New bloodwork and concerns for the next year

Kirsten Rasmussen

I just got results for Shaku's October 14 blood pull.  He has made it to Compensated IR status!!!!  I had hoped this would happen one day but honestly didn't think it was possible for him... Needless to say, I am thrilled!!  Case History is UTD.

On the other hand, his ACTH came back as equivocal and leaning in my opinion towards slightly abnormal at 102 pg/ml.  After his blood pull, I stopped soaking his hay and within a week he was laminitic with bounding pulses for the 3rd time this year (May 14, Aug 7 and Nov 10).  This happened just as we reached our exercise goal of 30 min trotting in hand without stopping, 3x/week.  Each time he had a laminitic flare-up this year it was only resolved by starting to soak his 7% ESC+starch hay again.  This is the first time we've had problems in the fall; spring has always been his usual setback time.

What worries me though are 2 things: 
1) last year he was fine eating the exact same 7% hay unsoaked summer-fall-winter (which is why I keep trying to stop soaking it), suggesting a significant worsening of his EMS in just 1 year (or early stages of PPID contributing?); and 
2) I have no guaranteed source of low sugar hay for next year, so when his current supply runs out next summer I am worried we are going to have to settle for a higher sugar hay that might not be safe for him to eat even soaked.

What I am thinking, some of which was briefly discussed with his vet, is: 
1) a trial of pergolide in August next year and use through to December; and
2) a prescription for emergency-use Metformin to have on hand in case he has a flare-up on soaked hay.

Does anyone have any advise to add to the above?  Anyone managing a horse with EMS that improves on pergolide even though they don't have obvious signs of PPID or a PPID diagnosis?  Or experience dealing with what appears to be worsening EMS each year?  Am I missing something critical?  He has never been tested for Lyme but doesn't have neurological issues, nor is he from a known endemic region.  What else could contribute to EMS other than PPID? 

I think it's fair to say that every year since 2016 when I first noticed his whiteline was separating he has gotten measurably harder to manage despite making changes to his diet every year, the 3 laminitic flare-ups this year being a new record for us.  The improvement in his bloodwork this year is really only due to increasingly stringent dietary measures I have taken since joining ECIR to try and get ahead of his EMS.  Since then, all of these changes have brought Shaku into the best condition he has been in since I got him in 2014, and as of October 14 we were finally winning.  I'm hopeful he will bounce back quickly from the latest setback, but I am worried about next year.  If his EMS continues to worsen, or if I can't find low sugar hay what will our situation be by this time next year?  That's why I'm asking for advice now, so we can try to sketch out a plan I can take to his vet in the hope that she will agree to it, in case he gets harder to manage through diet alone.

Kirsten and Shaku (IR) - 2019
Kitimat, BC, Canada
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