Recommendations on starting Metformin and Prascend


Lisa <lavoiestuff@...>
 

I have had Jamie on her new diet of TC Balance Timothy cubes, iodized salt, Vit E and flax for three weeks. 

It was recommended at three weeks to retest insulin as well as have TRH Stim test for ACTH. 
Was scheduled for tests and vet informed me day of appt they had to order test which takes two weeks. And recommended I wait till August as that is a better time for more accurate results. 

I informed the vet that Jamie has not made any improvements since April 21 visit and since new diet. and that I have to put her on NSAIDs to give periods of relief which I know is not recommended but to keep her comfortable and alive I have had to do it. 

Vet has agreed without blood test to put her on metformin and prascend until we do test in august. And to see if she improves.

I am looking for input, recommendations to starting her on these meds. Do I start with one first then add the other at a given time? 

I have read on using the APF before starting prascend.  I’m just curious if I should just start with one med first to see if there is improvement or start both at same time. 

--
Lisa M Lavoie
May 2022, Anderson CA

Case History: https://ecir.groups.io/g/CaseHistory/files/Lisa%20and%20Jamie
Jamie's Photo Album: https://ecir.groups.io/g/CaseHistory/album?id=275057


Sherry Morse
 

Hi Lisa,

Her bloodwork is not indicative of PPID at this time so unless she tests high during the seasonal rise or positive on a TRH test (which is not reliable during the seasonal rise) there's no reason to put her back on Prascend (assuming that you did stop it as previously discussed).  If you're concerned that she is PPID in addition to being IR you want to test sooner than later as you don't want to be 'chasing the rise'. 

Putting her on Metformin should show a difference within 7 - 10 days if it's going to work but the only way to know that is to monitor bloodwork and to some extent comfort level.  Ideally you would do bloodwork now and see where her insulin is at with diet changes alone.  If it's still elevated and you have tightened up the diet as much as possible you would then add the Metformin in and retest in 7-10 days to see if the Metformin is working. 

Again, unless she has elevated ACTH on a post-TRH stim test or during the seasonal rise or has symptoms without a positive ACTH result I would not be looking at putting her on Prascend now.  Do you have current trim pictures and x-rays that you could post?  Her trim could still be an issue at this point in addition to the insulin number.





Kirsten Rasmussen
 

Hi Lisa,

I can see the vet needing to order TRH and waiting 2 weeks for that to come in, but the insulin should be doable without delay.  You could just ask for insulin and glucose (and baseline ACTH if you're suspicious of PPID).

Since she's still in pain, I think it's critical to get insulin now and then start her on Metformin right away while you are waiting for the insulin result, and schedule a retest after 2 weeks on Metformin.

Jamie's trim also needs work and could be responsible for some of the pain, so if you post a full round of hoof photos as described here, you can request markups to guide your trimmer.

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


Lisa <lavoiestuff@...>
 

Sherry
Thank you for your reply.
She has not been on prascend since the very first dose was given and then recommended to take her off as her bloodwork was not indicative of PPID.  It was recommended by my vet if she did not improve after farrier work 4/22/22. 
But she had not been on an approved IR diet until 5/16/22 at which time I had gotten my CH properly inputted to the group and you kindly responded the next day with hopes I would see improvements with her comfort level as she was on the TC Timothy balance cubes.  It was then recommended once she was on the diet for 3 weeks to retest her insulin and have TRH stim test for her ACTH as she may well be early PPID. 
And as my request for recommendations on metformin and prascend was because I could not get the testing done with the vet  and have now requested just an insulin & glucose test but have not gotten a return call.  In the mean time Jamie has still not improved as far as her discomfort level so at this point I am wanting to just start her on metformin to see if there are any changes in her pain/discomfort.

The X-rays in my CH are less than 2 months old so not sure if you are wanting more current X-rays?  I do not have current trim pictures, but she is on a 4 week trim schedule and I do not have someone available to help me get the required photos.  My farrier is the farrier used by all the vets in our area as well as Sacramento CA area so I have confidence in him. Not to say he can't be missing something.  Jamie is due to be trimmed again on June 23 so I was going to have my farrier assist with the photo's at that time.
I do have photos (from 4/22/22 trim) in my CH but was unable to get complete photos of the right fore because of her inability to stay standing.

So at this point I am not sure what to do or direction to go.  And at this point seems like more issues are developing with Jamie....she finishes her breakfast and immediate goes to eating her shavings.  She is getting 12 lbs TC cubes split into 3 feedings per day with necessary added supplements (flat, vit E, salt) in the am and pm feeding.
--
Lisa M Lavoie
May 2022, Anderson CA

Case History: https://ecir.groups.io/g/CaseHistory/files/Lisa%20and%20Jamie
Jamie's Photo Album: https://ecir.groups.io/g/CaseHistory/album?id=275057


Lisa <lavoiestuff@...>
 

Kirsten

Thank you

I have requested just the insulin but have not gotten a return call.  I have tried to do everything in the proper time/schedule but in my area we deal with a huge vet shortage, mobile vets and knowledge of what I am dealing with.
The vet has prescribed the metformin for me to start her but was hoping to have some baseline before hand.  In the meantime Jamie continues to be uncomfortable. 
Yes, the trim pictures in my CH was at the start of Jamies issues and she was unable to be trimmed at her scheduled trim appointment due to the severity of her laminitis. So she was long when she did get trimmed and farrier did not want to do too much to completely put her down.  Since those pictures she has been done and is on a 4 week schedule.  I do not have assistance in getting photos taken and on 6/23 when farrier comes to do her I am going to have him help in getting the photos taken.
As I mentioned to Sherry (group member that's been assisting as well ) that I have great confidence in my farrier as he is who works for the vets in the area as well as Sacramento CA locations.  But I am not saying he can't be missing something.
With all this being said and the current situation with the vet and bloodwork I am just wonder if I am safe to just start Jamie on metformin and pray I see an improvement?
--
Lisa M Lavoie
May 2022, Anderson CA

Case History: https://ecir.groups.io/g/CaseHistory/files/Lisa%20and%20Jamie
Jamie's Photo Album: https://ecir.groups.io/g/CaseHistory/album?id=275057


Sherry Morse
 

Hi Lisa,

To be clear:
  • No repeat bloodwork done yet
  • Currently not on Metformin
  • Being fed 12lbs of cubes per day 
    • If that's the only thing she's being fed she should be eating 15.4lbs a day - is there a reason you're feeding her so much less?  Was she gaining weight on the correct amount for her weight?  If there's no reason that she's not on the correct amount for her weight I would suggest bumping her up the 3.4 pounds and see if that makes a difference with her trying to eat shavings.
  • If current trim looks like the x-rays from April and pictures posted in May her toes are still too long and need to be brought back.  
    • Ideally to get mark-ups you would want to post pre-trim pictures at least a week in advance and ask Lavinia for assistance. That would give her enough time to get you mark-ups before the farrier arrives.  Even just posting dorsal and side views if you can't pick up her feet to do the sole shots would be helpful.
      • IF she can't stand up you can take pictures of her feet with her laying down, this may be the best option for sole shots if you want to try for them at this point.
    • Taking pictures post trim for an evaluation is only going to work if you're going to fix what needs to be done right away.  Waiting another 4 weeks means the foot will have grown more and the mark-ups will not be helpful at all.
Were this my horse I'd want to get bloodwork done now for insulin and glucose at the very least and then make a decision on starting Metformin based on that.  I'd also look at getting the TRH test done to see if she is in fact early PPID as that could also be contributing to the rise in insulin and you want to get the insulin number down so that is out of the equation as being a reason for foot soreness.




Lisa <lavoiestuff@...>
 

Hi Sherry

Thank you 

Correct no repeat blood work as I have had a difficult time with my vet having the tests when I requested them last week (TRH stim test for ACTH and insulin level).  As mentioned I have requested just insulin glucose level but not hear back.
Correct, currently not on metformin.  
Feed amount was my understanding the cubes ratio to hay was less. (3 to 4 ratio)?  She was not gaining weight, was maintaining but has begun losing. She is at 1009 tape weight.
Current trim does not look like CH photos, has less toe and lower heal.
I will work on getting current pictures before farrier visit. Thank you for the suggestions on taking photos and what limited photos I can submit right now.
I am working on getting bloodwork insulin and glucose. That has been my goal but has not been easy.
--
Lisa M Lavoie
May 2022, Anderson CA

Case History: https://ecir.groups.io/g/CaseHistory/files/Lisa%20and%20Jamie
Jamie's Photo Album: https://ecir.groups.io/g/CaseHistory/album?id=275057


Sherry Morse
 

Hi Lisa,

Yes the cubes are fed at a 3:4 ratio to hay but unless you're trying to have her lose weight you need to figure the 2% of her ideal weight in hay and then convert that to pounds of cubes.  If you want her to be 1000lbs that would be 20lbs of hay or 15lbs of cubes a day.  You had previously said she was 1025lbs which would be 20.5lbs of hay or 15.375lbs of cubes a day.  

Either way 12lbs of cubes is not enough.  That is the amount of cubes you would feed to replace 16lbs of hay which is what you would be feeding an 800lb horse, not a 1000lb one.




Lisa <lavoiestuff@...>
 

Hi Sherry

Yes she was 1025 lbs but has dropped to 1009 lbs. 

I will increase her cubes to the 15 lb amount and see how she does.

On a positive note I contacted my vet again after our last conversation here and they are coming out Wednesday the 15th to do bloodwork (test for PPID) insulin etc.

Thank you for your time and help.  
--
Lisa M Lavoie
May 2022, Anderson CA

Case History: https://ecir.groups.io/g/CaseHistory/files/Lisa%20and%20Jamie
Jamie's Photo Album: https://ecir.groups.io/g/CaseHistory/album?id=275057