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Suspected IR but blood results suggest otherwise

emma@...
 

Hi

Just a little history (much more in case history).

My horse, Tom, had very severe laminitis May 2019. It appeared suddenly - had no indication that there were any problems beforehand.  He was on pain relief for a long time. By Sept 2019 he was sound and walking out around the fields and comfortably lunging (walk, trot and canter).  All seemed okay until around Jan 2020 when felt he was going downhill again.  Not lame, but real reluctance to trot when lunging. Also seemed more tender over stones.

In March, got a barefoot trimmer, moved yard, diet changed, in hand walking on tarmac. He is currently doing much better (walking in hand for 30-40 mins per day). Still extremely reluctant to trot (tends to start bucking, trot a few steps and then stops). Considering the food he is on, he is slow to put on weight and hardly full of energy.

Various blood tests were done 2019 and 2020.  All seem to suggest that he doesn't have IR/EMS/Cushings. However, something clearly not right otherwise he would not have had laminitis.  I have assumed he is IR. Would someone be able to look at his blood results to make sure we are interpreting correctly? (in his case study folder).  Any suggestions/recommendations welcome.

Thanks

Emma







Prior to laminitis he was ridden approx. 3-4 times per week, between 1-2.5 hours each.  Plenty of trotting, cantering and some jumping in the school and hacks across countryside with a little road work.  Since diagnosis very little exercise.  Walked around fields Sept/Oct 2019.  Also lunged and he could trot and canter.  Since January, he has become more reluctant to lunge and seemed more tender over stones.  Improved again since having barefoot trimmer. If I try and get him to walk on with more impulsion when in the school on a lunge rein then he will have a bucking fit and reluctantly trot with head up in the air - so I only ask for walk.
--
Emma M in East Sussex, UK 2020
Case History for Tom: https://ecir.groups.io/g/CaseHistory/files/Emma and Tom
Photo Album for Tom: https://ecir.groups.io/g/CaseHistory/album?id=249458

Lorna in Ontario
 

Hi Emma,

I want to take a look at your case history, but your links aren't live. To avoid copy/pasting, and just clicking on your links,can you do one more thing,please?

Just go back to Subscription,where you made your automatic signature.
Go to your signature box, put your cursor immediately after Tom in your first link,and hit Enter.
The link should turn blue( aka live)
Do the same for your photo album link. It should turn blue,too.

Thanks! 
Oh. Remember to scroll down and hit SAVE .

--

Lorna  in Eastern  Ontario
2002
Check out FAQ : https://www.ecirhorse.org/FAQ.php

Sherry Morse
 

Hi Emma,

You'll get a full welcome message soon but it would be helpful if you could post pictures of Tom as well as of his feet (directions on doing that can be found in the Wiki - https://ecir.groups.io/g/main/wiki#Photos-and-Hoof-Evaluation-Help

For his bloodwork - can you let us know if that was done fasting or non-fasting?  It's particularly relevant for the insulin level.  Considering the note on the glucose for the most recent test I'd be questioning if the insulin was definitely handled correctly when it was sent to the lab as well. 

Looking at his x-rays he has excessively long toes on all 4 feet which could be causing him mechanical discomfort with movement. He's also a bit thin soled on his front feet in particular which would correlate with being tender on stones and not wanting to trot either.  Being able to see the actual foot as well as what his current condition is can go a long way to helping us help you.




Cindy Q
 

Hi Emma

Welcome to the group! Thank you for filling up your CH and uploading your rads.

As Sherry has mentioned, if you could let us know whether he was fasted for the tests or whether he had hay in front of him (no grain) for the 4 hours leading up to his test please. I agree he does look thin soled on the fronts. Is he wearing any boots? I didn't see this mentioned in your CH. Boots and pads could help his comfort and protect what sole there is while it grows. He may be more willing to move freely and that load and unload can then promote circulation and sole growth. Even then it takes time but without the constant assault on his thin soles, you would have a better chance. The RH also looks a little broken back but it looks like his foot is not fully on the block so he may be leaning back partially. For hoof photos please look at our guide on the angles that are helpful. For ground level pictures (like dorsal and lateral), your camera should actually be on the ground so that the lens is aligned with the hoof rather than at a height pointing at a downward angle https://ecir.groups.io/g/main/wiki/1472

Below is our full welcome letter which has a lot of details on our protocol of Diagnosis, Diet, Trim and Exercise. A few preliminary comments while you take the time to go through it - It doesn't look like your hay was tested and Forageplus in the UK can help you with that as well as custom balancing. Are you rinsing and soaking (with excess water which is then drained away) and then rinsing your beet (RSR)? I see you feed quite a lot of beet at 1.6kg dry (which usually means before it has been soaked), is that figure correct? Anyhow beet can have a lot of surface iron on it if not RSR -ed which can throw the mineral levels in your overall feeding out of whack and this can also affect foot health.

The ECIR Group provides the best, most up to date information on Cushing's (PPID) and 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 Insulin Resistance (IR). These are two separate issues that share some overlapping symptoms. An equine may be either PPID or 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 IR is diagnosed by testing non-fasting insulin, glucose and Leptin. Leptin is the hormone that says "stop eating". Knowing this helps to differentiate if a horse is IR "at baseline" or if an elevated ACTH is "driving" the insulin up. In Europe, substitute adiponectin for the leptin test.

*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: IR 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 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. 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 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 IR/PPID individuals.

We do not recommend feeding alfalfa hay to IR/PPID 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.


--
Cindy and Glow - Sep 2017, Singapore
ECIR Primary Response




emma@...
 

Thank you all. LInks should be live now. I will update photos later this evening. Tom has been trimmed since the last x-rays were taken.  My trimmer and I have discussed boots but as he is comfortable walking on tarmac we have decided not to boot him as the trimmer suggests this will be better for the foot and sole development. He is currently walking out freely with no sign of discomfort.

2019 bloods.  These were taken pm. His last meal would have been about 7am (Happy Hoof).  His hay was soaked. He would have finished his hay by midday.
Karo syrup test. This was taken am. His last meal would have been the morning before and he had hay overnight (not soaked) but this would have all gone before midnight probably (sorry it was a long time ago and my notes aren't that detailed).

2020 bloods. Bloods were taken around 4-5pm.  His last meal (beet pulp etc) was at 9am. He then had an "easy to eat" haynet which he usually finishes by about 12pm.  He still had hay in a trickle net up until when the bloods were taken. This was the same for the Karo syrup test too.

I haven't had the hay tested as supplier keeps changing - not ideal but the hay is provided by the yard.
I am not rinsing the sugar beet at the moment.  It is the quick soak beet (ready in 10 mins).  I was using Speedibeet but my trimmer said to move to Kwik Beet which is lower in iron. Have been mixing the two but only a day or two left of the speedibeet.

Thanks
Emma
--
Emma M in East Sussex, UK 2020
Case History for Tom: https://ecir.groups.io/g/CaseHistory/files/Emma and Tom
Photo Album for Tom: https://ecir.groups.io/g/CaseHistory/album?id=249458

Lorna in Ontario
 

Hi Emma,

I couldn't find iron levels for Speedi-Beet or Kwik Beet, but many members use Speedi-Beet without issue. Maybe your trimmer has equine nutrition background, though, and has the skinny. Do you know the iron levels for each?

In any case,we do recommend rinsing,soaking,and rinsing beet pulp,for best results with our compromised horses.

Going to case history now. Thanks for changing the links!

--

Lorna  in Eastern  Ontario
2002
Check out FAQ : https://www.ecirhorse.org/FAQ.php

Sherry Morse
 

emma@...
 

I've put  some photos of Tom's feet in the album and some of him too.  I washed his feet so they are wet in the photos but I do also have photos of them dry if that would be better.

I can see that rinsing/soaking/rinsing really brings the iron levels down.  Once it is soaked for the full amount of time, it all goes to mush so not sure how you would rinse again. Do you just rinse the soaked beet in lots of extra water and pour out the excess?  Do you rinse it a second time when it is fully soaked or only partially.
--
Emma M in East Sussex, UK 2020
Case History for Tom: https://ecir.groups.io/g/CaseHistory/files/Emma and Tom
Photo Album for Tom: https://ecir.groups.io/g/CaseHistory/album?id=249458

Maxine McArthur
 

Hi Emma
I put beet pulp in a mesh laundry net for soaking and rinsing. The holes are big enough to let out any dirt, but small enough to contain the shreds. Some people use a colander. There are some great ideas on our sub-group Horsekeeping if you do a search of the messages there. 
--
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

 

 

On Mon, Jun 29, 2020 at 12:43 PM, <emma@...> wrote:
 
Emma,
The amount of iron in beet pulp varies quite widely. Our bags of Speedibeet in the USA are labeled with the amount of iron (shown as a minimum). Speedibeet sold elsewhere or in other batches may contain less iron. Check the label on the bag.

Like Maxine, I put the beet pulp in a nylon mesh laundry bag or lingerie bag. If you're feeding Speedibeet, you need to start by soaking it briefly in hot water to break apart the flakes. Then drain that water and soak it for 20 minutes longer in clean hot water. Finally, rinse it thoroughly in fresh water. The mesh bag retains the small pieces of beet pulp. Those of us who keep our own horses at home can process beet pulp in bulk once a week. After the final rinse and a brief drain, it can be weighed and frozen in plastic bags for individual sized servings. IIRC, I used portions weighing between 550 and 750 grams. It's a satisfying meal and safe for IR equines.

BP is not the only choice as a carrier for supplements, but it's a good one.

--
Cass, Sonoma Co., CA 2012
ECIR Group Moderator
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