From Endurance to Dressage
On Friday afternoon, I got a very surprising and happy phone call. Dr. Tolley called to share that Speedy's ACTH number came back at ... wait for it ... a 24! I think Dr. Tolley was even more surprised than I was!
A horse's normal ACTH, Adrenocorticotropic hormone, is between 9 and 35. High levels of ACTH cause an over production of cortisol from the adrenal glands which affects all sorts of systems. When we first tested Speedy in January of 2019, his ACTH level was 56. That's when my vet first diagnosed him with PPID, also known as Cushing's Disease. When we tested Speedy again this February, he was at a 134, even on a 1mg dose of Prascend. That was not a good sign.
We doubled his dose to 2 mg of Prascend and then backed that down to 1.5 mg with the plan to retest him at the end of ninety days. I wrote about that last week, which brings us to today. My vet says that Speedy is now what he would consider "under control," and his dosage, 1.5 mg, is perfect. But.
I just couldn't leave it at that because PPID is not a stagnant disease. Horses' ACTH levels fluctuate all year long, particularly in late summer/early fall. So I asked more questions. What do we do when ... ? What do we do if ... ? When should we check ... ?
Dr. Tolley's answers were pretty simple. ALL horse will show a rise in their ACTH levels if we check them in the fall, which is what I wanted to do. The problem is determining whether Speedy's ACTH levels have risen because the dosage isn't working or because they've risen normally. Essentially, Dr. Tolley is looking at it like this: Speedy ACTH level is now at what a non-PPID horse's level should look like. If we test him again in September, his numbers WILL rise like any non-PPID horse's would which is why that can't guide our decision to change his Prascend dosage.
Our plan is this: if Speedy has one late summer/fall abscess, we start watching him closely. If he has a second one, we re-test his ACTH levels and go from there. If he has no abscesses, we still recheck his bloodwork in late winter to get a new baseline for the next year. We'll adjust his medication based on that number.
With his numbers back in the normal range, I should be really happy, and I am, but I also want to keep ahead of things so that we can avoid those pesky abscesses. Future worries aside, the number 24 is a great thing to see.
In January of 2019, three abscesses in quick succession suggested to Dr. Tolley that Speedy might have PPID, also known as Cushing's Disease. We ran bloodwork and got back a lowish number, 56, but not low enough. Horses normally have an ACTH level somewhere between 9 and 35. Speedy's slightly elevated level combined with recurrent infections in the form of abscesses was enough to convince my vet that Speedy should be classified as a Cushing's Horse. We started him on 1 mg a day of Prascend.
Fast forward to August. The abscesses returned, plaguing him throughout the fall and winter. When we rechecked Speedy's ACTH levels in February, the numbers came back at 133, not what you would expect from a horse on Prascend. Dr. Tolley decided to double Speedy's Prascend from 1 mg to 2. Immediately, Speedy developed the Pergolide Haze. He became lethargic and dopey, all symptoms that usually go away once a horse is accustomed to the dosage.
I worried that by jumping to such a "high" dose so quickly, we would run out of room to adjust his medication. Dr. Tolley agreed that a 1.5 mg dose would be a good compromise. We also decided to give the dosage a 90-day trial period with bloodwork to be redrawn at the end of the three months. That deadline has arrived.
Since we were never quite sure that the February bloodwork was accurate, so many things can raise the ACTH levels, Dr. Tolley and I worked out a plan to get the most accurate ACTH bloodwork on Speedy that we possibly could. Instead of hauling Speedy down to the vet hospital, we decided that Dr. Tolley would come by one morning and do a quick blood draw while Speedy was resting quietly at home.
Conveniently for me, Dr. Tolley was scheduled to be out at the ranch yesterday morning to vaccinate seven of the horses at the ranch and examine the teeth of a few of them. Before pulling any other horses out, we walked up to Speedy and quickly drew a vial of blood. He didn't even know what hit him. Speedy had had his breakfast, all of his friends were around, he'd been sprayed for flies, plied with cookies, and was grazing in the yard. Everything was as right in his world as could be.
Well, nearly everything. Some time in the early morning Speedy either stuck his head through the fence and pulled it out roughly, or Izzy bit him. Right under his throatlatch he had a bloody scrape and a ginormous bag of fluid. Dr. Tolley eyeballed it and shrugged. What are you going to do? Horses.
So unless the scrape/bite was more traumatic than Speedy let on, his ACTH numbers should not be elevated due to the stress of traveling and being at the vet hospital. We should get the results back by early next week. Once we know what his numbers are, we'll adjust his Prascend according to my vet's recommendation.
Fingers crossed for numbers below a hundred. Below fifty would be even better, but I think that might be wishful thinking.
It's a lot easier to just call it PPID, or as many people call it, Cushing's Disease. After that post I did a week or so ago, I realized that I hadn't really done my due diligence. I heard "Cushing's Disease" a year ago January and simply gave Speedy his pill assuming that was that.
That wasn't really that, and unfortunately, that doesn't have a simple diagnosis, treatment plan, or recovery phase. The reason there is so much contention over the appropriate treatment of PPID is because there's a lot the medical establishment doesn't know. And even more so for horses in the earliest stages of the disease; horses like Speedy.
I spent a lot of time last week researching the disease; the Laminitis Site and the ECIR Group were good resources. PPID is a rabbit hole that goes on for miles and miles. There is no bottom, no end, no definitive answer. After realizing that I didn't really need to know the exact hormonal processes that were happening, I scanned the more technical aspects of the disease and focused my energies on treatment.
Several things jumped out at me. First, it is not necessarily easy to interpret the ACTH levels. To simplify things, the ACTH level indicates whether things are under control or not. A "normal" range is somewhere between 9 - 35. One problem with checking the ACTH level is that it can rise from a variety of factors, none of which mean that a horse even has PPID. Stress, whether from trailering, pain, or even seeing the vet, is enough to rocket up the ACTH level.
The time of year the test is given can also raise the levels. There is a well documented seasonal rise in all horses. From late summer, around August, all the way through to the end of December, all horses will experience a rise in their ACTH levels. Scientists don't exactly know why, but the reasoning is that it helps horses prepare for winter.
Some PPID experts encourage testing in the fall to see how high the ACTH levels rise. Others recommend testing when the ACTH levels should be at their lowest, January and February, in order to get a baseline measurement. There's no limit to the amount of times that you can test, it's simply a blood draw, but it's not cheap. I didn't look too closely at my last bill, but I think the test runs around $150.
The second thing I spent a lot of time researching was the dosage. The manufacturer recommends dosing by weight. In addition, the recommended maximum dose is 2 pills per day. While there are horses being treated with 5 - 10 or even more pills per day to control their symptoms, there is currently no published research using doses higher than 5 mg for a 1,000 pound horse.
Regarding the appropriate dosage, it should be noted that there is no cure for PPID. Prascend won't cure a horse; all it can do is control the symptoms. Even then there is no guarantee that Prascend will control them. That's why PPID horses still suffer laminitic events and ultimately death.
From the Laminitis Site, "PPID is a progressive disease, and the amount of Pergolide required to control the symptoms is likely to increase as the horse ages. Some horses only need Pergolide during the seasonal rise in the early stages of the disease. Many horses need an increased dose of Pergolide during the seasonal rise."
Once I felt that I better understood the disease, I gave Dr. Tolley a call. And as I knew he would, Dr. Tolley spent quite a bit of time with me formulating a plan for Speedy. The first thing that we both agreed upon was that Speedy is nearly asymptomatic. Of all the early signs of the disease, the only one that Speedy has is frequent infections, and those are limited to his feet in the form of abscesses. And interestingly, those have all occurred during the seasonal rise of the ACTH levels (late summer through early winter).
Dr. Tolley had three possible explanation for why Speedy's ACTH levels could have risen so dramatically while being treated with Prascend and showing no other clinical signs. A horse with levels like Speedy's should have shown something else to indicate the disease. First, Dr. Tolley posited that Speedy might not be getting the dose.
We talked about how the ranch owner doses Speedy. She stands with him until she hears him crunch it. Even then she watches closely for the "spit out." It happens every once in a while, but she's quick to locate it and pop it back in his mouth. She gives it to him in a place where it can be easily found if he does spit it out.
Speedy isn't the first PPID horse she's managed. Her own mare, Lilly, had PPID for more than 6 years before succumbing to laminitis. The ranch owner is an old hand at effectively delivering the pill. Dr. Tolley agreed that Speedy is more than likely getting his dose.
The second reason that Speedy's ACTH levels might have risen could be due to a "false positive". It is very possible that when Speedy's blood was drawn, he was under a high degree of stress, which we know raises ACTH levels. He had traveled nearly 40 minutes in the trailer, he was worried about Izzy's whereabouts, he was still dealing with a draining abscess, and he was facing the man who always sticks him with needles.
The third reason Speedy's ACTH levels might have risen is that his PPID symptoms are unaffected by the 1 mg. dose. This is a worst case scenario as it would suggest that his symptoms might not be controlled by Prascend. For now, we're going to assume his ACTH levels were high due to stress.
The next thing I wanted to know was how confident Dr. Tolley is that Speedy truly has PPID. When asked point blank how confident of his diagnosis was he, Dr. Tolley responded that yes, even though Speedy's symptoms are nearly non-existent, the fact that he has elevated ACTH levels combined with fall and winter abscesses, his diagnosis stands. Was there something else it could be, was there another explanation, should we look at something else? To each question, Dr. Tolley answered no.
Dr. Tolley has never resented my questions. He's never been offended when I've asked for a second opinion or when I've consulted a different medical professional. And in this instance, his response was the same; do more research, ask more questions, consult other doctors. He welcomed my perseverance and thanked me for really thinking about how to approach this disease.
So where does that leave us? First, we decided to reduce the dosage from 2 pills to 1 and a half pills for now. Dr. Tolley wants Speedy to maintain that dose for 90 days. At the beginning of June, he will come out to the ranch and do a blood draw with the intent of lowing Speedy's stress level. Getting the sample back to the hospital quickly will be a slight issue, but he thinks he can do it without affecting the results.
Based on that blood draw, we will either maintain the current dose or return to the 1 mg dose. We also have it in mind that we may need to raise the dose in anticipation of the seasonal rise in Speedy's ACTH levels. To determine that, we may need to do another blood draw in August.
When Speedy was very first diagnosed with PPID, I asked how many pills we could give him. Dr. Tolley's response was the same then as it is now. We can give him as many as we want, but in his experience, three or more pills haven't controlled the symptoms any better than the maximum recommended dosage of two pills. Every horse responds differently. We'll just have to wait and see.
When I pressed him for next steps, I was again met with his reluctance to answer. It was only when I finally explained that I wasn't searching for a miracle that he quit evading my question. Over the phone I could hear him give a sigh of relief. Essentially, we're already doing everything we can. That was his answer. We'll do bloodwork. We'll adjust his Prascend up and down. And we'll pray. I can do that.
Many of you have recently expressed your feelings about me as a human being. While I welcome comments and never delete the ones that are harsh or critical, I would ask that if you do choose to comment on this post that you do so in a way that fosters respectful conversation. I may not be making the same choices that you would make, but I am making them in consultation with my veterinarian. His opinion matters a lot more to me than does yours.
And life goes on.
"In a world where you can be anything, choose to be KIND."
- Jennifer Dukes Lee
I think the thing that surprised me most about the comments from yesterday's post was how quick some of you were to think the absolute worst of me. In contrast, I was overwhelmed with gratitude at those of you who chose to think the best of me. Thank you.
I have stipulated many, many times that while I write, I am not a professional. I don't get paid to put my thoughts down on paper. I do it because it is therapeutic for me. It helps me set goals, prioritize, celebrate, scream, shout, sing, and sometimes, to cry.
Some of you understood my feelings; I have a horse that will probably die long before I am ready for him to pass, and I won't be able to do a thing about it.
Except. The one thing I can do for him is choose his ending before he suffers. I can choose to let him go before he stands in excruciating pain as his coffin bone rotates into his sole. Laminitis. It's my worst nightmare. Speedy's version of Cushing's Disease seems determined to make this about his feet. How many laminitic episodes do I let him have? What's the magic number? One, three, eight? My heart answers for me; none. One is too many.
When Dr. Tolley and I evaluated Speedy more than a week ago, I asked him to help me make the right decision when the time comes. He could barely look me in the eye. He quipped, "oh, I'll be long gone before that happens." I knew what he was trying to say. He meant that Speedy has a long life in front of him and that he'll be retired before that fateful day arrives. That's what he tried to say, but I knew better.
I pleaded with him to listen, really listen. The last thing that I want is for Speedy to suffer. Dr. Tolley looked at me and nodded. In a voice that resonated with regret, he admitted that he has let horses live too long. Suffer too long. Even for him, a doctor of veterinarian medicine for more than 30 years, letting them go is still hard to do.
I told Dr. Tolley that I will do what seems right for Speedy. I will care for him as long as there is a good chance that he can lead a comfortable and happy life. I will not go to the ends of the Earth to keep him with me though. That's selfish.
If that makes me an asshole, then it does. I won't apologize for it.
Speedy and I just can't catch a break. On Thursday, Dr. Tolley called with the results of Speedy's most recent ACTH results. For those who are new here, Speedy has Cushing's Disease. Retesting the ACTH levels can indicate whether the disease is being controlled by medication or not. I wrote a Cushing's Tutorial here. I am not a vet, so take the information with a grain of salt. In short, Speedy's ACTH levels didn't fall as we had hoped; neither did they remain where they were. Oh, no. Instead, his have risen 239%.
In January of 2019, multiple abscesses in quick succession screamed red flag to my vet, especially since Speedy had never before abscessed and he was also quickly approaching his 15th birthday. Dr. Tolley ordered Speedy's first ACTH test. The results came back at only slightly elevated with a score of 56. While low, it was still too high for mid-winter, so Speedy was started on 1 mg of pergolide daily.
Throughout the rest of the winter and spring, things went well. In early August, he developed another abscess, and in November another one. And of course, we had yet a third one in mid-February. Speedy's still recovering from that one. It would seem that the Prascend was working through the first half of the year but not so much in the second.
I guess the good news is we now have an explanation for why the abscesses continued. The only thing we can do is increase Speedy's daily dose of pergolide from 1mg to 2. Prascend, the brand name for pergolide, isn't cheap though. I pay $2.13 per pill, and before you tell me I can get it slightly cheaper, I am aware of that.
I choose to order it through my veterinarian's online pharmacy because I don't have to do anything except change the AutoShip date when needed. Well, that and provide my credit card. My vet takes care of everything else. It's convenient, and for the $8.00 a box I might save by ordering through Allivet, I'll stick with my vet's pharmacy.
Let's be honest here; $4.23 per day is a lot of money. That's $29.61 a week or $131.13 a month. Even scarier, it's a whopping $1,543.95 a year. I can't afford more. Maybe it's more honest to say I WON'T afford more. It breaks my heart to say it, but at some point, the price of a treatment is more than I am willing to spend. In June, we'll test his ACTH levels again. This test will tell us if his Cushing's Disease is under control or not.
While it kills me to say this, if his numbers have risen even more, I can't justify spending $200 a month on three pills a day. I am willing to do a lot for my horses, but at some point, I'm just going to have to take a step back and let nature run its course. Will that be easy to do? Oh my gosh, no! It will break my heart.
For now, we're taking it one day at a time.
About the Writer and Rider
I am a lifelong rider.
I began endurance riding in 1996 where I ultimately completed five, one-day 100 mile races, the 200-mile Death Valley Encounter, and numerous other 50, 65, and 75 mile races. I began showing dressage in 2010.
Welcome to my dressage journey.
About Speedy G
Speedy went from endurance horse to dressage horse. After helping me earn a USDF Bronze medal in the summer of 2020, he is now semi-retired. Speedy is a 2004, 15'1 hand, purebred Arabian gelding. His Arabian Horse Registry name is G Ima Starr FA.
Izzy was started as a four-year old and then spent the next 18 months in pasture growing up. I bought him as a six-year old, and together, we are schooling and showing at the lower levels. He is a 2008, 16'3 hand warmblood gelding. His Rheinland Pfalz-saar International (RPSI) name is Imperioso.
CDS Sapphire Rider Award
Third Level: 63.514%
Third Level: 62.105%
2020 Show Season
(r) Ride-a-Test Clinic
(Q) Must Qualify
2020 Pending …
10/24-25 SCEC (***)
11/7-11/8 SB (***)
2020 Completed …
10/26-27/19 SCEC (***)
6/20-21/20 SCEC (***)
6/29 Ulf Wadeborn (c)
7/11-12 SLO-CDS (***)
7/27 Breen-Gurley (c)
8/30 Breen-Gurley (c)
9/20 Caveletti Clinic (c)
10/11 A. Newcomb (c)
2020 Qualifying Scores
Regional Adult Amateur Competition (RAAC)
3rd Level Qualifying Modified for 2020
2 Scores/1 Judge:
Score 1: 60.405% Atkins
Score 2: 62.432% Atkins
3rd Level Qualifying Modified for 2020
3 Scores/2 Judges:
Score 1: 60.405% Atkins
Score 2: 62.432% Atkins
Score 3: 61.750% Johnson
Stuff I Read