Hello, 
I've been a follower of ECIR and Dr K. for a while. The group helped me get my horse back from death's door at the end of 2020/2021. I will upload his full case ASAP but in short acute laminitis Nov 2020 (caused by bad management on my part, undiagnosed EMS, causing a complete gut meltdown resulting in laminitis - rotation and gas pockets in front feet - hell on earth). We got him back - he had 2021 off on grass free track with low s+s hay. He remains grass free. I brought him back into work Jan 22 and we had a great year trail riding in hoof boots and pads up to 6 miles on all terrain - he was doing so well. End of Oct he started showing signs of that he was not comfortable - holding his tail to the right was the first symptom - but he was still happy to march out even with his tail crooked. However he started to get less forward so having done my research I agreed to a course of Cartrophen (vet is suspicious of hock arthritis) after the 3rd injection he developed pulses - here is where it gets confusing as we also started the injections just as we were coming out of a cold snap in the UK (I did check for pulses are each injection and they only showed after the 3rd) we did not do the 4th injection. We're nearly three weeks with pulses now - raised to varying degrees in the AM after stabling - usually completely gone in the PM after turn out (though not always - but predominantly no pules in the PM) No signs of lameness on the trot up or circling but very low energy on the trot up. He is on a 4 week trim cycle - last trimmed 08/01/23 (there was some evidence of a stretch white line - my trimmer thinks this is due to his low heel / long toes hoof confirmation that we keep on top off - he sometimes has it sometimes not) we did a full blood panel - vet said nothing marked but everything is a bit 'meh' ...We've just done Insulin and ACTH that I am attaching here - please can I have help interpreting these results given the above...I'm really starting to panic about these pulses now and possible damage being done (scheduling x-rays asap) I'm not sure if I am dealing with winter laminitis or what?. 

glucose 4.8
triglycerides 1.0
total adiponectin 1.8

acth 26.0
insulin resting 13.6

thank you so much. 

There is nothing in these labs that would trigger metabolic laminitis and the pentosan should have had no effect on the feet. If the long toe/low heel got out of control, that could explain an inflammatory reaction in the feet. With winter "laminitis" they are typically obviously sore and not with elevated pulses but no harm in using sock, boots and leg wraps plus Jiaogulan https://ecir.groups.io/g/main/files/SEDATIVE%20EFFECTS.pdf .
--
Eleanor in PA

www.drkellon.com  BOGO 2 for 1 Course Sale Through End of January
EC Owner 2001
The first step to wisdom is "I don't know."

Thanks Dr Kellon. 
I've just this evening started him on Jiaogulan and AAKG as we are now going through another cold snap. I've also put cloud boots on this evening in addition to his leg wraps (that he always wears, with a deep bed) and he's well rugged. 
I will speak to my trimmer again re: the trim. 
I'm so stressed as to what is driving these pulses - what else could I look at?. 
He has been treated for ulcers previously (I think these started during box rest when he was acute and I didn't know any better about NSAIDS)..
Thank you again. 

--
Mary Brown 
U.K 
2023 (long time follower)

Are his feet flat? He probably needs to be in boots and pads until you can get his heels back under him. You're not alone in this. It's by far the most common trim problem we see. This approach works well https://hoofrehab.com/DistalDescent.htm .
--
Eleanor in PA

www.drkellon.com  BOGO 2 for 1 Course Sale Through End of January
EC Owner 2001
The first step to wisdom is "I don't know."

In front yes - they were not great before he got laminitis but no doubt they got worse (he had very slight sinking in his right fore) but rotation in both. I've been reluctant to change my trimmer as he got me through the absolute worse time and was so dedicated but Henry (horse) seems not to be improving in terms of building heel. I'm a big follower of Pete Ramey - I might need a second opinion on the trim. He is always in boots and pads for riding (all around) I have always put boots and pads on for turn out especially in the summer with the hard ground on his dirt track. Last winter I kept him booted 24/7 but this winter prior to the cold snap I had him out of his boots for turn out - he is in a sand and rubber mat turn out area over winter and as it was relatively mild I wanted to see how he did - but on reflection maybe this has aggravated his soles...he's back in front boots now 24/7...
My stress is also coming from the fact he is now not getting much movement as I don't want to work him while he has pulses - this is obviously not idea for a horse that has EMS. 
Thank you again - much appreciated. 

--
Mary Brown 
U.K 
2023 (long time follower)

Hi Mary. Your first post here triggers our welcome letter that is full of information for you to review. It sounds like you've been reading along with us for awhile now. I hope you find this information helpful.  As far as exercise, I would not exercise when there are pulses and your horse is sore, even with the boots in place. See what happens with the J-herb first and wrapping and see how he/she does, give it some time..

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. 

 

--
Trisha DePietro
Aug 2018
NH
Primary Responder
Dolly and Hope's Case Histories
Dolly's Photos 
Hope's Photos 
HOW TO SEARCH THE ARCHIVES: https://ecir.groups.io/g/main/wiki/1993     

Thank you Trisha. 

I will let you and Dr Kellon know how he goes with the J-herb and the AAKG and wrapping. I'm going to have to get double netting his hay I think to slow him down while he's not in work. Henry is still turned out in a small sand paddock where he can move as much or as little as he likes. These pulses are driving me crazy - I really hope the J-herb helps. 
Thanks again and speak soon. 
--
Mary Brown 
U.K 
2023 (long time follower)

Hi Mary,
You can get that second opinion from Lavinia here.  If you post the appropriate photos and radiographs, she can do mark ups for you and your farrier.  The first set is free; she charges for subsequent ones.  Much of the success of using the mark ups depends on the willingness of your trimmer to learn something new, and your ability to help in between scheduled trims.
--

To follow up on Martha, here is the link with instructions on taking, naming and uploading hoof photos for markups:
https://ecir.groups.io/g/main/wiki#Photos-and-Hoof-Evaluation-Help

--
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

Thanks Martha and Kirstin. 
I'm going to work on my case history this weekend and new x-rays are scheduled for tomorrow Monday. 
Keep you updated!. 
--
Mary Brown 
U.K 
2023 (long time follower)

Hello again, 

To follow up on all the tests we've been doing - the blood test for red worm came back positive stats below...(negative for tapeworm) 

I knew he needed to be wormed for red worm but as anyone who has been through acute laminitis can attest to - getting life back to normal takes time...I've been nervous to worm him (I had been fecal testing and tape worm testing) 

I feel terrible and won't sleep tonight - my vet is talking to her lab in the morning and I am speaking to my lab to work out how to address this given his previous laminitis, IR/EMS status and the current pulses...

My vet mentioned Panacur 5 day first then possibly another I forget the name of - she said we have to go slowly...we start treatment tomorrow. 

Any further advice? could this burden be affecting his feet causing pulses. 

serum 27.88,
probability > 1k // 64.80% 
probability > 5k  // 46.30% 
probability > 10k // 35.30% 

Thank you everyone!
--
Mary Brown 
U.K 
2023 (long time follower)

Don't do Panacur 5 day. There's too much resistance out there. Quest is another possibility or you can do three treatments with ivermectin (very safe), three weeks between treatments.
--
Eleanor in PA

www.drkellon.com  BOGO 2 for 1 Course Sale Through End of January
EC Owner 2001
The first step to wisdom is "I don't know."

Thanks Dr Kellon. 

I will talk to my vet about this...I will be doing the pre and probiotics around the worming anyway...
--
Mary Brown 
U.K 
2023 (long time follower)

Hi everyone, 
Just to update - X-rays all look okay I will create and add to Henry’s case file asap. 
I’ve been distracted because I’ve just found out this weekend that a feed supplier I use has had a contamination problem - I’m pretty sure my horse has eaten the same contaminated feed. I’m trying to work it all out but the timings are lining up with when the feed was supplied and this weird on set of illness. Luckily I had decided to do a 20 day L94 liver flush which I think helped him - he has improved. 

Could toxic feed cause pulses?.
I’m pretty sure this is what was causing the virus like symptoms…

The supplier has sadly been very secretive about it all. I’m talking to a few other owners of EMS/PPID and PSSM horse’s who’ve been affected. Sadly these have been most affected as the feed was aimed at them. 

thanks for listening. 

Mary. 

Mary Brown 
U.K 
2023 (long time follower)