Super high insulin results - will Metformin help?


Rhonda S
 

Hello, I've been following for a couple of years, this is my first post.

Just received results of recent bloodwork and I didn't know the numbers could go that high.

UofG
Insulin >1435 pmol/L (<300)
Glucose 7.0 mmol/L (3.7-6.7)

ACTH 3.6 pmol/L (2-10) 

Hay tested at under 10% ESC+starch
Balanced by Madbarn - Omneity, VitE/Selenium, Copper/Zinc, iodized salt, flax - she had only been getting flax and salt regularly for the few weeks before bloodwork
They recommended as optional Magnechrome and Jiaogulan which I haven't purchased so far.
No access to grass.

My case history needs to be updated, but the main details are:

Outdoor 24/7 with my other IR horse through winter 21/22 - they were overfed at night with long periods of no hay during day 8+ hours.
Sandy became sore in early March, had vet and farrier consult, X-rays, shoes pulled, trim according to xrays.
Remained sore walking on concrete or gravel.
Has been stalled at night on shavings over rubber mat, turned out in small paddock with sand during day.
Foam pads to walk across gravel and during turnout. Time spent walking in sand arena most mornings at liberty for 10-15 min. No forced movement.
Gradually felt much better until farrier trimmed again June 16 - immediately lame.
Had new X-rays June 20, LF is improved, RF is slightly worse. 
Ability to move is up and down. Stiff in mornings coming out of her stall. Comfortable as soon as pads put on her feet. 1" styrofoam. It's like she's a different horse. Some evenings she is slow and sore coming in, others she isn't. I am there every 12 hours or so.

Weight is currently 450kg by tape. Now that she is in stall overnight, she is getting 20lbs of hay (or less) per 24hr period. The number of flakes fed is really inconsistent per day, but she is not being overfed.  

I'm waiting for a call to talk to my vet. He has recommended levothyroxine and soaking hay.  She was already on levothyroxine in 2020/2021 but her hay wasn't fed by weight and the medication was not given daily.  I'm not confident the barn owner will properly soak hay. My boarding situation isn't ideal and I want to move my horses as soon as Sandy is up to the move.

Will Metformin help in this situation? Are those numbers so high they are likely a mistake? She wasn't fasted. 

--
Rhonda S

March 2020, Ontario

Case History: https://ecir.groups.io/g/CaseHistory/files/Rhonda%20and%20Sandy/Sandy%20Case%20History.pdf
Sandy's Photo Album: https://ecir.groups.io/g/CaseHistory/album?id=245195


Trisha DePietro
 

Hi Rhonda. Your first post creates a welcome letter for you. This letter highlights and explains the cornerstones of the protocol for IR/ PPID. Your insulin is very high. And, yes, I do believe Metformin will help you. The effective dosage is 30 mg/kg twice per day. I am sure others will chime in about your high insulin. I think after you read through the welcome letter, you will have a better understanding of your particular situation. You may have more questions. And please let us know what else comes to mind. We are here to help you, help your horses. 

Hello 

Welcome to the group! 

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 etiquettewhat 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:

  • low carb (less than 10% sugar+starch)
  • low fat (4% or less) 
  • mineral balanced  

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.

EXERCISEThe 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. 

--
Trisha DePietro
Aug 2018
NH
Dolly and Hope's Case Histories
Dolly's Photos 
Hope's Photos 
Primary Responder


Rhonda S
 

Thanks Trisha.  I was able to talk to my vet briefly - he has never prescribed Metformin before but agreed to let me try it. He is gone on summer vacation now for the next 10 days. He only prescribed 7000mg 2 or 3 times a day.  Sandy is 450kg.  Will this dose even be effective? I can only give it morning and evening.
--
Rhonda S

March 2020, Ontario

Case History: https://ecir.groups.io/g/CaseHistory/files/Rhonda%20and%20Sandy/Sandy%20Case%20History.pdf
Sandy's Photo Album: https://ecir.groups.io/g/CaseHistory/album?id=245195


Maxine McArthur
 

Hi Rhonda
Can you ask another vet at the practice to re-write the prescription? You need to give the correct dose for it to be effective. Morning and evening is fine. This information in our Files may be of use, and you can send the 2019 research paper to your vet if he doesn't want to prescribe the right dose. 
main@ECIR.groups.io | Files

--
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

 


Trisha DePietro
 

30 mg x 450 KG = 13,500 mg given twice per day = 27,000 mg. 
It sounds like he's willing to go to 21,000 mg per day. hmmmm, I'd need to see what Dr. K says. But if it were my horse with those numbers, I'd think some metformin is better than nothing....
--
Trisha DePietro
Aug 2018
NH
Dolly and Hope's Case Histories
Dolly's Photos 
Hope's Photos 
Primary Responder


Sherry Morse
 

Hi Rhonda,

That dose of metformin is not enough for your horse - she needs to be on 13,500mg twice a day.  Better to wait until you can get the correct prescription to start the medication.




Eleanor Kellon, VMD
 

How much metformin do you have? Any refills on the prescription? Give him as much as you can, divided into twice a day, to last the 10 days until your vet is back. Your insulin is indeed high, but we've had higher.
--
Eleanor in PA

www.drkellon.com 
EC Owner 2001


Rhonda S
 

Thank you everyone. I have enough tablets to give the full 30mg/kg twice a day, plus refills beyond that.

--
Rhonda S

March 2020, Ontario

Case History: https://ecir.groups.io/g/CaseHistory/files/Rhonda%20and%20Sandy/Sandy%20Case%20History.pdf
Sandy's Photo Album: https://ecir.groups.io/g/CaseHistory/album?id=245195


Kirsten Rasmussen
 
Edited

Hi Rhonda,

I just want to refer you to our summary on Metformin as it can cause mouth ulcers if not given correctly.

Also, if you are at the barn every 12 hours, could you soak a batch of hay?  You could divide up 24 hrs of hay into slow feed nets and get them soaking on one visit, then when you return 12 hrs later you could drain and rinse it, then prep the next batch.  Ideally we only soak for 1 hr in cold water or 30 min in hot water so maybe you could even do all it all in 1 visit?  I use cold water and with weighing and filling nets plus draining and rinsing it takes about 1.5 hrs to prep 24 hrs of hay for 1 horse.  I use the 1 hr waiting time to give him some attention/exercise and do other barn chores.  Even if you can soak it for a shorter time (30 or 40 min) it will still help.

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


Rhonda S
 

Thank you Kirsten.  I am using milk of magnesia and rinsing with water. 

As for soaking the hay - I have the time and would be more than happy to soak it but it is not an option for me at this barn. The owner does not have experience with EMS or IR and only sees me as someone who complains about how they are fed, because I want/need something different than the other boarders.  The rest of the barn gets free choice large round bales.  The hay is grown on property and I test it by taking samples on the DL from the feeder my horses share.  I am actively seeking a more suitable boarding facility or even property to buy.

--
Rhonda S

March 2020, Ontario

Case History: https://ecir.groups.io/g/CaseHistory/files/Rhonda%20and%20Sandy/Sandy%20Case%20History.pdf
Sandy's Photo Album: https://ecir.groups.io/g/CaseHistory/album?id=245195


Lesley Fraser
 

It can be more difficult when your horse has to be boarded rather than kept at home. I moved Omar 5 times trying to find a facility that would follow through with what I’d asked for to meet his PPID/IR needs, but once I’d moved him in it was never long before he ended up being treated the same as all the other ponies, in one way or another, and I was viewed as a bit of pain in the neck. It was heartbreaking and frustrating to turn up unexpectedly in the middle of the day and find Omar in a grass paddock instead of the non-grass one. Sometimes the supplements I’d weighed out for his feeds would still be lying in the feed room, or he’d be in his stable with someone else’s large-hole haynet of unsoaked, untested hay, instead of the small-hole haybag of tested hay I’d filled and left for him. Some facilities are much better than others, but the bottom line is that when you’re not there you have no control over what’s happening. I hope boarding facilities in the US and Canada are more clued-up about PPID and IR than they seem to be over here in the UK, but if you can find somewhere suitable to buy, that sounds like a great idea.




--
Lesley and over the bridge Omar,
11-2012, Sutherland, UK

Omar - Case History