Hello,
Thank you for adding me. I am a new member and my situation is that I had bloodwork done recently and I am confused by the response my vet has provided. I believe that my mare is at risk for laminitis going into spring but my vet has not flagged this as an issue. 

I own a 2012 Canadian mare. She lives outside 24/7, unblanketed, barefoot. She is an easy keeper and overweight. She is fed tested low sugar netted hay, mad Barn Amino Trace, flax, jiagulan and spirulina. Her paddock has minimal grass in summer. Her paddock is covered in snow right now, so she has had zero grass for 3+ months. I believe she must have EMS but my vet has not stated this. 

She had sore feet last June 2022 that resolved almost immediately with the emergency protocol. Vet wasn’t sure if it was due to a bad trim she’d had or laminitis. Her blood work was good at that time. 

I did bloodwork again on her in September 2022 and March 2023. I do not believe that her ratios looked great in the fall and I was surprised that they are worse now in March because there is no grass in her field right now. Her vet has not flagged any issue with her glucose & insulin results, except said her ACTH this spring is high and she should go on Prascend. This is very confusing to me because I understood that her ACTH levels are within the normal range and she has no clinical signs of Cushings. 

I’m hoping that I can receive some assistance in identifying if she is at risk for laminitis so that I can take action before it occurs. I’m also confused if she should be going on Prascend. 

Here are her bloodwork results:
June 14, 2022 - glucose 4.6mmol/L, insulin 49pmol/L
Sept 8, 2023 - glucose 5.0mmol/L, insulin 124pmol/L, ACTH 15.2pmol/L
March 8, 2023 - glucose 5.3mmol/L, insulin 217pmol/L, ACTH 4.6pmol/L

I hope that this post is appropriate for this forum. I appreciate any comments. 

Thank you.

--
Barbara in Ontario, Canada 2023

Welcome, Barbara,
Your first post signals a welcome message to be sent to you, and I will include that below. 
I just have a couple of questions for you then I will be attaching your message, there is a lot of information that will help you in this journey and we have tons more information in our files, and you can do a search of the messages (upper RH) that you can also find information regarding all kinds of topics and or questions, that are asked here.

Your blood work is a little confusing, do you know if your horse fasted during these tests? The insulin result seems low, was she tested at home or hauled? 
We don't recommend either of these because it can skew results. You will see in your welcome message what our testing protocols are, if she was fasted you may want to repeat the tests, being sure you follow the directions below.
Regarding her readings, we like to see the ACTH in the high teens to low twenties which would make her results satisfactory unless there are other factors as I mentioned.
We also take symptoms into consideration, although IR/EMS are two different things, horses can have one or the other and sometimes both, Prascend will only help if the insulin is driven by high ACTH. There are other medications we can suggest if insulin can't be controlled by diet and exercise but only as a last resort.
We do know that IR is metabolic. I would really tighten her diet if she is overweight, weigh her hay, and be sure she gets plenty of exercises if she's able. Some horses cannot have any fresh grass, so in those cases, we suggest no pasture time without a sealed muzzle.  We also recommend balancing your hay if you have had it tested, all horses benefit from a balanced diet. We have people that can help with that, if you could start a case history on your girl with all test results, x-rays, etc. It would be helpful.
HAY BALANCING (groups.io)
Let us know if you have any questions, again welcome.

Below is your personal introduction to DDT+E, the ECIR Group protocol found to immediately address the comfort and welfare of the metabolic equine. Bookmark this message so that during your journey you may return when you need to review more information. Blue font links in each section will lead to further evidence-based and sourced information. We include a folder specifically for vets and other pros. Links previously opened will display in grey when you return to this message.

IMPORTANT STEPS DURING ACTIVE LAMINITIS
PAIN RELIEF

• NSAIDs do not work on metabolic laminitis
  • Long-term NSAID use interferes with healing. We recommend tapering off NSAIDs after the initial days of use.
  • Icing does not work in most stages of laminitis and may make things worse.
  • If your equine's comfort level has not increased, then the cause of the laminitis has not been removed. The underlying cause needs to be addressed and the trim corrected.
  • Movement while using NSAIDs can cause further damage as pain is masked.
• For pain relief also see the use of jiaogulan and why it works.
• If the equine wants to lie down, do not encourage him/her to get up. Place feed and water where it can be reached easily without having to move more than necessary.

START YOUR CASE HISTORY. Request membership in the ECIR Group Case History site. Completing a case history is critical for in-depth, individual help. Bookmark this link. Our new Case History site is designed so that once you are registered and approved, and you have enrolled your equine, you can come in and select which section you wish to work on, returning as you need to add or update information. Please add copies of all your bloodwork results to support the details of your history. Further guidance to get you started is available in the Wiki.

In-depth step-by-step information is available from Dr. Kellon’s 2017  NO Laminitis! Conference lectures, including references to science explaining why DDT+E works. Download Acute Care for Endocrinopathic Laminitis and Tiered Management Approach to EMS and PPID on ecirhorse.org.

INFORMATION FOR YOUR VETERINARIAN.  After two decades, the ECIR Group knows recommendations in DDT+ E are often different from the equine veterinary community. We offer documentation of protocols, with deep background, evidence, and the science behind recommendations in the Veterinary Information folder. Please review and share this valuable supportive info with the team working on the ground with you.
 
INTRODUCTION to Diagnosis, Diet, Trim and Exercise (DDT+E)

DIAGNOSIS: Effective treatment requires correctly identifying the problem. There are two metabolic conditions causing laminitis that share symptoms. Equines can have one, the other, or both.   

• Equine Metabolic Syndrome (EMS)/Insulin Resistance (IR) - can appear at any age and may have a genetic component.
  • EMS/IR is diagnosed by non-fasting testing of insulin and glucose.
• Cushing's (PPID) - increasing age is the greatest risk factor for developing PPID.
  • PPID is diagnosed using the Endogenous ACTH test or TRH Stim Test.
• BEFORE CALLING YOUR VET TO DRAW BLOOD FOR DIAGNOSIS, READ THESE DETAILS. All ecirhorse.org sections can be printed or links can be emailed. Sharing them with your vet will help ensure correct testing protocols. Request email of digital or hard copies of the test results to add to your case history.

 

• TREATMENT:
  • EMS/IR is not a disease but a metabolic type. High insulin is responsible for laminitis 
and is controlled through diet as described below, with exercise as able.
    • ECIR Group has monitored use of specific medications that can be effective to lower insulin These do not replace a correct diet which must be in place first.
  • PPID not controlled through medication can raise insulin, leading to laminitis. High insulin causes laminitis, even at a sub-clinical level.
    • PPID is a progressive disease, treated by medication.
    • When first starting pergolide some equines may experience the "pergolide veil", a temporary loss of appetite, lethargy and/or depression. Wean onto the drug slowly and use the product APF to avoid this. Jiaogulan is also used in countries where APF is not available.
    • The best long-term results are seen when in diagnosed equines the ACTH is maintained in the middle of the lab reference range at all times, including during the annual seasonal rise. To accomplish this, the amount of medication may need to increase over time.
  • Neither EMS/IR nor PPID is ever cured, only properly controlled for the remainder of the equine's life. If your partner is both PPID and EMS/IR then both medication and diet management will be needed.

DIET: Crucial for an EMS/IR horse to lower insulin, the correct diet also supports the PPID equine’s delicate immune system.

In active laminitis, your first step is:

• Remove/reduce the most likely trigger — high insulin — by using the emergency diet.
• The emergency diet is untested hay, soaked for an hour in cold water or 30 minutes in hot water, which removes an average of 30% of the simple sugar content. Soaking does not remove starch.
• Make sure you dump the soaking water where the equine(s) can't get to it.
• Add ground flax seed (2 ounces by weight), and Vitamin E in oil (500 IU per 250 lb of body weight) to replace ingredients lost when grass is cured into hay. Magnesium, usually deficient, is added at 1.5 grams/day per 500 lbs body weight; (1/2 teaspoon feed-grade magnesium oxide) Iodized table salt is fed, 1-2 ounces for a 1000-pound horse.
• This diet is not intended for long-term use.
  
  DO NOT FEED:
  • Grass
  • Grain
    • Bagged feeds with a combined ESC and starch of over 10%
    • Bagged feeds with starch over 4%
    • Bagged feeds with fat over 4%.
  • Sugary treats, including apples and carrots
  • Brown/red salt blocks that contain iron which interferes with mineral balancing
  • Products containing molasses
  • Alfalfa hay
    • Protein and calcium are often high, which can contribute to sore footedness and make mineral balancing difficult.  

Your ultimate goal is:

• Grass hay, tested to be under 10% ESC + starch by wet chemistry analysis. While sugar converts 50% to glucose, starch converts 100%, driving a higher insulin spike. Starch should not exceed 4%.
• Excess and deficient minerals balanced. 
• Safe feeds used only in an amount needed to carry minerals and supplements, under 10% ESC and starch, with starch under 4%, and fat under 4% or less.
  
  • Almost all commercial feeds are not suitable for EMS/IR individuals.
  • It is important to know the actual analysis.
  • Please see the Country Specific info for some safe suggestions.
• To use a "stop-gap" product until you get your hay balanced, here is a list of "acceptable" ration balancers. This is a far second best from actual balancing.

TRIM: Addressing high insulin through diet and the realigning trim are the fastest ways to relieve pain. The proper trim for any equine is one that closely hugs and supports the internal structures of the foot for improved function. This type of trim is essential for EMS/IR/PPID equines, who are at increased risk for laminitis.

• In general, laminitic hooves require more frequent trim adjustments to maintain the proper alignment. We recommend the use of padded boots rather than fixed appliances (shoes, clogs).
• You are encouraged to obtain radiographs, hoof photos, and video to include in your Case History and help guide trimming needs for your horse. Example of good images are described in the Case History site and in the main group Wiki.

EXERCISE: The equine must be non-laminitic, off NSAIDs and comfortable.

• Do not force a laminitic individual to move, or allow its other companions to do so.
• Once the equine is moving around comfortably at liberty, hand-walking can begin in long straight lines with no tight turns. When finished walking, he/she should be as or more comfortable than when the walk began.
• Before serious exercise can begin, a previously laminitis individual needs 6-9 months of correct realigning trims without relapse.

ADDITIONAL RESOURCES

For a one-on-one, visual explanation of DDT+E, see ECIR Group Films.

For members outside North America, there are country-specific folders in the files and international lists in the Wiki to help you find local resources.

ecirhorse.org will provide more in-depth information. The FAQ section answers questions many new members have.

ECIR Group Facebook page.

ECIR Group Resources, printable for quick-scan access to more information when needed, such as in your barn.

ECIR discussion group Wiki provides information on the use of the Groups.io site including how to access the Case History site, information in the start here folder, message etiquette,  and many how-to pages.

Bookmark these pages, as well as this message, for easier access when you need more info.

--

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

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

Thank you for the quick response and this information!
I have created a case history and included a link in my signature below.
You mention that her insulin seems low, but I'm concerned that it keeps creeping higher each time I test her. I believe that her ratios indicate that she's IR/EMS?
With respect to the blood tests, she was tested at home and she did not fast in advance.
She doesn't currently have any clinical symptoms of cushings. I will follow up with my vet regarding their suggestion to put her on Prascend - maybe that was a mistake on their end.

Thank you.
--
Barbara in Ontario, Canada 2023
Zenny's Case History | ECIR Group Inc. (ecirhorse.org)

Barbara 
Let me clarify, sorry I apparently mixed up my US and CAN calculations (thanks to my Canadian mod Kristen for keeping track of me)!

Your units, ACTH should be in the middle of the range (2-10, so <6 pmol/L) or lower at this time of year.  Which is at 4.6 pmol/L (~20 pg/ml).  

Sept 8 result of ACTH 15.2pmol/L is actually ~68 pg/ml, which means this is pushing into the PPID range since anything above 50 or 60 is suspect, or if the horse is older than above 80.  If her horse was in its 20s, I'd be ok with that result.  But her horse is 11, so I'd be worried unless it was exercised/stressed/trailered before the test.  So, the ACTH was high last fall but is normal this spring.  That's a flag that the horse might have early PPID and maybe next fall they should test baseline ACTH again.  It's hard to get a TRH test in Canada, but it could be suggested anyways.

Apologies for the mix-up, hopefully, this makes better sense regarding the ACTH.



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

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 Barbara,

Yes her insulin is creeping up.  The latest one could be higher due to cold weather and/or less exercise in winter and/or different hay.  Her last 2 results are abnormal for a horse not getting grain meals, so yes, she has EMS.  That matches her breeding and tendency to gain weight.  You're still below the range where major issues start to occur, but if it climbs above 40 uIU/ml (or 240 pmol/L), I'd start getting more aggressive (ie soaking hay, more exercise). 

In the meantime, if you can test your hay to see the carb contents (ESC and starch should be <10% combined) and get the major and trace element profile, you can find out if the AT+ is doing a good job or not.  We have a list of people that are approved to look at your hay analysis and advise you for a fee.

Is she on Prascend?  How much and when did she start?  You can add that info to Medications in your Case History.  Given her Sept 8 result and young age (ACTH shouldn't go that high in an 11 yr old healthy horse), I would have her on Prascend at least seasonally (June - January), and test her outside the seasonal rise regularly to make sure she doesn't need Prascend year-round.  Sometimes the first symptom of PPID is fall laminitis, but if she's truly not displaying any other signs of it (polyuria/polydypsia, soft tissue injuries, muscle loss/wasting, uncontrollable allergies or airway irritation) you may opt to not treat her just yet, or to just treat her seasonally.

--
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 everyone for your comments! I really appreciate it. Zenny is not currently on any medication, but I will follow up with my vet to discuss Prascend and further testing. 

I do have test results on her hay, so thank you for the suggestion of getting that looked at for further advice. 

As for her free choice hay, I will discuss options with the boarding facility to switch her off the netted round bale to a more managed feeding schedule. 

Again, thank you!
--
Barbara in Ontario, Canada 2023
Zenny's Case History | ECIR Group Inc. (ecirhorse.org)