locked Velvet - New EMS w/ Laminitis Diagnosis


Melissa <mjc1133@...>
 

Velvet was diagnosed just after Christmas with EMS after bloodwork taken due to acute laminitic episode. This is my first EMS diagnosis and my very first exposure to laminitis even after having horses for over 40 years so I’m feeling lost & also overwhelmed.  Love, trust & respect my veterinary team but need to feel confident we are taking her down the right path, too. Note we are 2.5 weeks in on treatment plan. X-rays showed 4-6% rotation with good sole depth. My poor girl is miserable with hoof pain.

Medications:
*Note these are mixed together with about a tablespoon or so of unsweetened applesauce & administered orally via syringe. 
- Insulinwise 14 grams (.5 scoop) 2x daily
- Thyroid-L 12 mg (1 scoop) 2x daily
- Pentoxifyllin 4,000mg (10 tablets) 2x daily
- Relyne GI 1ounce (2 pumps) 2x daily
- Pain meds (these are in order of what we’ve tried)
   Bute 1 gram 1x daily & Banamine 8 cc 1x daily alternating between the two. This is no longer administered as the Bute was ineffective & vet was concerned about using Banamine longer term.
   Gabapentin 12 grams (1 scoop) 1-3x daily. She just started this in place of the Bute/Banamine rotation & it only seems to make her tired but still painful so far.

Diet
- Hay is Timothy/Orchard mix. switched to first cutting only, 2-3 flakes 2x daily in 1 inch slow feed net (previously she got a mix of cuttings free feed via the same slow feed net that lasted all day/night). Note that I am going to get all of our hay cuttings tested but we are getting some more 1st cutting so I want to wait to ship all samples at once.
- Triple Crown 30% Ration Balancer, 1/3 cup 2x daily

Hooves
- trimmed to remove a good bit of toe & heels files down
- wearing Clouds on all 4 hooves 24/7
- 12x12 matted stall with a good heaping layer of shavings throughout

Activity
- Stall Rest
- Permitted to roam the matted barn aisle while I’m cleaning stalls/feeding. I leave her door open & most days she doesn’t even come out. 

- Hand walking (so far we have only done this once bc she’s just too painful)

Sooooo…. Are we on the right path or are there changes we should make? Should I discontinue the balancer until our hay analysis is done then add in a balancer specific to our hay needs? How do I know hooves were trimmed properly? How do I know she’s progressing & not worsening? She does appear to have lost some of the crest on her neck & doesn’t seem as “bloated” if that makes sense.


————
Melissa Conn, PA, Jan 2023


Bobbie Day
 
Edited

Melissa welcome,
I'm sorry that Velvet is having such a hard time, I am here to welcome you to the group, I will be including our welcome message, it is full of information that will help you navigate through all this. We all have been there and it's so hard to see our beloved equines hurting but your here now and we will guide you along the way.
I will try to address your questions as best I can, but I can assure you that we have many very experienced mods that will also chime in to help you through this. 
Just a reminder that when you can please be sure to get your case history filled out as soon as your able, the more information you can give us the better we can advise you. Blood work, particulars about your horse, x-rays, diet etc.
 
Insulin wise - We do not recommend it as it has not proven to be effective in this group
Thyroid L - It's a good jump starter for weight loss but does nothing for laminitis, is Velvet overweight?
Pentoxifyllin - I have not heard of this but after looking it up it seems it is used to increase blood flow? Please see this link for J-herb which is highly recommended here for laminitis see this      message from Dr. Kellon regarding its use Jiaogulan versus NSAIDs   
Rylene - I personally am not familiar with this but it seems to be ulcer or digestive support?
NSAID'S - This is not recommended for horses experiencing laminitis, it does nothing for the pain. Please read this Why NSAIDs & Icing Are Not Recommended .pdf (groups.io) 
Gabapentin - Again it has not been proven effective for horses in this group we recommend that you instead find the source and remove what is causing the laminitis, consider Jiaogulan instead,
If you can post pictures of Velvets feet, we will be able to better advise you of her trim. Instructions are in your welcome message.
We do not encourage movement when your horse is in crisis, its good you have her booted. I would also suggest if your temps are below forty degrees you consider socks, and leg wraps to keep her warm, a lot of horses suffer from cold induced pain, the warmer you can keep her the better.
You can also do a search of our messages for additional information on all your questions. 
Below is your welcome message, please keep it handy. take your time and breathe we are here to help. The blue hyperlinks will take you to more in-depth information. 
Again, welcome to the group, let us know if you have any additional questions. 

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. 





--

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


Eleanor Kellon, VMD
 

As Bobbie said, we really need more details to help her. Yes to stopping the TC30 though and if you can do it, soak her hay before feeding. A large picnic cooler can be useful for this in winter.  She should also be tested for PPID if that hasn't been done and possibly Lyme disease. Other reasons for pain not letting up are the trim being incorrect or she may have abscesses/collections that need to drain which is extremely common. If you have poultice on hand, try warming a ball of it for each foot in your microwave. Put inside a heavy duty plastic bag and put the hoof in the bag before booting. Also clip any overhanging hair around the coronary band so you can keep an eye out for changes there which can indicate a collection trying to exit (e.g. red dots, swelling, cracking).
--
Eleanor in PA

www.drkellon.com 
EC Owner 2001


Melissa <mjc1133@...>
 

Thanks all. I called the vets office yesterday to get all her labs & xrays but have not yet received this far. I will follow up again today. She was tested for Lyme which was negative. I am not sure what else she may have been tested for beyond Cushings & EMS. 

I have not started soaking her hay because the weather has been awful cold & Velvet refuses to eat frozen hay. The weather outlook looks to be improving after this weekend though. I can stop the TC30 today no problem. Any concerns with me continuing to use unsweetened applesauce to administer her meds?  

This morning Velvet was down & didn’t want to get up so I left her alone & continued with my barn work after I called the Vet. After about 30 minutes she did get up & was extremely sore. Vet wants me to add Banamine (in morning) & Bute (in evening) along with continuing the Gabapentin 3x daily only halving her dosage each time.  I worry about all these meds though!
--
Melissa Conn, PA, Jan 2023


Eleanor Kellon, VMD
 

 Ask your vet to write you a prescription for Tramadol instead. It will actually help and without the side effects of NSAIDs. Tramadol isn't a "treatment" either in the sense it doesn't eliminate the cause but it will help with the pain until you get better control of the situation.  Dose is 5 mg/kg twice a day.
--
Eleanor in PA

www.drkellon.com 
EC Owner 2001


Melissa <mjc1133@...>
 

Oh wow this is great - I've used Tramadol for my dogs over the years with good success after surgeries, etc.  Can this be used to replace Bute, Banamine, Gabapentin?  I actually have Tramadol on hand but want to be sure I'm clear on usage.  My vet seemed surprised that I wasn't still administering the Bute/Banamine when he added Gabapentin but his office specifically told me to replace the Bute/Banamine with the Gabapentin so...???

My vet told me this morning that the next step was to start using OTC Tylenol.  Again, my worry has been medication overload causing more harm than good. 
--
Melissa Conn, PA, Jan 2023


Eleanor Kellon, VMD
 

Yes, Tramadol replaces everything. From what I've seen, NSAIDs, gabapentin and Tylenol (which has only been used added to NSAIDs) do very little for metabolic laminitis pain.  Tylenol is likely risky because of how many horses have elevated liver enzymes and likely fatty liver.  Tramadol has been used with gabapentin but with zero evidence it is doing anything more than Tramadol alone.
--
Eleanor in PA

www.drkellon.com 
EC Owner 2001


Melissa <mjc1133@...>
 

We ended up taking Velvet in to a Vet hospital tonight as her condition continued to deteriorate rapidly over the course of the day. They were going to work to stabilize her tonight then spend tomorrow doing a complete analysis including bloodwork, X-rays, etc. I believe she will be there for 2-3 days minimum. I did get some of Velvets labs today & the rest should be here tomorrow at which point I will work to get them posted with my case document. I will also share anything additional I receive from the vet hospital as well. 
--
Melissa Conn, PA, Jan 2023


LJ Friedman
 

I hope things get great for your horse. Just for others that are following the topic, tramadol has been shown to do absolutely nothing for dog pain as dogs don’t have the receptors that other animals do.
--
LJ Friedman  Nov 2014 Vista,   Northern  San Diego, CA

Jesse( over the rainbow) and majestic ‘s Case History 
Jesse's Photos

 


Eleanor Kellon, VMD
 
Edited

LJ,

I don't know where you got that information but Tramadol works well in dogs.
--
Eleanor in PA

www.drkellon.com 
EC Owner 2001


Elena Hernan
 

Is tramadol available through A regular Pharmacy, or in a supply catalog with script?
I am jumping in here, but Have been using everything mentioned without success-
I am trying to save Bitsy, but think about the damage of long term use of multiple meds.
She is positive Cushings, And EMS.
Struggling w/laminitis, which right now is quite bad. Any thoughts on “blocking “ her in order to get a good trim? She is non weight bearing on and off for about 10+ days. Thank you- Elena


--
Elena M. Baroni
Sonoma County,  California
Joined in 2022


Eleanor Kellon, VMD
 

Elena,

You need to get a case history and copies of radiographs up.  What is the "everything mentioned" you have tried?
See post 273130 re blocking for a trim.

If she is down, a trim won't make her any more comfortable and making her comfortable with Tramadol or anything else won't save her.  You need to control the PPID, EMS, stop any NSAIDs, etc. Things we have all see work time after time.

--
Eleanor in PA

www.drkellon.com 
EC Owner 2001


 

Maybe this study on OA in dogs? https://pubmed.ncbi.nlm.nih.gov/29393744/
--
Cass, Sonoma Co., CA 2012
ECIR Group Moderator
Cayuse and Diamond Case History Folder                
Cayuse Photos                Diamond Photos


Eleanor Kellon, VMD
 

Maybe - but depending on the type of pain it can be as effective as Fentanyl patches in dogs https://pubmed.ncbi.nlm.nih.gov/?term=dogs+tramadol&sort=date .
--
Eleanor in PA

www.drkellon.com 
EC Owner 2001


Eleanor Kellon, VMD
 

The  Conclusions and Clinical Relevance section here is a good summary https://pubmed.ncbi.nlm.nih.gov/24576316/

"Conclusions and clinical relevance: Different breeds of dogs might not or only poorly respond to treatment with tramadol due to low metabolism of the drug. Tapentadol and morphine which act directly on μ-opioid receptors without the need for metabolic activation are demonstrated to induce potent antinociception in the experimental model used and should also provide a reliable pain management in the clinical situation. The non-opioid mechanisms of tramadol do not provide antinociception in this experimental setting. This contrasts to many clinical situations described in the literature, where tramadol appears to provide useful analgesia in dogs for post-operative pain relief and in more chronically pain states. "

Tramadol itself has less direct opioid pain relieving activity than its metabolites. This study suggests some breeds may not metabolize it well so have less response but also acknowledges other studies find good results.

 We're off topic for this group so this thread is closed.
--
Eleanor in PA

www.drkellon.com 
EC Owner 2001