Zahr Update: Insulin and glucose results


Mikaela Tapuska
 

Hello,

Zahr's insulin and glucose labs are now uploaded into his file, and his case history is updated as well. When we did his blood test he didn't get his beet pulp w/ supplements at night check the night before or the morning of, only hay up until his bloodwork for the 24 hours prior (I was foolish and gave him 2 small crunchies out of habit when I brought him in - no molasses, just the little Hoffmann's cubes - but the vet said that little bit wouldn't have any effect). He was inside away from his hay for about 40 min prior to his blood draw.

His numbers came back as follows: https://ecir.groups.io/g/CaseHistory/files/Mikaela%20and%20Zahr/Tapuska_Zahr%20-%20IDEXX%20NSGLU%20results-%20May%209,%202022.pdf
Insulin: 37.2 uIU/mL
Glucose: 5.1 mmol/L

And from the ECIR calculator results:
G:I Ratio: 2.47
RISQI: 0.16
MIRG: 12

So I suppose this makes a lot more sense as to why he keeps having these episodes, even though I thought everything was controlled with the pergolide. I chatted with the vet yesterday morning, and she said since his insulin is pretty high even with the dietary changes we'd made prior to the test (cut out Nutrena feed, switched to RSR only beet pulp) we'll need to get him on something more to control it. She recommended either thyroid powder or Metformin for a couple of months to see if we can get that number down.

I was thinking to start with the thyroid powder first and work our way up to Metformin if that doesn't help, but now that I've had a chance to do some reading in the forum it doesn't sound like the thyroid powder would actually help to lower his insulin levels? There is some conflicting information online saying that it boosts metabolism and can encourage the body to use the insulin more effectively.

So would Metformin be the better choice for him? I haven't picked up the thyroid powder from the vet yet, and still have time to call and get his prescription changed. The main thing that worries me with that one is the mouth ulceration from it being caustic. He currently gets everything he needs in his feed - mineral balancer, DC & PEA for pain relief, etc. - so if he stopped eating it because of a sore mouth that would be a really big problem. I could see about having it syringed, that's how he gets his pergolide and he is a super good boy for that, but rinsing his mouth out after he gets it may be a bit much to ask of the barn owner if this is a long term thing. I can certainly discuss it with her though.

We are also on a transition hay for the time being, he is off the 1st cut brome mix now and is on an orchardgrass/fescue/timothy mix and should be getting a new hay by the end of June. I don't have an analysis on the current one, in the past this mix has been one that's been safe with all the sugar-sensitive horses at the barn, but now that I have these numbers I am pretty concerned about Zahr and I will get that tested asap. Hopefully we don't have to go to soaking his hay, but if we have to we'll make it work somehow.

Zahr has an appointment next week to have his ACTH levels rechecked, too, so I'll have that shortly to add to his case history.

As always, any suggestions would be much appreciated.

Thank you!

--
Mikaela Tapuska in Calgary AB, 2021

Case History: https://ecir.groups.io/g/CaseHistory/files/Mikaela%20and%20Zahr

Photo Album : https://ecir.groups.io/g/CaseHistory/album?id=274255


Sherry Morse
 

Hi Mikaela,

Zahr is definitely IR and good that you're getting his ACTH checked as that will indicate if he needs a bump in pergolide or not.  His insulin level is not in the danger zone so at this point I would suggest focusing on diet control AND getting the ACTH check done vs. using Metformin or Thyro-L.  Thyro-L will not have an effect on insulin so don't waste your money on that.  Zahr also doesn't look like he needs to lose weight which is what it is most commonly prescribed for so again, that shouldn't be a consideration.  As you only changed his diet a week before testing you don't really have a good sense how high his insulin was pre-diet change so were he mine I'd concentrate on making sure his diet is as tight as possible, get the ACTH checked and if he shows any signs of insulin going up (increased fat pockets, more of a crest) then consider Metformin.  




Mikaela Tapuska
 

Hi Sherry,

That's really good to know, and the vet did mention that the thyroid powder was usually for overweight horses which as you said, is not his case. He has gained a little bit of weight since the weather has gotten warmer (I'd still say he's around a 4.5/9) which is typical of him. To me he actually looks healthier, like he is in good shape for his age and condition and he has put on some muscle with that, as well. The vet and my farrier also commented on that (in a positive way).

What would be a reasonable amount of time to expect his tightened diet to have any impact on his insulin levels lowering? 

I was really worried this morning when I was reading the diagnosis article on the ECIR website, since it sounds like with his G:I ratio being far lower than the normal 10:1 and his RISQI under 0.2 he is at a high risk of laminitis. Is the level of the insulin itself the best red flag for another episode, and what is the danger zone level be for that? (Apologies, I looked it up on the site and couldn't find the number)

That sounds like a good plan to wait on adding any more drugs into the mix until we know for sure about his ACTH levels. I guess if those have gone up again then it would be pointless to add the Metformin if increasing his pergolide would solve the problem.

Thank you!

--
Mikaela Tapuska in Calgary AB, 2021

Case History: https://ecir.groups.io/g/CaseHistory/files/Mikaela%20and%20Zahr

Photo Album : https://ecir.groups.io/g/CaseHistory/album?id=274255


Sherry Morse
 

Hi Mikayla,

You should see a difference in blood test results in about 2 weeks although it may be more noticeable in terms of how the horse is acting before that.  We've found that insulin over 80 uIU/mL is where most horses will show signs of laminitis so Zahr's levels are high; but nowhere near that yet.    

It's a bit tricky figuring out the medication when you have a horse that's PPID and IR but since his insulin is not in that danger zone I think you have some wiggle room to sort out if elevated ACTH is playing into the elevated insulin or not.




Mikaela Tapuska
 

Hello again!

Zahr's ACTH results came in today, and we are in the high range again at 21.1 pmol/L. Or at least, high for him. He seems to be pretty sensitive to increases in ACTH - when he had his initial (and to date, worst) laminitis episode, he had ACTH levels of 24.7 pmol/L. So this is one more piece of the puzzle that helps explain his elevated insulin levels even with the dietary changes.
Lab results: https://ecir.groups.io/g/CaseHistory/files/Mikaela%20and%20Zahr/Zahr%20-%20ACTH%20May%2025,%202022.pdf

I am not panicking yet because his diet is under control, but I would like to get his ACTH lowered ASAP so that he doesn't have another flare up. When he had an episode last summer, his ACTH was incrementally higher than the IDEXX lab reference range at 10.1 pmol/L and my vet recommended we double his dose of prascend from 1 mg to 2 mg. He has been on this dosage since June 2021. I've yet to talk to my vet yet about this one (I got the results tonight while I was at work), but given Zahr's history would it be overkill to jump straight up to 3 mg daily to nip this in the bud or would 2.5 mg be more reasonable?

On that note, I think if I have to increase Zahr's dosage again I need to look into getting compounded pergolide for him instead of prascend. Although the latter works it is going to be too expensive to keep up at this dosage. So I need to find a compounding pharmacy that gets fresh pergolide in, if I remember correctly from other messages? 

At least this should mean that Metformin is off the table for now (hopefully) if his IR is mainly being aggravated by high ACTH levels right now and not getting out of hand on its own, so small silver lining there!

As always, any input is very much appreciated. Thank you!

--
Mikaela Tapuska in Calgary AB, 2021

Case History: https://ecir.groups.io/g/CaseHistory/files/Mikaela%20and%20Zahr

Photo Album : https://ecir.groups.io/g/CaseHistory/album?id=274255


Kirsten Rasmussen
 

Hi Mikaela,

That ACTH is very high.  I would definitely go up to at least 3mg and retest, and you likely need to go higher for the seasonal rise.  Note that 1mg compounded pergolide is not the same as 1 mg Prascend.  Approx 1.3 mg compounded is equivalent to 1 mg Prascend.  To make sure the dose doesn't drop when you switch, ask your vet to write the prescription as "x mg pergolide as pergolide mesylate".  Or, do the math....if you want the equivalent to 3 Prascend, you need 3 x 1.3 = 3.9 (4) mg compounded.

If you keep some Prascend on hand you can add it to the daily compounded pergolide to quickly increase the dose if/when needed, then get a new prescription for the full dose as compounded pergolide once you settle on a therapeutic dose.

In Canada we recommend using Island Pharmacy.  They are very good and will share their 3rd party potency testing with you or your vet upon request.   Talk to Kathleen at the Shawnigan Lake branch if you have questions.

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


Mikaela Tapuska
 

Hi Kristen,

Good to know the dosage difference between the two, thank you for the heads up. I'm going to try gradually increasing his dose to 3mg over the next few days, as the pergolide veil was quite noticeable when we doubled his dose last year. He'd already had his 2mg this AM so I gave him the extra 0.5mg when I saw him in the early afternoon (not sure if it'll have any effect that way but at least it gets the meds into him). He'll be on 3mg daily by Sunday.

And I'll get ahold of Island Pharmacy right away, thank you for letting me know about them!

--
Mikaela Tapuska in Calgary AB, 2021

Case History: https://ecir.groups.io/g/CaseHistory/files/Mikaela%20and%20Zahr

Photo Album : https://ecir.groups.io/g/CaseHistory/album?id=274255


Mikaela Tapuska
 

Oh, additionally I keep reading about APF in the forum and that it is a good product to help offset the pergolide veil, albeit that it is ideally given a few days before the medication increase. Will it have a similar effect even when given after increasing his pergolide? And is APF something they have to stay on full time once to keep the pergolide veil under control or is it given only for a short treatment period until improvements are seen?

Thank you!

--
Mikaela Tapuska in Calgary AB, 2021

Case History: https://ecir.groups.io/g/CaseHistory/files/Mikaela%20and%20Zahr

Photo Album : https://ecir.groups.io/g/CaseHistory/album?id=274255


Sue Ring
 
Edited

Hey Mikaela!!

I did not know about the "veil" until my horse exhibited the signs and went off of his feed....which I was using as a carrier for his supplements, Vit E, salt, flaxseed, PhytoQuench etc.  So to answer your question I did start him on APF AFTER the veil started, as I did not know about it until then....he rebounded and regained his appetite within 2 days so for us, it was a game changer.  I have kept him on it.  It seems to be good for him, he has shown no adverse reaction to it, he tolerates the pergolide well and he is on 3 mg......BUT, his recent bloodwork was so good, I am talking to the vet tomorrow about when/if to reduce him.  I know "seasonal rise" is ahead so we may just stay status quo to be sure he is well supported and continues to drop.......his ACTH went from over 1,000 (yes!!!! that's ONE THOUSAND) to 148!!!!  I know APF is pricey but what we have managed to do so far seems really good.  He is not IR.  I think Dr K said most horses should be on at least 8 ml of APF and that is where we are at.  I am thinking I will continue to supplement him until after seasonal rise and see where we go from there.  Best of luck with everything I hope APF works well for you!!!
--
Sue R in NC 2021

CASE HISTORY:  https://ecir.groups.io/g/CaseHistory/files/Sue%20and%20Shifty

PHOTO FILES: 


 


Sherry Morse
 

Hi Sue,

It would be helpful if you could update your Case History but 148 is still a very elevated ACTH and reducing the dosage when ACTH is well controlled is not something we recommend.  That just means you've found the dosage that works for your horse. 




Eleanor Kellon, VMD
 

Sue,

Are those post TRH numbers?  If so, it's still abnormal and I wouldn't drop his dose. Could you please update your case history?
--
Eleanor in PA

www.drkellon.com 
EC Owner 2001


Kirsten Rasmussen
 

Hi Mikaela,

Its difficult to get APF in Canada but I know one of our Canadian members looked into it a year or 2 ago and it was possible then.  You could try calling Auburn Labs to see if they have any ideas for sourcing it here.  Typically it is only given through the dose adjustment period as I believe it's quite expensive.  But some people do keep their horses on it long-term because it seems to help them so much.

Usually, without APF we recommend very slow titration in sensitive horses. ...ie, 1 or more weeks at 1/4 increase, etc.  That said, the higher the dose the horse is on already, the less of a veil they seem to get; it's as if they get used to it with time and exposure. 

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


Sue Ring
 

Hey Sherry,

Working on updating CH.  I misspoke and tried to edit my response, maybe did not/has not appeared??  I am speaking to my vet this week about proper dosage for upcoming seasonal rise and while I am VERY happy that he had such a dramatic drop in his ACTH numbers, I realize I need to keep him on this  downward ACTH trend and not pull back his dosage at this critical time.  Thanks!!  Very happy to be getting my boy back and to have found a pathway that is working thanks to your help and all those who contribute here, especially Dr Kellon!  
--
Sue R in NC 2021

CASE HISTORY:  https://ecir.groups.io/g/CaseHistory/files/Sue%20and%20Shifty

PHOTO FILES: 


 


Mikaela Tapuska
 

Thanks everyone, good to know regarding the APF. Perhaps I'll see how he does with this change, since we've already gotten started with the increase, and then go from there in deciding whether to try and bring it up here or not. Luckily so far he hasn't had issues with his appetite during dosage increases (knock on wood), he just gets quite lethargic and seems sleepy most of the time. Granted, that side effect of the pergolide has never entirely gone away since it showed up, so maybe I am misunderstanding the pergolide veil effect if it's usually more of a temporary effect during the actual medication increase.

Is it possible to split the prascend pills up accurately into quarters? I know they break in half well but I thought there were issues splitting most pills beyond that, as the manufacturers can't guarantee where in each half the active medicinal compound is concentrated. But knowing that, since he is sensitive, I think I'll keep him at 2.5mg for a few days longer before increasing it again to 3mg.

Thank you!

--
Mikaela Tapuska in Calgary AB, 2021

Case History: https://ecir.groups.io/g/CaseHistory/files/Mikaela%20and%20Zahr

Photo Album : https://ecir.groups.io/g/CaseHistory/album?id=274255


Sherry Morse
 

Hi Mikaela,

The problem with 1/4s is the spliting isn't very accurate.  Martha has a breakdown for syringing that she'll hopefully mention (I'm not having much luck doing a search to find how she does it).  This might help as well for the dosage increases Re: Insulin, leptin levels question (groups.io) Re: I'm blind or something (groups.io) as far as how to do the 1/4 increase.




 

Hi Michaela and Sherry,
I would divide the tablet in half along the break line and add one of the halves to a small measured amount of water, say 4ml.  Mix well and then draw up half of that amount (2ml) into an oral syringe and administer it.  Draw the remaining part up into the syringe put it in a dark cool place to administer tomorrow.  the Prascend will break down in water but not so rapidly that you will lose its effectiveness in a few days.  You could also do the mixing in a syringe and just administer half of it but that can get tricky so I don’t recommend that.
--
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


 
 


Mikaela Tapuska
 

Ah, I didn't realize that it would last overnight dissolved in a syringe, that is super handy. Thank you both for the advice on that! 

--
Mikaela Tapuska in Calgary AB, 2021

Case History: https://ecir.groups.io/g/CaseHistory/files/Mikaela%20and%20Zahr

Photo Album : https://ecir.groups.io/g/CaseHistory/album?id=274255


Frances C
 

Messing around to see if this works since I have a plethora of 6 cc syringes. For 1.25 mg Prascend. 
Insert 1 mg tab into syringe #1 and then draw in water to desired level.
Insert 0.5 mg tab (half) into syringe #2 and then draw in water to 6 cc level
Inject 3 cc of mix in syringe #2 into syringe #3 while holding finger over end piece then carefully insert plunger. You should have 3cc in #3
Store either #2 or #3 in refrigerator for next day.
I clean syringes after each use and they last me about 3 weeks. I purchased 100 of them for about $10.00 from a diabetic supply store online
--
- Frances C.
December 2017, Washington & California
Case history: https://ecir.groups.io/g/CaseHistory/files/Frances%20and%20Phoenix
Phoenix's Photo Album: https://ecir.groups.io/g/CaseHistory/album?id=12382


Mikaela Tapuska
 

Zahr is now on 3mg of Prascend daily, we worked him up slowly this time and he responded really well. His appetite for hay has remained (he is being a fusspants about his supplements, but that started a while before I made any changes to his meds) and he is still relatively bright, he doesn't seem to have been hit by the lethargy this time which is great!

Unfortunately, the vet is unwilling to write a prescription for compounded pergolide so we will have to make do with Prascend for a little while longer... However, I was able to contact another vet in this area who will, it is just going to be about two weeks before she can come do an exam on Zahr in order to write the prescription for him.

Based on the estimated timeline that Island Pharmacy gave me for the meds shipping out once the prescription is in, we'll likely hit the 3 week mark of being on 3mg Prascend daily by the time they arrive. So my question is, should I test Zahr's ACTH again at the 3 week mark of being on 3mg/day Prascend, or would it be better to give him another 3 weeks of being on the equivalent in compounded pergolide to make sure that he is responding to it the same way he is to the Prascend? My thoughts were leaning towards the latter, if that is to be the medication he will stay on going forward it would make most sense to test his ACTH levels in response to that itself. But of course, on the flipside that will be pushing him closer to the seasonal rise, which is probably already starting to take effect with it being mid-June. Any recommendations?

Thank you!
--
Mikaela Tapuska in Calgary AB, 2021

Case History: https://ecir.groups.io/g/CaseHistory/files/Mikaela%20and%20Zahr

Photo Album : https://ecir.groups.io/g/CaseHistory/album?id=274255


 
Edited

Hi Mikaela,
I would probably wait until he’s been on the new formulation 3 weeks before testing, as long as you can do it before August.  You don’t know for sure that he’s being controlled by 3 Prascend, so don’t be surprised if the testing says he needs more.  Just be sure to adjust the dose promptly if needed.
The fall rise technically begins with the summer solstice which is approximately today.  It starts slowly and builds so you have a little time but not much.

edited to correct terminology.
--
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