EMS/laminitis diagnosis in 21 year old ISH, non good-doer, not overweight

Kingofmagic05

Kingofmagic05

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Hi all.
Some of you may have seen my previous post about my 21 year old ISH coming down lame a couple of weeks ago.
Came out the stable lame on Monday 22nd December. Initially thought it was an abscess, had both the farrier and vet and they couldn't find anything. Vet advised box rest and bute for 7 days then reassess. Stopped bute on Saturday 27th as IU thought if it was an abscess, this would prevent it coming to a head. Found a thorn in right fore heel on Sunday 28th and thought that was the issue. Poulticed to get any remaining nasties out. Unfortunately by Tuesday 30th, he was crippled lame and couldn't even walk, obviously by this point the bute had worn off. Got the vet out straight away, as he started shifting weight onto hind legs - the typical laminitis stance. Got rushed to the vet hospital that evening and was diagnosed with EMS and laminitis. Insulin was at 307 - only meant to be 47. He is not a great doer over winter and is 3/4 TB and 1/4 ID. He is therefore leaner than your average ISH. Baffled as he is not overweight and isn't on high sugar feeds - in fact, all the feeds he is on are EMS friendly.
He is due to come home today from the hospital and I'm just stressing myself out on how to manage him. I have downloaded an app on my phone which tells me the NSC/fructose levels of the grass in our area so I know when to/when not to turn out.
Anyone else on here in a similar situation to me? Non-obese, non-EMS-characteristic sports horse type that has managed to develop EMS? If so, please can you advise me on how you manage?
Thanks in advance!!
 
This is a very wide reaching subject so just a few bits to get you started. There is a lot of reading needed
I would expect the vets to give you precise instructions as to what to do especially how much your horse is allowed to move with laminitis. They may give him medication for the EMS aspect. I would be very surprised if they let you turn him out onto grass both because of the grass(EMS) and because of movement in a laminitic horse

I presume they have tested for PPID cushings? This is very important and I presume as you haven't mentioned it you have no symptoms and a very negative test. If not I would be having a serious look at this and unless the ACTH test results are very conclusive perhaps looking at TRH testing

Have a look at thelaminitissite.org There is so much info on there both about PPID, EMS and dealing with them

Have you thought about winter laminitis (as well as EMS)
this link is worth a read to give you some info if you have not heard of this https://www.urbanhorse.com/urban_ho...MpZacQVcXb0rFfRznW_aem_5C8BmxLNiAFa85FysyC3FA

I have a similar horse, for mine no grass. Just not possible for him to have grass, he nibbles any grass on the side of his track and that is all and that is summer and winter. They are all different as to what they can tolderate. His feeds are unmollased sugar beet, timothy haylage, spillers L & L balancer, vit E, salt, Thunderbrook herbal chaff, micro linseed and VERY low sugar hay. You could have a look at hi fibre nuts, hay cobs, any of the dengie chops if he can eat alfalfa.

Mine is booted. Booted overnight in the stable and also on rubber matted stable, and booted when he wanders outside in the daytime. His feet are always kept warm. He is also very well rugged.

as I said this is a vast subject so this is just a start. Good luck with getting him home
 
I see you are new so welcome, you may not realise how popular this subject is :D:D

this thread is worth a read.

FieldOrnaments

Thread 'EMS management support/solidarity thread?'

Dunno if this will get any responses but I know there's a few people dealing with this horrid disorder - gosh give me a poor doer anyday over it! - so wondered if anyone would be interested in a thread for collective brainstorming and just a bit of support.
I've got two with it, D is on week two of ertugiflozin and currently lost 17kg and now in work. New forest is unfortunately now unsound due to arthritis (ironically from being in to get her off grass) and only lost 7kg
Can you get caregiver burnout from endlessly soaking hay? 🤣🤣
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I have been reading up a lot and have friends who have horses with EMS so have had chats to them, however, their horses are fat natives.
His PPID Cushings test came back negative.
He has never ever had an issue with any metabolic conditions or laminitis before now. So I would be very surprised if the vets advised no grass at all as he has grazed all his life perfectly fine. May be more of a case of limited turnout.
When you say booted, I'm assuming you mean hoof boots? Merlin is shod so never had to use them before. He is also well rugged and kept warm in a stable full of deep straw.
I have had him for 15 years (and several other horses before that), and EMS/laminitis is luckily something I've not had to deal with till now, so I'm just asking as many questions as possible!
Thank you!
 
I had a TB who got EMS and lami out of the blue one winter when she was about 6. Battled with it for a few years in the days before the drugs we have now. Joined a forum, watched as we all tried and horse after horse didn’t successfully make it back to grass. In the end I kept her off grass for two years - straw and low sugar haylage, no alfalfa, no anything that could set her off. Eventually, her system reset and she went back out on poor grazing, being eventually able to live out once more into her old age.

Also have a Shetland with it now - it’s age. She had access to the drugs and the difference they make is the whole world. Even off grass we couldn’t get her sound enough for the exercise she needed. With drugs, we could achieve that. She is now sound, off the drugs, in lots of work and happy.
 
Welcome to the yard clique no one wants to be a part of.
Unfortunately EMS doesn't care about breed and it's not uncommon in Irish draughts although you're correct that being overweight does predispose horses to it. There is also some limited research suggesting risk of insulin dysregulation may be increased by the usage of endocrine disrupting chemicals.
I would be interested to know if you also have results for adiponectin and if you have done a TRH stim test.
With acute laminitis padding by either boots or manual wrapping the feet and deep beds of small shavings can bring relief. Alongside bute you can also ask about paracetamol. Cold hosing is also good for pain relief and cold exposure also increases insulin sensitivity. It would be worth thinking about removing shoes to improve blood flow.
In terms of long term management unfortunately limiting turnout is not necessarily ideal if it also means limited movement ie stabling. Most modern pasture grass is not designed for horses, as it tends to be high sugar, high NPK low fiber like ryegrass. Horses need relatively large amounts of low nutrient, high fiber, remembering in nature they'd be grazing, and moving at the same time, 16 or more hours per day.
Ideally EMS horses should have <5% combined sugar and starch roughage in high quantities. Soakrd hay, straw and certain commercial chaffs - topchop zero, honeychop oat straw, dengie meaddowlite, soaked speedibeet - are what the diet should be based off, with vitamins and minerals added back in. Ad lib of these on a dry lot or track is ideal.
To improve insulin sensitivity and lower blood glucose going forward, there are various supplements that can be used but very high doses are required:
Ceylon cinnamon at doses of 220mg/kg
Nettle extract at 200mg/kg
Vitamin E min 15,000IU
Chromium (picolinate is the easiest to find form) 1000mcg /100kg body weight
Magnesium oxide

Boswellia can be a useful adjunct to pharmaceutical anti inflammatories in acute laminitis.
If adiponectin is LOW, astragalus can be useful to elevate it.
When the horse is able to move freely again exercise really helps. Interval training type work is more useful than long, slow pieces of exercise; the important thing is to elevate the heart rate for at least 10-15 min. As much turnout as possible without exposure to very sugary grass is good. Muzzles can be useful if the horse tolerates them but can't be worn 24/7. Cold exposure and weight loss, even if the horse isn't overweight, can be helpful; lots of us have found we can lower our horses insulin significantly by getting them to a body condition score many would consider far too lean (e.g multiple ribs visible). Clipping, even just a bib clip, and/or leaving unrugged, encourages activation of non shivering thermogenesis in brown fat which lowers blood glucose and improves insulin sensitivity.
If insulin is still high despite management changes there are drug options. Metformin is one, but has very low (less than 20%) bioavailability in horses so you need a LOT to see any change, and many animals don't respond at all. In such cases it's useful to ask about the class of drugs called gliflozins, which effectively mean sugar is filtered out of the blood by the kidneys and lowered that way
However they can elevate liver enzymes so bloods need to be monitored (milk thistle supplementation alongside can help).
If there is also Cushing's present the only thing that will prevent disease progression is treatment with pergolide/prascend, though it needs to be introduced slowly to avoid 'the veil' (syndrome of depression, inappetance, dementia, & lethargy). the TRH stim test also can't be used once a horse is medicated. The drug has a very short half life (~7hr) so splitting the dose into 2 or even 3 maintains a more stable level in the serum and can both help the PPID more and avoid side effects. I find fenugreek in feed (an appetite stimulant) can be useful.

I'm sure I've forgotten many things here, and I will caveat it with the disclaimer that I am neither vet, nor scientist, nor especial authority on EMS/PPID; just a passionate, nerdy owner who dreams of a day when no horse or pony or person has to deal with these horrible diseases.
 
Kingofmagic05 said:
I've just had vet back on the phone - glucose is back to normal but unfortunately he has been diagnosed in the early stage of PPID Cushings.
Click to expand...


That isn't the bad news that it sounds like. You now have a reason for the laminitis and I assume the vet will prescribe Prascend, which is usually very effective for controlling Cushings. The down-side is that Cushings/ PPID is a progressive condition.
 
Kingofmagic05 said:
I've just had vet back on the phone - glucose is back to normal but unfortunately he has been diagnosed in the early stage of PPID Cushings.
Click to expand...
That is not necessarily a bad thing as once on Prascend for the Cushings it may be enough to keep her free of laminitis and have more sound years ahead. Mine stayed sound for 5 years on Prascend and he was older than yours.
 
FieldOrnaments said:
Welcome to the yard clique no one wants to be a part of.
Unfortunately EMS doesn't care about breed and it's not uncommon in Irish draughts although you're correct that being overweight does predispose horses to it. There is also some limited research suggesting risk of insulin dysregulation may be increased by the usage of endocrine disrupting chemicals.
I would be interested to know if you also have results for adiponectin and if you have done a TRH stim test.
With acute laminitis padding by either boots or manual wrapping the feet and deep beds of small shavings can bring relief. Alongside bute you can also ask about paracetamol. Cold hosing is also good for pain relief and cold exposure also increases insulin sensitivity. It would be worth thinking about removing shoes to improve blood flow.
In terms of long term management unfortunately limiting turnout is not necessarily ideal if it also means limited movement ie stabling. Most modern pasture grass is not designed for horses, as it tends to be high sugar, high NPK low fiber like ryegrass. Horses need relatively large amounts of low nutrient, high fiber, remembering in nature they'd be grazing, and moving at the same time, 16 or more hours per day.
Ideally EMS horses should have <5% combined sugar and starch roughage in high quantities. Soakrd hay, straw and certain commercial chaffs - topchop zero, honeychop oat straw, dengie meaddowlite, soaked speedibeet - are what the diet should be based off, with vitamins and minerals added back in. Ad lib of these on a dry lot or track is ideal.
To improve insulin sensitivity and lower blood glucose going forward, there are various supplements that can be used but very high doses are required:
Ceylon cinnamon at doses of 220mg/kg
Nettle extract at 200mg/kg
Vitamin E min 15,000IU
Chromium (picolinate is the easiest to find form) 1000mcg /100kg body weight
Magnesium oxide

Boswellia can be a useful adjunct to pharmaceutical anti inflammatories in acute laminitis.
If adiponectin is LOW, astragalus can be useful to elevate it.
When the horse is able to move freely again exercise really helps. Interval training type work is more useful than long, slow pieces of exercise; the important thing is to elevate the heart rate for at least 10-15 min. As much turnout as possible without exposure to very sugary grass is good. Muzzles can be useful if the horse tolerates them but can't be worn 24/7. Cold exposure and weight loss, even if the horse isn't overweight, can be helpful; lots of us have found we can lower our horses insulin significantly by getting them to a body condition score many would consider far too lean (e.g multiple ribs visible). Clipping, even just a bib clip, and/or leaving unrugged, encourages activation of non shivering thermogenesis in brown fat which lowers blood glucose and improves insulin sensitivity.
If insulin is still high despite management changes there are drug options. Metformin is one, but has very low (less than 20%) bioavailability in horses so you need a LOT to see any change, and many animals don't respond at all. In such cases it's useful to ask about the class of drugs called gliflozins, which effectively mean sugar is filtered out of the blood by the kidneys and lowered that way
However they can elevate liver enzymes so bloods need to be monitored (milk thistle supplementation alongside can help).
If there is also Cushing's present the only thing that will prevent disease progression is treatment with pergolide/prascend, though it needs to be introduced slowly to avoid 'the veil' (syndrome of depression, inappetance, dementia, & lethargy). the TRH stim test also can't be used once a horse is medicated. The drug has a very short half life (~7hr) so splitting the dose into 2 or even 3 maintains a more stable level in the serum and can both help the PPID more and avoid side effects. I find fenugreek in feed (an appetite stimulant) can be useful.

I'm sure I've forgotten many things here, and I will caveat it with the disclaimer that I am neither vet, nor scientist, nor especial authority on EMS/PPID; just a passionate, nerdy owner who dreams of a day when no horse or pony or person has to deal with these horrible diseases.
Click to expand...
He's ISH so IDxTB - 3/4 TB so a lot leaner than your average ISH!
Vets have added padding to feet, recommended not touching his shoes until he is comfortable enough to do so. He is on a very deep bed of straw at home - not allowed shavings unfortunately but vet is happy with him being on straw. He's been on intravenous pain relief up till yesterday when he started back on oral bute, which he has responded well to.
I have downloaded an app which tells me the sugars in the grass in my area at any given time which will help me allocate his turnout time when he is ready to go back out. At the moment he is very much in the acute stage of his laminitis so getting that under control and keeping his insulin levels at a safe level is key atm. Vet has recommended literally just a handful of dengie hifi-lite just to give him his meds.
He was retired prior to this due to a previous suspensory injury. He can hack, he just isn't the easiest and I don't enjoy it but if it means regulating his insulin then he may need to resume his hacking career.
He's a poor doer so ribs are visible anyway. I wouldn't want him to lose anymore weight and vets have said the same.
He's been diagnosed today with PPID Cushings so they've started him on Prascend.
I am an ex-pharmacy tech so I am familiar with metformins and gliflozins ((SGLT2) inhibitors).
Vet seems to think he should be able to be managed through diet and Prascend. He is coming home this evening and we shall re-assess in 7 days when the vet comes back to see him. I haven't seen his full report yet as will get this when I collect him.
I have so much faith in Pool House vets where he has been. They've been excellent. I'm trying not to jump the gun and I am going to start with all the basic management techniques before I think of further drugs etc and follow my vets guidance.
Thank you for your info/advice!!
Its a minefield. I've had him 15 years and I honestly never ever thought he'd be the type to get lami.
 
Gloi said:
That is not necessarily a bad thing as once on Prascend for the Cushings it may be enough to keep her free of laminitis and have more sound years ahead. Mine stayed sound for 5 years on Prascend and he was older than yours.
Click to expand...
How old was yours when diagnosed if you don't mind me asking? :)
 
Kingofmagic05 said:
I've just had vet back on the phone - glucose is back to normal but unfortunately he has been diagnosed in the early stage of PPID Cushings.
Click to expand...
I also have a non overwieght EMS/laminits ISH. (well, the laminitis was 2-3 years ago now) I manage mine on a track system, strip graze in the spring/summer. use a Flexible Fillies muzzle if necessary, then gradually allow access to the middle of the fields with the other horses in late autumn /winter. Mine was also suspected PPID, but the vet said not to test so close to the episode as could get a false positive , and in fact tested ok , and has been ok ever since. Ertugiflozen (sp) bought the levels down really quickly, after 24 hours, the horse was so much more comfortable. I do test bloods regularly to keep an eye on things on both fronts, but so far, so good. Mine is retired with neck issues so not in work. lives out 24/7 as much as possible. Good luck with yours
 
rextherobber said:
I also have a non overwieght EMS/laminits ISH. (well, the laminitis was 2-3 years ago now) I manage mine on a track system, strip graze in the spring/summer. use a Flexible Fillies muzzle if necessary, then gradually allow access to the middle of the fields with the other horses in late autumn /winter. Mine was also suspected PPID, but the vet said not to test so close to the episode as could get a false positive , and in fact tested ok , and has been ok ever since. Ertugiflozen (sp) bought the levels down really quickly, after 24 hours, the horse was so much more comfortable. I do test bloods regularly to keep an eye on things on both fronts, but so far, so good. Mine is retired with neck issues so not in work. lives out 24/7 as much as possible. Good luck with yours
Click to expand...
This is so useful! Thank you!
Unfortunately mine is kept at my husbands dairy farm so no access to track system, however I may be able to strip graze his paddock. I'm assuming you get your vet to do the regular blood tests? Did you know they had EMS before they came down with laminitis?
 
Good to hear you have a diagnosis, and can make plans for his management. Cushings laminitis is a totally different kettle of fish to grass or stress lami. The pain levels can be very difficult to manage, and autumn/winter is the prime time for it to appear. Some horses can go completely off their food during the first six weeks of Prascend. Crushing the tablet onto a jam sandwich may help to get that down the hatch, plus anything else you can think of to keep forage going in. Insulin and blood sugar balance is a worry, but if there is a good response to Prascend, that becomes easier to manage as the condition is being held in check.
My Arab/Welsh was unlucky. He didn't respond to Prascend, and his pain levels became unmanageable. Fingers crossed your horse starts to make good progress.
 
Kingofmagic05 said:
This is so useful! Thank you!
Unfortunately mine is kept at my husbands dairy farm so no access to track system, however I may be able to strip graze his paddock. I'm assuming you get your vet to do the regular blood tests? Did you know they had EMS before they came down with laminitis?
Click to expand...
Ah, mine is on very poor / natural grazing. Yes, vet does the bloods. We went from appearing perfect fine, had feet trimmed as usual by our lovely farrier. After he'd finished, he said, " Can you drop me a message in a couple of hours, tell me how she is? I dont think she's quite right" ( he has known her most of her life). Then he loaded up his stuff, turned to me and said, " Actually, just get the vet, I dont think you'll be wasting your money". Lovely Vet came straight out, said she had laminitis, ran bloods, and said " because of EMS". Total bolt from the blue. (And it was absolutely nothing to do with the way she was trimmed, the farrier is amazing, does loads of remedial work with vets). With ongoing management, we always changed one thing at a time, ( like more grass/ bucket feed etc) and ran bloods to see the effect. She was on ulcer stuff too, as she really dislikes being stabled, although she had company next door.
 
Gloi said:
That is not necessarily a bad thing as once on Prascend for the Cushings it may be enough to keep her free of laminitis and have more sound years ahead. Mine stayed sound for 5 years on Prascend and he was older than yours.
Click to expand...

I was just going to post the same. A diagnosis is a good thing really as it's possible to prevent a reoccurrence once on medication.
 
My little mare is 26 this year. She presented with very similar symptoms to yours last July, she has low starch/low sugar feed and low sugar forage. Rocking laminitis stance so I called the vet and tested her for ppid/Cushing's. She's positive. We've put her on Prascend , one tablet a day, and she's turned out with a muzzle which she hates. But she's moving around and keeping the blood flow going to those hooves. Farrier initially put leather pads on her to keep her comfortable and he now feels she can have them off.

His advice was to keep her moving, bring her for walks like you would your dog, so she went for in hand walks for as much as I could tolerate.

She's 6 months in the Prascend and she's in flying form, back to chasing her younger friends around the field bucking and squealing as if she's one of them.
I'll get her out for little walks under saddle once I can ride again myself after my own illness.

It is a progressive disease so I'll be monitoring her with advice from vets and farrier along the way.
 
Highmileagereindeer said:
Good to hear you have a diagnosis, and can make plans for his management. Cushings laminitis is a totally different kettle of fish to grass or stress lami. The pain levels can be very difficult to manage, and autumn/winter is the prime time for it to appear. Some horses can go completely off their food during the first six weeks of Prascend. Crushing the tablet onto a jam sandwich may help to get that down the hatch, plus anything else you can think of to keep forage going in. Insulin and blood sugar balance is a worry, but if there is a good response to Prascend, that becomes easier to manage as the condition is being held in check.
My Arab/Welsh was unlucky. He didn't respond to Prascend, and his pain levels became unmanageable. Fingers crossed your horse starts to make good progress.
Click to expand...
I'm so sorry to hear that your horse didn't respond. That's so sad. :(
 
rextherobber said:
Ah, mine is on very poor / natural grazing. Yes, vet does the bloods. We went from appearing perfect fine, had feet trimmed as usual by our lovely farrier. After he'd finished, he said, " Can you drop me a message in a couple of hours, tell me how she is? I dont think she's quite right" ( he has known her most of her life). Then he loaded up his stuff, turned to me and said, " Actually, just get the vet, I dont think you'll be wasting your money". Lovely Vet came straight out, said she had laminitis, ran bloods, and said " because of EMS". Total bolt from the blue. (And it was absolutely nothing to do with the way she was trimmed, the farrier is amazing, does loads of remedial work with vets). With ongoing management, we always changed one thing at a time, ( like more grass/ bucket feed etc) and ran bloods to see the effect. She was on ulcer stuff too, as she really dislikes being stabled, although she had company next door.
Click to expand...
This sounds so similar to Merlin. He has a history of ulcers too. I'm really hoping I can eventually get him back out in the field as he loves going out. Like you were with yours, I'm just so shocked and its not quite sunk in yet.
 
Just to note, my vet advised me not to crush the Prascend tablets, and to be very careful handling them as they can actually cause us humans issues. I dissolve them in a small amount of warm water and mix into her feed. They don't take long to dissolve. I've been advised not to let it come into contact with my skin. She has a separate bucket to other horses on the yard which is only used for her and the tablets are kept secure away from other feeds and supplements to prevent cross contamination.
 
Kingofmagic05 said:
This sounds so similar to Merlin. He has a history of ulcers too. I'm really hoping I can eventually get him back out in the field as he loves going out. Like you were with yours, I'm just so shocked and its not quite sunk in yet.
Click to expand...
I know what you mean, I really couldnt quite believe it...Mine was out in a stable sized pen after 5 days, she was trashing the place, and the vet said the stress would be worse for her than being on harder ground. I strimmed all the grass down to bare earth, and put a double layer of those holey grass mats down ( didn't work, became a terrible trip hazard, so reduced it to a single layer) But this wasn't in January, she may have been a bit more grateful to be in if it was!.
 
I'm sorry to hear about your story, I'm going through a similar situation. Light weight WB that is fit and in full work, body score 4, not a good doer goes down suddenly with acute laminitis in all feet mid Dec, having never previously had any issues. Assumed it was cushings, but tests came back negative, and same for EMS. Vet's completely baffled, it's not a typical lami case so going to run the TRH test now to see if that gives any answers.
 
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