Pony struggling with IR
We have been struggling with EMS and laminitis in this 13 year old pony for the last 2 1/2 years. After several bouts of laminitis, multiple blood tests and X-rays up until last December between the vets and I we had determined the best formula to maintain his insulin levels at a reasonable level was absolutely no grass (he’s in a small dirt paddock), soaked Purina Integrity which is low sugar, high fibre and high fat, soaked hay (tested at 12% NSC), exercise, 1 pergolide tablet, 1 teaspoon of Levothyroxine. If the Levothyroxine was reduced, he would founder so it was determined to leave him on this drug forever. His weight was good though still cresty with bum fat pads however his ribs were showing.
Everything was going well and the pony felt so good he was throwing in a few bucks when being ridden! However on December 6 he foundered again. Being in Canada with the cold winters I could no longer soak his hay however I had finally convinced him to eat at least 40% of his hay diet in soaked roughage cubes tested at 9% NSC. Nothing else changed thus I’m thinking it’s winter laminitis. He hasn’t been responding well to bute and even on 3g a day he’s still sweating and in pain. He’s inside with a deeply bedded stall being fed roughly 13lbs of hay/roughage cubes, 4 lbs Integrity (same amount as before. Vet suggested this amount to try to encourage him to get his energy more from fat than sugar to help keep his insulin levels down), his Levothyroxine has been tripled as in the past increasing the dose on this drug has stopped the laminitis and pergolide.
He looked like he was feeling better and I put him out one day for a few hours for his mental health so he could see his horse friends from over the fence and in the snow to help keep his feet cool and the next day he was worse. So he’s back in his stall 24/7 again. Could this of retriggered winter laminitis?
We tried a week of banamine instead of bute to try to help with the pain and it worked well for a couple of days and then he was back to being in pain so we switched him back to bute.
We have tried metformin and Insulin Wise in the past resulting in no changes to his insulin levels. His last set of X-rays done in August 2022 showed his feet actually looked like the rotation had improved and was almost normal.
Does anyone have any suggestions on what else we can do for this poor little guy? Any pain relief suggestions? Thanks
Edit-I should include he tested positive for Cushings thus why he is on prascend. His glucose and Cushing levels are now within normal range but it’s his insulin that’s all over the place. He is turned out in boots. Our vets have said he’s the most difficult case they have ever had.
Today I received blood results from December 22 and his insulin is over 1435 pmol/L with a slightly elevated glucose at 6.9 mmol/L. In the summer his insulin levels was around the 400 level. There has been no change in his diet from summer to winter
Julia in Canada, 2018
Eleanor Kellon, VMD
You probably are having cold temperature reactions but the Integri-T is too high in sugar and starch at 12.99%. The safest thing for him, which is also correctly mineral balanced, is Ontario Dehy Timothy Balance Cubes http://www.ontariodehy.com/index.html#shop01-5 . For the pain, get him in wool socks inside boots and leg wraps. Lined shipping wraps work well and are safe. Start him on Jiaogulan https://madbarn.com/product/jiaogulan/ instructions https://ecir.groups.io/g/main/files/Pain%20Medication%20and%20Alternatives/Jiaogulan,%20Nitric%20Oxide%20Support,%20AAKG%20and%20Supps/Jiaogulan%20Doses%20and%20Precautions.pdf . Also speak to your vet about starting metformin at 30 mg/kg, twice a day.
Eleanor in PA
www.drkellon.com BOGO 2 for 1 Course Sale Through End of January
Hi Julia. Welcome back. I am sending you our welcome letter that will highlight the most important pieces of managing IR/ PPID horses. You received it before, but just in case you misplaced it, I am including it here for you. Dr. Kellon has made some recommendations for you as well ,specific to his diet, keeping him warm during the winter and managing the insulin with Metformin... The Integrity food is not helping you at all with that insulin level and its not needed when you use the Ontario Dehydrated timothy balance cubes that are made in Canada. You have a very long story with your pony, lots of challenges and some successes. But, its really hard to follow and give you the best advice...We really need a Case History created for your pony. This will keep the timeline, medications, diet, testing in a nice package, easy to review and readily available to all of the volunteers and Dr. K... How to create a case history is within the information that I am sending to you. If you get stuck uploading, downloading or anything inbetween, we can help you if you tell us where your stuck...
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:
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.
Dolly and Hope's Case Histories
HOW TO SEARCH THE ARCHIVES: https://ecir.groups.io/g/main/wiki/1993
My suggestion would be to put all the data you have into a case history for us to review and post a link to it in your signature.
To guide you about moving forward, it’s important to note that excess weight and fat pads are not contributing to his insulin levels. Instead they are the results of it. Reducing his weight will make him more comfortable as he will have less to carry on sore feet. You can’t do this by just increasing his Thyro-L as it it just acts to jump start weight loss, not maintain the loss. The pony will adapt to the change and return to gaining weight until his diet is adequately controlled.
In an earlier post, you mentioned that metformin was unavailable to you in Canada. Were you able to access it to try it?
Laminitis is not an inflammatory event, which is the reason the NSAIDs are not helping. It would be best to wean him off of those and address the pain issue at the source, the driver of high insulin. We often hear from people that an NSAID dose isn’t working and so they gave him more or switched to a different NSAID? Since the NSAID isn’t doing the job, there’s no reason to continue using it and contribute to the other side effects that NSAIDS are famous for.
If your case history reflects that you’ve tried the appropriate dose of metformin and there was no decrease in the insulin, there are other drugs to try which might well address the insulin but only if diet and trim are well managed too. Their use is more complicated and needs Dr. Kellon to offer you and your vet some guidance.
Martha in Vermont
ECIR Group Primary Response
Logo (dec. 7/20/19), Tobit(EC) and Pumpkin, Handy and Silver (EC/IR)
Martha and Logo
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