EMS, insulin levels, ertugliflozin - your experiences?

[Widgeon]

I will prefix this by saying that I trust my vet entirely and am just wondering what others' experiences have been, rather than looking for advice as such.

My cob had three weeks off in October while we got to the bottom of why he was hurting; eventually confirmed as his hock arthritis flaring up again, so nothing new there and we'll treat with steroid as we know it works well for him. However in the three weeks he was out of work he was piling on weight even on what appeared to be an unremarkable amount of grazing (although that said it was a very mild autumn). Prior to any steroids vet did a check of his blood and his insulin was far too high - 181 - consistent with a diagnosis of EMS. Based on what I know about him I suspect he's been this way since before I bought him; he's always been hard to keep slim so I manage him quite carefully anyway. We were just unlucky this autumn I think, with the time off for the painful hock coinciding with autumn grass.

Obviously we are working to get his weight and insulin levels down (soaked hay, straw - yum) prior to any steroids, so he's on Bute so he's not sore and has lost a lot of weight. As of this week, insulin is down to 121. Vet in't overly worried and has advised that the decrease in insulin tends to lag behind weight loss, but I've no idea how long we're looking at before it's down to a "normal" level that's safe to use steroids.

How long have others found that this took? And did anyone have to resort to ertugliflozin, or is the dieting and exercise more or less guaranteed to eventually do the trick? Is ertugliflozin worth a try? I'd be really interested to hear anyone else's experiences.

 

[GinaGeo]

Haven’t used Ertugliflozen personally but have heard it turn cases round, and bring insulin levels down very quickly, when it’s a bit of a last chance saloon.

I think it’s recommended to blood test regularly to monitor insulin levels and check kidney function hasn‘t been negatively effected. And I don’t think it is supposed to be used with NSAIDs, so I would check using it alongside Bute.

I managed to turn my EMS boy around with the help of Metformin, to get him comfortable. And he’s been successfully managed by management and exercise for the last three years.

 

[Widgeon]

I managed to turn my EMS boy around with the help of Metformin, to get him comfortable.

Thanks, this is all really interesting - I did wonder about metformin, I'll ask about that too next time I see the vet. I'm glad you got your horse back on track, I'm aware that some horses are much, much worse than mine so I'm quite grateful really that mine appears to be a pretty straightforward case and has never shown the slightest signs of laminitis.

Interesting about ertugliflozen and Bute, I'll ask about that too.

 

[SO1]

Do you need to use steroids could you use arthramid which does not have the lami risk?

Friends have used metformin to help get insulin levels down but exercise is also meant to be really good. If you can treat the hocks with arthramid then you might be able to get him moving more and that may help.

 

[Widgeon]

Do you need to use steroids could you use arthramid which does not have the lami risk?

No space in the joint unfortunately, we did discuss that when we first started treating the arthritis but it wasn't looking doable. I'd have gone for that if we could've done.

That's very encouraging about the exercise, I've been incredibly busy with work, so riding very little for the last couple of months - I am hoping that getting him back into work (he's comfortable on bute) will make a big difference. I'm very relieved to hear you say that!

 

[holeymoley]

You could try levothyroxin if you need to get weight down too. It speeds up metabolism so they loose weight on it but can be quite a changed character on it. I used it for 4 weeks i think it was, when mine had laminitis and it was a great help. Not used ertugiflozin as not needed to, that works by removing glucose which should bring the insulin levels down.

 

[Widgeon]

You could try levothyroxin if you need to get weight down too./QUOTE]

Thanks, this is useful to know - it's probably not needed right now as his weight is back under control with soaked hay and straw to eat, but I'm totally new to all this so it's good to know what's out there.

 

[Zoeypxo]

No space in the joint unfortunately, we did discuss that when we first started treating the arthritis but it wasn't looking doable. I'd have gone for that if we could've done.

That's very encouraging about the exercise, I've been incredibly busy with work, so riding very little for the last couple of months - I am hoping that getting him back into work (he's comfortable on bute) will make a big difference. I'm very relieved to hear you say that!

A friends horse had no joint space but after steroids didnt work they tried arthramid as a last chance saloon and it did work very well horse returned to work although much quiter life

 

[Highmileagecob]

EMS is basically type 2 diabetes. Exercise and management play a big part in controlling EMS, and it can be difficult with a good doer. Steroid therapy can play havoc with insulin levels, and a few days or weeks of irregular exercise seems to upset the balance too. I found with my cob that feeding as you are doing, combined with daily exercise when weather permitted, was effective in maintaining a balance. During summer, he was turned out 24/7, but wore a Tough 1 grazing muzzle at all times, which allowed him to access enough grass to keep him happy. Last summer, his failing teeth meant I had to abandon the muzzle, and as he is now fully retired I am holding my breath and praying he stays healthy.

 

[Widgeon]

Last summer, his failing teeth meant I had to abandon the muzzle, and as he is now fully retired I am holding my breath and praying he stays healthy.

Yes...I do worry about what we'll do when he has to retire one day - but we'll cross that bridge when we come to it. I've also found that regular exercise seems to be the key - in the summer when he's fit and we're doing "proper" hacks a few times a week, with the odd gallop, he stays in lovely shape even though he's on grass 24/7. I used to use a muzzle but I've managed to work out a strip grazing regimen that reduces the need for it, which is good as he was becoming quite expert at ripping it off! Yours sounds very similar to mine I think - best of luck keeping him well now he's not ridden.

 

[SEL]

We managed arthramid in hock joints with not much space so it might be worth a 2nd opinion on that. Mine had elevated insulin levels but nowhere near as high as yours. I didn't find levothyroxin helped at all with her weight but a friend had her Dales on ertugliflozin and was positive about the results. She'd had her on a track all summer with soaked hay and her insulin levels just weren't coming down until she did a course of it. I do think it has some nasty side effects though and I'm trying to remember where I read the article -will post it if I can

 

[Widgeon]

I'm trying to remember where I read the article -will post it if I can

Thanks, this is all really interesting - I've taken a look at this small trial (https://bmcvetres.biomedcentral.com/articles/10.1186/s12917-019-1811-2) but haven't had a proper look at anything else yet, so please do send the link if you find it.

I've had a word with our vet and I'm going to try another month of bute and work, and see where we are after that, then I'll think about ertugliflozin. My main worry is that the dieting and exercise might get his insulin levels down to a certain point, but no lower - but we'll see. I've got no real grounds for that theory, it's just a hunch. I'm under the impression that the goal is <20IU/ml....I should've confirmed that with the vet earlier, silly me.

 

[SEL]

Thanks, this is all really interesting - I've taken a look at this small trial (https://bmcvetres.biomedcentral.com/articles/10.1186/s12917-019-1811-2) but haven't had a proper look at anything else yet, so please do send the link if you find it.

I've had a word with our vet and I'm going to try another month of bute and work, and see where we are after that, then I'll think about ertugliflozin. My main worry is that the dieting and exercise might get his insulin levels down to a certain point, but no lower - but we'll see. I've got no real grounds for that theory, it's just a hunch. I'm under the impression that the goal is <20IU/ml....I should've confirmed that with the vet earlier, silly me.

I was on livery with a little Sec A who got awful laminitis after deciding to fence hop into a lush paddock. Even with box rest, soaked hay and a massive weight loss her insulin levels stayed elevated. I'm not sure whether some horses just have a predisposition to it.

Here's the article I read. I did Dr Kellon's nutrition course years ago and she has some useful stuff

Precautions When Using Canagliflozin or Ertugliflozin in Horses With Metabolic Syndrome | Dr. K's Horse Sense (wordpress.com)

 

[Highmileagecob]

I have recently sent a sample off to have a gut biome analysed, to see if I can make any diet changes that may help. One of my cob's main symptoms is that the COPD kicks in when things get unbalanced.

 

[Widgeon]

I have recently sent a sample off to have a gut biome analysed, to see if I can make any diet changes that may help. One of my cob's main symptoms is that the COPD kicks in when things get unbalanced.

Oh how interesting. A couple of years ago mine developed some sort of allergy / intolerance to dust or pollen in hay. I never found a definitive answer for quite what it is that sets his coughing off (i.e. is it the dust in hay or the pollen in hay?) but soaking the hay solves the problem (and I have to do that anyway to get the sugars out). I think in my case it's unlikely to be related as he was having no problem with a cough even when his insulin was (as it turned out) very high - but really interesting that your cob seems to have such a clear link between the two.

 

[Widgeon]

Even with box rest, soaked hay and a massive weight loss her insulin levels stayed elevated. I'm not sure whether some horses just have a predisposition to it.

Oh heck don't tell me that...haha! But seriously from everything I've seen and read I think you're right, some of them are very much predisposed to it. Mine being one of then. But we'll see how we do. Fortunately mine has never shown the slightest signs of laminitis so I can work him regularly now that I've got a bit more time, and hopefully that will do the trick.

Thanks for the blog post, I took a look at it then I had a bit more of a read about ertugliflozin and it does sound like it may be best not to use it with Bute. Because of that, and the cost of it, I think I'll see how we go with Bute and exercise for another month or two, then reassess.

 

[Highmileagecob]

I managed ten years of ridden work after diagnosis, with management alone. Being near hay in any shape or form will set him off coughing, so he has his own shelter and outdoor pen for night time, and turn out every day with the herd. Had to feed haylage, and had to keep him in work to maintain a minimum level of fitness. If he had any time off, the cough would start and it was back to walking in hand again. He's now 28 and I am adjusting his diet to cope with failing teeth. He isn't ridden any more, but does not pile weight on like he used to. Fingers crossed. Good luck with yours. Hope it is a happy outcome.

 

[Widgeon]

He isn't ridden any more, but does not pile weight on like he used to.

That's great news that you seem to have sorted it - very encouraging Mine will be fine, now I know about it I just need to be extra "on it" with his management. I've always been careful but I need to be extra careful!

 

[BimboMare]

I am on day 10 after starting our Welsh A on ertugliflozin as a last chance at treatment...

She has had PPID managed on Prascend for several years, and her ACTH levels have been normal for the last 3 years. Her Insulin levels were normal last Spring and her weight is well controlled. At the end of November, our pony developed laminitis that we haven't been able to control with box rest, strict diet control, soaked hay and Danilon with added paracetamol. She was suffering so much I called the vet to put her to sleep "if he had no other suggestions". (I was completely unable to get Metformin into her).

Vet suggested trying ertugliflozin and we started it on Christmas Eve. He has tried using other 'flozins' without success but has heard good reports of ertugliflozin so suggested a trial.

Well, I am currently impressed with the result. Although it's early days (and officially needs 21days to really assess a response) our pony has really improved by today. This morning I led her out and she actually trotted beside me when I took her for a leg stretch to the arena (first time out box in weeks). She had a good canter, and a buck and fart around the arena. I just really hope this continues.

I have weaned her down to a small dose of Danilon that I hope to stop in another couple of days. Thanks for the article SEL, I didn't know about the need for salt and will add it to her chaff tomorrow.

Happy to update with progress if anyone interested. Have to say that I haven't had the bill yet, so have no idea what the cost is!

 

[Widgeon]

Have to say that I haven't had the bill yet, so have no idea what the cost is!

I was quoted around £250 for a month, although for a much smaller pony perhaps the tubes would last longer and work out cheaper. If it works then that's not bad value at all. I'm very pleased it seems to be helping your pony, the whole situation sounds pretty grim for all of you. I think the grass last autumn was pretty unusual - we had minimal grass all summer so everything was lovely and easy, then in October the rain came and it started to grow and grow right into November. It definitely caught me out.

 

[foxy]

My boy has EMS, he is not over weight and was tested as he was not putting weight on and was very lethargic when ridden. His first results came back at 85 which is not anywhere as high as most. He has had 4 lots and we got down to 6 then his last test his levels had increased. I am feeding low sugar and starch feed and his hay is tested and he is ridden 4/5 times a week but still struggling with energy levels. But I did find out today that this can be a side effect of ertugliflozin. He seems to be in the minority as most EMS horses need to lose weight

 

[maya2008]

Joining you on this journey…our Shetland tested at 33 last week. She was already on part straw part high fibre tested haylage, and the only fat visible is on her neck (ribs easy to feel, no apple bottom). She was also already walking 30mins per day before the test. She’s improved enormously since we started her on the powdered LamiPro supplement so I am guessing her insulin levels would have been higher before. She can now trot and canter in her little mud paddock and often trots next to the kids when they are walking her.

Our vet’s advice is work her as much as she is able - they’re coming back out to assess and make a plan, and we have upped her walks to twice a day while waiting for that. I’ve recruited a sharer for when she’s ready as my kids have moved on to bigger ponies, so fingers crossed if we can get her in enough work she’ll be ok. Can’t say I will ever turn her out on spring or summer grass again though, and if she has to be retired eventually we will pts instead. No signs of arthritis though so fingers crossed she has many years of fun ahead.

 

[Widgeon]

No signs of arthritis though so fingers crossed she has many years of fun ahead.

That's good news - arthritis complicates everything! Hopefully having a sharer and getting her going in work again will do the trick. I'm planning to set up a track over the summer - sadly I think mine is another one who won't ever be allowed more than a sniff of spring or summer grass again :-(

I've just had blood test results back and we're down to insulin levels of 60 (180 in November, 120 in December, and now 60) so we are very much heading in the right direction using 24-hour soaked hay bulked out with straw. Another couple of months and we should be good to do steroids for the hock....I'll just have to be really, really careful when the grass starts to grow properly.

 

[Widgeon]

She’s improved enormously since we started her on the powdered LamiPro supplement so I am guessing her insulin levels would have been higher before.

Just to be clear, has the supplement helped the laminitis, or do you think it's also had an impact on her insulin levels?

 

[maya2008]

Just to be clear, has the supplement helped the laminitis, or do you think it's also had an impact on her insulin levels?

I have no test results from before, but she’s become noticeably sounder despite nothing else changing. Given the insulin levels will have caused the never ending won’t go away lami, it’s my guess it’s helped with that (as promised in the blurb about maintaining normal blood sugar and insulin levels). They do a specific one for ems though called Metabolic Tonic.

 

[Widgeon]

I have no test results from before, but she’s become noticeably sounder despite nothing else changing. Given the insulin levels will have caused the never ending won’t go away lami, it’s my guess it’s helped with that (as promised in the blurb about maintaining normal blood sugar and insulin levels). They do a specific one for ems though called Metabolic Tonic.

Thanks very much, that's interesting and I'll have a look at the supplement and its various ingredients.

 

[holeymoley]

Have any of you used L94 or P45 from trinity consultants for insulin levels? I use P45 through the summer. I had blood tests done for cushings etc before Christmas and my boy’s insulin was up at 300 i put it down to frosty grass, unable to soak hay, no exercise etc as we had a week or so of -7c temps. I have had bloods pulled again this week after a course of L94 and being back to normal re hay soaking, exercise etc. Mine is one of the ones that can’t afford to lose anymore weight. I’m really hoping this will be a low count.

 

[Widgeon]

Hi all, I thought I'd better post an update as I know people search this forum for info.

So, insulin went from 180 last autumn, finally down to 60 this Feb, with diet (soaked hay cut with straw) and exercise. He looked good, but still had stubborn fat pads, and then unfortunately it then crept back up to 73 in March at the first sniff of grass. So we started him on ertugliflozin.

He was initially on 5mg / day (15.1hh cob) and the fat was dropping off in front of my eyes, but it was too drastic and he was absolutely wiped out - could barely raise a trot and struggled to hack two (yes two) miles. So vet suggested dropping it to 3mg / day, which we did, and he was far, far better on that - normal energy levels.

He's been on that for around 6 weeks, with a track system and limited strip grazing onto stalky old grass. We blood tested yesterday and insulin is down to 37 - hooray! That's despite being on a bit of grass. He feels great too, perky and nice and light in canter. I need to have a chat with the vet about what to do next (probably medicate the hock and keep him on ertugliflozin another month or so to get insulin down to a "normal" range) but this is really good progress.

Additional details:
- Once he was on the lower dose he didn't seem to suffer any side effects whatsoever.
- He was having the paste in his feed every morning. We kept the syringes refrigerated until each one was in use and in the feed room.
- This is a horse who's never had the slightest signs of laminitis even when insulin was at its highest; don't ask me why, I'm sure the fact that he hacks long distances helps, but I suspect it's largely down to his individual metabolism and feet.

 

[maya2008]

That sounds good! Both I and a friend have had to gradually lower the dose (her pony has come off it) because eventually there is no more weight to lose but they keep on losing no matter how much you feed them.

My friend whose pony has come fully off it, has had one blood test and the levels have risen a little again.

 

[Widgeon]

My friend whose pony has come fully off it, has had one blood test and the levels have risen a little again.

That doesn't surprise me, I'm expecting them to go back up a bit coming off it but so long as it's only a bit, I can live with that!