A Cushings Comparison

Josh - April 11, 2009 - before being given pergolide to manage his Cushings

Josh's coat, at this time, was very patchy with areas of very long hair, most noticeable here along the bottom of his rib cage and as what looks like feathering on his forelegs.

Josh began taking pergolide in June 2009.  Below is a photo taken March 17, 2010.  His coat is still very thick, but of a much healthier texture and consistent length.

We will retest Josh's ACTH level in June to determine if his pergolide dose needs any adjustment.

Aha! Its NOT Just Our Imagination!

TREES current herd consists of 7 horses with confirmed Cushings, or PPID, diagnoses, and at least 3 other horses than show some symptoms, but had "normal" ACTH levels when tested.  Several times, we've discussed with our vet the possibility that the parameters defining "normal" may need to be re-evaluated.  If we had several horses showing clinical signs of PPID even when testing as Normal, it is likely that other owners experience the same thing.

Now, from the Jan2, 2009 horse.com article, "Equine Endocrine Disorders Discussed at AAEP," we see:

"It was pointed out that PPID is difficult to detect in its earliest stages, while advanced disease is relatively easy to recognize. The two most commonly used tests for PPID--resting adrenocorticotropin hormone( ACTH) concentrations and the overnight dexamethasone suppression test--can be used to confirm the diagnosis. However, these tests are less likely to yield positive results when PPID is first developing, so clinical judgment must be relied upon in these cases."

So, it's not our imagination.  Some horses exhibit clinical symptoms even though the test results do not confirm the diagnosis.

Fortunately,

"New diagnostic tests are being developed for PPID and might allow earlier detection of the disorder. These include the combined dexamethasone suppression/thyrotropin-releasing hormone (TRH) stimulation test, TRH response test (with ACTH concentrations measured 10 and 30 minutes post-injection), and oral domperidone challenge test."

It may seem odd to be so excited about these little advances but, considering that ten years ago Cushings was often viewed as a terminal illness, these "little" things can mean a lot to people caring for long-time equine family members.  The sooner a PPID patient is started on treatment and modified management techniques, the better the chances of preventing serious complications, which translates into a better long-term prognosis.

Herbal Insulin Resistance Treatment Options Reviewed

Herbal Insulin Resistance Treatment Options Reviewed

http://www.thehorse.com/ViewArticle.aspx?ID=15386

“Appropriate treatment for IR is controversial,” said Noble,” But the effective management of IR may prevent the crippling disease, laminitis.”

Some of these compounds are marketed for other uses, such as anti-inflammatories, anthelmintics, muscle builders, and coat conditioners. Scientific evidence demonstrating any beneficial effect of these herbs on insulin resistance in horses is lacking.

Noble and her coauthors emphasized, "The aim (of this review) is not to advise clinicians or horse owners about what to use, but to inform equine scientists contemplating research in this field."

Cushings/IR Talk, Jan12, 2010, Leesburg VA

Jan. 12, 2010 "Endocrine Disease in the Horse: Cushings and Insulin Resistance" will be presented by Dr. Martin Furr, professor and Adelaide C. Riggs Chair in Internal Medicine at the Marion duPont Scott Equine Medical Center ("Morven Park.")

All Tuesday Talk lectures will be held at 7 p.m. in the Marion duPont Scott Equine Medical Center's library, in Leesburg. No fee is charged for attending, but seating is limited and pre-registration is required. To register e-mail Amy Troppmann or call 703/771-6843. Additional information regarding the center and its services is available online.

Contact Kate Lee at cleepr@vt.edu or 703/771-6881.

 

For info on other scheduled talks

Cushings horses: Use topicals with care!

Its long been known that the administration of oral or injectible steroids like dexamethasone could cause complications in horses with Cushings.   This study shows that steroids in topical creams can be absorbed through the skin, causing measurable amounts to show up blood samples.

"We were really surprised to see such massive systemic changes in such a short time," Abraham said. "And this was in healthy horses.

The study, "Effects of dermal dexamethasone application on ACTH and both basal and ACTH-stimulated cortisol concentration in normal horses," was published in the August 2009 Journal of Veterinary Pharmacology and Therapeutics.

Read entire article:  Study: Topical Allergy Cream Can Produce Systemic Effects in Horses

Drum Roll, Please!

BRrdrdrdrdrdrdrdrdrdrdTT !!

Sometime last night, the shell cracked open and, both literally and figuratively, Sherman emerged!  Rather than staying sequestered in his stall all day and night, Sherm is now strolling outside on a frequent basis.  His eye has softened, he's inquisitive and seeking attention.  A far cry from the timid guy of the past few days.

Because he is very thin and is showing some physical signs that may point to Cushings, we are proceeding cautiously with Sherman's refeeding program.   Lack of weight can sometimes mask the severity of illnesses like Cushings and we want to avoid tiggering any complications like an episode of laminitis.

It appears Sherman is over his suspicion about the camera being a predator.  Don't be surprised if you see a lot of closeups of his nose from here on out!

TREES' Cushings Club

I just realized we frequently talk about our Cushings Club, but we've never really told you who the members are.  The official membership stands at six, but last summer's testing revealed two more may be at the jumping off point.  As we mentioned a few days ago, our new arrival, Sherman, looks pretty suspicious as well.  Not long ago, a diagnosis of "Cushings Disease," now known as PPID (Pituitary pars intermedia dysfunction,) was viewed by many as a death sentence.  Not any more!

And so, without further ado...........The Traveller's Rest Equine Elders Sanctuary Cushings Club:

Nate, mid 30's

Freddy, 26

Wade, 26

Sonny, 38

Josh, late 30's?

Henry, 25

Interestingly, all are geldings.  All are managed with pergolide and a carefully controlled diet (thank to all of our visitors for being very understanding about our "No Treats" policy,) and all are retested each year with pergolide dosages adjusted accordingly. 

Welcome, Sherman!

Here he is!  Our  new resident, Sherman (29,) is quite thin, but happily not as underweight as either Mona or Liz upon arrival.  It also appears, judging by the thick curly coat, that TREES may be adding another member to the Cushings Club.

Sherman, shortly after a small (too small in his  estimation) meal of Triple Crown Senior.

For now, Sherman seems a little disturbed by the camera, but we were able to catch him peeping over the door at us.

.

Thank you, Janie for helping bring this together, Amanda for filling in some details, Karol for the extra careful ride, Lori for offering Reiki when Sherman arrived, George, Heather, Catie and Jeanelle for helping to prepare Sherman's apartment, and everyone else following Sherm's arrival. 

Our new man was a little tired after his short trailer ride, so we're trying to give him some privacy for the evening.  We'll try to get more photos and post more information in the next several days.

How Beneficial Is Soaking Hay?

As a short follow-up to the previous post on laminitis, we wanted to bring attention to a study performed by the UK's The Laminitis Consortium.

Many people believe that soaking hay removes water-soluble carbohydrates, making the hay safe to feed to laminitis-prone horses. This may not be the case.

In this may 2009 study,:

“The results showed a highly variable leaching of WSC and substantially less leaching than reported previously for chopped hay soaked for 30 minutes” explained Clare Barfoot. “Very few samples reached below 10% WSC, despite prolonged soaking. The concern is that this strongly suggests that soaking may not be sufficient to render some hays safe to feed to horses and ponies prone to laminitis.”

Barfoot also says, "Soaking hay provides an additional safeguard but should not be relied upon.”

In addition, there is concern that soaking for a long time may remove so many other nutrients that deficiencies in protein, vitamins and minerals may result.

For more information, please read the Equine Science Update article, Laminitis: value of soaking hay?

Laminitis is Not a Disease

Read almost any horse-related magazine, forum, bulletin board or newsletter, and eventually, a discussion of laminitis will surface. “My horse has laminitis. What’s the best way to treat it?

The first thing to realize is that laminitis is not a disease unto itself. Laminitis - meaning “inflammation of the laminae” - is a symptom of something else going on in the horse’s body.

In other words, to control the laminitis, you must determine and treat the cause. Administering all the anti-inflammatory and vasodilating drugs on the planet will not help if the root cause is not addressed at the same time.

In TREES' case, the laminitic horses we care for all suffer metabolic disorders, some related to Cushings Disease, some not. In every case, though, all tend to have high insulin levels unless their diets are very carefully managed. In every case of active laminitis, the insulin levels were well above what is considered normal, sometimes as much as ten times the norm seen in unaffected horses.

To manage those horses' insulin levels, we think of their management in the same way we think of caring for diabetic humans. Foods low in sugars and other simple carbohydrates, small frequent meals, maximum turnout (exercise - also beneficial in keeping arthritic joints moving, and guts functioning properly), and plenty of water. In the food category, no sweet feeds, no apples, carrots, or other starchy treats, no sugar cubes, no peppermints or other candies, no cookies, no applesauce, no corn syrup, no maple syrup, no ....well the list is endless. What IS allowed is a feed low in non-structural carbohydrates, soaked alfalfa cubes, and hay (remember, though, that all hays are not created equally and greatly vary in sugar content.) That's it!

Do our horses feel neglected or unloved because they get no "treats." Of course not! Grooming, scratches and personal attention fill the definition of "treat" as well as any peppermint could. (An added plus of the "no edible treats" rule is that we don't have horses rooting around in our pockets while trying to work with them, or pushing and shoving each other when visitors arrive.)
And, of course, the ultimate benefit of eliminating every source of sugar we reasonably can eliminate is an appreciable reduction in laminitic episodes in even those horses previously deemed "chronic."

We do take a deep breath any time one of our "metabolic" horses takes one bad step but most often that bad step is not because of laminitis. Should laminitis, however, rear its ugly head again, we'll re-evaluate, find the cause, and work to resolve the underlying issue as we also nip the inflammation in the bud.

Meanwhile, since personal attention is our herd's "treat," please consider a visit. All you need to bring is your fingers! For an appointment: info@equineelders.org

Josh's New Coat

Update on Josh:

Josh arrived in April 2009, looking a little like a Lesser Virginia Yak. When I first saw a picture of him, I forwarded it to our vet with the note "I'm thinking Cushings." Her reply was something like "Yikes! I think your right."

Josh, April 11, 2009

When we ask our vet to evaluate or monitor a horse who has, or who is suspected of having, Cushings (more technically called Pituitary Pars Intermedia Dysfunction or PPID,) she takes a blood sample to measure the level of Adrenocorticotropic Hormone or "ACTH." Since ACTH levels naturally vary with time of year (its one hormone that increases as hours of daylight grow shorter, signally the body to prepare for winter,) we usually wait until late spring or very early summer to test.

In early June, we had a ACTH test festival, testing nine horses - 5 previously diagnosed were tested to see if their pergolide dosages were adequate, and 4 suspects. Two of the four suspicious looking horses were just grazing the upper end of the normal ACTH range. They will continue to be monitored and will be tested again next year. The other two of those four, however, Sonny and Josh, were added to the Cushings roster. As a matter of fact, Josh's numbers were not only high, they were "off the charts." We were not surprised. He did shed his yak coat in the spring, but it was immediately replaced by another winter coat. In May!

Josh was started on pergolide and within a couple of weeks, began to shed. He doesn't yet have a "normal" summer coat, but what a difference!

August 31, 2009

And finally, our favorite Josh update photo:

August 31, 2009

How's that for a 38 year old derierre?

More thoughts on pergolide

After an earlier post about the stability of compounded pergolide, a few other points we thought worth mentioning came to mind:

One is that there is no "standard" dose as there is for most other meds. In other words, there is nothing that says every horse should receive X mg/100 lbs body weight. It varies from horse to horse. If your starting dose doesn't seem effective, your vet may want to recheck ACTH levels and adjust as needed. We've had to adjust 2 or 3 times on some horses to get it right, waiting at least a month or more between the time we change dose and the next test. Pergolide is not one of those things that works overnight.

Second, be sure you know what concentration your pharmacy sells. We've had some pergolide that was 1mg/ml, meaning the horse gets 1 ml of liquid to get 1mg of the drug. We've also had some that was 0.25mg/ml (4 ml liquid = 1mg of drug) and now use 0.20mg/ml (5 ml of liquid = 1 mg of drug.) One advantage to the more dilute form is a lesser difference in dose if you don't measure to the exact hair.

Finally, *when* you test ACTH levels has an effect on results. ACTH naturally increases as winter approaches and is lower in summer, so season will affect your test results.. Some people compensate by giving a different dose of pergolide in the winter than in the summer. We haven't done that, but it is something to be aware of.

Is Your Horse's Pergolide Stable?

Long before it became a preferred treatment for equine Cushings, pergolide was used to treat Parkinson's Disease in humans. Serious side effects, however, led the FDA to remove pergolide from the market for human use in 2007. Since then, only certain forms of pergolide have been available for use in horses, but they had not been evaluated for stability, among other things.

Stability and Efficacy of Compounded Pergolide Examined outlines a few recommendations, based on findings of a study conducted at the College of Veterinary Medicine at North Carolina State University:

>Store compounded pergolide mesylate products in a dark container, protected from
light;
>Refrigerate products to help minimize excessive degeneration;
>Dispose of products within 30 days from date of compounding;
>Evaluate the color of the product prior to each use and discard any pergolide product that has undergone any change in color, and;
>Request that your pergolide is compounded by pharmacists that use only the officially recognized formula (by the United States Pharmacopeial Convention).

Based on comments by a regular TREES visitor, these suggestions do seem to have a big impact on how well pergolide works. Here, we only purchase two weeks worth of pergolide at a time from a pharmacy that does not compound the drug until it is ordered and it is always kept refrigerated. Our visitor has mentioned that other farms using different forms of pergolide or different storage techniques seem to see more obvious symptoms than we see here. That is far from scientific proof, of course, particularly since each Cushings patient may exhibit different symptoms to varying degrees and may respond to treatment differently than other horses. We know we are paying more for our pergolide than some other people, but it may be worth the extra expense if quality treatment helps to prevent serious complications such as laminitis.

When visiting the link to the article, please also pay attention to the sidebar concerning "Human Health," particulary if you are using pergolide powder:

In response to the demonstrated stability concerns of liquid pergolide products, there has been some discussion regarding the use of bulk pergolide powder in equine practice. According to pharmacists, this is not a realistic alternative to the, "pergolide problem" as inhalation or ingestion of pergolide mesylate by humans is unsafe. In particular, inhaled or ingested pergolide can cause damage to the central nervous system and cardiovascular system (heart and lungs).

Have you Goosed your Geezer Today?

As the hours of daylight decrease and colder weather approaches, our horses are beginning to replace their sleek summer coats with thick winter woolies. Many elder horses tend to grow thicker winter coats than they did in younger days. This is especially true of horses with Cushings Disease or PPID.

Thick coats can hide changes in physical condition. It is not uncommon for elders with marginal dental challenges to lose weight over the winter when tender pasture grass is replaced by chewy hay. Subtle changes in weight may not be immediately obvious under winter wear.

Begin now to note how your horse's body feels when you groom, scratch or hug him. Take note of the flesh, not only over the ribs, but also along the topline, over the hip bones and rump and across the shoulders. As the winter coat develops, feel under the hair for any changes in weight. Running your hand over the surface of a thick coat may not give an accurate assessment of condition.

Oracle ("Ori") shows how a Cushings coat can hide weight loss. Visually, there is no indication that Ori is underweight.

Under that coat*, however:

(*Please note, Ori was not clipped just for this demonstration. Hers was an abnormally long "cushings coat" causing her to sweat profusely, even in February. It was matted, unhealthy and putting her at risk for skin infection.)

So, goose your geezer, feel your fogey, scratch your senior. Get under that winter coat and monitor weight by feel rather than by sight. If needed, increase feed a little, use a blanket on cold nights to conserve calories, or find a more appropriate winter substitute for pasture. Its easier to prevent weight loss in winter than to put weight back on in winter. Goose early, goose often. Don't risk an unpleasant surprise when spring shedding begins.

PPID (aka Cushings)

Traveller's Rest is currently home to three horses and one pony with confirmed diagnoses of PPID, or Pituitary Pars Intermedia Dysfunction (commonly called "Cushing's Disease," or "Cushing's Syndrome.")


Researchers have found that horses with PPID have very few dopamine-producing neurons in the pars intermedia. Since dopamine inhibits the production of hormones by the pars intermediate, its absence allows excess hormone production which leads to the classic symptoms associated with Cushings.


While dietary management and supplements help control symptoms resulting from high insulin levels, and Trilostane can directly inhibit the production of cortisol, only one medication in current use addresses the dopamine deficit, believed to be the root cause of the problems.


That drug is pergolide mesylate, a medication originally prescribed for human Parkinson's patients. Upon diagnosis, all PPID horses at TREES are started on Pergolide.


Below is Oracle, diagnosed with PPID, but not yet started on treatment in this photo:



Freddie, on the other hand, has been on Pergolide for two years:
Symptoms of PPID are many and varied, though not every horse will have every symptom. Some things to watch for:

• prone to laminitis
• gains weight easily
• cresty neck
• unusual "fat pads"
• muscle wasting
• "pot belly"
• problems with thermoregulation, especially in warm or hot weather
• abnormally long, curly hair coat, year-round
• suppressed immune system
• excessive thirst and urination
• irritability in a previously good-natured horse
• occasionally, neurological complications