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New Lab Results for Audi


lindsaykrauland@...
 

As discussed in my previous thread, Audi has been on 1 mg pergolide since June 25. He initially was looking much better, with improvement in a number of PPID signs, but he has failed to gain weight. Additionally, within the last 2 weeks or so, he's developed a few new skin irritations, begun peeing more, and seems slightly less peppy. I suspected the seasonal rise might be affecting him, but I don't think his new labs support that. 

I just received a copy of the interim report from Cornell. ACTH is 33.7 pg/ml (range 9-35) and insulin is 11.24 ulU/ml (range 10-40). Leptin is still pending. Glucose run at the vet's office was 90.

So now what? 

He's pretty clearly not IR, right?  In light of that and his poor condition, should I be making any dietary changes? 

As far as PPID, is this a "good" number or not so much since it's at the high end of the range?  Finally, why is Cornell using 35 as a cut off at this time of the year during the seasonal rise?

--
Lindsay in TX 2020

Audi Case History:  https://ecir.groups.io/g/CaseHistory/files/Lindsay%20and%20Audi

Audi Photo Album:
https://ecir.groups.io/g/CaseHistory/album?id=248156 


lindsaykrauland@...
 

Was looking at the report in greater detail and see that Cornell says ACTH rises from mid-Aug to mid-Oct in the northern 2/3 of North America. 

That explains the reference range of 9-35, but research  I'veseen previously indicates the seasonal rise starts sooner? 
--
Lindsay in TX 2020

Audi Case History:  https://ecir.groups.io/g/CaseHistory/files/Lindsay%20and%20Audi

Audi Photo Album:
https://ecir.groups.io/g/CaseHistory/album?id=248156 


Lorna Cane
 

Hi Lindsay,

Were he mine, I would up his pergolide, based on changes you have noticed  both  early on and recently, and the new ACTH numbers.
Many people find that their horses need to be in mid range, late teens to early twenties, to be well controlled. Audi may be one of those horses. 
Sounds like he is.

--

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


 
Edited

The IR calculator states Audi is compensated IR, not that he is clearly NOT IR. It's still a good result!

My Cornell reports states:
Precautions for ACTH: Seasonal elevation of ACTH occurs...mid-August to mid-October....Samples taken during this time may have up to 3 times reference levels of ACTH in normal horses.

As for the timing of the seasonal rise in normal horses, there's a good chart here by week of the year.
https://liphookequinehospital.co.uk/wp-content/uploads/Seasonal-Changes-in-ACTH-Secretion2.pdf

Experience here shows equines with PPID can show both elevated ACTH and an extended seasonal rise. The optimal ACTH for a horse  being treated with pergolide for PPID is not necessarily identical to normal ACTH for a normal horse. Many of us have learned this with our own equines. My own does much better with ACTH in the low 20's regardless of the reference range in normal horses.

--
Cass, Sonoma Co., CA 2012
ECIR Group Moderator
Cayuse and Diamond Case History Folder                
Cayuse Photos                Diamond Photos 


 

I agree with Lorna.  If he were mine I would increase his pergolide.  My own horse was diagnosed PPID with only a modest ACTH elevation although he was symptomatic.  That said, it was not easy to get his ACTH down to the mid 20’s and, looking back, he was still symptomatic, even in that range.  I’ve seen other horses with what I considered to be wildly elevated ACTH levels come down to near normal on 1 mg of pergolide.  
--
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


 
 


lindsaykrauland@...
 

Thanks all! 

I agree that an increase in meds may be in order. I am hoping Dr. Kellon will chime in on that or that my personal vet will have some guidance. In the meanwhile, what do you all suggest would be a good new dose to try? 1.5 mg? More? Less?

And wow, I am totally confused by the IR calculator! I have read the ECIR article about IR, and I tried to get through the pony study that looked at the various proxy measurements (most of the discussion went over my head, to be honest). Still, I can't figure out how he's coming up as compensated IR?! I would've thought compensated IR would look more like a normal glucose with elevated insulin- but both his glucose and insulin are in range-- and his insulin is at the low end of the reference range! Can someone break it down for me how this works, please? And what does "high insulin responder" mean? (That's the comment I get for the MIRG measure.)
--
Lindsay in TX 2020

Audi Case History:  https://ecir.groups.io/g/CaseHistory/files/Lindsay%20and%20Audi

Audi Photo Album:
https://ecir.groups.io/g/CaseHistory/album?id=248156 


Kirsten Rasmussen
 
Edited

The range of 10-40 given by Cornell is the range of insulin values for horses who are described as healthy or "asymptomatic" (ie not laminitic or showing notable signs of IR) plus 2 standard deviations.  My horse has an insulin of about 40 right now and he is essentially asymptomatic.  But he is most definitely IR based on previous bloodwork and signs.  So the reference range given by the lab for insulin is just that, a reference range; it cannot be used to diagnose IR.  Instead, we use the pony study you are struggling with, which found abnormal insulin reponses in ponies on pasture with baseline insulin levels above about 10-12.  Acute laminitis was seen only in ponies with insulin above ~80.  I have had to reread that study a few times for any of it to sink in, it is complicated for lay people to understand.  :)
See this post by Dr Kellon: https://ecir.groups.io/g/main/message/245673

The reference range for ACTH of 9-35, however, is appropriate for diagnosing PPID.

That said, in Audi's case his insulin is just barely into the "Compensated IR" range and once his ACTH comes down to mid-range (ie, mid to low 20's) with a higher pergolide dose you might see his insulin drop a little, hopefully to about 9 which would put him into the "not IR" range with that glucose value.  Keep in mind that glucose is very sensitive to degradation if not handled correctly and can be higher than actually reported, which can also change the IR status from non-IR to Compensated IR with the ECIR calculator in cases that appear to be borderline.  I agree that Audi does not present like an IR horse, but its not impossible.  Regardless, Compensated IR status with such a low insulin is a great status for an IR horse to be at!  His PPID is the bigger issue so I would focus on lowering his ACTH further, then re-evaluate his insulin status once his PPID is under better control.

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


lindsaykrauland@...
 

Thanks, that does help to clarify it a bit!  I’ll need to wrestle with the pony study a bit more.  Maybe it’ll look less like Greek after a few more read throughs! HA

I have his leptin results now:  3.18 ng/ml.  Does this change or clarify anything?  I see that ECIR is moving away from leptin testing now.  So in the future I should not bother requesting a leptin test?

I’m waiting to hear back from my vet regarding increasing Audi’s pergolide dose.  Is 1.5 mg of compounded pergolide a good new dose to try? 

--
Lindsay in TX 2020

Audi Case History:  https://ecir.groups.io/g/CaseHistory/files/Lindsay%20and%20Audi

Audi Photo Album:
https://ecir.groups.io/g/CaseHistory/album?id=248156 


Sherry Morse
 

Hi Lindsay,

This is such a tough time of year to try to make a call on increasing a dosage of pergolide but 1.5 seems reasonable and then you can evaluate if you think his symptoms are getting better or not over the next few weeks.  If he's not showing signs of increasing weight gain, less drinking/peeing (given the heat conditions of course) then you may want to bump him up again.