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Updated Case History, please help


Tamara Gonsor
 

Since finding this group 8/2020 and starting the emergency diet, getting hay tested and balanced by Dr Kellon. We have implemented all recommendations by group, he made a huge turnaround with diet alone. Was doing so well that he was trotting and not foot sore at al, his body has changed a lot just with the emergency diet. His feet have been growing out nicely with no ripples indicating episodes. 

Blood tests (glucose and ACTH) in Feb. 2020 were quite high, I did not know at the time to test for insulin so was not tested.

Blood tests (insulin and glucose) in May 2020 came down quite a bit, vet said 10 points away from normal. Still at this point I hadn’t found ECIR group.


In learning from this group I wanted to test him during the seasonal rise to continue to get documented numbers. Also because the first few tests were taken fasted which I now know is not accurate. 


Blood Tests (ACTH, Insulin) Oct. 2020 and so very high, if I understand it correctly. 

I have updated my case history but I am still very unclear how to read blood results and my vet has not gotten back to me regarding this ATCH and Insulin results to explain (glucose blood got ruined per vet, she said it needs to be redrawn), I do realize that it is recommended for these all to be drawn and tested at the same time by same lab. 

Would someone be able to look at it just to confirm I am interpreting correctly? I realize we are not to upload blood results in our folder, I will delete as soon as I can confirm I am looking at it right. It looks like ACTH and insulin are VERY high. So high that I am concerned that I need to do something now for him. Should I put him on medication at this point?


I did read this post https://ecir.groups.io/g/main/topic/77763721#256711

Which may be exactly what is happening with Malik, he is clearly having trouble in this seasonal rise time. I just don’t know if this is a good time to start him on pergolide now?


Can these high numbers cause him to act loopy? He is not walking well as of a week ago now. He did have a small fetlock injury but that limping has ceased. All updated on my case history.  It feels like he did a complete flip from great to bad overnight, it was really in about 5 days time, very quickly. His diet is still tightly balanced per ECIR protocol. The only thing not 100% is salt because he won’t eat his supplements with the entire dose in it (split into 2 feedings), working him up. Was also recommended to put in water and spray on hay but he isn’t too interested in the hay the last couple of days either.  And the monosodium phosphate is still on backorder. 


I am scheduled to take Dr. Kellons nutrition class NRC Plus in December followed by her NRC Advanced after that. I feel so uneducated still, especially with the medication. I can’t wait to learn more in these classes so I can better help my horse. I continue to read here until then.

 
--
Tamara G. in Arizona 2020
Case History: https://ecir.groups.io/g/CaseHistory/files/Tamara%20and%20Malik
Malik Photos: https://ecir.groups.io/g/CaseHistory/album?id=252564


Lavinia Fiscaletti
 

Hi Tamara,

You are correct that those blood test results are not good as the insulin is over 200uIU/ml and the ACTH is 134pg/ml. He is definitely positive for both PPID and IR. No point in redoing the glucose unless you test insulin at the same time as the point is to see the relationship between the two, not only the raw number itself.

Not walking well may indicate he is starting to suffer from laminitis, so he needs to have the PPID treated as soon as possible.

--
Lavinia, George Too, Calvin (PPID) and Dinky (PPID/IR)
Nappi, George and Dante Over the Bridge
Jan 05, RI
Moderator ECIR


Tamara Gonsor
 

Ok Lavinia, thank you for confirming. Is this the time to start him on pergolide and if so what dose do I start him at?
I have been reading all day on this group. The doses seem to very per horse. It also seems that I would start him and then test again in 3-4 weeks?


--
Tamara G. in Arizona 2020
Case History: https://ecir.groups.io/g/CaseHistory/files/Tamara%20and%20Malik
Malik Photos: https://ecir.groups.io/g/CaseHistory/album?id=252564


Lavinia Fiscaletti
 

You'll need to discuss this with your vet but if this was one of my horses, I would definitely be starting him on pergolide as soon as possible.

Generally, 1mg is a common starting dose. As the rise has peaked, ACTH levels will be declining in normal horse now but that may or may not be the case in one with PPID. The good thing is that Twister's ACTH is likely not going to climb any  more this year, so you have a good chance of getting it controlled fairly quickly now.

Generally, it is recommended to retest after 3 weeks at the targeted dose to see where things stand. Titrating up the the prescribed dose,is also recommended to help prevent a possible "pergolide veil" effect from developing. You cna also administer the adaptogen APF when starting the meds to help combat any veil effects. How a horse reacts to the meds is very individual.

--
Lavinia, George Too, Calvin (PPID) and Dinky (PPID/IR)
Nappi, George and Dante Over the Bridge
Jan 05, RI
Moderator ECIR


Sherry Morse
 

Hi Tamara,

Lavinia has already addressed most of your questions, but I wanted to mention that you should absolutely leave your bloodwork results in your CH folder.  Not sure where you got the idea that it wasn't allowed.




Tamara Gonsor
 

Oh ok thank you Sherry, I was reading the directions and was recommended to hyperlink words in case history because uploading all blood work gets messy in the file and lack of space. I will go back and read again, I may have misunderstood. 

--
Tamara G. in Arizona 2020
Case History: https://ecir.groups.io/g/CaseHistory/files/Tamara%20and%20Malik
Malik Photos: https://ecir.groups.io/g/CaseHistory/album?id=252564


Kirsten Rasmussen
 

Hi Tamara,

We like the bloodwork to be summarized in the case history so we have all the data in one place, it's much easier for seeing any trends and making comparisons.  No problem with keeping the original pdf results in your Case History folder though, although we do ask that you block out the name and address of your veterinarian and clinic as a courtesy to them if you haven't already done so.

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


Tamara Gonsor
 

My vet is absolutely convinced that blood testing for ACTH/Insulin/Glucose non-fasting is a waste of time and will not give accurate results. I am completely on board with what is recommended here. The data, testing and experience speaks for itself. Does anyone have any advice? Should I be looking for another vet? I have asked her to read the website, I am hoping she will.

I am looking for the thread that talks about the differences in pergolide vs prescend and different forms to get it in. I thought I saved it. My vet is saying the only form I can get pergalide in is liquide and remember seeing that to not be the case. If someone knows the link to that discussion I would be most grateful! 

--
Tamara G. in Arizona 2020
Case History: https://ecir.groups.io/g/CaseHistory/files/Tamara%20and%20Malik
Malik Photos: https://ecir.groups.io/g/CaseHistory/album?id=252564


LJ Friedman
 

I don’t think any knowledgeable horse owner  fasts for those tests and certainly none of us use liquid pergolide. Sounds like two strikes. If you can get a non-liquid pergolide prescription capsule form, then just tell the vet you fasted as per the vets instructions and use your judgment etc. to do what needs to be done prior to testing. ie feed on the downlow (ssshhh)  Of course , if youv live in a big town you should probably find a new vet, but before you switch,, you interview the new vet and tell them you want to use compounded pergolide from Pet Health Pharmacy. and get their reaction.
--
LJ Friedman  Nov 2014 Vista,   Northern  San Diego, CA

Jesse and majestic ‘s Case History 
Jesse's Photos

 


Tamara Gonsor
 

LJ,

Why didn't I think of that. I'll just say I did. And thank you for the additional information!

One more thing I forgot to mention. This vet also won't retest after 3 weeks as recommended here, she said 1-4 months. My question is, it is 3 weeks once getting to recommended dose right? 

I found the link about pergolide vs prascend: https://ecir.groups.io/g/main/topic/compounded_pergolide_instead/77491396?p=,,,20,0,0,0::recentpostdate%2Fsticky,,,20,2,20,77491396
--
Tamara G. in Arizona 2020
Case History: https://ecir.groups.io/g/CaseHistory/files/Tamara%20and%20Malik
Malik Photos: https://ecir.groups.io/g/CaseHistory/album?id=252564


 
Edited

Hi Tamara,

A few thoughts to consider.  The first few years I used pergolide I bought it from a local compounding pharmacy.  It was in oil and I never had any difficulties with it in terms of stability.  It seemed to do the job and give appropriate results.  When I first learned that pergolide was unstable in liquid, I contacted the pharmacy and they explained that it was unstable in water and oil was fine.  My understanding is that carefully stored capsules are still better.

That local pharmacy went out of business eventually and I switched to Pet Health Pharmacy, NW of Phoenix.  They sell pergolide to many of us here and we purchase it weighed out in capsules.  I have purchased pergolide in oil from PHP so it’s still done that way for those who ask.  I used the oil fairly recently to gradually increase some pergolide doses without having to fool around with splitting capsules.  Your vet might feel more comfortable if she knows the pharmacy is local yet highly regarded.  I’m fairly sure this isn’t possible but I wonder if there’s a way to learn of local to you vets who use their services.

My vet took on a partner to focus on the equine side of things and she said to fast.  When I questioned her about that, it seemed that fasting to her meant ‘no grain’.  All the hay I wanted to feed was fine.  As LJ suggests, you could assume your Vet means the same, taking great pains not to ask.

Good luck!  Prascend (BI) does a lot of marketing to vets so you have a lot to overcome.  My experience with pergolide began before Prascend arrived on the market so my vets had experience with the compounded product.  They were eager for me to try Prascend and interested to learn that it wasn’t more effective in my case, at least.
--
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


 
 


Mary Marshall
 

My horse was fasted prior to this test.  The fasting meant no grain.  Hay and grass were ok.

--
Mary Marshall
Aiken SC
Joined-10/17/2020


Kirsten Rasmussen
 

This 2019 document from the Equine Endocrinology Group states that horses do not need to be fasted and can have access to hay or pasture, but no grain, prior to the TRH Stim test (it doesn't specify feeding conditions for the basal ACTH serum test but I would assume the same):
https://sites.tufts.edu/equineendogroup/files/2019/12/2019-PPID_EEGbooklet.pdf
If you do fast, the ACTH results will be somewhat lower.

We recommend a retest after 3-4 weeks on the prescribed dose so if your vet suggested 1-4 months you can ask for the shorter time-frame.

As far as testing insulin and glucose non-fasting, the same EEG Group says "resting insulin concentration" (Table 3) is done non-fasting and can be used for diagnosis; it gives ranges for positive, equivocal, and negative non-fasting results, in this 2018 document:
https://ecir.groups.io/g/main/files/2%20DDT%20-%20%20The%20Diet%20Diagnosis%20and%20Trim%20Protocol/EEG%20GUIDELINES%202018.pdf

Send these 2 documents to your vet.  If they still insist on fasting insulin, this is then refer to this paper for the actual upper limit of normal insulin, fasted, of 5.2 uIU/ml:
https://ecir.groups.io/g/main/message/247157

You can also explain that your horse doesn't live in a fasted state and it's more important for your management to know what your horse's insulin is like on their current diet, so you will know if dietary changes are needed.  As the owner paying for the testing, this is how you will get the most value out of these expensive tests.

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


Eleanor Kellon, VMD
 

Tamara,

Even the equine endocrinology group, university based, no longer recommends fasting for insulin testing https://sites.tufts.edu/equineendogroup/files/2020/09/200592_EMS_Recommendations_Bro-FINAL.pdf but you should feed nothing but hay.

 Fasting can also affect ACTH readings https://pubmed.ncbi.nlm.nih.gov/24906932/ - lowers it significantly.
--
Eleanor in PA

www.drkellon.com 
EC Owner 2001


Tamara Gonsor
 

Thank you all. I will use this and hopefully get this started sooner than later. 

--
Tamara G. in Arizona 2020
Case History: https://ecir.groups.io/g/CaseHistory/files/Tamara%20and%20Malik
Malik Photos: https://ecir.groups.io/g/CaseHistory/album?id=252564


Loreto Hosking
 

Re pergolide compounded in oil:

I changed from Prascend to compounded pergolide in oil several years ago, when my two PPID thoroughbreds hit doses required in the teens.

This formulation kept them in the reference range for years, with appropriate testing and dose adjustment. As a vet I am fortunate to be able to manage all of this myself.

My current crop of 3 PPID horses have also been on the oil preparation for years, keeping their ACTH in the mid- high-teens. They are routinely tested twice a year and the dose adjusted. Currently they are on between 4 and 8 mg of pergolide mesylate.

It’s easy to adjust and simple to administer, and at least in my case, appears to have very good stability.

Loreto Hosking


--
Loreto Hosking
Emerald, Vic, Australia
Flecky, Cruiser, Charlie and Pretzel (dec)
Poppy, Merlin and Toby
January 2016 approximately 


Eleanor Kellon, VMD
 

 Just to clarify, the liquid available here is in water, not oil.
--
Eleanor in PA

www.drkellon.com 
EC Owner 2001