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ACTH/IR results - Update - on Pergolide not doing well

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  • ACTH/IR results - Update - on Pergolide not doing well

    Update 11/30/12:

    Sept test from Texas A&M showed elevated ACTH.
    Result: 84 with ref range 18.68 +/- 6.79 pg/ml.
    For this lab >47 abnormal for seasonal rise.

    Started my horse on Pergolide capsules working slowly up to 1 mg/day - which he has now received for 5 weeks. I noted side effects that I had hoped would resolve weeks into treatment. They only worsened. ie loss of appetite etc. This past week he had two colic-like episodes that resolved with Banamine. The Perg given before evening meal.
    When it would kick in he would really start losing his appetite - to the point of leaving feed, standing head down in corner of pen - then start pawing.
    Enough is enough. Stopped the Perg and he was back to his normal self the following day.

    Decision - keep him off Perg and go back to CT berries?
    Start Perg again at .25 mg/day - then try .50 mg/day? If tolerated stay at .50 day for the next months?

    My horse shows symptoms of PPID - mostly with the long winter coat and with skin problems. Every year he does eventually shed out - but the summer coat still a bit long and so he is clipped.

    His past test results are listed below from an older thread. They have been elevated but not terribly so.

    Do some folks anyway lower the dose after the seasonal rise?

    Thanks so much any help.
    -----------------------

    Past history on my 26 y.o. Arab with four Cornell tests:

    His breakfast has always been alfalfa cubes. Nothing until late afternoon feed.

    March 2009 - Fasting
    ACTH - 23
    IR - 9.43

    March 2011 - Fasting
    ACTH - 42.3
    IR - 13.78

    (April 2011 started him on a teaspoon of Chastetree Berry powder am/pm)

    Sept 2011 - Non fasting (blood pulled 3-4 hours after he started eating)
    ACTH - 96 (seasonal rise test)
    IR - 22

    June 2012 - Non fasting (still on CTB)
    ACTH - 35.7
    IR - 43.15

    Ref. ranges of Cornell:
    ACTH 9-35 Ins. 10-40

    I asked the tech to repeat what she said about the June results because they are about opposite what I expected. My horse looks like a Cushings horse with long hair coat. Shed alot this past spring but grew some back - now shedding again a bit more. Still not close to a normal horse summer coat.
    His topline is not very good.

    I see no signs of IR. He is on the thin side. No fat deposits.

    So don't know what to think.

    CBC showed mild anemia with low RBCc and low hemoglobin count.
    Vet suggested possible encysted Strongyles and a PowerPak.

    CBC otherwise normal. Fecal negative.

    Thoughts on his ACTH/IR results? Perhaps the blood was a bad specimen?
    But how could that be - to show the IR as higher than expected and the ACTH lower than expected? Or else the CTB is keeping his ACTH levels down? But why the outward symptoms?

    Sorry I wrote so much. Thanks any thoughts.
    Last edited by grayarabs; Nov. 30, 2012, 10:26 PM. Reason: add/update

  • #2
    From what I understand, CTB has no effect on ACTH, only on Cushings symptoms. My horse started it in June of last year, then got ACTH results in Aug. of 721, extremely high even during a rise.

    Do you belong to the Yahoo Cushings/IR group? Lots of info there. I think they recommend using Pergolide based on symptoms, and not just test results. They also use an Insulin/Glucose calculator that may show the chance of laminitis/IR is lower than your test results show. Or, in my case, a higher chance although his IR/Glucose was within range.

    I just stopped using CTB on my horse; he shed heavily in early spring but still has a bit of hair left, like your horse. Interested to see what others have to say about your horse.

    Comment


    • #3
      Horses can be thin and IR. more on this later.
      "Kindness is free" ~ Eurofoal
      ---
      The CoTH CYA - please consult w/your veterinarian under any and all circumstances.

      Comment


      • #4
        By "IR" in the results do you mean insulin level? Or is IR the name of a test other than insulin?

        I was under the impression that CTB had been pretty thoroughly dismissed as something effective for this disorder.

        You are sort of also comparing apples to oranges with fasting vs. non-fasting blood tests. Were all done at the same time of day?
        Click here before you buy.

        Comment

        • Original Poster

          #5
          Thanks. To add - the week prior to his blood tests I had to call a different vet to see my horse. A vet I did not know but was highly recommended. An issue arose while waiting for our scheduled appt with our regular vet. (tear ducts occluded and worsening "scratches").

          Our reg. vet was very busy and could not come. The vet that saw my horse for his eyes said he would be already starting my horse on Perg/Prascend just by looking at him. And said my horse did not look IR.

          I will be getting test copies in the mail and talk to our reg. vet about the results and what to do.

          I do not know how to post pictures here - nor is my Coth account set up to allow me to do so. I have a couple of recent photos I could email to someone.

          Re: the anemia. Eosinophils not elevated because the "parasite" (small Strongyles) encysted and "protected" from the immune system? ie the white cells don't detect anything to go after?

          PS - Yes - I belong to the EC group but have difficulty navigating through it all.

          Comment

          • Original Poster

            #6
            *added info below

            The test is coded ACTH/IR. So that is how I report it. One draw. No stimulation.

            The first two times he was tested he had been fed breakfast - then nothing - then tested mid/late afternoon. ie fasting. I misunderstood how to set up for the tests.

            The last two tests he had breakfast (alfalfa cubes as usual) - and the blood was pulled within 3-4 hours after he started eating - ie mid/late morning.

            I understand the fasting aspect would effect the insulin levels/results. But also the ACTH results?

            To add: The interim vet prescibed meds to be applied 2x/day.
            BNP ointment (with Dex)for his eyes and Silvadene (with 10mg Dex powder) for his pasterns.
            The meds were applied for five days prior to but not on the day of the blood tests. I asked if the topical Dex could effect the tests and was told that it should not.
            Last edited by grayarabs; Jun. 10, 2012, 10:38 PM. Reason: remembered and added Dex info

            Comment


            • #7
              Originally posted by grayarabs View Post
              The vet that saw my horse for his eyes said he would be already starting my horse on Perg/Prascend just by looking at him.
              I suggest you follow this advice. Your horses blood work AND appearance says PPID. Pergolide is the only thing effective, and will also reverse the depression of the immune system that is causing the skin/eye infections. Very common in PPID horses.
              Are you feeding your horse like a cow? www.safergrass.org

              Comment

              • Original Poster

                #8
                Update in first post.

                Comment


                • #9
                  Unfortunately, taking you horse off the pergolide is a bad idea. It is a tough medication to start on and needs to be done extremely slowly to help minimize the side affects. Long term though it is what will be best for your horse.

                  Testing should not be done fasting but a few hours after feeding any grain but hay before is fine. Also, Cornell is the best lab in these situations you want to test ACTH, Insulin, Glucose, and Leptin.

                  Cushing horses especially can look thin also you mention your horses top line isn't great that is also another symptom, muscle wasting, occurs in many Cushing horses.

                  IR/Cushings often go hand in hand but they are two separate diseases. Unfortunately, the Pergolide will not help his IR. He is in need of a major diet change. Alfalfa is a no no you need to find a hay and feed that is low starch and low sugar.

                  I know you mentioned you found the yahoo group and I am a member there too. I agree it can be very overwhelming but feel free to message me here and help you navigate the site as best as possible. The information there is invaluable.

                  Jingles to your horse but the good news is that this is quite manageable with medication, diet, and exercise.

                  Comment


                  • #10
                    grayarabs,

                    A friend of a friend mentioned to me once her Cush horse also could not take pergolide. It made him very ill. I'll inquire more and see if she has any info to add.

                    Comment


                    • #11
                      You may want to talk to your veterinary team and see about backing off the Pergolide a bit. You may also want to try to feed more frequent smaller meals (if your schedule permits) and add fat. That way, you can increase calories without increasing sugar and you can also help keep his blood sugar more in the middle rather than spiking. He just may not tolerate the perg very well. The good news is that if you are diligent about his diet and exercise, neither the Cushings/PPID or IR are likely to cause life threatening illness.

                      You mentioned that he doesn't have IR type symptoms because he's thin--but actually, Cushings and IR can be interesting in that horses can present on the thin OR the grossly obese side of the spectrum. Nothing is easy anymore, eh???

                      Dr. Schott over at Michigan State University has done pretty extensive studies on these metabolic conditions and quite a bit of the info is available on the MSU Veterinary website. I've attended several of his seminars and learned a lot. My mare is IR....so welcome to the club!
                      A good horseman doesn't have to tell anyone...the horse already knows.

                      Might be a reason, never an excuse...

                      Comment

                      • Original Poster

                        #12
                        Thanks. DT yes would like to know about your friend's horse and Perg.

                        Again recent results - non fasting - mid morning draw:

                        June 2012 Cornell - breakfast alfalfa cubes

                        ACTH 35.7 (9-35)
                        Insulin 43.15 (10-40)

                        Sept 2012 Texas A&M - breakfast Chaffhaye alfalfa (very low NSC)

                        ACTH 84 >47 abnormal for seasonal rise
                        Insulin 9.7 <20 normal (added this result)

                        Our regular vet is hesitant about my horse being on Perg w/o a DS test.
                        Particularly after I told her of the problems/side effects.

                        The TAMU tests were run when another vet from her practice was out for another horse and I asked that while she was there - to have him tested - even though lab would be TAMU and not Cornell.

                        The TAMU insulin test had normal results.

                        My horse looks PPID with the long hair.
                        I just don't know that having him on Perg is a good idea - seeing how he negatively reacted to it still weeks after starting on it.

                        Not that test results tell the whole picture - but it seems that his results are not that high compared to other horses.

                        My main concern is the founder risk. He has shown no signs of it.
                        He is barefoot - and trimmed regularly. My trimmer says he has the best looking hooves of all the horses she does.

                        I am scared to put him back on Perg but almost equally scared not to.

                        Thanks again all help.

                        Comment


                        • #13
                          Well, the ACTH is the safest between that or the low dose dex suppression test but having it drawn in late summer or fall can give you false highs. However, a lot of Cushings/PPID stuff is diagnosed more by symptoms than tests even. THe hirsutism is pretty much a hug red flag with a full parade proclaiming Cushings.

                          Me personally? If I already was pretty sure that the horse had Cushings, I wouldn't pursue the low dose dex suppression test because the potential risks are a little higher than I would want to take for something I could feel pretty good about based on symptoms or other test results. You might retest the ACTH in the spring and see where you're at.

                          But the June test would indicate to me (not a vet nor do I play one on TV) that he needs to be well managed because he was already borderline high then and there isn't a guaranteed cut off for what IS a problem and what ISN'T. It's just a general guideline.

                          If he hasn't had issues thus far with founder/laminitis, then as long as you keep on top of his diet and exercise I PERSONALLY wouldn't feel too badly about keeping him off the perg and just being very strict about diet/exercise keeping in mind the IR component as well.

                          Forgive me, but I didn't see how old your horse is? Especially if this is an older horse, I wouldn't be too hell bent on perg if you can otherwise manage him. You can shave him for the hirsutism. If he gets really anorexic on the perg, what good are we really doing?

                          If he is younger and it's going to be an ongoing thing, I miht be looking for some other options to get him on the perg AND get him eating.
                          A good horseman doesn't have to tell anyone...the horse already knows.

                          Might be a reason, never an excuse...

                          Comment

                          • Original Poster

                            #14
                            Thanks BR. He is 26.

                            I am leaning towards not putting him back on Perg.

                            I am trying to remember what I have read about founder risks.

                            Cushings vs IR. The risk is higher for IR than PPID?

                            Is there a number/pct for horses that have PPID and founder and those that don't?

                            (FWIW there was a mare at our barn - obvious PPID - long hair, thin, no muscles, constant drinking and urinating, hooves very narrow, high heels, untreated, not managed, and she lived into her mid 30's - never foundered) (good for her - but go figure). (my horse does not do the increased drinking/urinating thing).

                            For PPID the risk is there year round - but moreso during seasonal rise months? That time passes when? Nov/Dec? Some folks lower the Perg dose after the seasonal rise - or even take their horses off Perg?

                            Does the TAMU "negative" IR test reflect on PPID severity? ie when PPID worsens the horse becomes IR? (again - my horse tends to be thin - no fat pads etc).

                            Thanks again all help.

                            Comment


                            • #15
                              Just a quick reply I'll come back with more info later but wanted to add that because Cushings is tumor related unfortunately diet doesn't fix most of the problem. Pergolide will help to relieve symptoms I know it is a pain to start a horse on but weaning a horse onto it extremely slow should help to avoid negative side affects.

                              Comment


                              • #16
                                I think some people reduce the Pergolide dose somewhere around April. My horse is on 3.25mg and I will retest in the spring after reducing the dose to 2-2.25mg. Not sure what comes out cheaper---the high dose or the testing, but I wonder if keeping a high dose year round makes it less effective in the long run.

                                Can you give him the highest dose he will tolerate, whether that is .25 or .5mg until the spring? This may not be enough to lower the ACTH now, but it may be enough after the seasonal rise. This time of year many horses are prone to founder (stressed grass, weather changes, less exercise) and the uncontrolled ACTH can contribute to that.

                                I'm assuming you're giving him the compounded capsules, and not the powder or liquid, right? And you increased it by .25mg at least every 3 days? It takes about 2-3 weeks for the dose to be fully effective, so those weeks added to the 'veil' (I think my horse had it for a week or two) could be why you're seeing him so miserable for quite a while. BTW, my horse only went through that when I first put him on the Pergolide; he hasn't been that way since then even though he's on a triple dose now.

                                There must be someone else on the Yahoo group who has experienced this with their horse. Good luck.

                                Comment

                                • Original Poster

                                  #17
                                  Thanks. I am thinking either no Perg for now - or try again to see dose he can tolerate. As PB said either .25 or .50 mg. Are those doses too low to be helpful?

                                  I started him slowly in October at .25 for five days, .50 next five days, .75 next five days - then 1 mg. He was on 1 mg for five weeks until I stopped it this week.

                                  IIRC I started seeing side effects at .50 mg - mostly dopeyness.
                                  I had expected that within a couple of weeks on 1 mg he would be adjusted and no more problems.

                                  No one else has had a horse exhibit colic-like symptoms weeks into treatment?
                                  Losing appetite is one thing - but pawing and wanting to go down is too much for me. Thank goodness the Banamine got him through those episodes.
                                  What would the Banamine have helped with if it was not colic?

                                  FWIW my horse has been given the dose in the evening at mealtime.
                                  I was the one that gave him his Perg the nights he was colicky. I always stay and watch him eat. (Because I enjoy watching him eat). Had I not been there when the Perg hit I would not have seen the colics.

                                  What if I had not and he was not given Banamine?
                                  Most evenings he is given feed and meds (in his paddock) and no one stays around to notice that he might have stopped eating/be starting to colic.
                                  I wonder how many times that might have happened?
                                  Apparently Perg kicks in in about 30 minutes and the concentration is lower 4-5 hours later? Meaning when he is fed the following morning - he looks fine to the barn staff.

                                  Ugh - I am tired. Too many sleepness nights this week worrying about this.

                                  Comment


                                  • #18
                                    Originally posted by grayarabs View Post
                                    Thanks. I am thinking either no Perg for now - or try again to see dose he can tolerate. As PB said either .25 or .50 mg. Are those doses too low to be helpful?

                                    I started him slowly in October at .25 for five days, .50 next five days, .75 next five days - then 1 mg. He was on 1 mg for five weeks until I stopped it this week.

                                    IIRC I started seeing side effects at .50 mg - mostly dopeyness.
                                    I had expected that within a couple of weeks on 1 mg he would be adjusted and no more problems.

                                    No one else has had a horse exhibit colic-like symptoms weeks into treatment?
                                    Losing appetite is one thing - but pawing and wanting to go down is too much for me. Thank goodness the Banamine got him through those episodes.
                                    What would the Banamine have helped with if it was not colic?

                                    FWIW my horse has been given the dose in the evening at mealtime.
                                    I was the one that gave him his Perg the nights he was colicky. I always stay and watch him eat. (Because I enjoy watching him eat). Had I not been there when the Perg hit I would not have seen the colics.

                                    What if I had not and he was not given Banamine?
                                    Most evenings he is given feed and meds (in his paddock) and no one stays around to notice that he might have stopped eating/be starting to colic.
                                    I wonder how many times that might have happened?
                                    Apparently Perg kicks in in about 30 minutes and the concentration is lower 4-5 hours later? Meaning when he is fed the following morning - he looks fine to the barn staff.

                                    Ugh - I am tired. Too many sleepness nights this week worrying about this.
                                    Get some sleep. Start thinking with a fresh brain tomorrow.

                                    Comment


                                    • #19
                                      I had a 25yo that could not handle Perg. I tried every which way to wean him on to it. His was on the lowest dose the vet recommended (1mg) and still no go.

                                      I chose not to keep him on it-however he also always had a massive sinus tumor that was not operable in his situation.

                                      Even without the tumor I would not have chosen to keep him on a life extending drug that would decrease his quality of life.

                                      I also know there ARE other drugs besides Perg...you could ask your vet about those.

                                      Comment


                                      • #20
                                        Ok, now that I have a little time to read through everything I have a little more feedback for you. However, I first want to reiterate how sorry I am that you are going through this. These diseases are so tough but the good news at least that they are treatable.

                                        I know there is an over abundance of information out there and that it is quite overwhelming.

                                        First steps, which you have taken, is diagnosing through bloodwork. The biggest to keep track of are ACTH, Insulin, Glucose, and Leptin. As I mentioned Cornell is the best lab to deal with in regards to these tests but as soon as the vet collects the bloodwork make sure it is spun and put on ice ASAP. Also, there is no need to have your horse fast for any of this just breakfast and hay as normal but a few hours after any concentrates are consumed. I wouldn't recommend doing the Dex test as the other tests are accurate enough for what you need and the Dex test has been known to trigger laminitis.

                                        Now since you have confirmed via bloodwork that your horse is PPID/IR next comes diet changes and medication. Now some horse's PPID initially can be managed on Chasteberry however long term that just isn't viable. Now I know you mentioned that at .5 mg is when you started to see side affects with the pergolide. It could be that your horse is extra sensitive and is going to have to been weaned onto the medication very very slowly. I don't have a ton of experience with pergolide but I'm sure on the yahoo group someone might have seen similar reactions.

                                        Now I know you mentioned he is currently getting alfalfa cubes in the morning and chaffhaye alfalfa. Is he turned out on pasture at all? Where alfalfa in general can be tricky is that many IR/PPID horses just don't do well on it. The starch is often higher then most realize, the amino acid profile is often not compatible with many IR/PPID horses, and the minerals difficult to balance.

                                        Here are some other options that are more suitable for PPID/IR horses. Ontario Balanced Timothy Cubes can be a complete replacement for your horse, I know you mentioned your horse needs to gain weight so molasses free beet pulp is an excellent option, grass hay that has been analyzed is an option or grass hay that has been soaked for an 1hr in cold water or 30 min in hot water. Now as far as supplements go vitamin E, iodized salt, magnesium, and ground flax are recommended.

                                        Now more specifically to help the IR diet and exercise are going to be what gets this under control. I'm not sure if your horse is currently in work or not but if not hand walking can be sufficient.

                                        I know this is a lot of information and I hope it helps! I k ow it is tough my own horse is IR and it has been a roller coaster of a ride! Jingles for your horse!

                                        Comment

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