Rose and Luluka having trouble getting accurate bloodwork


Rose@...
 

Aloha

Luluka tested in August with an insulin of 711 uIU/mL,  ACTH of 20.1 pg/mL.  
On September 20th I had a local small animal vet come out and run a new test after Luluka had been on 5 tablets of metformin 2x a day for about 3 weeks.   That vet is not an equine vet.  She sent the specimen in the wrong tube (not a EDTA plasma tube) so the insulin was supposed to be correct at 81.63 uIU/mL, but the ACTH was 45.2 pg/mL . When the vet realized she had the wrong tube she called Cornell and they said that Luluka's ACTH was probably okay based on the way the sample was sent.  
So then I get the equine vet to come out on 10-13-22.  I wait and wait and wait.  After about 3 weeks I call her to ask for the results.  Then a week later she sends me something showing that Luluka's insulin is now 32.54 uIU/mL and her ACTH is 276 pg/mL.  Now the notes on that blood test say that the sample needs to be kept chilled and plasma removed from the cells within 4 hours after collection or the results should be interpreted with caution.   I called the vet on it, as what I am seeing is that the Cornell notes seem to correspond to what they see in the sample.  Then I looked closer at the test results.  I know for a fact that the  blood was taken from my horse on 10-13-22.  The test results in the corner say it was sampled on 10-30-22, received on 11-4-22 and finalized on 11-7-22.  I am thinking the vet forgot to send it.  I have asked her point blank if this is the case but have yet to get an answer.   
I am trying to get the vet to come out again as I don't believe her ACTH is an issue based on the two samplings noted above and uploaded in my file.  She is still on 5 metformin twice a day.   Do I wait for another lab to determine if her insulin is accurate?   Should I reduce her metformin?   Honestly living in Hawaii the cost of those two samples was about $800 and I don't believe that they are accurate.   Can I rely on the insulin but not the ACTH as that seems to be the one with the stricter protocol for testing.  Any guidance.

Mahalo

Rose
--
Rose D in Hawaii 2022

case History:  https://ecir.groups.io/g/CaseHistory/files/Rose%20and%20Luluka
Photos:  https://ecir.groups.io/g/CaseHistory/album?id=277362


Kirsten Rasmussen
 

Hi Rose,

As long as the vet froze your sample after centrifuging it, and kept it frozen it's ok to ship it weeks or even months later.  But the insulin and ACTH could be artificially lowered if the samples weren't kept chilled then frozen for shipping.  How Luluka is doing should also give you an indication of whether her insulin has come down on metformin.  Once it's below about 80, signs of acute pain should go away, unless she has abscesses mobilizing.

The glucose number can give you a good idea if the sample has degraded due to improper handling as it is much more sensitive.  Glucose in a horse eating hay should be around 100, but anything from 90-100 is fine.  Once glucose starts dropping into the 80s and especially the 70s you can suspect some sample handling issues.
- 2021-08-05 bloodwork results.pdf: glucose is in diabetic range, likely due to inappropriate diet (not likely to have degraded so insulin and ACTH are accurate)
- 2022-08-17 Luluka Bloodwork.pdf: glucose below the reference range so it has degraded significantly, meaning insulin and ACTH are likely artificially low
- 2022-9-20.pdf: glucose is still ok so insulin and ACTH are probably good
- 2022-10-13 Bloodwork.pdf: it's hard to read but glucose is in the 70s so the sample has degraded and ACTH and insulin are artificially lowered

As for ACTH, the number would decrease, not increase, if sample handling is an issue.  Her Oct 13 ACTH is very high.  Given that September was normal and she is only 11 YO, I don't think I'd believe this result either.  I wonder if the sample wasn't centrifuged and if that could explain an unusually high value?  Dr Kellon? 

--
Kirsten and Shaku (EMS + PPID) and Snickers (EMS) - 2019
Kitimat, BC, Canada
ECIR Group Moderator
 
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Rose@...
 

Aloha

I finally heard back from vet.  She said the sample was spun down and frozen within 4 hours.   (if it was, it was at the tail end of that time as she had told me she had 2 other clients after me and then the drive back to her home would have made it tight)  She never admitting to forgetting to send the samples.  She just said that as long as it is stored in the freezer and shipped on ice the results are accurate.  Her response was that there is a seasonal fluctuation of hormone levels with increases in the fall.  She typically likes to test in Spring for the most accurate results.  At this point, if Luluka is continuing to do well, retest in spring.

So..... I kinda want to know what the numbers are.  Luluka is doing very well.  If I didn't know what I now know regarding EMS and diet, I would easily let her have pasture access.  As is, we are still working on her drylot.   I called the local small animal vet and asked if she can draw blood again.  The sample she took in September was in the wrong tube, I know she won't make that mistake again and will process quickly.   Will update when I get those numbers to see where we are at.   I don't want to chance it until Spring and say it's good.  I also don't want to throw away money if not needed, but I do feel it is important to truly know what I am dealing with.  

Your analysis of the data is very helpful
Mahalo
--
Rose D in Hawaii 2022

case History:  https://ecir.groups.io/g/CaseHistory/files/Rose%20and%20Luluka
Photos:  https://ecir.groups.io/g/CaseHistory/album?id=277362