e m s& c d client ed

Equine Metabolic Syndromeand

Cushing’s Disease

Joan Norton VMD DACVIM

Janssen Veterinary Clinic

Client Education Night

March 15th, 2011

Equine Metabolic Syndrome vs Cushing’s Disease

Younger horses (5-15yr)

Increased BCS

“Easy keepers”

Cresty neck

Risk of laminitis

Insulin resistant

Older horses (>15yr)

Cresty neck Pot bellied Long curly hair coat Lethargic Risk of laminitis May be insulin resistant

Equine Metabolic Syndrome

Insulin Resistance (IR) Similar to Type II Diabetes in humans Occurs in response to obesity

Clinical picture Cresty neck Sheath or mammary glad Tail head Above eyes

Obesity persists despite decreased feed

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Genetics Offspring of EMS mares will develop EMS at

maturity

Breed Ponies Warmbloods Morgans

Diet



Consequences of IR

LAMINITIS

Poor performance

Pedunculated lipomas (cause colic)

Liver disease

InfertilityQuickTime™ and a

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Diagnosing EMS

Clinical SignsBody condition measurements

Crest neck score and Obesity scores

Recurrent laminitis

Resting blood levelsGlucose and insulin

Combined glucose-insulin test

Oral glucose test



Metabolic Body Measurements

Height at withers

Circumference at girth

Neck circumference (3 locations)

Shoulder to hip length

More accurate BW

Cresty neck score

Obesity score

Excellent for short term monitoring between blood tests

Resting Blood Levels

Short fast required prior to testing Leave no more than 1 flake hay after 10p No grain in the AM prior to testing

Low stress environment Even mild stress can falsely raise glucose

Insulin >20µU/ml indicates IR Hyperglycemia (glucose >110mg/dl)

Cause for additional concern

Combined Glucose-Insulin Test

Short term fastingRequires an IV catheterIntravenous glucoseIntravenous insulinDraw blood every 5-10 min for 2.5

hoursUseful if resting levels are equivocalMonitoring treatment





Oral Glucose Test

Short term fasting

Give oral Karo syrup at 8am

Collect blood at 60 and 90 minutesTest insulin and glucose levels



Treatment Options

Diet Eliminate concentrates (grain)Limit or eliminate turnout on lush grassSlowly decrease hay to 1% BW a dayProvide vitamins/minerals

Target IR Metaboleaze

ExerciseProven to help insulin sensitivity



Medical Therapy

If diet and exercise alone failLevothyroxine sodium (Thyro-L)

NOT given to treat a thyroid disorder! Higher level than normally recommended Must restrict calories at the same time Treat for 3-6 months (typical cost- $1/day) Wean off at the end of treatment



Monitoring Treatment

Monthly measurementsBody weightCresty neck scoreObesity score

Recheck blood levels In 3-6 months depending on response



Cushing’s Disease

Pituitary Pars Intermedia DysfunctionPPIDHyperplastic pituitary gland

Secretes ACTH

Excessive production of cortisol by the adrenal gland In response to ACTH



Clinical Picture

Horse older than 15 years

Long curly hair coat, long guard hairs

Shift in metabolismEasy keeper becomes a hard keeper

Fat depositionSimilar to Metabolic Syndrome

Lethargy/Poor performance

Lameness/Laminitis episodes



Cushing’s Disease







Consequences of Cushing’s

LAMINITISDecreased immune function

Poor wound healingFoot abscessesDental diseaseDermatitisSinusitis





Diagnosis of Cushing’s

Recognition of clinical signs (hair coat)

Resting plasma ACTH

Dexamethasone Suppression TestSafety concerns

TRH Response TestDifficult to obtain reagents

Domperadone Stimulation Test

Metabolic Syndrome testing

Diagnosis of Cushing’s

Seasonal Variation ACTH/cortisol levels normally increase

Late summer and fall

Testing may be inaccurate from Aug-Nov

Mild stress can cause false elevation Trailer ride Exercise Other testing



Resting ACTH

Single blood sample

Requires specialized blood tubeMust be pre-ordered from laboratory

Large day-to-day variation



Dexamethasone Suppression Test

Pre-test cortisol sample Injection of dexamethasone (corticosteroid)

24hr post-test cortisol sample

Association b/w dex and laminitis Anecdotal Research has not been able to prove

Normal horses have low levels at 24hrs

Domperidone Stimulation Test

Pre-test ACTH sample

Give 1 tube Domperidone orally

Post samples at 2 or 4 hoursTiming depends on time of year

Affected horses have high ACTH levels



Treatment Options

Pergolide mesylate Once daily oral medication Powder or syrup Short shelf life (powder-60Dy, syrup-30Dy) ~$1.50/day

Cyproheptadine Twice a day tablet Less effective than pergolide Can be used in combination ~$14/day





Treatment Options

TrilostaneUsed in dogs with Cushing’s Disease

Dogs have a different pathogenesis May not be effective in horses

Expensive $800/month

Treat insulin resistance if present

Monitoring Treatment

Clinical signs and behaviorMay see initial dullness and poor appetite

First few days-week on pergolideThen see increase in attitude and activityProper shedding the next spring

Improvement in testing parametersLower resting ACTH Improved dynamic testing

Improvement in insulin resistance



Is there a connection?



*not true for every case

Transition State

EMS horses may develop Cushing’sUsually at an earlier age

Shift in metabolismToo fatToo fat in some places & too thin in others

High risk of laminitisAnd other complications

Early Detection Is Best!

Disease starts before clinical signs

All horses over 20yr likely affected

Disease worsens over timeEarly treatment may slow the progressionMonitoring therapy is importantMore medication may be needed

Janssen Metabolic Monitoring Program

Screen for EMS and PPID all at oncePhysical exam and body

measurementsResting blood levels

ACTHCortisol InsulinGlucose

Treatment recommendations

Pituitary Profile from

ACTH- $177.60

Cortisol- $85.40

Insulin- $63.50

Glucose- $63.60

Total- $390

Janssen Profile- ACTHCortisolInsulinGlucose

Total- $260.00

Savings of $130!



Final Thoughts…

EMS and Cushing’s are separate but related diseases

Early detection and treatment is bestPrevent “transition state”Ward off life-threatening complications

Proper monitoring is necessaryCorrect medication dosage



Early Detection ProgramQuickTime™ and a

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Basic Equine Chemistry

Complete Blood Count

Fibrinogen

Fecal Egg Count

e-Coggins

Savings of $40!



Questions?



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