New case history added - looking for help for cortisone induced laminitis episode


Ann Nuno
 

Hello,
I have just uploaded a case history and photo album for my coming 8 year old arabian gelding who developed laminitis in December after receiving cortisone injections in his SI joints.  He has a rather complicated medical hx with suspected neurologic issues vs. SI injury.  I decided to try the SI joint injections after seeking out another opinion.  Gelding is an easy keeper and had gained quite a bit of weight while off and in pasture and unfortunately developed laminitis after the injections. I have not done a metabolic panel but suspect he is IR or at risk for being IR due to how easily he gains weight and his voracious appetite.  While he seemed to have recovered fairly quickly and x-rays taken about one month post did not show any rotation or other changes, his soles were noted to be a bit thin. (Will upload x-ray images as soon as I receive copies from vet).  I have been trying to get him back on his exercise/rehab program while giving him some limited turnout to help his mental sanity but seem to have some re-occurring issues with sub clinical/low grade inflammation.  I check his hoof temperature daily with an infrared thermometer in order to quickly catch any inflammatory responses/increased heat. Initially I thought the periodic increases in hoof temperature were due to grazing but now I suspect may also be due to exercise/concussion as he once again had palpable digital pulses bilaterally after a training session in the arena last week.  His baseline morning hoof temperature is 48-53 degrees.  Every 2-3 weeks it will rise to 68-73 or so.  When this happens I don't turn him out and within 2-3 days he has gone back to baseline.  Since the laminitis, he is being kept in the barn which has a large stall/run in area with adjoining paddock/dry lot which has an area with sand.  He is turned out only in the morning from approximately 8am-10am with a grazing muzzle.  I did enlarge the hole on the grazing muzzle as otherwise he was getting very frustrated and running around crazy.  I am wondering if the laminae may have been weakened enough from the cortisone induced laminitis to be causing low grade inflammation and sensitivity to exercise/concussion and if so should I eliminate all exercise other than walking?  Will using hoof boots help this (just ordered).  Other suggestion/input/help appreciated.  
--

Ann Nuno
Gilroy, CA
2020

https://ecir.groups.io/g/CaseHistory/files/Ann%20and%20Nahar

https://ecir.groups.io/g/CaseHistory/album?id=263663


Sherry Morse
 

Hi Ann,

Looking at the picture of Nahar he is fat.  A 6 on the BCS scale is not normal - that would be a 4.5 - 5.  So if he's 845 now his ideal weight is probably closer to 800 pounds (or the 792 you list for 2018).  Based on that his total intake per day should be no more than 15.84lbs per day. That includes hay plus concentrates.  Is his hay actually being weighed now?  Is it being soaked?  Has it been tested?

If this were my horse I would cut his hay ration back and replace the Stable Lite (which has alfalfa and rice bran which are both not good for horses with IR) with a more appropriate feed.  That could be Stabul-1 pellets or Triple Crown Natural Timothy Balance cubes.  I would use the absolute minimum needed to get his supplements in to him. 

I would definitely be treating him as IR and arrange for testing ASAP to confirm this.  In the meantime if he is turned out on grass it should only be with a completely sealed muzzle as he doesn't need any extra food, and grass can cause laminitis in an IR horse.  Your experience with him getting worse on grass and better when he's kept in points to grass being a no go for Nahar at this point in time. Making the hole in the muzzle bigger just defeats the purpose of using it and while you may think it's kinder, it's really causing more issues.

At this point he shouldn't be in forced exercise at all if he isn't sound.  Hoof boots may help, but without a correct trim in place they may not help as much you'd like to see. If you can post pictures of his current trim as well as x-rays we'll be able to help you assess that. 




Cindy Q
 

Hi Ann

Welcome to the group!

You will find information below under Diagnosis on how to test him for insulin resistance. This can also give you a baseline figure for comparison in future. The official welcome letter below will also cover Diet, Trim + Exercise if the horse is comfortable). I agree with Sherry to tighten up his diet. Weigh the bermuda hay, remove the alfalfa and replace the stable lite to something safer. If you soak the hay for 1 hour, it not only reduces sugars but also calories. Would there be any possibility to clear the grass portion in the turnout (or block off the grass area) and feed him outside with slow feed hay nets spread out? This may help him have something to do while out.

As you mentioned he has thinner soles, boots would be helpful for protection/comfort.

If you have not tested your hay, Ca Trace while being safe, may not have the right amounts/minerals to balance your hay. Still worth to test your hay to dial in accurately. Please have a read of the detailed letter below as it covers a lot of helpful information. You can save this page link and keep coming back to it for reference. Let us know if you have more questions.

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. 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 - Sep 2017, Singapore
ECIR Primary Response





Kirsten Rasmussen
 

Hi Ann,

Generally after laminitis has occurred we recommend allowing at least 1/2 to 2/3 of a new hoof capsule to grow out before beginning ridden work.  All other exercise in hand or on a lunge line should err on the side of caution.  If you are seeing any hoof soreness after exercise, then it is too much too soon.  Increased digital pulses AFTER he has cooled down and his heart rate is back to normal are also worrying.  Hoof boots with thick soles and/or thick pads do help with concussion and if the sand paddock is fairly compacted then the boots will help with comfort. 

While checking temperatures is not the most reliable, if you are seeing a correlation with hoof temperature and pasture, then you are probably right that the pasture is increasing his insulin.  One issue with allowing Nahar continued mini-flareups on pasture is that it does continue to compromise the quality of the old lamellae, as well as the new lamellae in his hooves.   This could be setting him up for a more serious founder if the pasture ultimately proves to be too much for him, or when he gets his spring vaccinations, or any other trigger event.

It's really hard for humans to take our horses off pasture.   It can be hard to use a grazing muzzle, too, some horses in particular can be very difficult with it.  But founder is a life-threatening condition that is very expensive and painful, and takes a long time to resolve, so by preventing it from happening again you are doing the kindest thing.  One person's advise here was to look at a sealed muzzle as a source of freedom for the horse, allowing them to be on pasture with their buddies, rather than as a negative thing that restricts them.  Our attitude is important too.  If the sealed muzzle (a muzzle with the eating hole blocked,  but still allows the horse to drink and breathe comfortably) is a no-go, then finding a way to turnout in an area with no grass would be something to work towards.   Wooded paddocks or dry paddock or sand arenas are options.

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


Ann Nuno
 

Thanks for the input. I was not aware of the recommendation to wait for 1/2 - 1/3 of the hoof to grow out before resuming exercise when the laminitis episode was mild and if x-ray's showed no damage.  This is helpful to know and confirms my suspicion that even though no visible changes on x-ray the lamellae is weakened so not supporting him as it should.  He is not lame and only evidence that his feet are still a bit tender is that he is not getting good heel strike when walking on hard ground or rocks.  He looks fine when  moving in sand arena or if boots are on when walking on harder ground.

Such a challenge as he really needs to keep moving to minimize complications from his other issues.  I am planning to put in a track system/paddock paradise as I know he is going to need careful management and limited grazing moving forward. I don't think I can turn him out with a completely sealed muzzle as he was getting frustrated enough with the standard grazing muzzle that it was causing him to gallop around like a fire breathing dragon trying to get it off and I still have to be cautious about him falling due to his R Hind weakness and balance issues.

Such a catch 22 situation for this guy who really needs 24/7 turnout and rehab and now due to complications from an intervention to treat all his orthopedic/neurologic issues we are dealing with this.

Fortunately, grass is drying out quick here in CA and hopefully once it has died out and dried he will be able to have turnout.  I'll be sending in a sample of the dried pasture grass along w/ my new hay for analysis.



--

Ann Nuno
Gilroy, CA
2020

https://ecir.groups.io/g/CaseHistory/files/Ann%20and%20Nahar

https://ecir.groups.io/g/CaseHistory/album?id=263663


Kirsten Rasmussen
 

Hi Ann,

I wonder if he would be less upset with the muzzle if he can't eat out of it at all?  He might learn that he doesn't have to eat when he's out with his buddies.  I don't know what options you have, but turning him out after eating a hay meal (full tummy) and for short periods before coming in for snack, might help.  You'll figure out a system that works for you both (maybe your current system of measuring temps is the best compromise)...we can only advise on the EMS related care.

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


Candice Piraino
 

Ann,

You might want to check into another type of grazing muzzle. Many of my clients have used and loved Thin Line grazing muzzle. Its expensive, but I think it is one of the best ones on the market available at the moment. It is so tough to see them through this, but it is best for them in the long run. If he is truly being stressed out with the grazing muzzle, you will have to come up with another plan of action. Grazing only in the evenings, strip grazing or even creating a track system (paddock paradise)for him. 
--

Candice Piraino

Primary Response Team

September 2018, Summerfield, FL

Shark's Case History

Shark's Photo Album 

PHCP Barefoot Trimmer @www.arkhavenfarm.com