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Thank you for all of the above, again!!!
It can definitely happen. My horse is EMS and his insulin was dysregulated causing him to hold onto his stall rest chub and then some despite being fed a lower sugar and reduced calorie diet. We used canagliflozin to regulate his insulin and get the weight off. Coming into summer, he was trending towards losing too much weight. I was debating taking him off the meds for summer anyway (it causes a lot more urine output and I was worried about dehydration, among some other things).
I took a poll of my vet and some others who had IR horse clients. As well as an internal medicine specialist. Because while I hoped that getting rid of the fat would get my horse’s insulin response under control, I knew there was a possibility it would go back up (he also has asthma and some arthritis, although he’s never shown foot pain). They all said it was likely his baseline insulin would increase. His was never in the for sure positive range at baseline, but he did fail the Karo syrup test, with an off the charts spike that did not come down after 90 minutes. The internal medicine specialist recommended that I try discontinuing the drug to avoid having to increase the food ration. It is easy enough to start it up again. The other vets tended to lean towards increasing food via a higher protein source and keeping him on the meds.
One vet said she has one IR horse who is downright underweight. They use one of the other -gliflozin drugs on that one. That horse is prone to hyperinsulin laminitis. They can’t take the horse off the meds without a dangerous increase in insulin. It is a struggle to feed the horse enough for general body condition.
The studies on the -gliflozin drugs also do mention other horses like this. Ones that are not controlled without medications, but who have to also eat a larger ration also to try to maintain acceptable weight. So those horses do exist. I’d guess if you also have PPID going on, then that scenario might be more common than just EMS/IR alone.
I did wind up stopping the meds. His insulin did go up some. He put on about 10-15lbs of mostly muscle from the lowest weight point (ETA - lowest weight was a 120lb loss from fatty mcfatterson status), and he has been maintaining that (we have a livestock scale at the farm). He looks and feels great. We may have to resume the meds when the seasonal spike in insulin occurs in the winter, but in the meantime we are monitoring him.
I also knew one other TB who was semi-retired when he came to my barn because he was labeled as dangerous and unpredictable to ride. Owner was in college. Typical harder keeper TB even out of work. At one point, he developed laminitis. The X-rays revealed chronic low grade laminitis for a very long time. Possibly the entire time he’d been “unpredictable”. But otherwise seemingly not clinical, until it was. He did not recover. I felt so sorry for him and his owner.
The sugar test is super simple to do, and while you have to give a LOT of Karo syrup, at least it’s fairly tasty to them.
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Yes, I agree. Ruling out high insulin is always just a good starting point, and once ruled out you can then focus on less scary possibilities.
As to mechanical issues, that is the point I am trying to stress. Lots of horses have poor hoof care and don’t experience major issues in terms of pain and lameness from “mechanical issues.” Others flare up with pain at the slightest change.
In my opinion the latter case is not normal, and should be investigated for an underlying problem besides just a bad trim.
We really are in the infancy of understanding any of this. Sure EMS is widely recognized, but there seem to be outlyers who don’t fit the classic signalment-older, overweight and instead are young without fat-deposits. Do they have laminiopathy, neuropathy? Do they have spikes in insulin, but not true ongoing hyperinsulinemia. Do these spikes have a pathological consequence ro the laminae? We don’t know.
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Can someone talk more about this? Is it related to the ACTH seasonal rise? I’ve not been able to locate research on this. Thank you!
Thanks. Great post from real world experience.
On these hyperinsulinemic horses that are underweight I’ve had luck with coconut meal such as Cool Stance. It’s low in starch and sugar but high in protein and fat and supposedly is antiinflammatory. Most horses love the stuff and it makes a great mash for hiding pills and powders.
Yep, the dose of Karo is around 7ml per hundred pounds. The trick is only giving 25ml at a time so they can swallow it and not drool it out all over your shirt and mess up the test.
There is a lot we don’t know. So yes there are these underweight horses that technically don’t fit the EMS picture. In my opinion a vet cannot merely look at a horse and rule out high insulin or PPID. Horses who are ouchy after small modifications to shoeing and trimming should be investigated for insulin as well as other tendon/ligament/joint issues if insulin is ruled out.
The gliflozin drugs were disgned for humans with diabetes. Horses with high insulin are the opposite of diabetes. Diabetics have low insulin and develop high blood glucose. It’s the high glucose that can cause longterm problems for them, though low insulin seems to cause some issues as well. Nerves need insulin binding apparently in order to stay healthy.
Horses have high insulin but normal glucose, not low insulin with high glucose.
Gliflosin drugs work by increasing the amount of glucose the kidneys eliminate in the urine. If you are a diabetic who sufers from high blood glucose, that makes a lot of sense.
In a horse with high insulin but normal glucose, lowering the glucose even further to try to lower insulin doesn’t make much sense. In general the horses doesn’t have unusually high insulin because of too much glucose, but because they are IR and the insulin is not working. What we want is better insulin sensitivity, not below normal blood glucose.
But these drugs do work so for an emergency situation where the insulin is at 200 even with diet change and the feet are sore, it can be a life saver.
You are right that is there is more glucose in the utine there will be more water loss as well so dehydration could be something to worry about. I’d be worried about hypoglycemia as well, though I don’t see vets seeming to be concerned about this. I am.
But ultimately changing the lifestyle in terms of more exercise on a daily basis (if the feet can take it), eliminating any body fat(fat hormonally influences cortisol levels as well as insulin sensitivity), controllling sources of stress and inflammation should be what gets you control in the long run.
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It seems I have dominated this post for an entire day so I’ll let other people have their say, but I did want to just list some interesting facts about what we know about insulin and EMS. Hopefully these will make you think a bit:
-EMS can occur in horses as young as 5 years old
-TB’s are not the classic breed but they can develop it so you cannot rule out a 6yo TB.
-Adiposity is no longer considered a core trait of EMS but an accompanying complication that can make matters worse. You do not have to be fat to be EMS.
-Other potential causes for EMS other than genetics and fat have had some research confirmation such as Lack of diversity of the gut biome and Endocrine-disruptive compounds i(EDC’s) in the envirronment (including plastics and pesticides).
-Horses that live on farms within 30 miles of an EDC disposal dump have a higher incidence of laminitis.
-The liver clears 70% of insulin from the blood stream. Some more naturopathic-oriented vets prescribe milk thistle because of its benefits to liver function hoping to encourage the liver to pull more insulin out of the blood stream.
-There is a “lean-type” EMS and these non-obese horses may be insulin dysregulated rather than insulin resistant. They may even be horses who struggle to keep weight on.
-Insulin dysregulated horses may not have consistently elevated insulin but will show spikes in insulin after meals. These might only be identified in a test such as the oral sugar test which tests after food intake.
-Histological studies have found cellular changes in lamina after only 6 hours of elevated blood insulin.
-Horses experimentally maintained at an insulin level of 200 for only 48 hours already showed pathology in the lamina. In my experience many “normal” behaving horses test at this level, especially ponies and likely have had high insulin for months or years before showing foot problems.
So could a lean 6yo TB who suddely became sore-footed have lamina pathology despite not seeming to be insulin resistant on a baseline blood test? Yes.
I’m not saying it is common, but you can see why it’s still worth ruling out.
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It’s not related to ACTH. Insulin can increase in horses from December to February. The lab notes on my insulin tests say “Evidence is mounting that insulin concentrations are affected by season with higher concentrations detected in December, January, and February in the Northern hemisphere, suggesting a winter-associated exacerbation of ID.”
We monitored my horse’s bloodwork while he was on Canagliflozin. He had no noticeable change to glucose, which for him is typically in the 90s mg/dL. At the lowest insulin baseline reading, glucose was still 99. And one of his highest baseline insulin readings since losing the weight and off medication (36, though he was on pasture some that day), his glucose reading was one of the lowest for him at 93.
In fact, just after starting Canagliflozin we did a full panel to recheck triglycerides and his liver and kidney values, and glucose at this time was the highest at 115. There is a risk of bladder infections due to secreting more glucose in the urine, but lowering blood glucose seemed to not be a thing in horses. Of course, it’s a good idea to do a full panel pre-test and to monitor the horse while using anything like this that is still somewhat experimental.
The studies show that the drugs do lower insulin in horses. They also seem to have a direct impact on foot comfort (with the studies reporting improvement in ability to exercise for horses with hyperinsulinemia laminitis), although my horse doesn’t have any apparent foot issues so I can’t provide any personal observations on that. He lucked out with having the strongest feet of any horse I’ve had except maybe my Connemara pony.
Compared to other options like Thyro-L and Metformin, I found Canagliflozin to be super effective for weight loss, easy to administer, and other than the urine output did not have other notable side effects…no change in appetite or excitability. It is pricy, though. The other gliflozins have some more affordable options for long term use. Although we don’t know yet if there are big problems associated with long term use.
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This is very interesting to me. My lab work comes from Cornell and does not say that.
In September of 23, his insulin was 44. I asked my local veterinarian about testing in December, and was told no- there was no reason to.
In February he appeared footsore occasionally. The weather was up and down, and shamefully, I chocked it up to frozen ground coming and going. His feet weren’t hot and he had no bounding pulse. In March I had the university vets out to care for him. Sure enough, he was laminitic. He did not need to lose weight, but they suggested we put him on ertugliflozin. He’s thin now, so we are weaning him off of it.
His glucose is usually around 90, and has stayed in that range. His insulin has ranged from 19 to 34.
And he’s sound. I have a very good farrier, fortunately. I wish I’d called someone else to test his insulin in December. I feel we dodged a very large bullet and I’m so thankful. The plan is to continue to monitor his insulin going forward. He may go back on ertugliflozin in the fall.
He is wearing a muzzle now, is on InsulinWise, and I ordered MilkThistle for him today.
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You may want to test insulin after he’s been totally off the meds for at least a week. That’s what my vet recommended, and I’ve also been periodically monitoring it the past few months.
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Oh…believe me…I do, but thank you for the suggestion in case I didn’t😀. As my own n=1, I actually had it checked one morning, and then the following day after turn out. Are you using any supplements?
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I had him on different chromium based supplements for a long time, but after I cut his feed even further to what ought to have been a weight loss ration for his goal weight, I dropped some of the supplements just because I didn’t have enough food to mix them with, and they obviously weren’t doing much if he kept ballooning into obesity.
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Thank you for joining the forums and giving us all some great food for thought!
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Replying to you but also speaking to the general:
Let’s say she’s high insulin. I’m a bit lost about it - there’s so much information to absorb and a lot of it is “put them on a diet and get rid of fat and exercise them”. My mare really does not have any extra fat, is too footsore to exercise (until I figure out how to keep shoes on her, she’s sore in her boots and pads for anything but turnout), and I have her on TCS Gold (11?% NSC), Kalm n easy (14% NSC), orchard hay (not tested, I have limited storage and get loads from multiple places throughout the year), and basically no pasture. I had her on a ration balancer and alfalfa at one point but I just couldn’t get enough calories into her.
I did put her on Ultium when she was really thin, and maybe a month after that she got trimmed and came up sore. I immediately switched to Senior Gold. I could put her exclusively on the Gold and drop the kalm, but it’s rather expensive.
If she tests as IR, I just don’t know what else reasonably I could do to manage her.
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I’ll share I’m now using Buckeye Low N Steady- it’s 8.5 NSC. He likes it! I had trouble finding it locally. Chewy had it. Mine is not heavy at all.
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Thank you for all this info! My retired mare is IR by Karo test as of March; her insulin value got a little high a few years ago but this was the first time a Karo test showed IR.
This is the first year she hasn’t had at least an hour of turnout on grass; she gets minimal hand grazing with me.
She had “possible old laminitis” in the RF 12 years ago but has never (knock wood) gone full blown laminitic. Keeps good sole depth as long as she’s shod with pads. We had a barefoot + boots for turnout period when I retired her, but BO is unwilling to deal with the hassle of boots and she’s out 24/7 now on a dry lot with a shed. Outside 24/7 is essential for her health now.
She has very upright pasterns so her coffin bone angle is very steep but it matches her pasterns and hooves so we aren’t doing much with her hooves. For whatever reason, when shod she does a bit better in shoes that are a little tight, and higher heels… but again this matches her Xrays.
She’s a retired, easy keeping Morgan with anhydrosis, lots of arthritis, and mild heaves, plus she’s ulcer prone, so managing everything is a balancing act. She gets first cut low sugar hay, and two feedings of 1/2 pound ration balancer and a cup of Outlast. Her hay is in a small hole 1 inch net, but it does NOT slow her down much. She attacks nets like she’s greatly offended by them! A hay ball is better but not great for outside use if it’s at all muddy.
Keeping her weight down and exercise up isn’t easy. I take her walking on the trails a few times a week, weather allowing. Treat with Thryo-L if her weight gets too high… Most recent change, which for whatever reason is working, is adding Metaboleeze supplement. Our vet isn’t normally big on supplements, but she’s seen good results with it. I wish I had a current photo because she looks so good right now.
I wish she could be shod with something a bit more hoof-friendly, but that’s all I’d change right now.
Photo from 2 months ago…
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Interesting about Metaboleeze. That’s one I haven’t tried. I went through my horse’s history… In 2019, his insulin was 17.6 on 6 scoops of Metabarol. I’d still be doing that (and robbing banks to pay for it) but he now won’t eat it and I can’t syringe the powder down his throat, either.
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Yes these are the hard ones, seemingly no fat to lose and too sore to exercise. I’ll reiterate that not all insulin problems are IR. A horse can be lean and not have elevated baseline insulin yet insulin spikes anytime starch and sugar are consumed. That is what we call insulin dysregulated. In my opinion these daily spikes are enough to cause sore feet. 11% NSC is too high, 14% is way too high, and unknown orchard grass could be anywhere. I just saw some in Oregon test at 18%! Grazing, even for an hour, in my book can be too much.
I like the rule that nothing in the diet should be high enough in NSC to spike insulin. Every meal needs to be below that 10% including the pasture.
Not that you have to do this forever, but it would be an interesting trial to go 4 days with nothing in any meal above 10%, which means no high NSC supplements, no grazing and soaking all the hay at least an hour in warm water.
Yeah, I know, it’s a hassle and your horse hates soaked hay and isn’t happy staring at grass over the fence… What I am saying is that if you do this for 4 days and your horse is better, then you are on the right track as far as a need to further tweak the diet.
I’ve had good look with coconut meal (Cool Stance) as a good calorie supplement that is low in starch and sugar yet high in calories and very pallatible to most horses. Mix that with alfalfa pellets and add warm water to form a mash. Yummy. (Do not feed it dry as it soaks up a lot of water quickly.) And as will all diet additions and changes, make the transition gradually.
Also, sore feet and over 10 years old-test for PPID because this often gets overlook because the vet is not seeing the overt signs of later stage Cushings (the hair coat, lethargy, top line loss).
A study showed that giving Prascend even when the horses did not test positive for PPID did help with insulin regulation. The researchers I believe question if the Prascend really helps with IR or perhaps the horses were so early in the PPID that tests were not detecting it. That is wht the TRH stimulation test is the way to test for PPID.
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Hi, older horse, some possibility of IR or ID, annhydrosis, heaves. That all points to PPID. Have you tested? Do you test every year?
Further the heaves is airway inflammation which makes your job harder as inflammation will always drive up insulin making it hard to get things under control. And treating the repiratory issues with steroids again exacerbates your insulin problem, and if you have lamina issues, is really contraindicated.
Studies suggest that for exercise to be helpful in directly reducing IR, it really needs to be high intensity with heart rates at 130-170 and for 30 minutes. That is not to say that hand walking and hikes is not helpful. Anytime the muscles are working you are both burning calories and also using up insulin that is floating around in the blood.
On another note about the feet. From a distance she appears to have at least a RF club foot. Club feet come in vatious grades, and some are even within the normal angle range. What makes a club foot? A short DDFT. Can a horse within normal angles have a short tight DDFT? Yes.
You are right to not try to make her feet look less upright. When you chops heels off, you actually cause the DDFT to be even more tense, create chronic soreness and lack of sole depth in the toe. Meanwhile the heels just grow faster. The problem is not high heels, it’s a right DDFT.
So please look at this photo closely. The mare’s LF foot is all the way back but the heel has not come off the ground. She’s starting to break at the carpus (“knee”) instead, before her heel comes up. Tis could be a result of what I discussed above. While she appears to have pretty short toes, with a club foot scenario, they often need even more breakover reduction than what many farriers feels comfortable with. There are lots of ways to do with with metal or composites. A Softrider Arena or a Visani Full Roll in composite, or a Mustad Equilibrium or Morrison Roller might be possible metal options.
Also note that the right front is landing with the carpus broken forward as well. That suggests DDFT tension as well. You are on the right track with not trying to lower her heels to achieve a less upright look. You have to work with what they have. I’ll reiterate that club feet are a DDFT (deep digital flexor tendon) issue, not a high heel issue. The high heels are a response to the tight DDFT unweighting the heels. The more you lower the heels the worse you make DDFT tension and the worse the problem becomes. Thin soles, soreness and eventually pedal osteitis and eventually euthanasia because no one was willing to try a different approach or actually understand the problem completely.
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