E M S& C D Client Ed

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Client Education Meeting from 3-15-11 discussing Equine Metabolic Syndrome and Cushing\'s Disease

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E M S& C D Client Ed

  1. 1.    Equine Metabolic Syndrome and Cushing’s Disease Joan Norton VMD DACVIM Janssen Veterinary Clinic Client Education Night March 15 th , 2011
  2. 2. Equine Metabolic Syndrome vs Cushing’s Disease <ul><li>Younger horses (5-15yr) </li></ul><ul><li>Increased BCS </li></ul><ul><li>“ Easy keepers” </li></ul><ul><li>Cresty neck </li></ul><ul><li>Risk of laminitis </li></ul><ul><li>Insulin resistant </li></ul><ul><li>Older horses (>15yr) </li></ul><ul><li>Cresty neck </li></ul><ul><li>Pot bellied </li></ul><ul><li>Long curly hair coat </li></ul><ul><li>Lethargic </li></ul><ul><li>Risk of laminitis </li></ul><ul><li>May be insulin resistant </li></ul>
  3. 3. Equine Metabolic Syndrome <ul><li>Insulin Resistance (IR) </li></ul><ul><ul><li>Similar to Type II Diabetes in humans </li></ul></ul><ul><ul><li>Occurs in response to obesity </li></ul></ul><ul><li>Clinical picture </li></ul><ul><ul><ul><li>Cresty neck Sheath or mammary glad </li></ul></ul></ul><ul><ul><ul><li>Tail head </li></ul></ul></ul><ul><ul><ul><li>Above eyes </li></ul></ul></ul><ul><li>Obesity persists despite decreased feed </li></ul>
  4. 4. Equine Metabolic Syndrome
  5. 5. Equine Metabolic Syndrome
  6. 6. Why? <ul><li>Genetics </li></ul><ul><ul><li>Offspring of EMS mares will develop EMS at maturity </li></ul></ul><ul><li>Breed </li></ul><ul><ul><li>Ponies </li></ul></ul><ul><ul><li>Warmbloods </li></ul></ul><ul><ul><li>Morgans </li></ul></ul><ul><li>Diet </li></ul>
  7. 7. Consequences of IR <ul><li>LAMINITIS </li></ul><ul><li>Poor performance </li></ul><ul><li>Pedunculated lipomas (cause colic) </li></ul><ul><li>Liver disease </li></ul><ul><li>Infertility </li></ul>
  8. 8. Diagnosing EMS <ul><li>Clinical Signs </li></ul><ul><ul><li>Body condition measurements </li></ul></ul><ul><ul><ul><li>Crest neck score and Obesity scores </li></ul></ul></ul><ul><ul><li>Recurrent laminitis </li></ul></ul><ul><li>Resting blood levels </li></ul><ul><ul><li>Glucose and insulin </li></ul></ul><ul><li>Combined glucose-insulin test </li></ul><ul><li>Oral glucose test </li></ul>
  9. 9. Metabolic Body Measurements <ul><li>Height at withers </li></ul><ul><li>Circumference at girth </li></ul><ul><li>Neck circumference (3 locations) </li></ul><ul><li>Shoulder to hip length </li></ul><ul><li>More accurate BW </li></ul><ul><li>Cresty neck score </li></ul><ul><li>Obesity score </li></ul><ul><li>Excellent for short term monitoring between blood tests </li></ul>
  10. 10. Resting Blood Levels <ul><li>Short fast required prior to testing </li></ul><ul><ul><li>Leave no more than 1 flake hay after 10p </li></ul></ul><ul><ul><li>No grain in the AM prior to testing </li></ul></ul><ul><li>Low stress environment </li></ul><ul><ul><li>Even mild stress can falsely raise glucose </li></ul></ul><ul><li>Insulin >20µU/ml indicates IR </li></ul><ul><li>Hyperglycemia (glucose >110mg/dl) </li></ul><ul><ul><li>Cause for additional concern </li></ul></ul>
  11. 11. Combined Glucose-Insulin Test <ul><li>Short term fasting </li></ul><ul><li>Requires an IV catheter </li></ul><ul><li>Intravenous glucose </li></ul><ul><li>Intravenous insulin </li></ul><ul><li>Draw blood every 5-10 min for 2.5 hours </li></ul><ul><li>Useful if resting levels are equivocal </li></ul><ul><li>Monitoring treatment </li></ul>
  12. 12. Oral Glucose Test <ul><li>Short term fasting </li></ul><ul><li>Give oral Karo syrup at 8am </li></ul><ul><li>Collect blood at 60 and 90 minutes </li></ul><ul><ul><li>Test insulin and glucose levels </li></ul></ul>
  13. 13. Treatment Options <ul><li>Diet </li></ul><ul><ul><li>Eliminate concentrates (grain) </li></ul></ul><ul><ul><li>Limit or eliminate turnout on lush grass </li></ul></ul><ul><ul><li>Slowly decrease hay to 1% BW a day </li></ul></ul><ul><ul><li>Provide vitamins/minerals </li></ul></ul><ul><ul><ul><li>Target IR </li></ul></ul></ul><ul><ul><ul><li>Metaboleaze </li></ul></ul></ul><ul><li>Exercise </li></ul><ul><ul><li>Proven to help insulin sensitivity </li></ul></ul>
  14. 14. Medical Therapy <ul><li>If diet and exercise alone fail </li></ul><ul><ul><li>Levothyroxine sodium (Thyro-L) </li></ul></ul><ul><ul><ul><li>NOT given to treat a thyroid disorder! </li></ul></ul></ul><ul><ul><ul><li>Higher level than normally recommended </li></ul></ul></ul><ul><ul><ul><li>Must restrict calories at the same time </li></ul></ul></ul><ul><ul><ul><li>Treat for 3-6 months (typical cost- $1/day) </li></ul></ul></ul><ul><ul><ul><li>Wean off at the end of treatment </li></ul></ul></ul>
  15. 15. Monitoring Treatment <ul><li>Monthly measurements </li></ul><ul><ul><li>Body weight </li></ul></ul><ul><ul><li>Cresty neck score </li></ul></ul><ul><ul><li>Obesity score </li></ul></ul><ul><li>Recheck blood levels </li></ul><ul><ul><li>In 3-6 months depending on response </li></ul></ul>
  16. 16. Cushing’s Disease <ul><li>Pituitary Pars Intermedia Dysfunction </li></ul><ul><ul><li>PPID </li></ul></ul><ul><ul><li>Hyperplastic pituitary gland </li></ul></ul><ul><ul><ul><li>Secretes ACTH </li></ul></ul></ul><ul><ul><li>Excessive production of cortisol by the adrenal gland </li></ul></ul><ul><ul><ul><li>In response to ACTH </li></ul></ul></ul>
  17. 17. Clinical Picture <ul><li>Horse older than 15 years </li></ul><ul><li>Long curly hair coat, long guard hairs </li></ul><ul><li>Shift in metabolism </li></ul><ul><ul><li>Easy keeper becomes a hard keeper </li></ul></ul><ul><li>Fat deposition </li></ul><ul><ul><li>Similar to Metabolic Syndrome </li></ul></ul><ul><li>Lethargy/Poor performance </li></ul><ul><li>Lameness/Laminitis episodes </li></ul>
  18. 18. Cushing’s Disease
  19. 19. Consequences of Cushing’s <ul><li>LAMINITIS </li></ul><ul><li>Decreased immune function </li></ul><ul><ul><li>Poor wound healing </li></ul></ul><ul><ul><li>Foot abscesses </li></ul></ul><ul><ul><li>Dental disease </li></ul></ul><ul><ul><li>Dermatitis </li></ul></ul><ul><ul><li>Sinusitis </li></ul></ul>
  20. 20. Diagnosis of Cushing’s <ul><li>Recognition of clinical signs (hair coat) </li></ul><ul><li>Resting plasma ACTH </li></ul><ul><li>Dexamethasone Suppression Test </li></ul><ul><ul><li>Safety concerns </li></ul></ul><ul><li>TRH Response Test </li></ul><ul><ul><li>Difficult to obtain reagents </li></ul></ul><ul><li>Domperadone Stimulation Test </li></ul><ul><li>Metabolic Syndrome testing </li></ul>
  21. 21. Diagnosis of Cushing’s <ul><li>Seasonal Variation </li></ul><ul><ul><li>ACTH/cortisol levels normally increase </li></ul></ul><ul><ul><ul><li>Late summer and fall </li></ul></ul></ul><ul><li>Testing may be inaccurate from Aug-Nov </li></ul><ul><li>Mild stress can cause false elevation </li></ul><ul><ul><li>Trailer ride </li></ul></ul><ul><ul><li>Exercise </li></ul></ul><ul><ul><li>Other testing </li></ul></ul>
  22. 22. Resting ACTH <ul><li>Single blood sample </li></ul><ul><li>Requires specialized blood tube </li></ul><ul><ul><li>Must be pre-ordered from laboratory </li></ul></ul><ul><li>Large day-to-day variation </li></ul>
  23. 23. Dexamethasone Suppression Test <ul><li>Pre-test cortisol sample </li></ul><ul><li>Injection of dexamethasone (corticosteroid) </li></ul><ul><li>24hr post-test cortisol sample </li></ul><ul><li>Association b/w dex and laminitis </li></ul><ul><ul><li>Anecdotal </li></ul></ul><ul><ul><li>Research has not been able to prove </li></ul></ul><ul><li>Normal horses have low levels at 24hrs </li></ul>
  24. 24. Domperidone Stimulation Test <ul><li>Pre-test ACTH sample </li></ul><ul><li>Give 1 tube Domperidone orally </li></ul><ul><li>Post samples at 2 or 4 hours </li></ul><ul><ul><li>Timing depends on time of year </li></ul></ul><ul><li>Affected horses have high ACTH levels </li></ul>
  25. 25. Treatment Options <ul><li>Pergolide mesylate </li></ul><ul><ul><li>Once daily oral medication </li></ul></ul><ul><ul><li>Powder or syrup </li></ul></ul><ul><ul><li>Short shelf life (powder-60Dy, syrup-30Dy) </li></ul></ul><ul><ul><li>~$1.50/day </li></ul></ul><ul><li>Cyproheptadine </li></ul><ul><ul><li>Twice a day tablet </li></ul></ul><ul><ul><li>Less effective than pergolide </li></ul></ul><ul><ul><li>Can be used in combination </li></ul></ul><ul><ul><li>~$14/day </li></ul></ul>
  26. 26. Treatment Options <ul><li>Trilostane </li></ul><ul><ul><li>Used in dogs with Cushing’s Disease </li></ul></ul><ul><ul><ul><li>Dogs have a different pathogenesis </li></ul></ul></ul><ul><ul><ul><li>May not be effective in horses </li></ul></ul></ul><ul><ul><li>Expensive </li></ul></ul><ul><ul><ul><li>$800/month </li></ul></ul></ul><ul><li>Treat insulin resistance if present </li></ul>
  27. 27. Monitoring Treatment <ul><li>Clinical signs and behavior </li></ul><ul><ul><li>May see initial dullness and poor appetite </li></ul></ul><ul><ul><ul><li>First few days-week on pergolide </li></ul></ul></ul><ul><ul><li>Then see increase in attitude and activity </li></ul></ul><ul><ul><li>Proper shedding the next spring </li></ul></ul><ul><li>Improvement in testing parameters </li></ul><ul><ul><li>Lower resting ACTH </li></ul></ul><ul><ul><li>Improved dynamic testing </li></ul></ul><ul><li>Improvement in insulin resistance </li></ul>
  28. 28. Is there a connection? *not true for every case
  29. 29. Transition State <ul><li>EMS horses may develop Cushing’s </li></ul><ul><ul><li>Usually at an earlier age </li></ul></ul><ul><li>Shift in metabolism </li></ul><ul><ul><li>Too fat </li></ul></ul><ul><ul><li>Too fat in some places & too thin in others </li></ul></ul><ul><li>High risk of laminitis </li></ul><ul><ul><li>And other complications </li></ul></ul>
  30. 30. Early Detection Is Best! <ul><li>Disease starts before clinical signs </li></ul><ul><li>All horses over 20yr likely affected </li></ul><ul><li>Disease worsens over time </li></ul><ul><ul><li>Early treatment may slow the progression </li></ul></ul><ul><ul><li>Monitoring therapy is important </li></ul></ul><ul><ul><li>More medication may be needed </li></ul></ul>
  31. 31. Janssen Metabolic Monitoring Program <ul><li>Screen for EMS and PPID all at once </li></ul><ul><li>Physical exam and body measurements </li></ul><ul><li>Resting blood levels </li></ul><ul><ul><li>ACTH </li></ul></ul><ul><ul><li>Cortisol </li></ul></ul><ul><ul><li>Insulin </li></ul></ul><ul><ul><li>Glucose </li></ul></ul><ul><li>Treatment recommendations </li></ul>
  32. 32. Pituitary Profile from <ul><li>ACTH- $177.60 </li></ul><ul><li>Cortisol- $85.40 </li></ul><ul><li>Insulin- $63.50 </li></ul><ul><li>Glucose- $63.60 </li></ul><ul><li>Total- $390 </li></ul><ul><li>Janssen Profile- </li></ul><ul><ul><li>ACTH </li></ul></ul><ul><ul><li>Cortisol </li></ul></ul><ul><ul><li>Insulin </li></ul></ul><ul><ul><li>Glucose </li></ul></ul><ul><li>Total- $260.00 </li></ul><ul><li>Savings of $130! </li></ul>
  33. 33. Final Thoughts… <ul><li>EMS and Cushing’s are separate but related diseases </li></ul><ul><li>Early detection and treatment is best </li></ul><ul><ul><li>Prevent “transition state” </li></ul></ul><ul><ul><li>Ward off life-threatening complications </li></ul></ul><ul><li>Proper monitoring is necessary </li></ul><ul><ul><li>Correct medication dosage </li></ul></ul>
  34. 34. Early Detection Program <ul><li>Basic Equine Chemistry </li></ul><ul><li>Complete Blood Count </li></ul><ul><li>Fibrinogen </li></ul><ul><li>Fecal Egg Count </li></ul><ul><li>e-Coggins </li></ul><ul><li>Savings of $40! </li></ul>
  35. 35. Questions?

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