metabolic disorders in horses...some horses get fat in summer and then skinny in winter truths of...
TRANSCRIPT
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Metabolic Disorders in Horses
Cushing’s Disease (PPID) & Insulin Resistance
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▪ Dr. Caitlin Eaton
▪ Dr. Jen Cassano
▪ Renee Gregoire
▪ Jackie Gosselin
▪ Kara Kirchherr from Boehringer Ingelheim o Thank you!
Introductions
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Overview
1. Review of BCS and principles of nutrition
2. Equine Metabolic Syndrome
3. Pituitary Pars Intermedia Dysfunction (PPID)
www.minnesottafarriers.com
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▪ How do I assess body condition
▪ WHAT – WHY and HOW of feeding
BODY CONDITION SCORINGFEEDING 101
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▪ Body condition score
o What is body condition scoring
o What does it mean
Body Condition
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Regional Adiposity
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Assessing condition…
Extreme emaciation.Spines, ribs, hips and tail head extremely prominent.
Withers, shoulders and ribs easily discerned.
BCS 1
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Assessing condition…
Spinous processes are readily discernible .Hip bones are rounded but easily discerned.
Withers, shoulders and neck are accentuated.
BCS 3
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Assessing condition…
Ribs cannot be easily seen but can be felt .Withers appear rounded over spinous processes.
Neck and shoulders blend smoothly into body.
BCS 5
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Assessing condition…
Ribs can be felt with deep finger pressure .Back has a slight crease down its length.
Neck, shoulder and tail head show visible fat pads.
BCS 7
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Assessing condition…
Ribs can be felt with deep finger pressure .Back has a slight crease down its length.
Neck, shoulder and tail head show visible fat pads.
BCS 7
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Assessing condition…
Ribs can be felt with deep finger pressure .Back has a slight crease down its length.
Neck, shoulder and tail head show visible fat pads.
BCS 9
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Assessing condition…
BCS 9
Ribs can be felt with deep finger pressure .Back has a slight crease down its length.
Neck, shoulder and tail head show visible fat pads.
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Score the Butt
AB C
D E
Which Butt is a 1? 3? 5? 7? 9?
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Score the Butt
AB C
D 1
Which Butt is a 1? 3? 5? 7? 9?
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Score the Butt
3B C
D E
Which Butt is a 1? 3? 5? 7? 9?
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Score the Butt
A5 C
D E
Which Butt is a 1? 3? 5? 7? 9?
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Score the Butt
AB 7
D E
Which Butt is a 1? 3? 5? 7? 9?
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Score the Butt
AB 7
9 E
Which Butt is a 1? 3? 5? 7? 9?
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BCS for the Hind End
3
5
7
91
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A CB
D E
SCORING THE CREST
Which Crest is a 1? 3? 5? 7? 9?
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A C1
D E
SCORING THE CREST
Which Crest is a 1? 3? 5? 7? 9?
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A C
3
B
E
SCORING THE CREST
Which Crest is a 1? 3? 5? 7? 9?
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A CB
D 5
SCORING THE CREST
Which Crest is a 1? 3? 5? 7? 9?
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7 CB
D E
SCORING THE CREST
Which Crest is a 1? 3? 5? 7? 9?
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A 9B
D E
SCORING THE CREST
Which Crest is a 1? 3? 5? 7? 9?
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CREST SCORING
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▪ Laminitis
▪ Insulin resistance
▪ Joint and bone strain
▪ Reproductive issues
▪Thermoregulation
Health Concerns When Exceeding Ideal Weight
Uh oh!
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Myths of the overweight horse:
▪ Some breed standards are supposed to have an Apple Butt
▪ Some breeds are just Big-Boned
▪ Some breeds are Easy Keepers
▪ Some horses get fat in summer and then skinny in winter
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Truths of the overweight horse:
▪No breed standard promotes obesity
▪ Some breeds are predisposed to insulin resistance. These breeds may be sensitive to a high starch/high sugar diet.
▪Horses need to EXERCISE year round to maintain a good weight
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Where did we go wrong?
▪Uncle Jimmy’s Big LickyIngredients: Ground Corn, Sugar, Corn Syrup, Oats, Soybean Meal, Soybean Hulls, Wheat Middlings, Vegetable Oil Refinery Lipid, Corn Germ Meal, Molasses Products
Like giving a kid a lunch bag of penny candy so they are BUSY for a while
▪Hay WAS less expensive to feed in the past
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What Are We Feeding?
▪Concentrates– Corn, Barley, Oats
▪High sugar treats – Mints, Sugar Cubes, Carrots, apples, Commercial Horse Treats
▪Why is that a problem?
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The Horse’s Furnace
Front Furnace (stomach/small intestines) – Burns Hot
Rear Furnace (large intestine/cecum) - Burns Long & Slow
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Over-feeding Non-StructuralCarbohydrates
• Rapidly increases blood glucose levels• Insulin levels increase• Can lead to Equine Metabolic Disease
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Feeding StructuralCarbohydrates
• Stable blood glucose levels
• Continuous forage feeding* Promotes normal gut activity * Chewing buffers stomach* Reduces Stress
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% Non-Structural Carbohydrates
ALFALFA HAY 11.4%
GRASS HAY 13.3%BEET PULP 12.2%
OATS 50.7%
BARLEY 63.1%CORN 77.0%
MOLASSES 58.4%Optimally < 15%
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Hay Stretcher - Hay Pellets – Forage cubes what is the difference?
▪Hay Stretcher Pellets
▪Hay Pellets
▪Haylage/Forage Cubes
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How should we feed?▪ Feed concentrates 3-4 meals/day
▪ Feed concentrates AFTER a hay meal
▪ Feed Hay In multiple locations
▪ Use Slow Feeders (Nibble Net/
Horses that score 7 or above on Body Condition SHOULD NOT be turned out on grass PERIOD
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What about Horsey Treats
▪Apple peels
▪Homemade horse treats made with ground Flaxseed meal
▪Peanuts in the shell
REMEMBER FOOD IS NOT LOVE!
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Food Is Not Love – But Time Together is!
▪ Horses in all day turnout spend 90% of their time STANDING
▪ Stabled horses should be hand-walked 30-45 minutes
EXERCISE BPM KCAL/MIN
Walk 60 bpm 24 kcal/min
SlowTrot/Jog
90 bpm 56 kcal/min
Fast Trot/Jog
120 bpm 99 kcal/min
Canter/Lope 150 bpm 159 kcal/min
Gallop 180 bpm 230 kcal/min
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Bring a Curry Instead of a Cookie!
• Assess Body
Condition Score twice
a month
• Post it on your barn
calendar to track the
score
• Use a weight tape to
track your
• bi-monthly weight
assessment
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Low Carb Horse Treats
▪ LOW STARCH APPLE CINNAMON HORSE TREATS
▪ Ingredients:
▪ 1 lb. bag of Bob’s Red Mill organic ground flaxseed (from Wal-Mart or grocery store)
▪ ½ cup Unsweetened applesauce
▪ 2 tbs. Cinnamon
▪ 2 cups hot water
▪ Cookie sheet, and parchment or wax paper
▪ Directions:
▪ Preheat oven to 350 degrees. Put ground flaxseed into mixing bowl add the Cinnamon and mix. Add applesauce, then HOT water. Initially mix with rubber spatula, then use your hands until the dough is smooth.
▪ Cover cookie sheet with parchment or wax paper. (Do NOT use cooking spray.) Place dough on paper covered cookie sheet to evenly cover it. The thinner you spread the dough, the crunchier your horse cookies will be. Cut the dough into squares BEFORE baking; this allows them to come apart easily after baking. They are difficult to cut apart once baked.
▪ Place in preheated oven and bake at 350 degrees for 70 - 75 minutes. Turn off the oven and let them sit in the warm oven for another 30 minutes to increase crunch.
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Equine Metabolic Syndrome
▪What is Equine Metabolic Syndrome (EMS)?
▪How do we diagnose it?
▪What is the goal of treatment?
▪What is insulin resistance?
▪What is the link between insulin and laminitis?
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▪ A large part of diagnosis can be correctly made through physical characteristics.
Identifying EMS & PPID
▪ Test to detect early disease
▪ Test to monitor treatment
▪ Pre-treatment vs Post-treatment
▪ Are the treatments working?
▪ Do we need to get more aggressive with treatment?
www.northernfloridaequine.com
www.tonette.co.uk/photo_album1.html
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▪ Defined as having three characteristics
1. Regional adiposity• OR generalized obesity
2. Insulin Resistance (IR)
3. Laminitis• A predisposition to laminitis• A current or a previous bout of bilateral lameness
Equine Metabolic Syndrome (EMS)
www.tonette.co.uk/photo_album1.html
http://www.talkaboutlaminitis.co.uk/ppid-symptoms-and-diagnosis/
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▪ GOAL: to diagnose early and establish a treatment protocol to PREVENT laminitis.
Diagnosis & Treatment
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▪ Breed and physical characteristics
Identify Horses at risk for EMS
www.northernfloridaequine.com
www.tonette.co.uk/photo_album1.html
▪ At Risk Breeds
o Pony Breeds
oMorgans
o Paso Finos
oMiniature horses
oSaddlebreds
oWarmbloods
oMost breeds possible, but unlikely in Thoroughbreds & Standardbreds
▪ Physical characteristics
oCresty neck
o Fat deposits under the skin
o Easy keeper (can’t lose weight)
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▪ Baseline/ Resting Insulin
oNo need to fast
oNo grain, just hay
oInsulin > 50 U/L = Insulin dysregulation
• High specificity, low sensitivity
• But what if you get a midrange value (20-50) and still suspect insulin dysregulation?
Diagnosis – Insulin Resistance
Insulin will be elevated with:
1. Large grain meals
2. Pregnancy
3. PPID
4. Illness/Stress/Pain
5. EMS
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▪ Dynamic testing is more sensitive than baseline
▪ Oral Sugar (Glucose) Test – (OST)
oFasting (6-8 hours)• 1 flake hay 10pm
oKaro syrup (light color, not lite)• 75 cc per average sized horse
• 1 hour prior to blood draw
oIf Insulin > 45 U/L = Insulin dysregulation
Diagnosis – Insulin Resistance
Insulin will be elevated with:
1. Large grain meals
2. Pregnancy
3. PPID
4. Illness/Stress/Pain
5. EMS
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▪ Leptin
oA hormone produced by metabolically active fat
oCan help quantify the amount of internal adipose tissue
oAvailable with insulin testing on a metabolic panel
▪ ACTH baseline / TRH stimulation testing
oPPID status essential to know in EMS management
Additional Diagnostic Tests
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1. Diet → FAT → Insulin Resistance → Laminitis
2. Insulin Resistance → FAT / regional adiposity → Laminitis
Not all fat horses are insulin resistant and
not all insulin resistant horses are fat.
1. Goal: Diagnose early establish a Treatment protocol
PREVENT laminitis.
Insulin Resistance
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Endocrine system 101
http://www.merckmanuals.com/pethealth/horse_disorders_and_diseases/
Adipose
Pancreas
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Endocrinology 101 – Insulin
Blood Sugar ↑
Blood Sugar ↓
Insulin
Glucose Uptake
Glucose Uptake
Pancreas
Fat
Liver
Muscle
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Endocrinology 101 – Insulin
Blood Sugar ↑
Blood Sugar ↑
Insulin
Glucose Uptake
Glucose Uptake
Pancreas
Insulin
Fat
Liver
Muscle
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Insulin ↑
Growth Factors ↑ and Blood Flow ↓
Cells Energy Crisis
Cell Death and Inflammation
Enzymes ↑
that break down laminae
Laminitis and Insulin
▪ Inflammation/ breakdown of the laminae that connect the coffin bone to the hoof wall
▪ As the laminae weaken, the opposing forces on the coffin bone cause rotation and sinking
*De Laat et al Equine Laminitis: induced by 48 h hyperinsulinemia in
Standardbred horses. Equine Vet J 2010, 42:129-135
Normal Laminitis
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▪ GOAL: to diagnose early and establish a treatment protocol to PREVENT laminitis.
Diagnosis & Treatment
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▪ Weight Loss
o↑ physical activity
o↓ caloric intake
▪ Regular exercise
oImproves insulin sensitivity even before weight loss or a change in fat distribution
Weight management
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▪ Start with 10 minute handwalk 3-5 times per week
oPonies hand-walked 10 minutes per day lost weight!
oWon’t self-exercise!
▪ 2-3 exercise sessions per week
oHandwalking, Lunging, or Riding
o20-30 minutes per session
Weight Management – Step 1Exercise Regimen
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▪ Eliminate pasture access
oConfine to drylot or use grazing muzzle
▪ Eliminate grain from diet
oReplace with ration balancer
▪ Restrict/limit hay intake
o1.2- 1.5% body weight
Weight Management – Step 2Calorie reduction
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▪ Appearances aren’t everything
oCannot assess calorie and sugar
content visually
oRequires a forage analysis
▪ We can refer you to a Nutrena or
Poulin nutrition specialist to assist
you with a forage analysis
Hay and pasture analysis:
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▪ Leach out water soluble carbohydrates in order to reduce overall carbohydrate levels in hay.
▪ Use large clean bucket and completely submerge flake hay
▪ Soak hay for 60 minutes in cold water
▪ Recommended to reduce sugar content in high risk laminitis
Soaking hay…
*Longland et al Effect of soaking on the water-soluble coarbohydrate and crude
protein content of hay. Vet Rec 2011 168:618-622
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▪ Mineral-vitamins lost in soaking hay
▪ Available in a pelleted formulation so horses believe that they are still getting grain!
oStill have calories and carbohydrates
Mineral and vitamin supplements
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▪ Metformin
oHuman diabetes medication
oFor short term use• Active laminitis
• Reduce high insulin levels
▪ Levothyroxine (Thyro-L)
oIncreases metabolic rate for weight loss
oFor use in horses:• That cannot exercise due to laminitis
• That have failed to lose weight despite diet and exercise
IR medication
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▪ New research indicates many horses with Cushing’s disease (PPID) also have EMS
▪ Could EMS be a precursor to PPID or do they occur together?
Insulin Resistance may be a precursor…
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TAKE A BREAK!
QUESTIONS?
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Equine Cushing’s-like Disease akaPars Pituitary Intermedia Dysfunction aka PPID
?
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Equine Cushing’s-like Disease akaPars Pituitary Intermedia Dysfunction aka PPID
Weight
Diet
PerformanceAppearance
Feet
?
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Equine Cushing’s-like Disease akaPars Pituitary Intermedia Dysfunction aka PPID
He is always slow to shed out...
He lost muscle because I gave him the winter off…
She used to be fat, but this winter helped her lose the weight…
• 30% of horses > 15 years of age
• equally geldings & mares
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Pituitary Pars Intermedia Dysfunction (PPID)
Early Signs
1. Increased lethargy
2. Regional shaggy haircoat
3. Delayed shedding
4. Loss of topline
5. Regional adiposity
6. Loss of Topline
7. Abnormal sweating
---
1. Recurrent Corneal Ulcers
2. Recurrent Hoof Abscesses
3. Desmitis/Tendonitis
4. Recurrent Laminitiswww.northernfloridaequine.com
This Photo by Unknown Author is licensed under CC BY-SA
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Pituitary Pars Intermedia Dysfunction (PPID)
Advanced Signs
1. Dull
2. Exercise intolerant
3. Poor shedding
4. Round abdomen
5. Muscle atrophy
6. Regional Adiposity
7. Poor Performance
8. Loss of Topline
9. Increased Thirst/Urination
---
1. Blindness
2. Delayed healing of wounds
3. Laminitis/Hoof Abscesses
4. Suspensory Ligament/Tendon laxity
www.northernfloridaequine.com
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PPID: an endocrine disorder
http://www.merckmanuals.com/pethealth/horse_disorders_and_diseases/
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Cortisol – the stress hormone
• Too much cortisol is damaging
• Moderateamounts of cortisol are necessary
•Abnormal fat production•Weakened immune system•Increased urine output•Poor digestion, prone to EGUS•Poor performance
•…to name a few…
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Diagnosis for PPID
GOALS:
1. Test to detect early disease
2. Test to monitor treatment
www.northernfloridaequine.com
www.tonette.co.uk/photo_album1.html
!
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Pituitary Gland
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Normal pituitary function
CRH
ACTH
CORTISOL
CORTISOL
adrenal gland
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Abnormal pituitary function
CRH
ACTH
CORTISOL
CORTISOL
adrenal gland
ACTH
CORTISOL
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▪ Resting ACTH concentrationo No grain within 12 hours
o ACTH ↑ with pain and stress, no testing during laminitis flare-up
o Blood handling
o PPID if ACTH > 35 pg/ml
▪ Seasonal elevation
o mid-July-mid-Novo ACTH ↑ in late summer and autumn in
healthy horses
Diagnosis – PPID
CRH
ACTH
CORTISOL
CORTISOL
adrenal glandJuly-Nov ACTH Result
Negative <50 pg/ml
Equivocal 50-100 pg/ml
PPID >100 pg/ml
CORTISOL
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▪ TRH stimulation
o Normal resting ACTH
o Safe
o Not during mid-July thru mid-Nov
1. Baseline ACTH
2. Give synthetic Thyrotropin Releasing Hormone (TRH)
3. 10 minutes, post-TRH ACTH
Diagnosis – PPID
CRH
ACTH
CORTISOL
CORTISOL
adrenal glandNov-July ACTH Result
Negative <110 pg/ml
Equivocal 110-200 pg/ml
PPID >200 pg/ml
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▪ TIMING NO LONGER A PROBLEMo Response to treatment
▪ NO LONGER RECOMMENDEDo Dexamethasone suppression test
o TRH stimulation measuring cortisol
o ACTH stimulation test
o Resting cortisol concentration
o Diurnal cortisol rhythm
Diagnosis – PPID
• Dexamethasone Suppression TestThis Photo by Unknown Author is licensed under CC BY-NC-ND
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▪ Pergolide mesylate
o Prascend
▪ Dosing – daily, for life
o Proper technique
o Open & prepare immediately before dosing
o Tablets allow dosing changes
PPID Medication
CRH
ACTH
P
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▪ Side effects – minimal!
▪ Permitted for showing with medication report form
▪ Re-testing ACTH
o 3-6 months
o Annual
o Same test form as diagnosis
▪ Clinical signs improveo 3-6 months
Treatment Follow-up
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PPID: Whole horse treatment
▪ Medicate with pergolide
▪ Resolve dental issueso Annual oral exam +/- float
▪ Maintain hoof healtho Survey x-rays
▪ Exercise! o Modulate insulin levelso Maintaining muscle masso Joint health
▪ Dietary changes…
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▪ calorie but carbohydrate feeds…
PPID – Feeding
EquidDoc is in no way affiliated with the aforementioned companies or products…
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Laminitis Treatment
METABOLIC LAMINITIS
▪ Anti-inflammatory
o NSAID – Bute
o Cryotherapy in initial onset
o DMSO
▪ Control insulin levels
o Medication
o Eliminate sugar
▪ Control ACTH levels
o Pergolide
o Increase dose
OTHER CAUSES
▪ Anti-inflammatory
o NSAID – Bute
o Cryotherapy in initial onset
o DMSO - uncertain
▪ Control insighting factors
o Treat infection
o Stop colitis
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To summarize:
EMS
▪ Age <15 yo
▪ Pony, Morgans, Arabians, Warmbloods, Saddlebreds, Paso Finos, other
▪ Normal hair coat
▪ Obesity or regional adiposity
PPID
▪ Age > 15 yo
▪ Any breed
▪ Long, thick, sometimes curly, delayed shedding, excessive sweating
▪ Weight loss, swayback, pendulous abdomen, regional adiposity still possible
If your horse has laminitis they must be tested for these two diseases!
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PPID
1. Diagnose with ACTH test, TRH Stim
2. Treat with pergolide as directed by your veterinarian
3. Exercise once laminitis is under control
4. Feed low WSC & starch feed, if thin feed fat based calories
5. Soak hay if also IR
To Summarize:
EMS
1. Diagnose w/oral sugar test
2. Weight loss with thyroxine as directed by your veterinarian
3. Exercise once laminitis is under control
4. Feed low calorie, low WSC & Starch feed
5. Soak hay
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Questions?