Restarted Apollo on Metformin on 10/5 (cleared by vet after oral exam); ate half dose on wet hay in evening.  He ate full dose on wet hay both morning and evening on 10/6 & 10/7.  Didn't go as well morning of 10/8, took 45+ minutes; added small amount of CocoSoya oil in water to wet hay plus mixed more dry hay with wet (done every 15 minutes until gone).  In evening, tried with a small amount of CocoSoya in water to wet hay but wouldn't eat it.  Tried spraying hay with "alfalfa tea" but didn't help.  Put small amount of soy hulls in mash to see if he liked then and his answer was "NO" (found mash untouched morning of 10/9).  Began syringing evening dose of Metformin mixed with Cherry flavored Milk of Magnesia on 10/9.  Have him eat hay for a few minutes before giving Metformin (thinking saliva produced by eating might help prevent mouth irritation) and then back to eating hay.  So far no yawning or weird jaw movements.  However since 10/10, although ate morning Metformin dose on hay moistened with "alfalfa tea", each day took longer (60-90 minutes) and needed to add even more dry hay to get him eat all of medication.  Today he wouldn't eat morning Metformin dose on wet hay mixed with dry, even after 2 hours with nothing else to eat.  Mixed remaining dry hay with wet and eventually ate all of it (3 hours total).  His appetite for mash has also decreased this week and this afternoon he refused to eat any mash with supplements, just walked away.  Prior to restarting Metformin he was consistently eating mash with usual supplements.  

Current supplements: ground flax (6 ounces/day), Elevate Vitamin E powder (3 scoops/day) and VB Pro (1.5 ounces/day), divided into 3 feedings, instead of 4 as he's least interested in mash in evenings. (gets plain mash).   Daily roughage: 20 lbs orchard grass hay and 4 lbs of OD timothy balance cube mash.  Weight stable; maybe slight decrease in cresty neck and fat pad by tail.  No signs of foot soreness.  Wearing Cloud hoof boots with pads 24/; being changed daily.  Also gets 7 grams of Jiaogulan 2x/day, 20-30 minutes before eating.  He does eat his Prascend (2 mg) in small amount of Stabl 1 pellets.  Still eagerly eats hay if there's no Metformin in it.  Last time he was  on Metformin, he ate hay very slowly and didn't look like he felt well.  Kathleen finished hay mineral balancing and said Apollo's hay doesn't need much.  Will be transitioning him to her diet recommendations when receive new individual supplements.  She also advised giving 1/2 dose of Vermont Blend until then.

Even though Metformin shouldn't affect a horse's appetite, Apollo seems to disagree.  Regarding metformin, my choices are:  1) try mixing Metformin laced hay with rest of dry hay (gets 5 lbs hay/feeding) even if it takes him 3+ hours to eat it all (will that affect effectiveness?);  2) begin syringing his morning dose of Metformin too and increase risk mouth ulcers; or 3) give up on Metformin entirely which probably means I'll have to try soaking his low sugar hay to lower his insulin.  Also likely I'm going to have to syringe his supplements too if continue giving Metformin.  I know Apollo's not deliberately trying to be difficult but I'm tired and frustrated living this way because after a year, it's not getting any easier.  Taking care of him is pretty much first thing I do in the morning when I get up and the last thing I do at night before I go to bed.


--
Karen B.
Wisconsin
2022
Apollo Case History: https://ecir.groups.io/g/CaseHistory/files/Karen%20and%20Apollo
Photo album:  https://ecir.groups.io/g/CaseHistory/album?id=275817

Hi, Karen.
I hear your frustration. First, a couple of small items. I don't recommend soaking hay with 3.88% ESC assuming you're feeding the Groeschl hay now. That's assuming you sampled the load of hay carefully with a probe and checked multiple bales, meaning 25% to 30% of the load? Also, in your CH, I hope you mean 2 Tablespoons salt are fed daily. Two teaspoons are not enough. It doesn't have to go in all at once. You can a bit to his mash, dissolve some in water and sprinkle on his hay. 

Second, on metformin, it sounds like your best option is syringing. You might need more MOM than you used last time. Relative to the number of pills in Apollo's dose, you're using the same amount of MOM that I used but with 154% more metformin. I know adding more MOM is a pain because you might need to use more than one syringe full. But that's the only thing I can think of, along with rinsing his mouth (which I expect you're doing). 

Metformin isn't the last ditch insulin reducer, if none of this works out. At some point with a thicker sole, Apollo should be able to increase exercise. That can make a big difference.

Could Appolo have ulcers?
--
Cass, Sonoma Co., CA 2012
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On Fri, Oct 14, 2022 at 06:59 PM, Cass in NorCal wrote:

Hi, Karen.
I hear your frustration. First, a couple of small items. I don't recommend soaking hay with 3.88% ESC assuming you're feeding the Groeschl hay now. That's assuming you sampled the load of hay carefully with a probe and checked multiple bales, meaning 25% to 30% of the load? Also, in your CH, I hope you mean 2 Tablespoons salt are fed daily. Two teaspoons are not enough. It doesn't have to go in all at once. You can a bit to his mash, dissolve some in water and sprinkle on his hay. 

Second, on metformin, it sounds like your best option is syringing. You might need more MOM than you used last time. Relative to the number of pills in Apollo's dose, you're using the same amount of MOM that I used but with 154% more metformin. I know adding more MOM is a pain because you might need to use more than one syringe full. But that's the only thing I can think of, along with rinsing his mouth (which I expect you're doing). 

Metformin isn't the last ditch insulin reducer, if none of this works out. At some point with a thicker sole, Apollo should be able to increase exercise. That can make a big difference.

Could Appolo have ulcers?
--
Cass, Sonoma Co., CA 2012
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Hi Cass,
Don't know how I can add more Milk of Magnesia as I already need to use 2, 40 ml syringes to give him his 20 pills/20,000 mg dose.  I put 30 ml Milk of Magnesia + 10 ground up pills in each syringe which fills up syringe.  Use a different/clean syringe filled with 20 cc of plain water for rinsing after each syringe of Metformin).  Gave Apollo his evening dose of Metformin by syringe tonight and now he won't touch his hay.  Mash from this afternoon was still in his feeder too. So he's made the decision about what to do about Metformin for me.  No more!  

By ulcers, do you mean gastric or mouth ulcers?  His mouth was checked by vet last week before I restarted Metformin and he didn't see anything.  Also it had been a little over 2 weeks between stopping metformin and having his mouth checked.  I'm not a vet but I would think 2 weeks is enough time for mouth ulcers to heal as mucous membranes are highly vascular tissues.  As for gastric ulcers, I don't think so as I haven't seen any other signs like loose manure or sensitivity to touch.  He normally loves hay and will always eat it before mash.

As for soaking hay, I'm relieved to hear you don't think I need to soak it.  It is Groeschl hay, Apollo is eating and was tested by grower before we bought it.  Grower is a family run commercial ag business specializing in low sugar/starch hay and they guaranteed their hay.  I don't know how many bales they tested but since this issue has come up before, I sent a sample to Equi-Analytical awhile ago and had them run wet chemistry carb package just to make sure.  We took samples from 20 bales of about 300 total we had (think grower had 400 bales in lot) and used our own Best Harvest hay probe.  Our results were just 0.3% higher in total ESC+starch than grower's (I think our ESC was slightly higher and starch slightly lower, but don't have results handy).  This hay's most consistent quality I have ever had and no weeds.  Hay comes in 21 bale "Bale Barron" bundles.  They can control size of bales while they are baling so bales are also very consistent in size.  They got their start in making hay for their alpacas which need very specific requirements to produce best fiber and bring highest price.

Regarding salt, yes it should be 2 Tablespoons of salt and not 2 teaspoons.  I'm not doing that now because he has free choice plain white salt and there's also some in Vermont Blend.  I do find it's interesting that he didn't really touch his free choice salt all summer but then started eating fairly large quantities when he wasn't eating his mash with supplements.  Maybe just a coincidence. 

I feel bad for him right now.  It's definitely not like him to not eat hay! 
--
Karen B.
Wisconsin
2022
Apollo Case History: https://ecir.groups.io/g/CaseHistory/files/Karen%20and%20Apollo
Photo album:  https://ecir.groups.io/g/CaseHistory/album?id=275817

My horse Joker is 6 weeks into getting Metformin. I think he had a reduced appetite about a week and a half into getting the meds. I also experienced him eating the meds in his grain well at first and then he eventually would not. I have been syringing the meds twice a day now for the last month. Joker did get mouth sores and cracked lips the first week of syringing when I was not rinsing. Since then I have been applying vaseline to his lips before syringing with MOM and meds then rinsing with 3 syring fulls of water. Joker is much happier now about it being administered and his lips have healed. I feel like his appetite did improve after I was syringing and rinsing his mouth thoroughly. 
--
Anna Warzecha, MI, 2022

Joker (IR), Coco (PPID, IR)
https://ecir.groups.io/g/CaseHistory/files/Anna%20Warzecha:%20Joker%20%28IR%29,%20Coco%20%28PPID%29

Hi, Karen. I meant gastric ulcers. The symptoms can be variable, and sensitivity to touch or girthiness aren’t legitimate symptoms. Refusal of feeds besides hay is typical along with repeatedly walking away from hay when the horse is hungry. We don’t suggest gastroscopy. It’s more cost effective to run a short trial of omeprazole paste for 3 to 5 days. The effects are really obvious in just a few days. 

Thanks for clarifying how much MOM you’re using. Sounds like plenty. 
--
Cass, Sonoma Co., CA 2012
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Hi Cass,
Good to know I used enough MOM because there is a limit to how much volume I can get down. Two 40 ml syringes full of my Metformin concoction plus two 20 ml syringes of water is a lot to ask a even a large horse to swallow.  Don't think his problem is related to mouth sores as haven't noticed any yawning, chewing or unusual jaw movements like last time his appetite changed.  He also doesn't look like he feels bad like he did then.  

Not only did Apollo refuse his hay last night, we could not get him to eat his Prascend tablets in Stabul 1 pellets which is unusual.  Generally comes right over when you rattle them in his bowl.  We didn't give him any mash last night but hay was gone this morning, which is a good sign.  We are not going to give him more Metformin, at least for now, but I'll keep what I have left just in case.  I've learned never to say "never again".

Interesting that girthiness isn't a sign of gastric ulcers in horses.  It's been awhile but saw a YouTube video of a guy demonstrating sensitivity to touch on horses with documented cases of gastric ulcers of different levels of severity.  Don't remember if he was a vet or not but there definitely seemed to be a strong correlation.  I'll let you know if I find it again.  I did a search last summer because I suspected our young horse had gastric ulcers.


--
Karen B.
Wisconsin
2022
Apollo Case History: https://ecir.groups.io/g/CaseHistory/files/Karen%20and%20Apollo
Photo album:  https://ecir.groups.io/g/CaseHistory/album?id=275817

Update:  Pleasantly surprised to report Apollo ate all of his morning timothy cube mash with all of usual supplements.  Hope it continues so I don't need to syringe them in too.

I found video on YouTube on DePaoloEquine site. Titled "Equine Ulcer Diagnosis" and done by Dr. Mark DePaolo, DVM.  He demonstrates palpating acupuncture points on horses with documented cases of gastric ulcers.
--
Karen B.
Wisconsin
2022
Apollo Case History: https://ecir.groups.io/g/CaseHistory/files/Karen%20and%20Apollo
Photo album:  https://ecir.groups.io/g/CaseHistory/album?id=275817

Hi Karen,

Prior to Metformin Apollo's insulin was in the low 60s?  Was he footsore then?  Was that while eating only the new Groeschl hay?  Was it being soaked at the time?  The Metformin brought his insulin down about 15 units, which isn't much considering all the trouble you're having giving it.  The concern is that 62 is not far from 80, which is where acute laminitis can occur in some horses.

Since you've stopped the Metformin, just continue to monitor insulin and ACTH regularly.  You shouldn't have to soak that hay, but if it helps lower his insulin then keep doing it.  Try to incorporate exercise, in padded boots so he's comfortable.  If he has another laminitic episode you might want to try one of the "flozin" drugs, but they are expensive and come with a whole other set of worries so I'd wait until you get to the point where can't keep him sound with strict management practices.

--
Kirsten and Shaku (EMS + PPID) and Snickers (EMS) - 2019
Kitimat, BC, Canada
ECIR Group Moderator
Shaku's Case History
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Acupuncture point diagnosis for gastric ulcers is not accurate.
--
Eleanor in PA

www.drkellon.com 
EC Owner 2001
The first step to wisdom is "I don't know."

Hi Kirsten,

Except for when farrier cut his LF sole in July, Apollo has not been footsore since April 2022 while wearing Cloud boots with pads.  Currently, he walks without hesitation out in paddock on moderately soft ground, including downhill, and on concrete aisle inside barn. Last month, we've tried keeping boots off overnight in deeply bedded stall and noticed some difficulty putting boots back on in mornings.  More uncomfortable standing on left foot while right held up.  Trying it again now and he's doing better.  Have noticed since backing toes and reducing wall flares, he doesn't run around as much in paddock with our other horse.  With hoof walls taken out of weight bearing, his soles seem to have developed thick callouses.  He's noticeably more comfortable standing for hoof trimming since putting 1/2" open cell sponge rubber pads inside Cloud boots but need 6 mm soft EasyCare comfort pad on top to prevent hooves from ripping rubber.  Open cell foam doesn't flatten under his weight like EVA closed cell foam thus provides better compression/release shock absorption.  We made our own as commercial pads not available in size he needed from on-line company called TenderCushion.

Regarding insulin levels and specific hay:  On 10/15/21, insulin 97.01 / ACTH 35.5 (Cornell) on ECIR emergency diet soaked, untested grass hay (previous year's hay mixed with new crop).  Started 1 mg Prascend after TRH stim test 10/29/21.  New hay tested by local certified forage lab <10% ESC+starch but high iron so thoroughly rinsed before feeding.  Did well until end April 2022, then became noticeably stiff and footsore in mornings but greatly improved after being turned out in paddock all day  No increased warmth or digital pulses noted. Lab work done: insulin  >200 / ACTH 12.1 (Cornell), started soaking hay.  Dr. Kellon thought hoof pain due to poor circulation, recommended Jiaogulan and quickly improved. On 6/3/21 insulin 117.94 / ACTH 11.2 (Cornell) on same soaked hay. Began increasing Prascend from 1 mg to 2 mg on 6/28. Started new soaked hay (Utica) on 7/18 but this hay very inconsistent quality i.e. some bales had red clover so couldn't be fed and others mostly stems with few leaves. Did not do well on stemmy hay, began acting like going to colic and consulted vet.  Didn't put in case history because not IR/PPID issue. Couldn't get low ESC+starch Groeschl hay delivered before 8/15, so started only other grass hay available on 8/3; tested by Equi-Analytical ESC 7.4 + starch 2.1, so soaked 1 hour before feeding.  Started transitioning to unsoaked Groeschl hay on 8/15 after blood sample drawn: insulin 62.60 / ACTH 10.3 (Cornell).  Metformin started 9/7/22; insulin on 9/14 was 47.35 / ACTH 20.1 (Cornell) while eating unsoaked Groeschl hay. Grower had tested hay by wet chemistry (Ohio lab): ESC 3.88 + starch 1.92 = 5.80  We sent another sample from 20 bales to Equi-Analytical:  ESC 4.9 + starch 1.2 = 6.1  Didn't start soaking because only 0.3% difference.

Karen B.
Wisconsin
2022
Apollo Case History: https://ecir.groups.io/g/CaseHistory/files/Karen%20and%20Apollo
Photo album:  https://ecir.groups.io/g/CaseHistory/album?id=275817

Addendum to above:  Sorry but put wrong starch amount for soaked hay I was feeding before blood draw on 8/15.  As sampled was ESC 7.4 + starch 0.5 (not 2.1) so total was 7.9% before soaking and not 9.5%.  Tired eyes looking at several hay sample reports.
--
Karen B.
Wisconsin
2022
Apollo Case History: https://ecir.groups.io/g/CaseHistory/files/Karen%20and%20Apollo
Photo album:  https://ecir.groups.io/g/CaseHistory/album?id=275817

Hi Karen,
I know you don’t think Apollo has ulcers because he’s always preferred hay.  If he were my horse, I would still give him a trial run of UlcerGard - one tube daily for 4-5 days.  If he’s eating fine now, wait on the trial as you need to have some visual you are hoping to see improve.  He just seems overly put off by what’s in his feed.  I can’t imagine why Elevate or Emcelle would turn him off to his feed.  

The other thing I would do if he were mine would be to try to increase his pergolide.  I saw that you cut back at one point.  Was that because he wouldn’t eat?  If his insulin decreases as a result of more PPID control, that would be really useful.  I know it’s hard to decide what to do, with Apollo on pergolide and relying on TRH stimulation to judge how controlled he is.  I have one like that myself.  There won’t be any harm in increasing his pergolide even if it does not affect his insulin.

Don’t hesitate to add things to your case history even though you think they aren’t appropriate.  He’s an IR/PPID horse and all details are important and help to fill in the picture.
--

If insulin is 47 on unsoaked Groeschl hay, then soaking it might bring it down significantly.  I found with a hay that tested 7% s+s, when I started soaking it (soaked, it tested about 4% s+s) my horse's insulin went from about 42 down to 17.  So yes, soaking can make a significant difference.  You have to decide if you think it's worth the effort.

I later learned that undiagnosed PPID was making my horse more sensitive to sugars, even though his ACTH was always normal when tested.  During the seasonal rise it was just getting above the normal range.  Now on pergolide he can eat that same 7% hay unsoaked and his insulin was about 20.  I have to be very aggressive with his pergolide dose though.

--
Kirsten and Shaku (EMS + PPID) and Snickers (EMS) - 2019
Kitimat, BC, Canada
ECIR Group Moderator
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Kirsten and Karen, we need to back up.  Karen, would you please clarify which hay was being fed when Apollo’s testing was done? Copy and paste the link to analysis in your CH folder. 

Please clarify if you are still feeding that same hay? I somehow got the impression you are feeding the Groelschl hay at this link: 

https://ecir.groups.io/g/CaseHistory/files/Karen%20and%20Apollo/2022-07-27%20Groeschl%20orchard%20grass%20hay%20test%20%20%20%20.pdf

As Fed, the analysis shows ESC of 3.88%, not 7.4%. I thought this was confirmed, a tiny bit higher, by wet chemistry at Equi-Analytical. That EA analysis is where?

--
Cass, Sonoma Co., CA 2012
ECIR Group Moderator
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Kirsten,
I am hoping that is the case for me too. Stoped soaking low sugar/starch hay and insulin again went way high.
Regarding using ACTH as the marker for PPID. I want to make sure this is correct and I think it adds to what you are saying for this discussion... ACTH is only 1 of 4 blood markers that can be out of wack with PPID but it is the biomarker that is tested.
There can be other markers that would indicate PPID but we don't have easy means of measuring them.  Is that correct?
Thank you
--
Lesley Bludworth 
Phoenix, AZ   7/2022
Sophie TWH mare
https://ecir.groups.io/g/CaseHistory/files/SophieB%20Case%20History
https://ecir.groups.io/g/CaseHistory/album?id=277749

Lesley, yes.  I'm not sure if there are 4 hormones, I'd have to look it up.  I think that is why we see tight control of ACTH (teens to low 20s year-round) is so effective for PPID horses, because the other hormones involved are also better controlled when ACTH is.  It's not that necessarily that the other hormones are harder to measure, we just don't have established procedures/assays for them available commercially, so it's just not done.

--
Kirsten and Shaku (EMS + PPID) and Snickers (EMS) - 2019
Kitimat, BC, Canada
ECIR Group Moderator
Shaku's Case History
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Thank you Kirsten.
--
Lesley Bludworth 
Phoenix, AZ   7/2022
Sophie TWH mare
https://ecir.groups.io/g/CaseHistory/files/SophieB%20Case%20History
https://ecir.groups.io/g/CaseHistory/album?id=277749

Hi Cass,
Sorry for confusion. I'll review to see if that helps.  Since Apollo became laminitic last fall, his Prascend dose was increased 1 mg in anticipation of this year's seasonal rise and some thought it might also decrease his insulin.  I had wanted him on Groeschl hay (ESC 3.88 + starch 1.92) before blood work but grower couldn't deliver it in time.  Turned out on 8/14, Apollo had blood drawn in morning and Groeschl hay arrived in afternoon, so I started feeding it unsoaked that evening.  Utica hay (Equi-Analytical tested ESC 6.8 + starch 1.1, iron 124 ppm) was purchased in July because I was running out of last year's hay and didn't yet have firm delivery date for Groeschl hay.  Unfortunately, Apollo didn't do well on Utica hay (started 7/18) ? not digesting and causing GI/colic Sx so switched to 1st cutting grass hay from our small field (Equi-Analytical tested ESC 7.4 + starch 0.5, iron 325 ppm) on 8/3.  Also rinsed hay before soaking because of high iron.  Apollo was eating our grass hay when blood work done on 8/14.  Starting Metformin on 9/7 and necessary follow-up blood work occurred near peak of seasonal rise. Thus one blood test gave ACTH & insulin during seasonal rise and checked if Metformin was working.  Doing insulin level before starting Metformin as well as after would have cost $288 each test and couldn't justify cost given both Utica hay and our 1st cutting grass hay had 7.9% ESC + starch and were both fed soaked.  Double checked carbs in Groeschl hay via Equi-Analytical: ESC 4.9 + starch 1.2 which is only 0.3% difference from grower's hay test.

I'm thinking checking Apollo's ACTH and insulin now as well as sending soaked Groeschl hay sample to Equi-Analytical for carb analysis would provide best info to help decide how to proceed.  Any thoughts/suggestions?
--
Karen B.
Wisconsin
2022
Apollo Case History: https://ecir.groups.io/g/CaseHistory/files/Karen%20and%20Apollo
Photo album:  https://ecir.groups.io/g/CaseHistory/album?id=275817

HI Martha,
I appreciate your input about ulcers but I don't think it's the problem.  Apollo has never been a fan of mash and always preferred hay.  Within 24 hours of stopping Metformin he was back to eagerly eating his hay and taking his 2 Prascend tablets in small handful of Stabul 1 pellets. I've always had to give mash first then wait until he finished it before giving him hay.  If I give both mash and hay, he'll always go for hay first and leave mash until later when there's nothing else to eat.  I don't think he's as hungry as he used to be when his IR/PPID was less controlled which correlates to his latest leptin being lowest it's ever been.  He also eats hay slower than he used to and had vet check his mouth and float teeth on 10/5 so that's not an issue.  I think he's just a very picky eater about anything put in his mash unlike our other horse who licks his feed tub clean no matter what is in it.  Apollo doesn't mind Elevate but definitely doesn't like Emcelle since he eats mash best when it's not in it  However, he used to eat Emcelle just fine in his mash earlier this year. I think Emcelle has a distinct odor, almost alcohol like smell, that I'm sure he can detect too. I prefer Emcelle to Elevate because it's most bioavailable form of Vitamin E available and costs less i.e. 1000 IU of Elevate is 36 cents and Emcelle is 24 cents. I get mine from customequinenutrition for $122 includes shipping and 1 liter bottle provides 500 doses of 1000 IU vitamin E.  





--
Karen B.
Wisconsin
2022
Apollo Case History: https://ecir.groups.io/g/CaseHistory/files/Karen%20and%20Apollo
Photo album:  https://ecir.groups.io/g/CaseHistory/album?id=275817

Karen, to summarize, if I understand:
-Apollo was fed soaked hay when his last bloodwork was drawn, but you don't have an analysis of the ESC on that hay after soaking. As Fed but unsoaked,  ESC was 7.4%+1.1% starch.
-Apollo is now being fed unsoaked Groeschl hay with ESC of 4.9%+1.x% starch. 

I like your plan. Current information on Apollo's ACTH, Insulin and Glucose is important to make sure you're everything possible to support his recovery. 

 If you vet can get out quickly to do the blood draw, you can wait on the soaked hay sample until after you receive new insulin results. It would be proactive to soak a sample of the Groeschl hay now and send it for analysis in case his insulin remains high. Soaking can wash off some of the minerals and change balancing. A full 603 analysis including minerals would be most helpful to your hay balancer to balance the diet if you must soak. Soak and dry the sample well, using a fan in the garage if the weather is damp. 
--
Cass, Sonoma Co., CA 2012
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