Recurring Laminitis & Ertugliflizin


kalloway@...
 

Hi Everyone,

I am having continuing battles with Faith. She had another laminitic episode last week.

I am struggling to understand why we are still seeing her slip into laminitis. It seems that we are consistently walking on the edge of it. She has not been out on pasture for 3 years. I was feeding 2 different sources of hay that both were tested and had results of 3.8% &  6.98%  esc/starch with starch in both being below 1%. (Hay tests are save into my file.) when she had her latest episode last week. Her hard feed is speedibeet with supplements & salt.

I had vet out to her to draw bloods for a non-fasting insulin & glucose test where her Insulin has tested above normal range (71 mU/L with normal being up to 20.) Blood test is on my file. Her insulin was tested in January 2022 and it was 17 mU/L  and previously in 2018 and it was also normal (fasting test and I don't  have a copy of the results)

She has previously been tested to see if she may have a hormonal issue but that came back as normal according the the vet (I don't have a copy of the test results). Her ACTH was 23 pg/mL when tested in January 2022 (normal is below 50 at that time of year). She has never tested above normal in ACTH but is on 1mg tablet of Prascend/Pegolide.

Is Ertugliflizin a possible answer for a horse that is living on the edge with no obvious cause that I can see? What are people's experiences with this drug?

Am I missing something that might be triggering this?? 

Thanks

--
Karen
Victoria Australia
March 2021


Eleanor Kellon, VMD
 

The only thing missing is lots of exercise but that's not an option when laminitic. Ertugliflozin is certainly an option. I've only heard of one failure. Same precautions as for canagliflozin.
--
Eleanor in PA

www.drkellon.com 
EC Owner 2001


Sheri and Peaches
 

My mare is on Steglatro proactively, because her insulin and weight were steadily creeping upwards, despite diet management and exercise.  I feel your frustration!   With the Steglatro, my 11yo Peaches has finally been able to start losing weight, and her insulin is controlled. She has not been laminitic, so far.  I lost my 23yo gelding to founder and felt like the writing was on the wall for Peaches.  So, my experience with Steglatro has been positive.  The downside is that it is a diuretic, and Peaches prefers to urinate inside her stall.  I feel like I'm cleaning four stalls, instead of just two. 

I assume you have already looked closely into Faith's trim?  Pumpkin's founder was largely mechanical, caused by a farrier that refused to trim his toes (long story with the lesson: be a louder advocate). 

Pricepropharmacy in Canada has been shipping very quickly and has Steglatro in stock.  Dr. Kellon has an info sheet for your vet if you go this direction, as you'll need to monitor GGT and TG.  L-carnitine supplement to help with triglycerides. 
--
Sheri P in IL 2021
Peaches Case History & files:  https://ecir.groups.io/g/CaseHistory/files/Sheri%20and%20Peaches


kalloway@...
 

Thank you Dr Kellon and Sheri for your replies. I will look at the fact sheet and give it to my vet. 

I have a trimmer caring for Faith's feet who is experienced with Laminitis and follows the ECIR recommendations. 

Given the insulin test results I am really putting the latest laminitis down to high insulin levels. Why it is high I can't explain on the face of it with the hay tests that I have been given. HOWEVER I I am becoming suspicious that all is not as it would seem in those test results. If they samples taken were only from a bale or 2 then they might not be representative of the 200 bales I have from one of these suppliers. There is variation in the bales that makes me think this is possibly the case, especially in light of Faith's insulin test results. It is either that or my mare is really sensitive to sugar levels and needs hay extremely low to not have insulin high. If it is the latter then that may become impossible to manage unless this drug works. 

 
--
Karen
Victoria Australia
March 2021


 
Edited

Hi Karen,
I see that Faith has been diagnosed PPID and she’s on 1mg of pergolide.  There is nothing in your case history to suggest you’ve tested her ACTH since her last dose increase several years ago.  I would definitely keep up with that testing as PPID is a progressive disease and often requires a dose increase with time.  Elevated ACTH can result in increased insulin levels.

edited to add
I just saw in an earlier post that you have tested her ACTH recently and it was low.  Something you said made me wonder if it was ever high.  I might consider increasing the pergolide (in a separate experiment from soaking the hay) to see how it affect the insulin.  TBs are rarely insulin resistant without PPID involvement.  It’s generally the smaller, thriftier breeds and ponies which become IR at baseline.  There’s always the exception and the rest of the breeding mix matters as well.
--
Martha in Vermont
ECIR Group Primary Response
July 2012 
 
Logo (dec. 7/20/19), Tobit(EC) and Pumpkin, Handy and Silver (EC/IR)

Martha and Logo


 
 


Maxine McArthur
 
Edited

Karen, I'd soak the hay and see if it helps her.
The Feed Central tests are done using NIR method, which can give a lower ESC+starch result than tests done using the wet chemistry method. The other thing you could do is take a sample using at least 30 of your bales and send it to Equi-Analytical in the US for a wet chemistry analysis. I have done this before (it's not that expensive and they email you the result) and the wet chem result was a bit higher than the NIR result given by the hay supplier. With a really sensitive horse you need to know. Equi-Analytical has instructions for taking samples on their website and the forms. They are quick to respond to emails also, if you have questions. 

--
Maxine and Indy (PPID) and Dangles (PPID)

Canberra, Australia 2010
ECIR Primary Response

https://ecir.groups.io/g/CaseHistory/files/Maxine%20and%20Indy%20and%20Dangles 
https://ecir.groups.io/g/CaseHistory/album?id=933

 


kalloway@...
 

Thanks Martha for your response.

Yes I have had her ACTH levels tested every year since I was advised to put her on Prascend (even though her ACTH test came back as a negative for Cushings. The vet felt it might help her because she has classic signs of being an EMS horse. Fat above eyes, cresty neck, fat deposits in various locations).

In February 2020 I was advised to get her ACTH tested which came back at 80. The Lab ranges I have seen for the time she was tested here said that 80 was the top of the normal range for that time of year. 80 is the highest she has ever tested at and this was the point that I was advised to increase her dosage from 1/2 to 1 tablet. A couple of weeks before I had been weaning her off prascend to test to see if she actually had cushings at all as I had been feeding her tablets for years without a positive ACTH Test. Now I can't really say if she does not and it is now it is too risky to take her off the drug to test. 



--
Karen
Victoria Australia
March 2021


kalloway@...
 

Thanks Maxine for your response.

I have another source of tested hay at the moment that I have put her onto and she is much improved to what she was a week ago. But she is still not 100% right though so I am not sure if I have lowered her Insulin enough or if she needs time to recover. I am thinking the quickest way to assess where she is at it to re-test her insulin levels (and also to test her ACTH to rule that being an issue as well)  so I am currently trying to get the vet back out to take bloods again. 

Thanks for the hay testing suggestions I will look at that in time.  

Perhaps I am wrong but I am hopeful that the insulin was spiked by something that was too high. If I can't lower her Insulin then I have grave concerns that I have a very big problem that may not be manageable without help.

--
Karen
Victoria Australia
March 2021


Kirsten Rasmussen
 

Hi Karen,

I agree with testing ACTH, and non fasting insulin and glucose at the same time.  A draft-TB cross is a very unlikely combination for having EMS at baseline, although I'm sure it's possible.  EMS is due to genetics and Prascend does not treat EMS.  Diet, exercise--and in very hard to manage cases, medications (not including pergolide)--are used to treat high insulin resulting from EMS.

PPID is a disease that can also cause high insulin, and it is treated with pergolide/Prascend.  If you want to wean her off pergolide to test ACTH you should do it as far outside of the seasonal rise as possible (so, in September-October in Australia) to minimize the risk of laminitis, and ask for a TRH Stim test where you get both baseline ACTH and ACTH after a dose of TRH is administered.  In the meantime, I would consider increasing the pergolide dose to see if there are any positive results on insulin or hoof pain/pulses.

I will say that my horse never tested positive for PPID, but in hindsight I'd say at least there were 4 years before my vet and I decided to try pergolide (after his ACTH came back at the maximum end of the range during the seasonal rise in 2020) during which he displayed signs of PPID like loss of topline and increasingly difficult to manage EMS/IR.  He was getting noticeably more sensitive to sugars every year and it got to the point in 2020 where I didn't know if I could keep him alive the next year if he worsened again.  Now that he's on pergolide his insulin has gotten easier to manage, so his hay doesn't have to be quite as low in sugar and sosked) and he is no longer a train wreck waiting to happen.  So there are times where trying pergolide is reasonable, even without a positive ACTH result.  In your case, given your horse's breed, I think it's reasonable to strongly suspect PPID and if you have elevated insulin then trying a pergolide increase is reasonable.  1 mg may not be enough, especially as PPID is progressive in most horses.

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


Kirsten Rasmussen
 

Hi Karen,

I asked Dr. Kellon about Faith privately and she confirmed that it is extremely unlikely that Faith would have EMS based on her breeding.  So, Ertigliflozin is the wrong medication to consider since that's for horses with EMS.  Its likely that Faith has uncontrolled PPID and that is driving up her insulin.  While her ACTH was good going in to the rise in January, you need an ACTH test (with insulin and glucose) during the peak of the seasonal rise (mid-March in Australia).  Her ACTH was probably significantly elevated, especially if you took her off pergolide.  With PPID horses, we try to keep their ACTH in the mid-teens to low 20s, YEAR-ROUND, since they seem to do better when ACTH is not allowed to increase above that, even during the seasonal rise.  That means increasing pergolide in anticipation of the rise several months in advance.

Hopefully next year you can test her ACTH, insulin and glucose (all 3 together, every time) several months before, and again at the peak of the rise.  If ACTH isn't notably elevated during the seasonal rise but insulin is still really high then you need to consider increasing the pergolide dose until insulin normalizes since its likely the PPID driving the insulin, not her diet (although that can worsen it) and not because of EMS (she very likely does not have EMS because of her breeds).  ACTH is only 1 of several insulin-raising hormones that are elevated from PPID.  Some horses may not have very high ACTH but if one or more of the other hormones are elevated from the PPID then insulin can be, too.  Unfortunately we only test for ACTH so there's no way of knowing if the other hormones are controlled at the current pergolide dose for sure, but we do know that pergolide has an effect on those hormones, too.  So if Faith's insulin is high, its fair to assume her PPID is not controlled and that her pergolide should be increased until her insulin normalizes.

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


kalloway@...
 

Thanks Kristen for your messages.

it gives me some hope that there is an answer that will help me with Faith’s care. Is it worth testing ACTH now? I have contacted vet today and he will be coming out to draw bloods to test either tomorrow or Monday. 

--

Karen
Victoria Australia
March 2021


Kirsten Rasmussen
 

Yes, it's worth testing it now.  Make sure you get insulin and glucose, too.

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


Maxine McArthur
 

Karen, make sure your vet knows the correct blood handling protocol—the right tubes, chill them spin within four hours of collecting (sooner if possible), freeze overnight then send the next day so it arrives cold at the lab. If my vet draws blood on a Thursday or Friday they process then keep it in their freezer until Monday before sending to the lab to make sure it’s not left sitting around untested over a weekend.  


Correct handing guidelines here: https://www.ecirhorse.org/DDT+E-diagnosis.php


Maxine and Indy (PPID) and Dangles (PPID)

Canberra, Australia 2010
ECIR Primary Response

https://ecir.groups.io/g/CaseHistory/files/Maxine%20and%20Indy%20and%20Dangles 
https://ecir.groups.io/g/CaseHistory/album?id=933

 


kalloway@...
 

Thanks Maxine. Unfortunately I did not see your message until after the Vet came and took bloods. I am doubtful that he followed the protocols. 

The results came back with ACTH of 22.9 but if correct protocols were not followed who knows what her true reading is. I am still waiting on the insulin results from the blood taken.

It is rather frustrating that I have had 3 blood tests taken in recent months to try and understand what is going on and something is wrong each and every time! So I am still literally in the dark.

--
Karen
Victoria Australia
March 2021


Kirsten Rasmussen
 

Can you ask your vet how the sample was handled?  And if you requested glucose it's usually obvious if handling wasn't ideal because it degrades faster than ACTH and insulin.

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


kalloway@...
 

Glucose tested as 3.7 mmol/L.

I have had 3 tests in the last 6 weeks that has tested glucose. Not obvious degrading when compared BUT if they are not collecting correctly then they all might be impacted!! 
26th April  2.9 mmol/L(Lab did not want to test Insulin because horse was not fasted! So Vet agreed to not testing without discussing with me)
23rd May 4.4 mmol/L (Insulin 71 mU/L)
6th June 3.7 mmol/L (still waiting on Insulin results)

I will talk to vet about how bloods are handled but results are what they are now so unless I go round 4 then for blood tests I am not really going to know.

Since drawing the bloods I have increased her Prascend from 1 to 1.5 tablets. Noticing a bit of a change in her and my trimmer was out this morning and also noticed some changes in her. Importantly no active laminitis. Given we are seeing some positive changes I think it is worth continuing on the 1.5 tablets and re-testing in a 3-4 weeks to see where we are at. At which point I will discuss testing protocols with the vet! 
 
--
Karen
Victoria Australia
March 2021


Kirsten Rasmussen
 
Edited

What is the lab's reference range for glucose?  Those numbers appear very low to me, only the 4.4 seems ok and even that is worryingly low for an unfasted horse, but your lab reference range might be different.  My lab in Canada is 3.7-6.7 pmol/L.  If they are at the bottom end of your range it's likely the sample was not kept chilled and then frozen before shipping overnight to the lab.  You can read and share the Cornell sample handling protocols for ACTH off our website to go over with your vet:
https://www.ecirhorse.org/DDT+E-diagnosis.php

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


kalloway@...
 

3.3 to 6.7 mmol/L. So yes it is possible that handling protocols are not being followed. 
--
Karen
Victoria Australia
March 2021