Hello everyone. I've known this group has existed for what feels like forever but had scraped by without until this fall. Crimson has probably been borderline crushing's for at least a year and may have had some degree of IR before then too. However he's been on a predominately IR friendly diet most of the time I have owned him which may be why it is only now causing significant enough symptoms to be caught.

 

So, about Crimson:
29 year old TB Cross with a history of reoccurring lameness but not traditional laminitis.
Retired at 7 for "undiagnosable hoof unsoundness", turned out to a dry lot to baby sit long yearlings for ten years. I acquired him in 2010 at 17 years old and began rehabbing his body and feet. We've had many ups and downs, months of great soundness, weeks of being tender. He's predominantly been sound barefoot in boots most of the time I've owned him. We do lots of trail riding and dressage these days but in July of this year he had a bout of lameness after having done very well for a few years. The next trim uncovered abscesses in three of his feet and he seemed to be recovering quite nicely. We just started increasing workload again in August when he started shedding quite a bit of sole at each trim and getting progressively worse after each trim (Aug, sept, oct). We had x-rays taken and noted some rotation, significant pedal osteitis, thin soles and localized degeneration of a spot on each coffin bone. The concern was keratomas so we had an MRI done and ruled that out. We then chased the laminitis causes which led to the endocrine panel being run which came back as positive for PPID and IR. I will note that this is not the first time we have run this panel as I have had concerns over IR and cushings most of the time I've owned him, and he did not show as positive the last time which I believe was a year ago. Since the radiographs were taken he has been put on Isoxiprin/Aspirin and had a shot of Osphos.

Other thing to note, Crimson has to be on an all pellet soaked diet and has a pretty hard time consuming enough feed to maintain his weight.

Diet (Pre-diagnosis)

• 10.5 lbs Alfalfa, Timothy. Brome hay pellets (Mountain Sunrise)
• 8lbs Triple Crown Senior Gold
• 2lbs Renew Gold
• 4oz Omega Horseshine
• 2.5 scoops Easy Breathing (https://www.naf-equine.eu/uk/breathing/easy-breathing)
• 2 tablespoons Iodized Salt
• Smart and Simple Vitamin E (providing 5000 IU of Vitamin E)
• 1 scoop Cosequin ASU powder (recently changed from Smart Stride Ultra)

Current Diet (started last night, no idea of he'll eat this or not yet):

• 18 lbs Bermuda pellets (Mountain Sunrise)
• 2.5 lbs Cool Stance Coopra
• 4 oz. Omega Horseshine
• 2 tablespoons Iodized Salt
• Smart and Simple Vitamin E (providing 5000 IU of Vitamin E)
• 1 scoop Cosequin ASU powder (recently changed from Smart Stride Ultra)

Outstanding diet questions: Can I leave him on the cool stance and Omega Horshine? Should I stop the Cosequin?

My other outstanding question is around sourcing the pergolide. I had planned on ordering from Chewy, any concerns there? My vet also wants him on metformin for the IR diagnosis which I didn't see mentioned in the files.

--
Amanda C in Southern California, Joined 2022

Hello Amanda, welcome to the group! And thank you for being so specific, it helps our volunteers immensely.
Your first post here signals your welcome message, there is a lot of great information to absorb, and you may have seen it already but please read it when you are able and let us know if you have any additional questions, we're here to help.
As you may know, we operate on the principle of DDT/E, it looks like you have the first part covered. We would love a case history with all his results when you can manage it, his weight, body condition, all information is very important.
I do have a couple of suggestions.
1-   I will note that this is not the first time we have run this panel as I have had concerns over IR and cushings most of the time I've owned him, and he did not show as positive the last time which I believe was a year ago.
This is not irregular, what most vets consider "normal" may not be at all. Please have a read here. 
https://drkhorsesense.wordpress.com/2022/04/04/laboratory-reference-ranges-are-not-the-same-as-normal/
2- You were right in changing his "pre-diet", we don't recommend alfalfa for these horses as it can make some footsore and it sounds like he has problems with abscesses and thin soles, I will leave the hoof concerns to our hoof experts but please get all his x-rays uploaded so we can correctly advise you. You can also give him Jiaogulan to help with working those out. 
3- I would start him on the emergency diet included in your welcome message, some good (tested to be below 10% S&S) grass hay, magnesium, flax, and vitamin E. Horse shine is fine for flax.
I've also included a link to our safe feeds list, I would definitely remove the Chopra. 
Safe Bagged Feeds.pdf (groups.io)
4- This contains MSM which is not recommended for IR horses -  
1 scoop Cosequin ASU powder (recently changed from Smart Stride Ultra). 
You can read more about joint care here, you can also do a search of the messages, it's a constant topic here, instead consider other options for his joints. you can use glucosamine, chondroitin, and HA for example and Devil's Claw for pain. No MSM, Yucca. 
Re: joint supplement help (groups.io)
https://drkhorsesense.wordpress.com/2020/05/30/joint-care-advanced/
You can order his medication from any reputable source, some use their vet, Valley Vet Supply, and Chewy just to name a few. I would shop around, sometimes you can find a better deal that way. Here is the information on Metformin from our files but it's hard to advise you without specific test results. 
EVJ 07-146 Durham (groups.io)
Finally, I will encourage you to get his forage analyzed and balanced as soon as you are able, all horses benefit from this but especially horses compromised by PPID and IR. As I mentioned as soon as you can upload the x-rays, test results, etc. we can better advise you. Please let us know if you have any questions. Again welcome!

Hello 

Welcome to the group! 

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 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 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.

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. 

 

 

Bobbie and Maggie 
Desi (over the rainbow bridge 7/21) 
Utah, Nov 2018
ECIR Group Primary Response 

https://ecir.groups.io/g/CaseHistory/files/Bobbie%20and%20Maggie
https://ecir.groups.io/g/CaseHistory/album?id=271156

https://ecir.groups.io/g/CaseHistory/files/Bobbie%20and%20Desi 
https://ecir.groups.io/g/CaseHistory/album?id=78821

Hi Amanda,

I want to add that glucosamine is NOT OK with IR.

Since your horse is Tb, it's unlikely he was IR until he became PPID positive. It also sounds like he has the very common condition of long toe and underrun heels, which can cause a mechanical laminitis where the lower hoof wall pulls away from the bones but the bone aligment is normal (aka capsular rotation).

Agree with stopping the Copra. Older Tbs are hard keepers for sure but this may improve once his PPID is controlled.

Many of our members have horses on metformin.  See this folder from our files https://ecir.groups.io/g/main/files/4%20Insulin%20Resistance/Metformin .
--
Eleanor in PA

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

Thank you Bobbie and Dr. Kellon. I'm working on the case study and getting rads and photos uploaded but it will take me a few days.

I did want to address one key point, everything Crimsons eats needs to be soft and/or soaked. So we won't be doing hay analysis as we are feeding hay pellets. They have been analyzed by the company though. Currently I'm feeding bermuda but timothy and orchard are also options. https://mountainsunrise.com/products/

He isn't showing a ton of interest in eating the bermuda pellets so far though so I am interested in adding an appetitie stimulant if possible. I've done fenugreek in the past but see there are some commercial products available as well. This change is going to be a very significant drop in calories for him heading into winter and I'm a bit nervous he's going to drop weight like crazy.

I also just ordered the pergolide, starting with the liquid to slowly build up to the required dose and then I'll switch to capsules. Are a to z blond bits of health an appropriate "carrier" for the meds? It seems they should be safe but I thought I;d ask just in case.

--
Amanda C in Southern California, Joined 2022
Crimson's Album

You can make your life a lot simpler by using Timothy Balance Cubes from Ontario Dehy. They have an extensive distribution network in CA (contact ahenriques@...) or if you have a Triple Crown dealer they have them under their Naturals product line.  These are guaranteed safe and already mineral balanced. You can soak them, use them as a carrier. Liquid pergolide, unless in oil, is a bad idea. Potency fades after two weeks. You can also safely feed him some Stabul 1 feed available from Chewy.com and up to 1 lb of stabilized flax. If he's not wild about his new diet, get him some CocoSoya oil, which you can also get on Chewy.com, and divide up 2 oz/day between meals. It doesn't take much. Even barn cats go for it.
--
Eleanor in PA

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

On Wed, Nov 9, 2022 at 03:39 PM, Eleanor Kellon, VMD wrote:

You can make your life a lot simpler by using Timothy Balance Cubes from Ontario Dehy. They have an extensive distribution network in CA (contact ahenriques@...) or if you have a Triple Crown dealer they have them under their Naturals product line.  These are guaranteed safe and already mineral balanced.

Does this mean if one feeds Ontario Dehy Timothy Balance Cubes one does not need to add other minerals?

Thank you

 
--
Patty and Inky
https://ecir.groups.io/g/CaseHistory/files/PATTY%20AND%20INKY
https://ecir.groups.io/g/CaseHistory/album?id=268362
horse located in SE Wisconsin
owner located in north suburb of Chicago
joined Aug 2019

Patty,

Yes. You only need to add flax, vitamin E and salt.
--
Eleanor in PA

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

Thank you again. 

I will grab a bag of timothy balance cubes and see if they soak up fast/well enough for him to eat. I only feed one of his three meals and the barn staff just empties a bag of dry ingredients and a jug of water into a feed pan when they feed so typically we need something that soaks relatively quickly. Mountain sunrise also has a Bermuda plus pellet which they say is designed for the cushings horse. I'll do some comparing on that as well. Thank you for the tips on tasty additives as well. Stabul makes a fenugreek pellet that we've tried with success in the past.

Is the A to Z cookie going to be ok to hide pergolide in or were you thinking the Stabul 1 might be the carrier?.
--
Amanda C in Southern California, Joined 2022
Crimson's Album

The Balance Cubes soak pretty quickly but not immediately. Maybe 15 min to mostly soft?  However if you totally COVERED them with water your horse might eat slow enough for them to soak well. Also Mountain Sunrise has a timothy pellet too. 
--
-Chris
May, 2019  Big Bear Lake, California
https://ecir.groups.io/g/CaseHistory/files/Chris%20and%20Monte 
https://ecir.groups.io/g/CaseHistory/album?id=95892  

Chris,

The Mt Sunrise are not tested and not guaranteed below 10%.
--
Eleanor in PA

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

The balance cubes went over quite well day 1 but 18lbs (about his max consumption) and the 1 lb of flax is only 68% of his required calories. Keep in mind we were feeding over 100% to maintain weight so this is still a huge drop in caloric intake. I have Satbul 1 coming to fill the gap. Is there a max safe amount of that feed?

The other good news is he does seem to be improving comfort wise 

I have the day off (thank you veterans for your service!) So should be able to complete the case history and get all the photos uploaded today.
--
Amanda C in Southern California, Joined 2022
Crimson's Album

Hi Dr Kellon, I am very interested in which joint supplements are safe and effective for IR horses. I see that glucosamine and MSM are not safe for IR horses. Do you recommend HA or other options? 
--
Emma + Tater, probable EMS / IR
joined 10/26/22
Colorado
Photo Album
Case History

Actually I see in this thread that I should search for topics. I will do that :)
--
Emma + Tater, probable EMS / IR
joined 10/26/22
Colorado
Photo Album
Case History

OK! Case History and photos are added. There has been a trim since the latest photos and once the mud dries up enough to get new photos I will. 
--
Amanda C in Southern California, Joined 2022
Crimson's Album
Crimson's Case History

Both HA and chondroitin are safe.
--
Eleanor in PA

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

Amanda, please note that when feeding the balance cubes, you only feed 75% as much by weight compared to hay.  They are much higher in calories than hay because of the beet pulp in them.  So you might be closer to your target than you think. 

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

Snickers' Case History
Snickers' Photo Album

I should add that some horses are more sensitive to Stabul 1 than others.  Crimson, being a TB cross with no ongoing history of laminitis, may not be as sensitive as long as his PPID is well controlled with pergolide.  I can't advise on a 'safe' amount to feed, other than to say feed the minimum you need to get the job done.

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

Snickers' Case History
Snickers' Photo Album

Thank you Kristen! I'll monitor closely to ensure we keep improving now that the stabul 1 is introduced. It was a hit last night so hopefully that means he'll eat a larger portion of feed in general. I use feedxl to calculate feed requirements and currently that looks like 15lbs of cubes and 9 lbs of Stabul 1. If I can I'll increase the cubes and decrease the stabul 1 over the next few weeks. To date the max volume Crimson has been willing to eat works out to about 18lbs of feed so I'll be curious to see how he did with this new ration when I get out to the barn this afternoon.
--
Amanda C in Southern California, Joined 2022
Crimson's Album
Crimson's Case History

 Amanda,

There is no doubt that older horses, especially older Tbs, not to mention with PPID, are difficult to keep weight on but that amount of food sounds excessive. I wouldn't want him much heavier than he is in your November photos, maybe 20 pounds tops. For best digestion and absorption, all meals should be wet. You can also improve digestion with Absorb-All https://www.uckele.com/aloe-vera-pellets-4-3lb.html . Also keep dry cubes available 24/7 in a separate container, for munching.
--
Eleanor in PA

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

--
Amanda C in Southern California, Joined 2022
Crimson's Album
Crimson's Case History