Updated Case History with New ACTH/Insulin Levels


Jamie Miller
 

Hello. I have updated Walker's Case History File and his most recent bloodwork. My vet is not keen on putting him on cabergoline given his age, the mass in his sinus cavity, and basically her inexperience with using it. He is tentative to walk on front right, but equine podiatrist believes that may be due to a small abcess or sore in sole. March 17th xrays indicated no change since his original xrays in the summer of 2019.  Basically, he hasn't gotten worse and was comfortable in Sigafoos.  Now, to trim and check feet more often, he is in Easy Boot Stratus with pads. Clinically, he seems ok spirit-wise, alert, eating, lying down/getting up.  

Diet: 18 lbs soaked Timothy Balance Cubes spread across 3 meals per day, Herbal Mune, Lunq EQ, CocoOmega, salt, Vitamin E-5000 powder, no grass, no hay

Questions: 
1. Since his ACTH levels are no different on 2 pills vs. 4, can I just bring him back down to 2 1x/day .. and given the fact that my vet is not comfortable with the medication switch?
2. Are there any boot recommendations or treatments for his feet?
3. Metformin seems to have brought his insulin levels down considerably, so should that be continued?  What would be the exact protocol for its use?


Date
Prascend During This Reading
  ACTH pg/mL (2-30) Insulin ulU/mL (10-40) Glucose Leptin
2/6/2019 not prescribed yet   85.6 182.5    
5/7/2019 1 pill 1x/day   30.1 128.89    
12/13/2021 2 1x/day   72 >200 104 (normal) 9.86 (normal)
3/17/2022 2 1/4 2x/day split dose between AM and PM   49.3 68.59    
4/27/2022 3 1x/day   66.8 165.99    
5/20/22 3 1x/day   45.9 125.7    
6/17/2022 4 1x/day 1 scoop InsulinWise (stopped, didn't drop insulin) 124 131.34    
7/27/2022 4 1x/day Metformin started 6/22/22 65 45.12  
--
Jamie Miller
Louisville, Kentucky, USA
July 2019
Horse: Hiram Walker
Walker Case History: https://ecir.groups.io/g/CaseHistory/files/Jamie%20and%20Walker
Photo Album: https://ecir.groups.io/g/CaseHistory/album?id=93084
Link to Profile for Hiram Walker


 

Hi Jamie,
Thank you for updating all your data!

If Walker were mine, I would leave his pergolide as it is until late December, after the fall rise.  This isn’t a good time to be changing pergolide doses.  I am interested in the timing of your test results.  I tried to line each test up with the previous dose increase and I wasn’t convinced that there was a three week interval between them.  Is there a reason you are testing ACTH as frequently as you do?  To my mind, the ACTH results look pretty erratic. You may need to rely more on symptom observation to judge whether he’s well controlled.  In any case, I would hesitate to make changes now.

I know next to nothing about boots but there many others here who have tons of experience.

That’s super that the metformin is working.  You have to keep giving it to maintain the effect and it may lose effectiveness with time.   Here’s a short write up that covers the question people ask.
--
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
 


Kirsten Rasmussen
 

Hi Jamie,

I understanding wanting to reduce the Prascend.  4 pills a day are expensive!  In my opinion, you should ask your vet to switch him to compounded pergolide to make it more affordable (keep in mind that 1mg Prascend = 1.3 mg compounded, so do some math to make sure you're not dropping his dose when you switch), and you should increase the dose until you see ACTH come down to mid-20s or lower.  It's possible he doesn't respond to pergolide well, but if Cabergoline is out of the picture then getting aggressive about increasing pergolide might help.  We have many horses on much higher doses, some over 20 mg, because that's what they need to control their ACTH.  Hiram has a lot of issues but uncontrolled PPID does not have to be one of them if you can get your vet on board.

For his feet, he really needs his toes brought back on all 4, if they still look like they did back in May.  If he is comfortable in his current boots with pads, then there is no need to change to a different style.

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


Jamie Miller
 
Edited

Thank you. 
We were doing labs every three weeks (or so) to see if the small increases in Prascend were having a positive impact on levels.  Once we got to 4 mg per day, the vet suggested Insulin Wise to see if that might help overall.  As suspected, it didn't, so we tried Metformin along with the 4 mg of Prascend.  The idea was determine if the Prascend could drop the insulin, as suggested by the guidance here, or if we really needed to go to Metformin and address the high insulin levels.  Now we are at the point where Metformin has done it's job, but I'm back to addressing that ACTH.  I didn't realize there was another option other than cabergoline, so I was thinking .. "if it doesn't matter what dose of Prascend he's on, then why continue with so many pills.  It makes no sense.  I increased his pills from 3 to 4 mg and his ACTH levels shot up to 124. 

I am still working on his feet and trims with the farrier.  It is really unfortunate how little knowledge and skill is out there in the vet and farrier world.  He may need new boots because his are 3 years old.  They've held up but now have a little tear in the back.  So, I figured if I were to get him new boots, maybe this group might have some preferences.  His equine podiatrist put him the Easy Boot Stratus and they have a wedge attached to the bottom.  The podiatrist's rationale for the wedge is to support him with tight tendons or muscles (?).

His case history is updated, so it may be easier to see his results over time in that document instead of the chart I attempted to insert.  I thought it might be helpful to place it in this message, but something got lost in translation. 

Thank you. 



Jamie Miller
Louisville, Kentucky, USA
July 2019
Horse: Hiram Walker
Walker Case History: https://ecir.groups.io/g/CaseHistory/files/Jamie%20and%20Walker
Photo Album: https://ecir.groups.io/g/CaseHistory/album?id=93084
Link to Profile for Hiram Walker


 

Hi, Jamie. 
Hiram's ACTH levels shot up despite the small increase in pergolide because the dose is clearly inadequate. That's because the seasonal rise has already started. PPID horses can have extreme elevations of ACTH during the seasonal rise if their PPID isn't well-controlled. Here's more information on the timing of the seasonal rise. We are now in week 31. https://ecir.groups.io/g/main/files/Blood%20Testing%20for%20IR%20and%20PPID/Blood%20Testing%20for%20Cushings%20-%20PPID/Seasonal%20Influences%20on%20ACTH/Liphook%20-%20Seasonal-Changes-in-ACTH-Secretion2.pdf The ACTH levels in the charts reflects normal increases in ACTH in normal horses that don't have PPID. PPID horses can have increases that are multiples of the increases shown on the chart.

More information on the seasonal rise here: https://www.ecirhorse.org/seasonal-rise.php This is particularly important:
Higher ACTH means higher cortisol production. Cortisol itself makes the veins in the hoof less responsive to vasodilators. This alone is probably not enough to trigger laminitis (although it could trigger foot pain if the horse already has compromised circulation). Cortisol also induces insulin resistance, or worsens it if it is already present, which correlates with the documented PPID horses on the ECIR Group that also develop increased insulin and G:I ratios. Since every horse has a different starting point, every horse will have a different risk factor from the Seasonal Rise in ACTH and cortisol.

These risks are why those of us who have been treating PPID horses for some years increase pergolide aggressively in anticipation of the seasonal rise. We don't target the normal range for normal horses. PPID horses aren't normal. Oxidative damage in the brain destroys, or, at the very least, inactivates the dopaminergic neurons. We therefore target ACTH levels that would be somewhere in the middle for normal horses, in the teens to very low 20's pg/ml.  Lots of details are explained in ECIR resources such as this one: https://www.ecirhorse.org/physiology-ppid.php 
-- 
Cass, Sonoma Co., CA 2012
ECIR Group Moderator
Cayuse and Diamond Case History Folder                
Cayuse Photos                Diamond Photos


Sherry Morse
 

Hi Jamie,

You're currently in the position of chasing the rise but I would not drop his Prascend dosage.  Instead you may want to discuss switching to compounded pergolide and upping his dosage to the equivalent of 5 - 6 Prascend per day.  PPID is a progressive disease so it's not a surprise that more medication is needed as Walker has gotten older. 

Agree with Kirsten about his trim still needing quite a bit of work.  No change since 2019 is not the direction you want to be going in.




Jamie Miller
 

Thank you.  I have kept his pills at 4 mg per day, but increased to 5 mg this evening and have sent a message to my vet about changing to compounded pergolide.  I had stayed with Prascend because I thought (could be mistaken) that the compounded version would have too much variability in its components, which might cause inconsistency?? Again, I'm a novice here, only have Walker and his issues to learn from.  He is 34, and he has had high insulin levels for quite awhile, only relying on the Prascend to try and address it, but as you can see, it really hasn't.  The metformin has brought it down from 124 - 130 to 45.  While still above the Cornell range of 10-40, I think that is a good thing for him.  

My heart aches about his trim, but I will continue to advocate for what needs to be done or reaching out to others in my area to connect with a different farrier.  I am just so frightened of not finding the right one and that I will end up causing even more damage than what has already occurred. Are there any questions that I could use to "screen" them?  And, what answers might I look for? 

Thank you. 
--
Jamie Miller
Louisville, Kentucky, USA
July 2019
Horse: Hiram Walker
Walker Case History: https://ecir.groups.io/g/CaseHistory/files/Jamie%20and%20Walker
Photo Album: https://ecir.groups.io/g/CaseHistory/album?id=93084
Link to Profile for Hiram Walker


Sherry Morse
 

Hi Jamie,

If you get your pergolide from a reliable pharmacy and in capsule form there is really no difference (other than cost) than using Prascend.  You are using the Prascend to address his elevated ACTH which may or may not be contributing to his elevated insulin.  Even if it is not though, you still need to control the ACTH for all the reasons Cass mentioned earlier.  




 
Edited

Hi Jamie,
The problem I’m having, and you did a fine job of entering data, is that I’d like to see a calendar including dates of both increases in  dose and of blood draws for testing ACTH with results.  We don’t ask for that so I set up two windows on my iPad and compared the dosage chart with the testing chart.  I should have made a screen shot so I could review it again but I did not so I think I will do that in a bit.  In my quick review, it appeared that you might not have been waiting three weeks after each dose increase before testing and in some cases it seemed you tested twice without making an increase in between.  This might all be explained by my misreading of the dose increase dates.  Maybe you could recheck those dates for me, please?  But, I agree with the others.  This sort of inconsistency of ACTH results is what led me to switch to cabergoline.  But I was already at a high dose of pergolide when this happened so my incentive to change was also quite high.  
--
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
 


Jensmccabe
 

Hey Sherry-

Is there a list of pharmacies that do compounding in capsules anywhere?

Also considering making that switch for cost-savings…

j
--
Jen McCabe
Laytonsville, Maryland 
Joined 2022
+ Odin (2010 BLM Mustang Gelding - IR, dx 2022), Bella (2008 BLM Mustang Mare - PPID/Cushings dx 2000) + Fiki (2015 Arabian, ok so far!)
Odin and Bella Case Histories


Bobbie Day
 

Jamie
i have been using Avrio
their number is 844-270-6700
i know there are a couple pharmacies that do it, I believe Chewy has even started compounding.
I pay around 80.00 (+ or -) for ninety days.
im just bumping my horse up so it could be more. You’ll just need your vet to call it in. 


--

Bobbie and Maggie 
Desi (over the rainbow bridge 7/21) 
Utah, Nov 2018
NRC Plus 2020, NAT, C&IR March 2021
ECIR Group Primary Response 

https://ecir.groups.io/g/CaseHistory/files/Bobbie%20and%20Maggie
https://ecir.groups.io/g/CaseHistory/album?id=271156

https://ecir.groups.io/g/CaseHistory/files/Bobbie%20and%20Desi 
https://ecir.groups.io/g/CaseHistory/album?id=78821


Sherry Morse
 

The compounding pharmacy list is in the Wiki:  https://ecir.groups.io/g/main/wiki/1137




 

Hi Jamie,
Bet Pharmacy, which formulates the cabergoline injectable, is located in Lexington.  If you call them, they might be willing to share the name of a vet or two in your area comfortable using their product.  Then, perhaps, you could consult with them about how it is used.  Or they could consult with your vet.  I began using it with a horse about the same age as Walker.  Unfortunately, my experiment was not lengthy because my horse succumbed to what appeared to be a colic a few months later.  My daughter, a vet, ordered the product and did the injections, watching for any untoward signs, of which there were none.  I did not use APF because he had been on a very high dose of pergolide but I found that I definitely should have as his veil was quite remarkable.  My experience led me to the conclusion that the pergolide had not been totally effective for a long time.  While he had been getting pergolide for many years, with constantly increasing doses which resulted in lower ACTH levels, I reached a point where the blood test results no longer reflected the doses he was getting.
It’s just another tool in your toolbox which should not be ignored.  
--
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
 


Kirsten Rasmussen
 

I would ask any new prospective trimmer if they would be willing to follow the markups Lavinia did for you this spring.  Show them the markups.  Look for someone specializing in barefoot trimming, not a farrier, vet-farrier, or equine podiatrist.  Someone who is not set in their ways and that is willing to have a discussion with you and answer your questions.  Don't order new boots until you get the trim in order.  His boot size will change.

5 Prascend = about 6.5 mg compounded pergolide.  I'd start with requesting that, then use your leftover Prascend to increase the dose for the rise if he needs more.  When pergolide doses get higher, you need to do bigger increases to be effective.  That's what we mean by being aggressive.  Little 0.5 or 1 mg increases aren't going to do much.

Glad to see the Metformin is helping, his insulin is much better now! 

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


Jamie Miller
 

Thank you all.  My vet returns from vacation next week, so I'm hopeful we can move in the direction of compounded pergolide going forward. I completely understand that he is 34, has expired teeth, and a mass in his left sinus cavity .. . but I still want to ensure a quality life.  I evaluate him several times per day, knowing I'm on borrowed time (mostly because of the mass).  Anyway, having the resources for the compounded pergolide and information about how to screen for farriers is helpful.  I had a barefoot farrier when he was first diagnosed and she told me she would trim him, that I was torturing him and he should be put down.  I turned to the only resource I thought was best at the time, which was an equine podiatrist from Rood and Riddle in Lexington, KY. 

Here is link to a video I took of him tonight.  He seemed in good spirits and willingly walked - to my amazement - down the road less than a quarter mile to visit and see some other horses.  It seemed to excite him and give him purpose, as he is the only horse we have, though he has chickens, goats, cats, wild turkeys, geese and deer around the farm where he lives. He seemed willing and I didn't want to take that from him. 

https://youtube.com/shorts/VYq3hDjuOLY


--
Jamie Miller
Louisville, Kentucky, USA
July 2019
Horse: Hiram Walker
Walker Case History: https://ecir.groups.io/g/CaseHistory/files/Jamie%20and%20Walker
Photo Album: https://ecir.groups.io/g/CaseHistory/album?id=93084
Link to Profile for Hiram Walker


Kirsten Rasmussen
 

Given the mass and Walker's age you might be able to make an argument for trying high doses of compounded pergolide, or even Cabergoline, because since he may not have much time left you want to make sure it's not ongoing laminitis from PPID that forces you to let him go.  Perhaps your vet could see it as a bit of an experiment to see if you really can get his ACTH and insulin down, with enough meds on board, to get him comfortable.  Just a thought.  The Metformin is helping,  which is great, but it is probably a temporary effect because we know it wears off in most horses over time.  It gives you some time to work on lowering ACTH, which in turn should bring insulin down and end the chronic laminitis.  Another note: although we don't recommend it as a rule because the published research doesn't support it, there are rare PPID horses that seem to do better with 2x/day dosing, which is another option to try if you increase the pergolide dose dramatically and find his ACTH still isn't responding. 

I don't know what your physical abilities are, but perhaps you could work on rasping those toes back on all 4 feet yourself.  A little bit every few days, using Lavinia's markups as a guide.  Many of us had to take hoof care into our own hands, literally, since we could not find trimmers willing to follow Lavinia's guidelines.  Some are women with arthritic hands, bad knees, etc trimming their own horses.

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


Jamie Miller
 

Thank you, Kirsten. 

I do plan on increasing his dose - either with Prascend or with compounded pergolide.  I will also talk with her again about the cabergoline option and share the document that Dr. Kellon provided to me.  We are monitoring the mass based on xrays and clinical signs (breathing, heart rate, respirations, etc.).  He had a CT scan at Rood and Riddle in Lexington, KY back in December 2021 (9 months ago), but I don't see a need for repeat scans.  Therefore, it really is a day by day thing.  He seems to still be breathing alright. Though, now that I think about it .. he has to be on doxycycline to help with any infection caused from the mass.  In July his breathing was terribly rumbled and he had a bulge near his nostril and when administered Doxy, his nose drained yellow stuff for a whole day, then he seemed fine, breathing better. 

He started on Metformin June.  I know have him on 5 mg Prascend, which I could increase.  He just had bloodwork done.  When would you suggest doing bloodwork again?  I thought it was recommended to check levels at least 3 weeks or so after changing a dose. I could be mistaken. 

I saw a video of Dr. Simon Morris rasping the toe.  Walker has never had that done by any farrier - barefoot or otherwise.  I am capable and willing.  How do I learn and what tool do I get?  I am in the process of looking for someone to follow Lavinia's markups that she did a few months ago. 

I realize that my time with him is limited. and I agree that a week early is better than a day late.  When I see him, like last night in the video, still have some interest in life, I find it hard to just end his.  Even with all that he has going on, I am not confident that when I look at him, and he looks at me, that he's telling me "it's time".  Hope that makes sense.  https://youtube.com/shorts/VYq3hDjuOLY

I appreciate the wisdom, experience, and expertise of this group. 
--
Jamie Miller
Louisville, Kentucky, USA
July 2019
Horse: Hiram Walker
Walker Case History: https://ecir.groups.io/g/CaseHistory/files/Jamie%20and%20Walker
Photo Album: https://ecir.groups.io/g/CaseHistory/album?id=93084
Link to Profile for Hiram Walker


Lavinia Fiscaletti
 

Hi Jamie,

One thing to remember is that the elevated ACTH is suppressing his immune system, which will make him more prone to developing sinus infections and will make it harder for him to clear them.

At the moment, it doesn't sound like it's time for Walker. I lost my 34yo QH to a thyroid tumor that grew large enough to surround both his trachea and esophagus. It was constricting both, making it harder and harder for him to breathe and swallow. It was diagnosed after he started breathing like Darth Vader one day. He had a tracheostomy done (which prevented him from suffocating) so he could be safely sedated for the CT scan of the mass. I had to make the decision to end his life when it became impossible for him to take in enough food to maintain body condition and I wasn't going to let him starve. You'll know when his time has come.

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


Jamie Miller
 

Thank you, Lavinia.  That makes sense.  I have him on 5 mg of Prascend right now and hoping to make the move to compounded pergolide, as was suggested by some in this post. I also have him on Uckele's Herbal0-Mune to provide additional immune system support.  

I'm hopeful that I will know it's time.  I'm sorry to hear about your old guy.  It seems the consensus is that if a horse lives to 34 and living a fairly decent life comfortably, then that is good.  It speaks to the great love and care you've dedicated to him.  Walker had a rumbled breathing in July and needed to do something, so the vet recommended Doxy right away. A day and a half after starting him on it, the bulge went down and his nose drained for two days straight. 

Breathing and Draining Video
--
Jamie Miller
Louisville, Kentucky, USA
July 2019
Horse: Hiram Walker
Walker Case History: https://ecir.groups.io/g/CaseHistory/files/Jamie%20and%20Walker
Photo Album: https://ecir.groups.io/g/CaseHistory/album?id=93084
Link to Profile for Hiram Walker


Lesley Bludworth
 

Jamie,
He looks supper happy to me.
You will know when.
Love him up.



From: main@ECIR.groups.io <main@ECIR.groups.io> on behalf of Jamie Miller <jamiepiunti@...>
Sent: Saturday, August 6, 2022 1:50:59 PM
To: main@ECIR.groups.io <main@ECIR.groups.io>
Subject: Re: [ECIR] Updated Case History with New ACTH/Insulin Levels
 
Thank you, Lavinia.  That makes sense.  I have him on 5 mg of Prascend right now and hoping to make the move to compounded pergolide, as was suggested by some in this post. I also have him on Uckele's Herbal0-Mune to provide additional immune system support.  

I'm hopeful that I will know it's time.  I'm sorry to hear about your old guy.  It seems the consensus is that if a horse lives to 34 and living a fairly decent life comfortably, then that is good.  It speaks to the great love and care you've dedicated to him.  Walker had a rumbled breathing in July and needed to do something, so the vet recommended Doxy right away. A day and a half after starting him on it, the bulge went down and his nose drained for two days straight. 

Breathing and Draining Video
--
Jamie Miller
Louisville, Kentucky, USA
July 2019
Horse: Hiram Walker
Walker Case History: https://ecir.groups.io/g/CaseHistory/files/Jamie%20and%20Walker
Photo Album: https://ecir.groups.io/g/CaseHistory/album?id=93084
Link to Profile for Hiram Walker

--
Lesley Bludworth 
Phoenix, AZ
Sophie Case History 7/2022
https://ecir.groups.io/g/CaseHistory/files/SophieB%20Case%20History