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Cushings treatment for the "doesn't test for it" horse?

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  • Cushings treatment for the "doesn't test for it" horse?

    My 22 year old Paint gelding is clearly showing the beginnings of Cushings. Vet was out in April and we pulled blood, but he was easily in the normal range. However....she and I both agree he's "got the look", though to be fair, he's always been a bit chubby, tended toward cresty, and doesn't tolerate heat well. Exercise helped all that tremendously. But now that he's retired-- I cannot support two in training/boarding so he's home-- I am not getting him ridden enough to really manage his weight that way and his old, arthritic hocks are happy not working anymore.

    He is on restricted pasture, low sugar orchard, no grain (just a pelleted vitamin) and a pinch of alfalfa to make him love me ( ).

    But his new symptom is his enlarged and hardened sheath, and increased smegma/smell. So...do I contact my vet and put him on prascend? His buddy is on it, and does beautifully on his dose. Vet was hesitant as he just isn't testing but admits that isn't always the end all. Any other measures I should be taking? I have plunged into a few online Cushing's sites but I'm overwhelmed.
    Proud member of the "Don't rush to kill wildlife" clique!

  • #2
    Are you managing his diet as well?

    Comment

    • Original Poster

      #3
      As in low sugar hay, restricted amounts, no grain, limited pasture? Yes. What do you recommend? Vet was pleased with his diet.
      Proud member of the "Don't rush to kill wildlife" clique!

      Comment


      • #4
        Originally posted by Calvincrowe View Post
        As in low sugar hay, restricted amounts, no grain, limited pasture? Yes. What do you recommend? Vet was pleased with his diet.
        Yeah that's all I meant. Figured you would be with another similar horse. Right, I missed that you said this in your original post. Sorry about that!

        Comment


        • #5
          What exactly do you mean by "test for it"? I'm not trying to be rude, only to figure out what evidence you have (or could potentially add to your arsenal) in this situation.

          I've also personally been in the midst of trying to figure out if symptoms in an aging horse are early signs of PPID or not, and IME not all vets take the same diagnostic approach to metabolic disorders. Based on talking extensively with vets at the local vet school and another well-respected practice about it, it's my understanding that:
          • Resting ACTH can be in the normal range in a horse that has clinical signs of PPID, and this is not uncommon in the early stages of the disorder.
          • TRH challenge testing is more reliable for diagnosing early PPID than simply checking plasma ACTH in a single sample.

          So if your vet drew a single blood sample and tested ACTH, (s)he is likely to be able to distinguish a pretty well established PPID/Cushings situation based on those results. But a horse that has a suggestive symptom or two and is in early stages of PPID is more likely to be identified with the TRH stimulation (where they take a baseline sample, administer TRH, and take a second sample several minutes later). If you haven't done a TRH stim test, it might be worth talking to your vet about it.

          Another thing to note is that a fatty sheath and other fat deposits (e.g. along crest) can be associated with insulin resistance, which doesn't necessarily entail PPID/Cushings. If that's what you're dealing with, your low sugar diet and other preventative management steps are the core measures involved with treatment, but you may need to double down on some of the dietary management (e.g. get really detailed and serious about balancing vit/min/macronutrients and get really really painstaking about controlling sugars and starches) to keep up with where his body is headed. A TRH test might help you figure out whether you're dealing with PPID (which pergolide will help with) or IR (for which pergolide might not be the best way forward). For IR, the testing usually involves measuring insulin, glucose, and leptin in a blood sample.

          Some resources that I've found helpful are the Equine Cushings and Insulin Resistance Group and this summary of diagnosis and treatment of equine PPID. Both have some pretty straightforward explanations of the diagnostic pathways for identifying metabolic diseases without glossing over too much detail.

          It can be really frustrating to get to the bottom of some of these metabolic problems without letting things progress too far -- good luck getting answers and figuring out the way forward!

          Comment


          • #6
            I have one who may be similar to your horse's situation, so I'll share my experience of the last 2+ years. Easy keeper , 24 year old Fjord. A bit cresty but not terribly so. Vet brushes it off a bit as being a breed characteristic. Small fat pads on shoulders and tail head if I don't keep his weight tightly under control. Had one crazy summer and winter when he would sweat in weird patterns and without obvious reason (like on a 15 degree day). At that time his coat was also growing out a bit curly. He did shed like a normal horse, not a Cushings horse though. Once I insisted that the vet test, horse showed up normal on several ACTH tests, but did have slightly elevated insulin level and low thyroid.

            According to the numbers, the vet diagnosed IR and low thyroid. He was put on a low NSC diet with small hole hay nets. He was also put on a low dose of Thyro-L so see if we could bring his weight down a bit and get rid of fat pads. This combination did lead to improvement even though I had already been feeding pretty much an IR diet for years (appropriate measured amount of hay, ration balancer only, no grain).

            Still had mild sweating issues. Vet and I agreed that he really was pre-Cushings inspite of lab numbers. With vet's, blessing, I started him on chasteberry (which has several pergolide-like compounds in it.) Sweating has disappeared (except when appropriate, such as after a good workout). This spring his hair coat grew in straight and he no longer looks like a Cushings horse. I'll keep him on the chasteberry unless he starts showing much more obvious signs. I am prepared to go to pergolide if needed. A this time the vet doesn't really want to yet. He is also now on Heiro, which is an IR supplement. It's pricey and I've recently talked with my vet about using less pricey Remission instead. She says several of her clients have had good results with it too. (Knock wood, he has never had any laminitic issues, but I'm not ready to tempt fate at this point.)

            x-halt-salute covered the IR issue quite nicely, so I won't repeat, but will say I second those comments and recommendations. Good luck, it can be a frustrating puzzle at first.

            Comment


            • #7
              Originally posted by x-halt-salute View Post
              WBased on talking extensively with vets at the local vet school and another well-respected practice about it, it's my understanding that:
              • Resting ACTH can be in the normal range in a horse that has clinical signs of PPID, and this is not uncommon in the early stages of the disorder.
              • TRH challenge testing is more reliable for diagnosing early PPID than simply checking plasma ACTH in a single sample.
              My vet says this, and this has been relayed by several posters here in the past too

              You'll have to wait for Dec 1 though for the TRH Stim test, unfortunately.
              ______________________________
              The CoTH CYA - please consult w/your veterinarian under any and all circumstances. - ET

              Comment


              • #8
                Originally posted by JB View Post
                You'll have to wait for Dec 1 though for the TRH Stim test, unfortunately.
                Why after Dec 1?

                The reference levels published by Tufts Equine Endocrinology group specify mid-Nov through mid-July as the appropriate season for testing (in the Northern Hemisphere) and my vet usually treats Aug-Dec as the "seasonal rise" window. I had the test run on my horse just a couple weeks ago, so I'm curious if there's something I'm not aware of (but should be) about early summer TRH stim testing!

                Comment


                • #9
                  Curious what the ACTH numbers were? I agree that a horse developing Cushings may not have numbers in the positive range, but I am curious if they were actually "low" or just "normal" - e.g. close to the borderline positive. A retest might be worth doing. (Or the TRH instead).

                  Comment


                  • #10
                    Originally posted by x-halt-salute View Post

                    Why after Dec 1?

                    The reference levels published by Tufts Equine Endocrinology group specify mid-Nov through mid-July as the appropriate season for testing (in the Northern Hemisphere)
                    https://now.tufts.edu/news-releases/...ls-ppid-horses
                    "At present, the TRH stimulation test should only be used between December and June, which is the only period in which cut-off values have been established. " though your link is a newer date than this one.

                    This book (Interpretation of Equine Labratory Diagnostics, 2018) says "no reference values for mid-July to mid-November", but then only gives numbers for positive-for-PPID if you're in the Dec-June time frame, which leaves the last 2 weeks of Nov in limbo
                    https://books.google.com/books?id=FL...cember&f=false

                    So I guess to be safe I'd go with Dec 1. I guess if you do it Nov 25 and get ACTH significantly higher than 110 you'd know it's a positive LOL

                    and my vet usually treats Aug-Dec as the "seasonal rise" window. I had the test run on my horse just a couple weeks ago, so I'm curious if there's something I'm not aware of (but should be) about early summer TRH stim testing!
                    Yes to the Aug-Dec-ish as a seasonal rise. With the ACTH test, a marginally PPID horse may not have a significant enough rise to raise red flags. Early PPID horses may have a normal ACTH test this time of year. I've never seen anything about any TRH testing from June-Dec, though I'm not entirely sure why as I just don't know enough about how all those hormones and drugs work.
                    ______________________________
                    The CoTH CYA - please consult w/your veterinarian under any and all circumstances. - ET

                    Comment


                    • #11
                      My 20 year old has been treated for Cushings with Prascend for the last two years with decent results up until recently. He never tests 'positive', or even borderline high. After ruling out any other potential issues for the slow shedding, loss of topline, increased drinking etc, etc, my vet contacted Cornell after his last test. They recommended a trial on Prascend to see if there was improvement in symptoms. Jack showed good improvement on the medication, so we are continuing to treat.
                      The medication along with a controlled diet has helped tremendously. He's recently showed signs of slow shedding again, so we are increasing the dose.

                      Comment


                      • #12
                        Originally posted by Calvincrowe View Post
                        My 22 year old Paint gelding is clearly showing the beginnings of Cushings. Vet was out in April and we pulled blood, but he was easily in the normal range. However....she and I both agree he's "got the look", though to be fair, he's always been a bit chubby, tended toward cresty, and doesn't tolerate heat well. Exercise helped all that tremendously. But now that he's retired-- I cannot support two in training/boarding so he's home-- I am not getting him ridden enough to really manage his weight that way and his old, arthritic hocks are happy not working anymore.

                        He is on restricted pasture, low sugar orchard, no grain (just a pelleted vitamin) and a pinch of alfalfa to make him love me ( ).

                        But his new symptom is his enlarged and hardened sheath, and increased smegma/smell. So...do I contact my vet and put him on prascend? His buddy is on it, and does beautifully on his dose. Vet was hesitant as he just isn't testing but admits that isn't always the end all. Any other measures I should be taking? I have plunged into a few online Cushing's sites but I'm overwhelmed.
                        When you say was “tested” for it..did your vet do the tsh stim test ..with pre & post stim blood samples?? That’s the only way to truly indicate if your horse has elevated acth due to Cushings(PPID)...I wouldn’t put my horse on Prascend unless he absolutely had Cushings ...other things that can be done are giving Thyro L, and a metabolic supplement such as Metaboleeze or something similar...grazing muzzle in spring & fall if overweight...steaming or soaking hay to reduce sugar , and feeding an appropriate low starch/sugar feed
                        R.I.P. "Henry" 4/22/05 - 3/26/2010 We loved you so much....gone but NEVER FORGOTTEN...i hope we meet again

                        Comment


                        • #13
                          Originally posted by ladipus View Post
                          .I wouldn’t put my horse on Prascend unless he absolutely had Cushings
                          Except there are a lot of situations, quite a few presented on this board if you use the right search terms to find them, where "absolute" was not part of the situation. But things were "hmmmm" enough that the vets, and universities concurring, decided "won't hurt, let's see if it helps" and many times it has. We're understanding more and more about Cushing's and how the current tests, especially ACTH, are not always very good at picking up early bloodwork issues, and you just have to go on what's going on with the horse in front of you.

                          That doesn't mean you just put the 25yo who has a bit of loss of topline on Prascend just to see, it's not a starting place. You go through all the other more likely culprits first, but then at some point if those things aren't making improvements, it's something to try. If that doesn't help either, then just wean him off.

                          ...other things that can be done are giving Thyro L, and a metabolic supplement such as Metaboleeze or something similar...grazing muzzle in spring & fall if overweight...steaming or soaking hay to reduce sugar , and feeding an appropriate low starch/sugar feed
                          While that's pretty appropriate for the IR/EMS horse, it isn't likely to do anything for the pre-pre-PPID horse (though won't hurt at all), unless he's also overweight (and weight *loss* is often one of the earliest symptoms of PPID). It never hurts to feed a horse as if he is, or is likely to become IR. It may not be necessary to go to extremes if he's not actually IR, but the easy keeping, muzzled and still overweight horse does need special attention.
                          ______________________________
                          The CoTH CYA - please consult w/your veterinarian under any and all circumstances. - ET

                          Comment


                          • #14
                            Originally posted by JB View Post
                            With the ACTH test, a marginally PPID horse may not have a significant enough rise to raise red flags. Early PPID horses may have a normal ACTH test this time of year. I've never seen anything about any TRH testing from June-Dec, though I'm not entirely sure why as I just don't know enough about how all those hormones and drugs work.
                            Thanks. I think Tufts is working on "fall" reference levels for TRH stim testing, but obviously we don't have that just yet.

                            I'm pretty comfortable with early June testing and my vet's interpretation of results (and would probably be comfortable testing right about now, too, though not much later in the year). If Tufts and local vet school both think reference levels are legit through June I'm not going to fret. Window would definitely be closing for OP if they want to pursue the more sensitive test, though.

                            Comment


                            • #15
                              I have been actively dealing with horse/ponies on the metabolic spectrum since 1996. Prior to that, I suppose I was working with them, but I didn't know what I was seeing in terms of giving it a name.

                              In all of that time, I have seen every different permutation on testing you can imagine. My personal opinion is that the testing is more valuable to a Vet (they make money on testing) than it generally is to the animal you are dealing with.

                              Without a base line, for example, from when that animal was asymptomatic, IMHO, you've got nothing, because the testing is simply too broad in it's parameters. Even if you did have a before and after, I simply do not think that you have much.

                              There is no harm whatsoever in feeding horses who might be at risk a low carb diet from the get-go. Everyone here gets fed that way, and the way that I look at it is that it's healthier for them anyway. If you have a horse who has moved to the danger zone, you probably need to be a bit more careful, and add meds, but if you are already working with a feed program that addresses the possibility, IMHO you are way ahead of the game. If your program doesn't put the animal at risk, you are going to get alot further.

                              I believe that there have been serious efforts to have people do testing to support the efforts of those trying to study metabolic issues, however, while their intent may be to do the best they can for the animals, at the end of the day, I am completely on board with a local Vet, who has stated that if it looks like a metabolic horse- treat it like one.

                              Every time I see a thread saying OH MY GAWD!! Brownie FOUNDERED! I feel horrible for owner and beast, but I also consider that more often than not, it shouldn't be a surprise when your overweight, cresty pony with adipose fat pads around their tail head comes up laminitic.
                              When someone shows you who they are, BELIEVE them- Maya Angelou
                              www.americansaddlebredsporthorse.net
                              http://www.asbsporthorse.blogspot.com/

                              Comment


                              • #16
                                The researchers and vets I've talked with about PPID all agree that our currently available lab tests (endogenous ACTH and TRH-stim) are not sensitive enough to pick up Cushingoid horses until an advanced stage of the disease has been reached. I watched an excellent presentation a few years ago that confirmed this suspicion via necropsy, and my experience with Montana was in line with this thinking. He never tested outside the high end of the normal range for resting ACTH. We treated him based on clinical signs (excessive urination, slightly delayed shedding, and topline wasting). He was on Prascend daily for several years. I had him necropsied after we euthanized him, and his anterior pituitary was 50% larger than normal. NO ONE who didn't know that horse very, very well would have recognized PPID in him.

                                Most vets who are up on the current research are of the "if it walks like a duck..." mindset when it comes to PPID. Since the clinical signs are in and of themselves diagnostic, for the most part, blood work is more about ruling out co-morbidities (like IR/EMS) and monitoring treatment response.

                                TLDR version - if it were my horse, I'd start treatment immediately.

                                Comment


                                • #17
                                  If you haven't already, I would run a test for insulin resistance. It's much more accurate than the Cushing's test, and the symptoms are all maddeningly similar, so I would definitely want to rule that out. My old gelding's IR was diagnosed after an enlarged sheath and it's basically impossible to tell the difference between the two diseases going solely by symptoms.

                                  That said, my guy also never tested "positive" for PPID over a period of several years, but it was another "walks like a duck" situation. My vet started him on medication after a long period of tests and observation, so it wasn't a first resort. But, Prascend was absolutely helpful and if I were in the same situation again, I'd turn to it sooner than I did, because everything was right in front of us apart from that confirming test.

                                  Good luck! It sounds like you're doing everything right, and I hope things work out well.

                                  Comment


                                  • #18
                                    Originally posted by MareBegger View Post
                                    If you haven't already, I would run a test for insulin resistance. It's much more accurate than the Cushing's test,
                                    More accurate for what? An IR test doesn't look at ACTH. The ACTH test doesn't look at glucose level response times. IR and Cushing's are entirely separate diseases.

                                    and the symptoms are all maddeningly similar,
                                    Usually not. The IR horse tends to be a total food-hound (because they're usually also leptin-resistant) and overweight, unchecked they often develop a crest and fat deposits. The Cushing's horse tends to lose weight/muscle mass as a first symptom, not to mention the stereotypical hair shedding issue.

                                    Often IR issues come on the heels of Cushing's, but there are plenty of Cushingoid horses who never become IR, just as there are plenty of life-long IR horses who later develop Cushing's. The tests are very different because the causes are very different.

                                    My old gelding's IR was diagnosed after an enlarged sheath and it's basically impossible to tell the difference between the two diseases going solely by symptoms.
                                    Often it's very easy to point to one disease or the other based on symptoms, as long as they aren't co-existing.
                                    ______________________________
                                    The CoTH CYA - please consult w/your veterinarian under any and all circumstances. - ET

                                    Comment


                                    • #19
                                      Originally posted by Montanas_Girl View Post
                                      The researchers and vets I've talked with about PPID all agree that our currently available lab tests (endogenous ACTH and TRH-stim) are not sensitive enough to pick up Cushingoid horses until an advanced stage of the disease has been reached. I watched an excellent presentation a few years ago that confirmed this suspicion via necropsy, and my experience with Montana was in line with this thinking. He never tested outside the high end of the normal range for resting ACTH. We treated him based on clinical signs (excessive urination, slightly delayed shedding, and topline wasting). He was on Prascend daily for several years. I had him necropsied after we euthanized him, and his anterior pituitary was 50% larger than normal. NO ONE who didn't know that horse very, very well would have recognized PPID in him.

                                      Most vets who are up on the current research are of the "if it walks like a duck..." mindset when it comes to PPID. Since the clinical signs are in and of themselves diagnostic, for the most part, blood work is more about ruling out co-morbidities (like IR/EMS) and monitoring treatment response.

                                      TLDR version - if it were my horse, I'd start treatment immediately.
                                      It sounds like you're recommending against TRH stim testing based on your false negative experience with resting ACTH testing.

                                      While there are, of course, incipient PPID cases that go undetected by any of the available tests, the TRH stim test has a sensitivity of 94%, I believe, vs. 80% or so for resting ACTH this time of year, so it could potentially be a valuable diagnostic tool for OP.

                                      A differential diagnosis that also includes IR testing could also be a useful next step. As JB notes, IR and Cushings/PPID are two separate diseases and the symptoms that OP notes are entirely consistent with IR without PPID.

                                      Prascend treatment without a confirmed diagnosis is certainly worth considering, but the best available endocrinology research suggests that there are more and better diagnostic steps that could be pursued if jumping straight to a drug trial doesn't make sense to OP or OP's vet. I know that my vets, who are "up on the current research" in that they do some of that research, tend to opt for diagnostics beyond springtime resting ACTH before calling on the old "walks like a duck" adage and starting a horse on Prascend.

                                      Comment


                                      • #20
                                        Originally posted by x-halt-salute View Post
                                        It sounds like you're recommending against TRH stim testing based on your false negative experience with resting ACTH testing.

                                        While there are, of course, incipient PPID cases that go undetected by any of the available tests, the TRH stim test has a sensitivity of 94%, I believe, vs. 80% or so for resting ACTH this time of year, so it could potentially be a valuable diagnostic tool for OP.
                                        I'm not recommending against testing at all - just pointing out that, while a "positive" test is confirmation of PPID, a "negative" test is not necessarily definitive. While the TRH stim test is slightly more sensitive than resting ACTH testing, it still can't detective the disease until the horse reaches an advanced stage. That's all. PPID symptoms - especially the hair coat changes, which have no other identified cause - are often treated as diagnostic for this reason. It's important for horse owners to understand this so that they don't get a false sense of security from a negative test result.

                                        Comment

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