk of magnesia should be added?

Also Can metformin be given at same time as any of his other meds?  Gets J-herb in morning and night plus Thyrol-L (being weaned off) and Prascend in evening.  Not positive on Apollo's exact weight so how to figure safe but effective dose?  When should insulin level be retested?  How long does he stay on metformin, until it stops working or when insulin goes down?

Regarding increasing Prascend.   This is in addition to metformin?  Should I increase now?  Start with 1/2 tablet increase and then wait 3-4 days before adding another 1/2 tablet?  He had some difficulty when first started Prascend last year but didn't last very long.  Gave APF a couple of days but he really hated it and didn't make big difference.
--
Karen B.
Wisconsin
2022
Apollo Case History: https://ecir.groups.io/g/CaseHistory/files/Karen%20and%20Apollo
Photo album:  https://ecir.groups.io/g/CaseHistory/album?id=275817
 


Sherry Morse
 

Hi Karen,

Metformin dose is 30mg/kg 2x a day. You'll need to use a weight tape or the weight calculation chart (https://ecir.groups.io/g/main/files/Case%20History%20Tools/Tools%20and%20How-To%20Help/Horse%20Weight%20Calculator.xlsx) to figure out his weight and convert from pounds to KG.  

You can give Metformin with other meds and you'll want to recheck his insulin 7 - 10 days after starting Metformin to see if he's responding to it.  If he does he will stay on it at least until he reaches his ideal weight and his ACTH is in the lower end of the reference range. You do want to increase your dosage of Prascend now even with adding Metformin in.  




a.k.a.petpalace2@...
 

Is there any benefit in terms of blood titer levels to splitting pergolide into equal amount for morning and evening doses or best to stick to once a day?  
--
Karen B.
Wisconsin
2022
Apollo Case History: https://ecir.groups.io/g/CaseHistory/files/Karen%20and%20Apollo
Photo album:  https://ecir.groups.io/g/CaseHistory/album?id=275817
 


Sherry Morse
 

Hi Karen,

Dose splitting pergolide decreases the therapeutic amount in the bloodstream so we do not recommend it.  In the horses on the group that are being dosed 2x a day it's usually an extra dose to help maintain therapeutic levels when a single daily dose does not.




a.k.a.petpalace2@...
 

Good to know.  I will wait until usual time Apollo gets Prascend today to start increasing his dose.  
--
Karen B.
Wisconsin
2022
Apollo Case History: https://ecir.groups.io/g/CaseHistory/files/Karen%20and%20Apollo
Photo album:  https://ecir.groups.io/g/CaseHistory/album?id=275817