Thank you to everyone for your guidance.  Here’s where we are at:

  Changed his feed to TC Balance Timothy

  Current supplements:
       Jiaogulan from Uckele, 3/4 of a 7g scoop am & pm
       Table salt, up to 1 Tlbs am & pm, still increasing.
       E-5000 powder from Uckele (already had this but willing to try capsules if necessary. I question if he will eat them though.)
      TC Golden ground flax, just under 1/2 cup am & pm
      Uckele Phyto-Quench pellets, 1/2 scoop am & pm, just added today.

  Soaking hay, serving 2% of body weight

I will do blood work again in 2 weeks for glucose, insulin and ACTH following your guidelines.  Will also have new rads taken to benefit the farrier.  

I’ve secured a hay pick and will gather, soak, dry and submit it for 603 testing.  When I get the report back I will submit it for mineral balancing.

After reading all the links provided by moderators and also doing my own searches on the ECIR site for information, I still have questions.  Much of the data is quite old (2002 etc) and seems to conflict with current advice.

How long do I keep him on the jiaogulan?  Just found an undated report on the site about serving jiaogulan before his meal. Being a boarding barn that is a challenge.  I’ve included it in his other supplements.
 
Should I be giving Phyto-Quench pellets at the same time as jiaogulan?  The report mentioned above says that basically all the ingredients in Phyto-Quench pellets make jiaogulan less effective.  I just added the PQ today so can quickly remove them.

If appropriate to give, are Phyto-Quench pellets preferred over just devils claw?

Do I need to add magnesium oxide?  I overlooked that in the Emergency Diet list.  The TC Balance has magnesium but doesn’t specify what kind.

Overall Dot is doing much better.  He still walks very carefully but has a brighter eye and is eating well.  He is also not laying down very often now.  Not sure what to attribute this to.  We were making such good progress since his April event then he suddenly crashed.  Could have been the flu/rhino shot, the Equimax wormer or the brief run.  The gas lines on his front feet are pretty severe.  I am anxious to talk with the farrier on Monday.  She will be coming every 2 weeks now to keep the toes short.  We will discuss hoof boot options also to see if we can find something preferable to the Clouds.  Those have helped him tremendously.

Is the process somewhat automatic once you upload your case history, or do I need to request reviews of the report and hoof photos?

Thank you all SOOOO much!!
  
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Nancy O, Colorado, 2022

https://ecir.groups.io/g/CaseHistory/files/Nancy%20and%20Dot

https://ecir.groups.io/g/CaseHistory/album?id=280596

Hi Nancy,

Yes let us know when you want your uploaded files reviewed.  Your Case History hasn't been updated since I last looked.  Once you get your radiographs, you can rake a full round of hoof photos, as described here, then request a set of free markups to guide your trimmer.

With an insulin >200 in September, Dot was well on his way to another acute laminitis.   Often vaccines/dewormers are the final straw when insulin is already out of control.   I'm surprised he wasn't acutely laminitic prior to all that as insulin above 80 uIU/ml puts them in the danger zone for acute laminitis, but all horses are individuals and some can be comfortable with higher than ideal insulin.

Sounds like things are moving in the right direction and the hay soaking has helped a lot.  Jiaogulan can be served with meals, just double the effective dose.  I'm not sure why it's contraindicated with Phytoquench pellets so will be interested to hear what others say.

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

Snickers' Case History
Snickers' Photo Album

Magnesium oxide: it depends on your hay analysis.  In your case I would say yes, you should add it until you get your soaked hay mineral balancing done.  You can buy a "lifetime" supply cheaply at a feed store.  The magnesium in the TCTNB cubes only balances the cubes.  It doesn't add enough magnesium to balance your hay.  The hay cubes are a complete diet feed, not a mineral supplement.

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

Snickers' Case History
Snickers' Photo Album

Everything I can currently provide is already in the case history.  I would appreciate a thorough review so I can get all blood work done on the next vet visit.

x-rays will be done at that visit also, and fresh hoof photos after the next trim.  When that is complete I will upload and request markups.  Same plan for mineral balancing after my soak hay is analyzed.

Is jiaogulan a lifetime supplement for him, or just part of the emergency diet?  Asking only so I know how much to buy.
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Nancy O, Colorado, 2022

https://ecir.groups.io/g/CaseHistory/files/Nancy%20and%20Dot

https://ecir.groups.io/g/CaseHistory/album?id=280596

Hi Nancy,
I’m not sure a “thorough review” will come through in one post so keep your eyes open for more than just mine.  We volunteers come to our job from different perspectives and are likely to make different observations.  Rarely are they conflicting but instead add to the bigger picture.
It’s hard to address the diet without knowing his present and ideal weights.  We strive for a BCS of 4.5 to 5.  The vet scored him at a 6 at 900 pounds and you described his weight as “normal”.  You may have meant normal for Dot but we generally consider a 6 as overweight.  Now you estimate his weight at 821# and he’s still normal.  I don’t see any ribs in his photo.  Can you feel them?  He may still need to lose a few pounds but he’s not too far off.  If we fed him as though his ideal weight was 800# and he continued to gain, you would know that’s too much for him and need to cut back.  Two percent of 800# is 16 pounds, which is what he’s now getting.  If you can’t feel his ribs or easily see them when he moves, I would cut back a bit.  The 4# of cubes he’s getting is the equivalent of 5# of hay.  He needs to have loose salt, ground flax and vitamin E added to his diet.  Magnesium is also recommended until his hay is analyzed and balanced.  The Himalayan salt has impurities in it, generally iron which is a no go for IR horses and they rarely eat enough salt off a block.

You haven’t adjusted his pergolide dose in 4 years which is a little unusual because PPID is a progressive disease.  Some hold steady for longer than others but his most recent ACTH tests suggests he needs more pergolide.  We try to maintain an ACTH of high teens to low 20’s, year round, for horses with PPID on pergolide.  
If you think his weight looks good, he doesn’t need Thyro-L, which acts to jump start weight loss but you need to wean him off very slowly as his body needs to adapt to not having it.  Something to discuss with your vet.
Why did you discontinue the metformin?  His insulin is very high.  Are you soaking his hay?  I would soak the hay and feed him the emergency diet for a few weeks before the vet comes to test him again so you can see what soaking can do to decrease his insulin.  For the blood testing, I would ask for insulin, glucose and ACTH.  If you feed him soaked hay for two weeks and then test, you will be far enough along in the rise not to have that affect the results.
I’ll let someone else address the feet.  Have any changes been made to the trim since the last radiographs were taken?  That’s what I would be looking for in a new set.  If you haven’t made any corrective changes then I would expect to see more of the same in a new set of radiographs.  Radiographs are expensive and you want the most value for your investment.  This is a case where other opinions might well be different from mine and I could be persuaded otherwise.
Hope this helps!

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Hi, Nancy. A few issues. Every time you have a question, you need to post to this forum. The Case Histories and Photo Albums are not scoured by hardworking ECIR volunteers until there's a specific need. Your questions should be posted as new topics with a relevant subject line: https://ecir.groups.io/g/main/post

On Jiaogulan, the exact amount is dosed "to effect." You want to check before it's fed and then a couple of hours later to confirm that the gums are pinker. There is no fixed dose for every horse or pony. Since you're mixing it with other feed, this is especially important in Dot's case to check for pinker gums a couple of hours after it's fed. Yes, you can feed Jiaogulan with PhytoQuench as confirmed by this message from Dr Kellon. https://ecir.groups.io/g/main/message/277968
We don't know if Dot will need Jiaogulan forever. Based on my experience, I'd continue to give it for its vasodilation/pain relief effects, for it's ability to mobilize abscesses, and as prophylaxis for cold-induced laminitis/neuropathy until next spring.  Dot's trim has a way to go with those long toes, so count on continuing Jiaogulan for many months. 

After reviewing your photo album, a few things jump out. To state the obvious, you will need photos of all requested views on all four feet for hoof markups, not just the most involved feet. The views and labeling are described in detail in the Wiki. https://ecir.groups.io/g/main/wiki#Photos-and-Hoof-Evaluation-Help Also, it is much easier for your trimmer and for those of us looking at photos if you trim the hair away from the coronary band. That hair hides additional hoof wall that can trick the eye. Here's an example from my own horse: https://ecir.groups.io/g/CaseHistory/photo/7296/3381755 Last, Dot isn't eating out of a hay net. My guess is that you're changing that. To be clear, EMS ponies need the discipline of hay nets to slow down their eating and to regulate their consumption. 

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