New to the group!

My 17 year old QH trail mare was dx with PPID 2 days ago with a plasma TRH Stimulation test - results : that was 253 pg/ml. Chem panel done Glucose 85.

Started on 1mg/daily Pergolide 11/10. - I decreased to half pill after reading your info. 

Recommended to use 1 mg daily x 2 months then retest her ACTH-

Symptoms - lethargy, depression, no go, wanting to stand still x 3 weeks.

Shod dt very thin walls - via X-ray being reshod next Tuesday - have alerted Farrier.

 

Pertinent history - Peptic ulcers x 5years- controlled

Spinal surgery @A&M 5/20. recovered well

Trailered to CO for riding x 1 month in September

 

Nutrition- alfalfa 1 flake x 3/day, dry pasture, grain- senior feed from BlueBonnet 1 scoop x2 a day.

physical condition very good for age - no crest, at ideal weight, shiny coat,

 

Activity - ridden 3- 4/ week trail -3-4 miles per ride, small amount of arena work

 

Questions-

Should I have her tested for IR? Hgb A1C? What is the most sensitive / specific test for IR?

Recommended to use Pergolide 1 mg/dailyx 2months then retest ACTH level. Is this enough time before retesting? Thank you.

_._,_._,_

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Jennifer, Austin, TX. 2020

Hi Jennifer!  

Welcome to the ECIR group.

I will address some of the issues in your post and then forward the group welcome letter telling you all about what we do here and how it relates to your horse.  There are lots of links to follow so you may find the answers to many of your questions within the letter and we are here to try to help you with any other questions you might have.  We frequently refer to D,D,T&E which stands for diagnosis, diet, trim and exercise, the foundations of our care plan.

I can see that you have begun working on a diagnosis, which is of course the first step.  Your mare was diagnosed PPID with a TRH Stim test in early November.  The problem here is that there have been no lab normals determined for TRH Stim tests done in the fall so this time of year it’s not possible to determine accurately if the test is positive.  The seasonal rise technically begins on 6/21 and ends on 12/21, although the change is quite gradual at the beginning and end.  I would suggest retesting after the first of the year.  If your vet wants to do the Stim test again, the mare should be taken off pergolide for at least 3 weeks in advance,  Otherwise you can do a regular ACTH test.

At the same time, you would want to test insulin and glucose.  Quarter horses are not often IR unless as a result of PPID.  That testing plan should give you a much better reading of what’s going on.  Normally you can test the effectiveness of the pergolide after 3 weeks of being on the drug at the desired dose.

I see lots of room for changes in her diet.  The one that stands out is alfalfa which can make some horses footsore.    Have you been feeding her alfalfa all along?  No one knows what causes it but it might be worth removing it for awhile to see if that helps.

I think I have answered your questions, plus a bit more, so I will leave you with the welcome letter I promised.  I think you will find lots of interesting and useful reading there.  Be sure to let us know when more questions arise.

Welcome to the group! 

The ECIR Group 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 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 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 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: 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 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 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 spike. Make 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 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. 

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Jennifer, Austin, TX. 2020

thank you for the initial response - she is on alfalfa as management of her peptic ulcers per vet. they were severe and we have gotten them under control after treating her with ulcergard x 2 months and a scope post treatment to check effectiveness. 

can the test value of 253 pg/ml be that inflated and be false - what would inflate it?

glucose level done it was 87mmol/l but no insulin level - should that be done now  and should it be fasting? thank you
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Jennifer, Austin, TX. 2020

On Thu, Nov 12, 2020 at 09:52 PM, <jg2wolf@...> wrote:

Symptoms - lethargy, depression, no go, wanting to stand still x 3 weeks.

Hi Jennifer,

I'm wondering  if her feet have a bearing on the above symptoms? Can you post pictures of her feet,in case there are improvements that could be suggested about the trim,in order to help her?

Here's info on how to take hoof photos....
https://ecir.groups.io/g/main/wiki/1472

 
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Lorna  in Eastern  Ontario
2002
Check out FAQ : https://www.ecirhorse.org/FAQ.php

Hi Jennifer,
I’m not suggesting the data from the test is false, just that the studies have not been done to allow for a meaningful evaluation.  Dr. Kellon may have some input based on her own observations.  If you retest the ACTH once the fall rise is complete, the values will be more informative.  Managing PPID involves regular and sometimes frequent ACTH testing.  In order to evaluate the effectiveness of your treatment, you need data you can interpret.  

As with Lorna, my first thought was with her feet.  Insulin and glucose samples should be drawn at the same time.  They should not be fasting but there are more details in the welcome information about what that means.  We want the horse to be in as normal a situation as possible, having been munching along without any disruption.  With the ACTH testing, you also want as little disruption as possible.  Draw the blood at home under quiet circumstances.  My horse’s ACTH was elevated by having his teeth floated prior to having his blood drawn.  We redid it a week or two later and it was fine.  You will learn a lot along the way.  I wasn’t familiar with this group when my horse was first diagnosed so I had a lot of catching up to do.

Now that you mention it again re the alfalfa.... is there any chance the ulcers are active again?  From my own experience, I tend to associate ulcers and PPID.  I don’t believe there is any research to back this up but I was observing gastric issues in my horse, Logo, before my vet suggested he might be PPID.  After starting him on pergolide, those issues became much less troublesome.  I did my own research by giving initially cimetidine but later GastroGard for a bit to see if it made a difference in what I was observing.
--

Hi Jennifer,

I agree it sounds like feet could be the major issue here.

As for ACTH, early November is still within the tail end of the seasonal ACTH rise.  What was the ACTH before TRH was given. We don't have data on normal responses to TRH during the rise yet so the test is not recommended then.
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Eleanor in PA

www.drkellon.com 
EC Owner 2001

Thank you for your responses. I have read most of your educational info - what a great resource. 
regarding the ulcers - before the trip to CO I started my mare on ulcergard x1week before the trip, through the trip and one week after the trip, trying to mitigate/manage her ulcer return, You being up a good point.   Due to readings on your site, I decided to start her medication trial with a tapering (she has not shown signs of the veiling) but bc she was moderating lethargic, I thought I'd try to prevent the veiling so I could ride her.  BUT, if I do the tapering then her original 2 month 1mg pergolide test, will not end until Feb, tapering up 0.25 every 4 weeks- so is Feb too late to get an accurate ACTH seasonal change? Thank you again for all of the advice - it has been extremely helpful.  I 'll ask about the risk/benefit of changing her feed to hay from alfalfa. 
Jennifer, Austin, TX. 2020

Jennifer, is it possible you misread the advise on tapering?  I think tapering up by 0.25 mg every 4 days to 1 week is more consistent with what we usually recommend, so it should take 1 month tops if all goes well.  

Not all horses experience a veil but you won't know until you try.  Some horses are fine with 1mg/day at the beginning.  A little bit of lethargy and reluctance to eat would be a normal reaction.  Extreme lethargy and refusal to eat or drink would be a rare reaction, but one where you would stop and try again with APF and maybe smaller doses with longer periods between increases.

If you decide to re-do the TRH Stim for diagnosis purposes,  I would do it between January and May, but you'll have to stop the pergolide for several weeks before the stim test.

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

Jennifer, could you share the pre-stim ACTH value as Dr Kellon requested?  That will give us more information than the post-stim value for this time of year.  If it is abnormally elevated, too, then early PPID is likely.


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

Hi Jennifer,

As Kirsten mentioned, the tapering is done by increasing the dose by .25mg every 4 days. That would get you to the prescribed 1mg daily dose in two weeks. You can retest 3 weeks after that.

Unfortunately, no matter how you do it at this point, the retest will be outside the seasonal rise period as that ends in Nov. The retesting result won't be able to be reliably compared to your previous test result. It will, however, give you an answer to where your girl stands at that point.

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

yes, I did read the tapering protocol wrong_ thank you so much for all the eyes on this case. the ANTECH lab paper 
-- states "endogenous ACTH baseline is 18pg/ml. and the endogenous ACTH post (10 min) is 253 pg/ml- please let me know if that is what you need to correctly interpret. Thank you again.  My mare is shod - do you still want me to upload pics? - if so I can get them tomorrow . 
Jennifer, Austin, TX. 2020