EMS/Cushings - an ethical dilemma

Orchardbeck

Orchardbeck

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I suspect my mare may have equine metabolic syndrome. She is 23, a typically good doer for most of her life (14hh arab x welsh b), had a laminitis episode this time two years ago and puts weight on just looking at grass. Since the laminitis I have gone gone to great pains to keep her weight down (muzzling, antilam feed, low sugar etc), and she seems much better for it - a lot more agile and full of energy when previously she mooched around and napped (perhaps footy from too much grass).

Anyway, I am aware of tthe current LTAL campaign and the free blood testing, and have spoken with my vets about costs, treatment implications and procedures etc. I have also spoken with my farrier who also thinks there may be something hormonal going on. However, the issue I have is that the vets have quoted £50 ish per month for Prascend, should she need it.

That is a steep cost for me to bear - an extra £600 per year. As a result, I am dragging my heels to get her tested as I know that if I have a definite answer as to whether she has EMS/cushings for certain (I think she is more EMS than cushings, for what it is worth) I will be faced with a difficult decision as to whether to medicate or not.

I mentioned this worry to my farrier who agreed and said the drugs take up to two years to work properly anyway - what's to say something else may not happen to her in that time, being the age she is? (grim thought, but after a colic episode related to a dodgy feed at christmas, entirely possible).

At the moment she is doing very well with diet management and exercise - does anyone else 'manage' the condition without drugs?
 
I'm in a similar situation, in that my mare is 20 and typically appears to have metabolic issues going on. I have also heard negative things about prascend and personally if I found it was prohibitively expensive to treat then I'd do my best with diet, exercise and herbal products until quality of life was affected and then pts.

Vitex or chastreeberry/agnus castus are supposed to be helpful for cushings type symptoms and used successfully in trials by the laminitis clinic, it can be purchased relatively cheaply online.
 
Your last paragraph says it all really - 'at the moment she's doing very well with diet management and exercise.'

I lost my horse about a month ago. He was an ex racer who had cushings and was a very poor doer, but kept getting laminitis.
He wasn't medicated for the cushings as the medication made him very depressed and he would lose his appetite completely. He also had other issues going on, which made me decide to stop the medication and try for quality of time left over quantity.

It is a very difficult thing to deal with, made worse for him as he had other issues with chronic pain and arthritis.

If I had a horse that was doing very well though without medication, I wouldn't feel guilty at all about not medicating.
 
If she's doing well without medication then I definatly wouldn't medicate. My lad also has some symptoms and has had 2 borderline tests, he's on chasteberry liquid and is doing fine.
He's only 14, so I feel that I should hold off any medication for now as he's coping, he will probaby get a lot worse over the next few years and will have medication then, if he cannot cope without.
Not sure about it taking 2 years to work though, was under the impression it took a few weeks to show an effect, although getting the right dose can be tricky.
 
Pergolide is the Equivalent human licensed drug which is available in 250 micrograms and costs about £45 for 100 tablets from a local independent pharmacist. Prascend (which is licensed for horses) is not available in similar dosages so a vet can still prescribe Pergolide were that dosage is required. Simply get a prescription from your vet and take it to your pharmacist.
Pergolide is distributed my IVAX Pharmaceuticals London E16 2QJ
 
It sounds as if you are doing very well without prascend so there is no need to medicate. I had a horse on with cushings. He had to have pergolde (prascend) as no matter what we did, he kept getting laminitis. The pergolde made him very depressed & unwilling to eat. If at all possible, hold off as long as you can. I lost my horse last year after 8 years of battling with cushings. Good luck
 
Yes. Pony is only 13 and had borderline cushings and EMS tests 6 months ago. Vet wanted to do follow up tests for each, but I have stalled for the same reasons as you - didn't want to get pressured into expensive medication, some of which I haven't heard great things about (Pracend). Pony is hard work to manage but ok on hay on bare paddock, permanently looks too thin cos the only place she puts weight on is her crest, but is sound and happy. I even got her a mini pony as a friend who she loves to bits. She had 8 months worth of box rest for severe laminitis 4 years ago now and has been borderline many times since. I will not put her through that again, if she gets it, that's it, pts. Sorry if that sounds harsh, she is my pony of a lifetime and watching her suffering last time was horrible. If your pony is doing ok on diet and exercise, then save the medication for when you start struggling with that regime imo.
 
PeterNatt said:
Pergolide is the Equivalent human licensed drug which is available in 250 micrograms and costs about £45 for 100 tablets from a local independent pharmacist. Prascend (which is licensed for horses) is not available in similar dosages so a vet can still prescribe Pergolide were that dosage is required. Simply get a prescription from your vet and take it to your pharmacist.
Pergolide is distributed my IVAX Pharmaceuticals London E16 2QJ
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I've heard that due to the cascade system, vets are unable to prescribe pergolide for newly diagnosed cases, only existing ones. :confused:
 
That is right touchstone, my vet confirmed it, but pergolide is more expensive gramme for gramme than Prascend just now.
There are a couple of ways to reduce the cost - you could try her on Vitex (chasteberry) which is the herbal version. I read that it only alleviates the symptoms, rather than delay the progression, but if ACTH levels in the blood are only slightly raised it could be an option.
Or get your vet to write you a prescription and buy Prascend on line. I just got a pack of 160 1mg tablets for £136 from Vet Medic, which including the cost of the prescription (my vet charges £14, some don't charge at all) still works out at less that £1 a day. Still a significant cost, and Prascend only comes in 1mg size but you can break them in half to try a daily dose of 500 microgrammes, so you could halve that.
 
My daughter's semi-retired pony tested positive to Cushings. The vet said it was up to us whether we gave him Prascend, as we managed his condition very well with diet & lifestyle management. We decided to try at, as he is a great wee chap and we wanted the best for him.

The drug really did not seem to agree with him at all and made him very unhappy and ill. I understand that this can be temporary and you can 'work through it' but we decided not to bother as he had been happy enough before. He has Agnus Castus.

So be aware the drug is not necessarily a 'magic bullet' - like all drugs it comes with its own issues and side effects. If your pony is happy, I wouldn't go there myself - and that advice has nothing to do with the cost.
 
I have a mare who has Cushings and started on Paracend and it made really depressed and she lost loads of weight. It took 6months off it for her to get to being the same pony but older.
We want to make time stand still and make them better but sometimes its just better just to have a happy old horse and let go when the time comes. My pony is chestnut now looks like a highland cow and the hair on her legs is so long you could plait it, love her.
 
I speak as someone with a 15yo horse on prascend. Without it he would now be non existent. He has been on it for 6 months and the results have been remarkable. I also had an older arab who had undiagnosed cushings and was PTS as a result of laminitis. How I wished I had had the knowledge about cushings at that time and been able to have the chance to test him and treat him before the laminitis. He may well still be alive.
It costs around a pound a day to treat. To me animal ownership brings responsibility to find the money to treat them if necessary. Vitex is not cheap. I tried it. Didn't work and was a waste of money, better to put the money towards the correct treatment. If your horse gets laminitis again that is not cheap to treat. Much better to try and prevent it.

I don't see how you can make any judgement without testing the horse. Then you have some definite results on which to make a decision. There is no way that I would not test a horse that had already had laminitis.

I did not have a problem with side effects but I introduced prascend very slowly and carefully.

It doesn't take 2 years. Mine is now almost fully back to normal ie under control, in 6 months and had turned a corner within a couple of months. I too thought he had EMS not cushings. How wrong I was.
 
M was diagnosed as having Cushings at the beginning of the year with an ACTH reading of 44.2 (top end of 'normal' being 29).

He started on half a tablet of Prascend a day which did make him depressed, so he came off it for 10 days, then back on one quarter of a tablet a day.

He's much happier now, ears pricked, exercise building back up and his bloods were taken again last week: he's gone back down to 29.2 - so in my case, I've been very happy with the result.
 
My 20 retired gelding is on Prascend and the results were almost instantaneous. He is so much happier, one of the symptoms of Cushings is an uncontrollable appertite, which was quickly controlled and I can now maintain a healthy weight without him looking starved all the time.

Prascend is expensive, but the fact that I can manage his lifestyle so he is out 24/7 and doesn't get the recurring bouts of laminitis means tht for me the sums add up anyway.
 
Friends horse has Cushing, she is 28, only just been diagnosed, friend hasn't put her on any meds as she is managing it herself.

My appy is IR, he is on metformin because he fat bad lami three years ago and we are slowly reducing it but I doubt we will feel comfy having him off it.

It's up to you and your horse at the end of the day, if you can manage it without meds then do so.
 
paddy555 said:
I speak as someone with a 15yo horse on prascend. Without it he would now be non existent. He has been on it for 6 months and the results have been remarkable. I also had an older arab who had undiagnosed cushings and was PTS as a result of laminitis. How I wished I had had the knowledge about cushings at that time and been able to have the chance to test him and treat him before the laminitis. He may well still be alive.
It costs around a pound a day to treat. To me animal ownership brings responsibility to find the money to treat them if necessary. Vitex is not cheap. I tried it. Didn't work and was a waste of money, better to put the money towards the correct treatment. If your horse gets laminitis again that is not cheap to treat. Much better to try and prevent it.

I don't see how you can make any judgement without testing the horse. Then you have some definite results on which to make a decision. There is no way that I would not test a horse that had already had laminitis.

I did not have a problem with side effects but I introduced prascend very slowly and carefully.

It doesn't take 2 years. Mine is now almost fully back to normal ie under control, in 6 months and had turned a corner within a couple of months. I too thought he had EMS not cushings. How wrong I was.
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I agree with most of your post, but take issue with the fact that you say it is 'your responsibility to find the money' to treat them for a disease which is essentially age related; that prolongs life rather than cures disease, that not all horses do well on, and could potentially cause an owner to face financial difficulties. I'd view pts as needed as 'treatment' too in these cases where the horse is suffering. Agnus castus can be purchased for about a tenner for 60 days supply, and has been shown to help some horses.
 
paddy555 said:
I don't see how you can make any judgement without testing the horse. Then you have some definite results on which to make a decision.
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I absolutely agree. If you have the horse tested, you don't necessarily have to start the medication if they do have cushings (especially if your current management programme is working) but at least you're armed with all the facts. Then, if the horse deteriorates you know that you can give Prascend a go.
Also, it is no good assuming that the medication will be too expensive until you know how much your horse would need. My mare only needs 1/2 a tablet daily, so even though my vet charges about £1.20 per tab, it only costs me about 60p a day. And now that I've discovered Vet Medic (thanks to the lovely people at HHO :D), I know I can get it for about 85p per tablet, so only 42p per day.
When my horse originally had the test done, I decided to hold off on the medication as her ACTH levels were high but not scarily so, and I thought she was doing well enough as it was. Shortly after I changed my mind, as she kept getting abscesses (and I mean at least 2 a month!) so the vet started her on 1/2 a tablet, and it has honestly been a life-saver! She didn't become depressed on the medication, and it only took 6 or so weeks before I noticed the difference (i.e. she stopped getting abscesses!). She started the Prascend early December last year and hasn't had an abscess *touch wood* since January.

Basically, if I were you I would have the horse tested because at least then you will have all the facts.
 
I had Henry tested last year, as I knew something hormonal was going on. He still got footy despite being underweight and being exercised, plus he had the fat pads and ribby but cresty appearance. He was well below the danger zone for Cushings and vet said that he looked more EMS when she took bloods. Best thing for that is what you're doing i.e. diet and exercise. I muzzle much more, this year due to yard move and although I hate the things, I have to admit that he's like riding a 10 year old again (he's 21). From research and vet conversation, Metformin is limited in effect, anyway.

Second the agnus castus recommendation. If you're managing as you are, then if you did get a positive test for either EMS or Cushings, I'd try that first, as it sounds like your horse is early on if she has either.
 
touchstone said:
I agree with most of your post, but take issue with the fact that you say it is 'your responsibility to find the money' to treat them for a disease which is essentially age related; that prolongs life rather than cures disease, that not all horses do well on, and could potentially cause an owner to face financial difficulties. I'd view pts as needed as 'treatment' too in these cases where the horse is suffering. Agnus castus can be purchased for about a tenner for 60 days supply, and has been shown to help some horses.
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I'm sorry I didn't suggest PTS. That was simply because it never occured to me. If the horse had a high reading then there is a drug to treat it which may well give it a good quality of life for years to come. It would just never occur to me to put such an animal to sleep. Peronally I regard it as my responsibility to care for my horses into their old age dealing with whatever problems they have before finally putting them to sleep when their quality of life deteriorates. That to me is part of horse ownership however I realise that everyone doesn't think the same.
However obviously PTS it is an option. The point at issue here is that the OP doesn't have any accurate information on which to make a judgment. I don't know of any studies where vitex has improved the ACTH levels. It me that would be important.

Bear in mind OP it depends on your test result. If you got a result of around 100 would you not treat it? what about 200?
Essential IMHO (and having been there) to know exactly what you are dealing with. I have several friends where the first sign of a problem has been full blown laminitis. That is not a good place to be.
 
It's got to be about you, your horse and your own personal opinion.

There is free cushings vouchers available at the moment - must be worth it surely?
Medicating with prascend could well be cheaper than quoted - I medicate my 16.2hh on 1mg a day, purchased online in bulk (160 tabs at a time) and even with a prescription charge this costs less than £1 a day. So a monthly pharmaceutical charge of under £30 ... not so different to an off the shelf supplement of dubious benefit?

I have a late teens TBx who is retired through injury. Discovered about a year ago he was cushings and he is far far better on daily prascend.

My ethical dilemma with him was more about whether I should proactively manage his laminitis risk - and given his age and retirement status I decided not to - he is out 24/7, unrestricted in grazing (although not fed extra), he is medicated and I accept that my choice may mean he gets laminitis. When he does he will immediately be PTS. For me quality of life is more important than his quantity of life.
 
I'd just like to say that I've found this thread really interesting and thought provoking. One of my old lads has recently had a borderline result for the cushings test and the vet gave me three options:

1) Re-test using a hormone to confirm or otherwise the borderline test;
2) Do nothing until the autumn, manage his diet and do a little gentle work then re-test; and
3) Put him on Prascend anyway and see what happens.

Because the test was borderline and he is well in himself now that a low sugar, hi-fibrre diet is in operation (he'd be fat if it wasn't for his lost topline) we've decided to go with option 2 for now and 3 if he starts to deteriorate. I've very much hoping that we can carry on with option 2 as I really don't want to be giving him medication that he may not need - especially now I have heard that it may not be the godsend that some proclaim it to be.
 
If you do decide that medication is the only option, I can highly recommend asking your vet to write you a repeat prescription and to then get the medication from your local pharmacy. My horse has EMS and is on both pergolide and metformin, and for a months supply of metformin the vet quoted c.£200 which is extortionate. However, when we asked the chemist in our local Tesco how much they would charge for the exact same thing, they quoted around £20 per month! And so of course this is where we have been buying meds for the past few years, the vets just shrugged their shoulders and said that is fine for us to do it that way - no apology for the enormous mark up! It makes me very sad to think that so many horses are likely to have been pts just because of the ridiculous costs of medication from the vets.

Good luck!
 
paddy555 said:
Peronally I regard it as my responsibility to care for my horses into their old age dealing with whatever problems they have before finally putting them to sleep when their quality of life deteriorates. That to me is part of horse ownership however I realise that everyone doesn't think the same.
However obviously PTS it is an option.

I don't know of any studies where vitex has improved the ACTH levels. It me that would be important.
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But keeping an animal happy and healthy into old age and then putting to sleep when quality of life is affected is exactly what I do. I just don't consider that expensive medication that may or may not improve the horse is always the best option for every horse or owner. If you have had great results and no problems in funding it then great, but not every owner is in that position.

The Laminitis Clinic did studies with vitex, which is just agnus castus, and out of the 25 horses used 12 showed a reduction in ACTH, 9 showed an increase and 4 stayed the same. http://www.laminitisclinic.org/Vitex.htm As said previously, the active ingredient can be purchased online much more cheaply and is worth a try for the op I think.
 
3OldPonies said:
(he'd be fat if it wasn't for his lost topline)
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sorry, getting away from OP's question but lost muscle and topline would be danger signals for me if they went along with a borderlne result. That was what my cushings horse lost and what prascend gave him back.
 
That's why I'm going for a re-test in the autumn. I'm not going to just let this go away, but the vet was in agreement that with his levels as they are at the moment by managing diet and exercise we are quite safe to wait for a re-test. I do hear what you are saying though, as I've put quite a lot of worrying time on the subject of his topline.
 
touchstone said:
The Laminitis Clinic did studies with vitex, which is just agnus castus, and out of the 25 horses used 12 showed a reduction in ACTH, 9 showed an increase and 4 stayed the same. http://www.laminitisclinic.org/Vitex.htm As said previously, the active ingredient can be purchased online much more cheaply and is worth a try for the op I think.
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from the "discussion" section of that link I don't find the case for reducing ACTH levels very proven and they were trying to develop a product to sell.

there is more info on vitex half way down this page http://www.thelaminitissite.org/u-v-w-x-y-z.html

not very convincing that it is an alternative for prascend in any but very early cases. I was hopeful and tried vitex but it was a waste of time and money. I had no results whatsoever yet after only days on prascend I was starting to see results.

sitting pretty, I think the chemist route for pergolide is only for previously diagnosed horses. Newly diagnosed ones have to go via the vet route ie prascend. And yes it is a rip off. :(
 
I was at a laminitis talk recently and it was said that pergolide was being withdrawn from human use due to side affects which hasnt been seen in horses just people. I would DEFINITELY get the free test to know what you are dealing with. If he has EMS then keeping weight off and plenty of work is all they need as far as i know. If its cushings then the only effective treatment is prascend. My pony is only on half a tablet and we get a prescription from the vets and order online for the best price possible. Vitex only treats the symptoms so it wont stop them getting recurring laminitis etc.
 
paddy555 said:
I speak as someone with a 15yo horse on prascend. Without it he would now be non existent. He has been on it for 6 months and the results have been remarkable. I also had an older arab who had undiagnosed cushings and was PTS as a result of laminitis. How I wished I had had the knowledge about cushings at that time and been able to have the chance to test him and treat him before the laminitis. He may well still be alive.
It costs around a pound a day to treat. To me animal ownership brings responsibility to find the money to treat them if necessary. Vitex is not cheap. I tried it. Didn't work and was a waste of money, better to put the money towards the correct treatment. If your horse gets laminitis again that is not cheap to treat. Much better to try and prevent it.

I don't see how you can make any judgement without testing the horse. Then you have some definite results on which to make a decision. There is no way that I would not test a horse that had already had laminitis.

I did not have a problem with side effects but I introduced prascend very slowly and carefully.

It doesn't take 2 years. Mine is now almost fully back to normal ie under control, in 6 months and had turned a corner within a couple of months. I too thought he had EMS not cushings. How wrong I was.
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I agree, My horse was diagnosed with Cushings and the Prascend has his hormones under control within about 4 months. I would have your horse tested and then at least you know for definite what you have to deal with.
 
I managed my old cushings mare for years on agnus castus. She lived with cushings for about 12 years after diagnosis and with hindsight she'd had it for much longer. She outlived everything else on my vet's books that was diagnosed at the same time as her and she was well in her 30s when I finally lost her to melanoma. I know the agnus castus doesn't work for all, but it certainly worked for her - she was still hairy but she drank a lot less, was a lot sounder, and more importantly it was like the fog that surrounded her life cleared when she was on it and she was far less depressed. The way I looked at it was that if we tried the small guns first then we would still have the big guns in our back pocket if we needed them.

It is worth getting the test while it's discounted, as at least you have a baseline. But how you treat/manage it after that is up to you.
 
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