Laminitis and EMS, when to make the call?

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Belmont

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Feeling very alone, let down by vets and would really appreciate advice from anyone bothered to read!
Back story: 19yo mare, a good doer and always on a low sugar and starch diet and muzzled in the spring/summer months. Lame end of November and sent videos to the vet. No typical signs, just a little swelling above both fetlocks. Vet advised to leave out for a few days until they could come out to do a full lameness work up. Quickly diagnosed with laminitis and x-rays to show mild rotation in fronts, with very thin soles (always been barefoot). Vet took blood to test for cushings, but as she didn't have a cresty neck, didn't bother testing for EMS:rolleyes:. ACTH came back at 64, so started on a low dose of prascend (half tablet every other day). Farrier didn't think squish pads were essential, so decided to shoe her. Mare taken off the grass and on soaked hay and made a quick improvement. Had a flare up in Jan when we had snow and pipes froze, so no soaked hay. Improved again when back on soaked hay. Had another flare up in Feb, and deteriorated rapidly, so vet out, although this time a different vet. More xrays showed further rotation, and this vet decided to test for EMS. Insulin was off the scale (over 300). Mare straight on to Invokana and fitted with squish pads, and improved. Steady improvement over 4 weeks, gradually reducing pain relief and another blood test showed she was now negative for cushings and insulin down to 150. All going in the right direction so continue on. Another 3 weeks later and farrier popped over to assess, and she trotted up sound (on 1 bute a day). Then reduced to half a day and trotted sound for the vet a few days later. Plan to continue for another 2 weeks until farrier back out to either remove or replace squish pads. However yesterday morning, she's crippled again.
I have very nearly run out of funds completely. I've spent a fortune on the vet and farrier over 5 months. I am 3 weeks away from my wedding, and have had to downscale that and cancel our honeymoon to fund her recovery (much to my fiancé's disappointment!) but that's still been a huge expense and all really rubbish timing. I was so confident we were getting somewhere, I was devastated to see her lame again when nothing has changed.
On one hand, I can't afford another 6 months of xrays, blood tests, squish pads etc. I have given her a good 10 years and worry about her quality of life with the EMS. I am fortunate to have a large grass-free corral, but don't want to keep her in there forever. I rent a small yard and the rent is increasing, but a rare space has come available on the small livery yard round the corner, which I could move my other horse to, and save money. The liveries help each other out so having a lie in or an evening off would be novelty!
On the other hand, she's coping amazingly well in herself. She is generally bright eyed and very resilient. I'd love to hack with my friend again. I also would love to get her competing again in dressage if she came sound.
I am really conflicted. I know laminitis is a long road, and I feel let down by the vets as she wasn't diagnosed with EMS until 3 months after lami diagnosis and worry that means a really poor prognosis long term. I can live with not riding her again, but I worry she'll never be able to graze again and that makes me sad.
I don't want to make any decisions until at least after my wedding as I know my brain is all over the place, but would love some advice on timescales. How long do you fight before calling it a day?
 
It's not something you can really fight hard for a few months then go back to business as usual unfortunately. It needs permanent careful management and yes, there are some horses who really can't tolerate grass (of the type that predominates on yards in the UK at least).

Only you can say how long you are prepared to keep going for really but it can be a very very long road especially if there is rotation present and anti inflammatories (paracetamol is quite effective and often given alongside Bute) are often needed for quite a while at least initially. Though it's good you're on the ertugliflozin, this can be an absolutely life saving drug and insulin levels of 300 seem bad but are recoverable/manageable.
 
It's your horse and your responsibility and therefore your choice. I don't think you would be wrong to PTS as this is what I imagine you are seeking opinions on.

Is the horse overweight? Personally, if the horse is not, then yes, I think I would PTS. If the horse is overweight, then I would follow the protocol I did with mine, which was to drastically lose weight and have every rib visible for months, as this reversed mine's EMS to totally normal bloods.

Mine now grazes, with a muzzle, and is kept on high fibre haylage. If he could never graze again then yes, I think I would PTS. Starving him was awful. But, I knew it was for his good and for a purpose.
 
I'm really sorry your in this scenario. It can be a roller coaster, as you are sadly finding out.

Honestly? I think if funds are already an issue, I'd be thinking PTS.

Managing EMS is do-able (in most cases) but hard and at times stressful but it would be even harder to be stressing about whether I could afford an unexpected vet's call out fee or routine X-rays, the next round of medication or the next prescription charges.

I'm not saying you need to be a millionaire to own horses but I do think you need a certain level of financial buoyancy to do the right thing by the horse, especially if they have on-going medical needs. And I do completely appreciate this financial buoyancy has become harder and harder with the cost of living crisis.

In a more general sense, for me, the horse needs to be able to able to live as near a normal life long term as possible for me to keep going. Mine is on an individual bare paddock/strip grazed section some of the time with soaked hay. But, importantly for me, he is able to be turned out on grass too & be a horse with his herd. If he stops being able to cope with this and has to spend more of his time either box rested or isolated on a bare paddock, I'd be thinking long and hard about his quality of life.

Everyone has their own lines in the sand and there's no one-size-fits-all answer, but those are just my own thoughts.
 
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You are not alone, there are many of us but it’s a lonely position because we are probably the only one at the yard. I’ve been managing mine for 10 years now with no further episodes of laminitis since the very first one. It’s very intensive and I’m sure other liveries think I’m potty with the meticulous way I manage her but she’s in great health and I ride her lots. She is out grazing in winter, other times she might be out with a muzzle. Sometimes she is in and on soaked hay for weeks. By now I know exactly how to manage her successfully. She’s the love of my life and her quality of life is hugely important to me but it’s a compromise. I look upon it as saving her life.

If I was managing her like this and she still repeatedly came down with laminitis I would pts because I won’t have her in pain.

I think you also need to consider yourself and the impact on your life at this stage in your life. Dealing with EMS is time consuming, physically demanding hauling big soaked haynets (I’ve already had a rotator cuff tear and surgery because of that and the other shoulder is going the same way) and a big fat worry on your mind. xx
 
If she’s bright I absolutely couldn’t PTS. I’d be looking at what ling term affordable options would work even if it meant sending to track full time.
 
I've got a long term retiree who lives 24.7 in a muzzle at this time of year with steglatro on top of that. I have agreed with the vets we do bloods every 2 months (unless I have any issues or drastic weight loss) and I don't x ray.

Other people wouldn't spend the money but she's happy (she'd be happier stuffing herself senseless on Spring grass but there are limits)

If you want to PTS then that's understandable but if it is purely about costs then get a bit tough with the vets and tell them what you can / cannot afford.
 
It’s your choice, although I would caveat that it’s also affecting your fiancé financially and day to day.

I forget all the details but mine had laminitis about ten years ago, following we think atypical myopathy. Rotation in all four, Imprint shoes, three months box rest, he sort of came right but never came back into full work, and after a final vet work up was pts aged about ten, after five years of worry. The final winter he was living out, naked and blanket clipped, with a muzzle, on grass only, and was still gaining weight. I had him pts before the laminitis got him again. It was all absolute hell and whilst I adored him and was terribly upset, literally for years, it was the right thing to do (I couldn’t have moved him anywhere as he didn’t travel, and he wouldn’t stable alone - there were various issues).
 
Red-1 said:
Is the horse overweight? Personally, if the horse is not, then yes, I think I would PTS. If the horse is overweight, then I would follow the protocol I did with mine, which was to drastically lose weight and have every rib visible for months, as this reversed mine's EMS to totally normal bloods.
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Thank you. She’s a part bred NF so I’ve always watched her weight, but vet didn’t bother doing an EMS test initially as she didn’t think she was overweight and didn’t have a cresty neck. She has since lost 45kg and looks really quite poor. I think I’ll keep going and see what insulin is at her next retest, hopefully it’s continued to come down 🤞🏻
 
pistolpete said:
If she’s bright I absolutely couldn’t PTS. I’d be looking at what ling term affordable options would work even if it meant sending to track full time.
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Thank you. I will look into track livery, unfortunately it’s not something I can set up on my rented land but there is somewhere locally.
 
Possibly not what you want to hear, but Cushings is probably driving the EMS. When the two show up together it is difficult to find a balance, as one or the other seems to flare up as soon as you appear to be getting somewhere. If she were mine, I would monitor Cushings levels, maybe do a STIM test, and make a decision based on how well she is responding to pergolide. Any remedial treatment, tracks, muzzles, boots and pads etc. are useless unless the Cushings is well under control. Hope your mare can come good.
 
Having learned over the years with a range of animals, not just horses, that if there is no quick resolution, you are just on a long, slow downward spiral,
I would probably carry on as you are doing until after the wedding and then unless there is a real prospect of an excellent quality of life for her, I would pts. We had 2 Cushings horses who both spent about a year on Prascend before having to be pts because of uncontrollable symptoms, not a qol judgement. Others do spend years on it but not with EMS and laminitis in the mix.
Your fiance sounds wonderfully tolerant.
 
Belmont said:
Thank you. She’s a part bred NF so I’ve always watched her weight, but vet didn’t bother doing an EMS test initially as she didn’t think she was overweight and didn’t have a cresty neck. She has since lost 45kg and looks really quite poor. I think I’ll keep going and see what insulin is at her next retest, hopefully it’s continued to come down 🤞🏻
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They have to be absolutely skinny for a while to potentially reset EMS. Mine looked awful, to the point that, if people were rude, I had to call the vet to be reassured that I was not going too far. I was afraid of having the RSPCA called and the vets visits were to document on his records that the vet was saying they had seen him and I was doing it on vets orders. At one point, he had a rug on 24/7. Fly rug to ride even!!! I couldn't let people see him. He is now just 'slim' and his ribs are easy to feel but not sticking out like they had to be.

His tests went down and down, from into the hundreds to in the teens!!!

It was an awful few months but he was only 15, and is now 21 and living the life, so short term in the scale of things.

Mine was only borderline cushings at 27.5, but that has not progressed. Ypurs may be different with a higher cushings issue, but I would talk about the skinny diet with your vet.

I still don't think that PTS would be wrong, btw.
 
Belmont said:
Thank you. She’s a part bred NF so I’ve always watched her weight, but vet didn’t bother doing an EMS test initially as she didn’t think she was overweight and didn’t have a cresty neck. She has since lost 45kg and looks really quite poor. I think I’ll keep going and see what insulin is at her next retest, hopefully it’s continued to come down 🤞🏻
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It's definitely hard work, EMS. If weight is under control, plus steglatro, but no exercise is possible (or there is plenty of exercise), and the condition is still not manageable, I would feel considering PTS is a very reasonable proposition. Especially if your finances are under such pressure that you've had to cancel your honeymoon and make changes to your wedding.

With mine I do not Xray, and insulin test once/twice every year. He is shod, can be ridden for exercise. Mainly monitored by checking pulses/hoof warmth, and can go out to graze, but only for a very limited number of hours. The rest of the time he has a stable and hardstanding yard area, and nets of soaked hay mixed with straw.

However in terms of finances even just the steglatro/invokana is (depending on dosage) quite a big expense, on top of feeding hay year round, and bedding year round. If all this was not keeping his condition under control, I would be thinking about calling it a day as laminitis is a very painful thing to have, and not going out to graze will inevitably have other consequences for physical and mental wellbeing.
 
Lots of sympathy from me.

I also had one diagnosed with both cushings and EMS despite being slim. Even when all her bloods were where they should be she continued having bouts of laminitis. Seeing her in that much pain was horrific.

Rotation was slight but her soles were very thin. Did they measure your pony's soles from the xrays? If not, I'd ask for that to be done.

Vet warned that it was unlikely she'd ever be able to be turned out again, not just because of the grass, but because if she stepped on a stone, even in hoof boots or wrapped feet, it would be excruciatingly painful for her. She could never be exercised either. At that point I called it a day as she'd have had no quality of life at all.

I think if you can get them to a place where they can be exercised, then you have much better chance of keeping it under control, but it can be a long road to get there. I feel for you.
 
Highmileagecob said:
Possibly not what you want to hear, but Cushings is probably driving the EMS. When the two show up together it is difficult to find a balance, as one or the other seems to flare up as soon as you appear to be getting somewhere. If she were mine, I would monitor Cushings levels, maybe do a STIM test, and make a decision based on how well she is responding to pergolide. Any remedial treatment, tracks, muzzles, boots and pads etc. are useless unless the Cushings is well under control. Hope your mare can come good.
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Ok that’s interesting. I was surprised when she was diagnosed as she shows no signs (other than lami ofcourse). I read that levels can be raised when they’re in pain, and she was in an awful lot of pain in December when vet first came out. I followed the vet’s guidance of the very low dose, but took her off prascend when she had the EMS diagnosis and started Invokana. Although she was only on half a tablet every other day, it was a real mission to get her to take it and when the insulin was off the scale, I blamed that for laminitis and then made the decision to stop the prascend. 4 weeks later she’s negative for cushings so that backed my theory that she never actually had it and it’s purely EMS. I’ll chat to vet and start her back on it. Thank you
 
Belmont said:
Ok that’s interesting. I was surprised when she was diagnosed as she shows no signs (other than lami ofcourse). I read that levels can be raised when they’re in pain, and she was in an awful lot of pain in December when vet first came out. I followed the vet’s guidance of the very low dose, but took her off prascend when she had the EMS diagnosis and started Invokana. Although she was only on half a tablet every other day, it was a real mission to get her to take it and when the insulin was off the scale, I blamed that for laminitis and then made the decision to stop the prascend. 4 weeks later she’s negative for cushings so that backed my theory that she never actually had it and it’s purely EMS. I’ll chat to vet and start her back on it. Thank you
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On the other side of the coin, my vet would be likely to agree with you ie it was EMS all along! I kept querying Cushing's and so far any possible Cushings type symptoms seem to have reduced/disappeared now that insulin is under control.
ETA Cushings test was negative
 
southerncomfort said:
Rotation was slight but her soles were very thin. Did they measure your pony's soles from the xrays? If not, I'd ask for that to be done.
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Thank you and sorry to hear your story 😞
Yes right was 7mm and left 5mm in December, vet advised they should be 10mm. I hope they would have improved a bit by now having worn the squish pads.
 
The fact you've struggled to control this over winter would lean me towards pts unfortunately. I controlled my boy for over 10 years using a combination of muzzling, restricted grazing and exercise, but even he had a permanent (floppy) crest. When it started to harden I knew I had to quickly up the management regime, and it's ongoing. I became an obsessed weather watcher as any rain would mean danger, especially after a dry period. I did find a paper that linked tumours with pedunculated lipomas with EMS and my Exmoor had both when PM'd after being pts (astrocytoma extending into the thalamus), but have lost it somewhere along the way. He never tested positive for Cushings, but it's interesting that you also see the puffy fetlocks. This is all we had, too, along with floppy crest (apart from the one laminitis attack at aged 16).
 
Cushing levels will rise in autumn, as the light levels reduce, and fall again in spring, when daylight hours start to lengthen. It affects insulin/blood sugar regulation, and the body's natural regulation of protein requirements seems to go haywire. It produces pain which isn't easily controlled by usual NSAIDs. Maybe read up on Cushings and see if any more symptoms fit. The Laminitis Site is a good starting point, and there is loads of information out there.
 
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