New case history


roisin.mccourt@...
 

Hello all
 
I have a 5yr old mare who suffers from intermittent systemic inflammation. She'll go well for 4-6 weeks before having a flare up which can last for a day, days or if really bad, weeks. A flare up starts with her looking depressed, then she will be reluctant to go forwards/ load, she can be explosive under saddle and she has been dangerous to shoe in the past (obviously I don't when she is sore now I understand there is inflammation). There are no obvious triggers. She is under vet supervision.
 
I have at times felt heat and a digital pulse in her feet and there are rings on her hooves, but there are no signs of rotation on x ray. I have x rayed her feet twice in 2 years.

At the start of July this year she had a major episode; I restricted her grazing to an overgrazed track, she stopped work & vet put her on omeprazole.  She started a nutritionist's diet.  At the start of August she had another episode & vet felt heat in her feet, so she came off grass altogether.  On 18 August she was still too sore to be shod.

Grateful for any advice you may have.  I had her equibiome tested & we are waiting for their probiotics/ recommended supplements.
 
 Her diet is as follows:
 AM
 5kg soaked hay 
 50g lucerne chaff
 100g sugar beet pulp
 150g timothy smart feed
 150g brown top chaff
 15g salt
 7g KER CoQ-10
 112.5 kelato gastroaid
 
LUNCH
3kg soaked hay 
150g timothy smart feed (harvest grains)
150g lucerne chaff
5g oily herbs (thyme/ oregano)
 
PM 
4kg soaked hay
100g lucerne chaff
 150g sugar beet pulp
 200g brown top chaff
 20g salt
 17g KER nano-e
 112.5 kelato gastroaid

Thanks in advance

--
Róisín Magee
2022
New Zealand
https://ecir.groups.io/g/CaseHistory/files/Roisin%20and%20Lizzy/Lizzy%20case%20history.pdf


Eleanor Kellon, VMD
 

Systemic inflammation isn't a diagnosis - it can be component of many different very serious disorders that don't just come and go as you described. If you think her problem is systemic inflammation, what brought you here?

Equibiome testing is a waste of money IMO. We don't know enough yet to accurately interpret it.
--
Eleanor in PA

www.drkellon.com 
EC Owner 2001
The first step to wisdom is "I don't know."


roisin.mccourt@...
 

Hi

Thanks for the reply.

Understood that 'systemic inflammation' isn't a diagnosis but vet can't work out what is causing it, so we don't have a working diagnosis.  The inflammation seems to 'settle' in her feet (vet's words) so it is laminitis.  The intermittent laminitis and that on the PPE vetting I was warned that she was overweight and might be prone to developing 'metabolic syndrome' is what brings me here.

Sorry - not a vet.  But this has been going on for two years and while I would say my management of whatever the problem is has improved, I don't have any idea of what the problem might be.

--
Róisín Magee
2022
New Zealand
https://ecir.groups.io/g/CaseHistory/files/Roisin%20and%20Lizzy/Lizzy%20case%20history.pdf


Cindy Q
 
Edited

Hello Roisin

Thanks for uploading your casehistory (CH). I'll be sharing our official welcome letter below. You will see detailed information set out in sections titled DIAGNOSIS, DIET, TRIM + Exercise (when horse is comfortable and stable). From your CH, I see:

1) You have not done testing for Insulin Resistance (IR) and cushings (PPID). I cannot see an estimated age for your mare. A large percentage of laminitis is metabolic related. You should test for IR and PPID to either get baseline figures, potentially figure out a common trigger for laminitis or eliminate a common cause. Details below under Diagnosis.

2) Diet - We have details of recommended diet, including the Emergency Diet. Your horse had laminitis quite recently and I advise to relook at your whole diet and follow our recommendations, which also benefit horses who are not metabolic. Y
ou are feeding a lot of different things and a lot of them are NOT in line with our feed recommendations. Some highlights:
- brown top chaff - the colour is not indicative of low ESC and starch. 
- lucerne - often found to make horses footy so unless your horse is proven to not be sensitive to lucerne/alfalfa, eliminate
- 12kg of meadow hay. You are currently feeding about 2% of your horse's weight in hay. I saw she has gone from fat to "normal" in your CH with a score of 8 to 4. Continue to monitor that and try to keep her at about 4.5 for now. Being a cross PRE, the Spanish horses can be at higher risk of IR. Are you able to test your meadow hay?
- Beet pulp pellets: Beet pulp tends to contain high amounts of iron from the making process and/or surface dirt. We recommend to rinse, soak and rinse till the water runs clear to remove such.
- Harvest Grains Timothy Smart Feed - According to their website 
https://www.harvestgrains.co.nz/timothy-smart-feed/ they have ESC 4.4% and starch 2.2%. These figures are below our recommended maximums so that much is good. A caution that the figures do not seem guaranteed so you may find out more by contacting them and trying to ask them for a recent analysis, how often they test their product to ensure they are within their published figures, whether they update these published figures from time to time if the sampling change, whether they have information on their common deviations/ranges, what the source of "legumes" are (alfalfa is a legume hay). If your horse is improving well on this, for me, if I need something more than just hay as a taste tempter for the beet for supplements, I would continue this with caution. The more information you can get out of them, the more informed your choice will be and if you could share it back here with us, you can be helping other members in NZ.

If any other members are familiar with this feed and have success/cautions, please jump in here!

- Kohnke's Own Cell Vital - This has added iron, almost as much as the zinc. (I know this is a widely available brand in Australia) If you are looking for a mineral supplement that is safe and available in New Zealand and has no added iron, comes in versions with and without selenium, you can contact Carol Layton of Balanced Equine https://balancedequine.com.au/ . She has a few suppliers in NZ and may also ship direct to NZ (My friend in NZ has purchased several times). Ultimately, feeding an approved and safe mineral supplement as a balancer is a 2nd choice to testing the hay and customised mineral balancing (which Carol is also able to assist with). And both of these are feeding general supplements with added iron.

- Mitavite Performa 3 oil - For Omega 3 source, we recommend flaxseed ground (fresh or stabilised) or flaxseed oil. If your horse is allergic there are alternatives, but as this is the first ingredient in your performa 3 oil product, I don't think that is your concern. For flaxseed oil, the recommended amount for your horse would be about 40 to 50ml as a guide (about 2.5 to 3 tablespoons daily). If she needs a bit more calories, you can increase. For flaxseed ground it would be 3 oz (maybe 3/4 cup to start but weigh to be accurate).

Here is the full letter, and please take your time to go through it and ask more questions as you need.

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. 

--
Cindy and Glow (over the rainbow bridge) - Sep 2017, Singapore
ECIR Primary Response





Eleanor Kellon, VMD
 

You need to read your welcome letter carefully and also read the sections on diagnosis at www.ecirhorse.org. This has nothing to do with inflammation. Being overweight isn't a cause of metabolic syndrome, it's a result.
--
Eleanor in PA

www.drkellon.com 
EC Owner 2001
The first step to wisdom is "I don't know."


roisin.mccourt@...
 

Thank you so much for taking the time to have a look at Lizzy's case history and to offer some help.

I have got in touch with Carol - I previously raised concerns about the high level of iron in our grass with both the vet and the nutritionist; the vet is looking in to it, but the nutritionist was very firm that high levels of iron are NOT an issue for horses.  I had also previously asked the nutritionist to remove lucerne from Lizzy's diet, but she was very firm on that too - she does not think lucerne is an issue...  Reading your advice and the information on this website has made me quite anxious that I am not being well advised...

I have uploaded our recent hay/pasture test and also updated Lizzy's case history to include IR testing from last year and her age (6).  I am soaking the hay because of the high sugar levels.

Thank you again
--
Róisín Magee
2022
New Zealand
https://ecir.groups.io/g/CaseHistory/files/Roisin%20and%20Lizzy


Kirsten Rasmussen
 

Lizzy's insulin is too low to indicate EMS/IR when she was tested; however, once physical maturity is reached around 5 yrs old, insulin can start to climb in horses with EMS.  With her PRE breeding, I would monitor insulin annually to make sure it stays low. 

If her behavioural flareups coincide with being in heat, her insulin could be high at those times.  You may want to test insulin when she is in heat or when she is experiencing a flareup.  You also noted laminitis rings in her hooves.  This could actually be a trim issue (ie, mechanical), but again warrants testing insulin.  Heat and digital pulses are not always due to laminitis.  Abscesses, hot weather, getting up from laying down, etc, can cause either or both signs.  It is also possible (but not as likely) that the first insulin test result was not processed correctly and is artificially low.  Please read the Diagnosis section and hyperlinks in your welcome email and share it with your vet.

Basically, she needs to be retested for insulin and glucose during a flareup.  I would also add ACTH to see if she has PPID....it would be EXTREMELY unlikely at her age, but we know it is possible.

Regardless if she has EMS or not, all horses benefit from proper mineral balancing and Carol Layton is who we recommend in your region.  The high iron in your grass, and high manganese in your grass AND hay need to be accounted for in the trace mineral balancing.

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


Kirsten Rasmussen
 

I forgot to add that you can upload hoof photos and xrays by making a photo album in the Case History folder, then add the URL to your signature and let us know they are uploaded.  If there are obvious mechanical issues or signs of laminitis, we should be able to see it.

See instructions here on taking photos, naming them, and making an album.

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