Please report adverse reactions to Prascend

12/3/2013

Important - please report any suspected adverse reactions to Prascend.

Many owners inform us that their horses have shown symptoms of the "pergolide veil" - when horses go off their food and/or become depressed or lethargic soon after starting pergolide/Prascend - and we have had the occasional report of horses seeming to develop mild diarrhoea or colic which is perhaps linked to pergolide treatment.

Boehringer Ingelheim, the drug company that makes Prascend, would like owners to report any suspected adverse reactions to Prascend, either to your vet (and ensure that he/she reports it), or direct to Boehringer Ingelheim.

If you message BI yourself, please give the name and contact details of your vet, your full name and contact details, the name, age, breed and approximate weight of your horse, the date the treatment started, the dose of Prascend given, the date you noticed the reaction, for how long you noticed the reaction, the outcome and a description of what happened. BI will ensure these reports are followed up and reported to the Veterinary Medicines Directive.

We know that these adverse effects can be quite common and usually pass quickly, thanks mostly to the ECIR group who have been recording these effects for many years and coined the phrase "pergolide veil". However, it is very important that the drug companies and licencing authorities are also informed, so that any problems can be fully investigated and hopefully advice given to lessen the chances of any adverse effects being seen.

Pergolide appears to be an extremely effective and safe drug, there are horses on the ECIR group who have been on pergolide for 10 years and more, quite a few at high doses (over 5 mg/day), with no problems whatsoever. However, the pathology of PPID, the pharmacokinetics of pergolide and the interactions of neurochemicals and hormones make this an incredibly complicated area of medicine, so it's no wonder there can be a few "teething problems" when first starting treatment. Accurately reporting any problems experienced will almost certainly lead to more knowledge and improvements in the future - so please do it!

NB many owners in the USA have avoided pergolide veil symptoms when using APF at the same time as introducing pergolide - see Pergolide - ECIR Group. APF can now be bought in the UK from ForagePlus.

18 Comments

Susan Canaday

2/24/2016 05:56:53 pm

My 25 year old gelding diagnosed with Cushings is showing aggression and anxiety with Pergolide. What are my options? We have tried 1/2 pill every other day with 1 whole pill the other day, we have tried dividing the dose AM and PM, I am not sure I can drop the dose to half as his tests showed a very obvious change in his results.

The Laminitis Site

2/24/2016 10:05:27 pm

In our experience, the same dose of pergolide should be given every day, and the majority of horses seem to do best with a once daily dose - changing the dose from day to day does not seem beneficial.

The correct dose is the lowest possible dose that controls clinical signs and ideally blood hormone levels, without causing side effects. A low dose is sometimes all that is required to reduce hormone levels significantly.

When side effects are seen, according to the Prascend data sheet, treatment should be stopped for 2-3 days then reintroduced and built up slowly - the data sheet actually suggests starting with half the dose, but it may be best to build up more slowly than that, so perhaps 0.25 mg for 3 days or so, or until that dose appears to be accepted, then 0.5 mg for 3 days and so on. See http://www.noahcompendium.co.uk/Boehringer_Ingelheim_Limited/Prascend_1_mg_tablets_for_horses/-53062.html and http://www.thelaminitissite.org/articles/starting-pergolideprascend.

As mentioned above, some owners have reported success when giving APF at the same time as introducing pergolide. In the UK APF is available from ForagePlus - https://forageplus.co.uk/product/apf/.

Presumably there is nothing in his diet that could be affecting the pergolide - no herbs or supplements or other medication?

Are you confident that the diagnosis of PPID is correct? ACTH can be raised by stress and some medication - see http://www.thelaminitissite.org/ppid-faq/does-a-high-acth-result-mean-my-horse-has-ppid, and clinical signs must be present and should form the basis of a diagnosis of PPID - see http://www.thelaminitissite.org/articles/is-it-ppid-or-is-it-ems.

If you are using Prascend, It is important to report the side effects you are seeing to Boehringer Ingelheim (BI) or the VMD. You can also ask experts at BI for advice through the Talk About Laminitis Facebook page - https://www.facebook.com/talkaboutlaminitis/.

You might like to join our Facebook support group and provide more details about your horse - https://www.facebook.com/groups/475349259169277/.

Carol Bush

2/7/2017 05:45:24 pm

My 30 year old draft has become very aggressive to my other horses after being on Prascend for several months. He started on 1mg July 2016. He is also picky about what he will eat and chases others away from the hay. Now that it is spring I'm going to try reducing or stopping the Prascend.

Carolyn Steel

11/8/2017 05:46:29 pm

I have a fifteen year old gelding. This year after a bout of laminitus he was tested positive for cushings. He was started off on half tablet. Retsted his levels were fine. In Sept he went lame but came sound really quickly. He was tested again and his levels increased His dose was increased to one tablet per day. At this point he went off his feed for few weeks. Now taking hard feed but displaying aggressive behaviour in terms of rearing when being led( plants and then if continued to ask to move forward rears) he is also aiming his bum at me with bucks. He is due to be retested in few weeks.

Alison Steele

2/10/2018 07:24:13 pm

My 29 year old mare has been on prascend for several years now. I'm convinced it makes her depressed and definitely puts her off her food. I'm considering taking her off the prascend. She has 1.5 tablets a day

The Laminitis Site

3/7/2018 10:55:18 am

Going off of feed (particularly bucket feed) and becoming depressed may be signs that the dose of pergolide is too high.

2 things should be considered:

1. Has the horse definitely got PPID? Were clinical signs seen as well as above normal ACTH results when the PPID was diagnosed. There are many reasons why ACTH can increase, besides PPID - see: http://www.thelaminitissite.org/ppid-faq/does-a-high-acth-result-mean-my-horse-has-ppid.

2. If the horse has definitely got PPID (so treatment with pergolide is recommended), is the lowest possible dose being given and is it being adjusted appropriately throughout the year?

It is important that the dose of pergolide (Prascend) is as low as possible - the data sheet says: "it is therefore recommended to titrate to the lowest effective dose per individual based on response to therapy, whether it is effectiveness or signs of intolerance."
http://www.noahcompendium.co.uk/?id=-447753.

Many horses require an increase in dose during the seasonal rise, to keep their PPID under control, with a decrease in the dose around December.

Andy Durham suggested in a 2015 webinar that, for some horses, it may be that a higher dose of pergolide is needed initially to bring the PPID under control, and that that dose may then be able to be reduced. This hasn't been proven by research yet, but Hal Schott found that horses kept on a low dose of pergolide showed greater improvement after 2.5 years than after 6 months, so there does appear to be a long-term effect - see p19 https://sites.tufts.edu/equineendogroup/files/2013/10/Equine-Geriatric-Workshop-II-DRH-2014.pdf.

So it may be that after several years on Prascend, she now needs a lower dose.

Pergolide is generally a safe and effective treatment for PPID, and the consequences of untreated PPID can be serious, so reducing the dose rather than stopping treatment altogether may be a better long-term solution. This is something that must be discussed with your vet, taking her history and current clinical signs and blood test results into account.

We have had success with changing the timing of giving bucket feed and pergolide treatment, for horses that were considered to be on the correct dose of pergolide. We have not found a pattern common to all horses, but some horses seem happy to have their tablet at the same time or just before a bucket feed, and others seem happy having at least 6 hours between tablet and feed, so experimenting with when you give the tablet/s may be worth trying.

Michele Goldberg

3/14/2018 06:51:18 pm

My 10yr Hanovarian Geld had a high acth end of November 2017...it was 148 ...vet suggested starting on Prascend ...I started at 1/4tab ...increased to half 4days later...then increased to 3/4 tabs about 1week later ...then finally had him at 1full tab by mid December....his attitude and behavior have completely changed ...ranging from dull and depressed... to spooky, excitable , wild and now very aggressive to his other pasture mate that he’s always lived with and got along fine before starting Prascend ...he’s also completely lost his appetite and is super picky about his feed to the point where he’s refusing to eat and shows no interest most days ...he used to greet me at the gate when time to come me in and now most of the time he’s withdrawn and shows no interest in even coming in ...or he’ll spook and not let me catch him ..he’s been on 1mg 1 full tab for approximately 90days now ...I have him on APF and ulcer medicine treatment neither of which has made a difference in behavior or appetite

The Laminitis Site

3/26/2018 01:06:03 pm

When a reaction is seen to pergolide, particularly when the dose has correctly been increased gradually, the first question that should probably be asked is whether the horse definitely does have PPID. PPID can be difficult to diagnose in the early stages, and there are many things that can increase ACTH, that have nothing to do with PPID, including taking blood after a horse has been sedated, allowing unseparated blood to be frozen or come into contact with ice, as well as stress in its many forms - see:
http://www.thelaminitissite.org/ppid-faq/does-a-high-acth-result-mean-my-horse-has-ppid. A horse must have clinical signs as well as above normal ACTH for a diagnosis of PPID. PPID is seen in horses as young at 10, but it is still reasonably rare to see it in horses this young.

Abnormal fat deposits such as a cresty neck and bulging supraorbital hollows are often seen when a horse has EMS. An above normal leptin result (24.36 (1-10) suggests that a horse is overweight, but not necessarily that it has insulin dysregulation/EMS. Insulin of 13.64 (10-40 and glucose 103 (71-122) appear to be within normal ranges, if the blood was tested after the horse had been eating his usual hay or grass – it is now recommended that resting insulin tests are fed, not fasted.

Further testing for EMS/insulin dysregulation, e.g. using the oral sugar test as long as the horse does not have/has not recently had laminitis, might be something to discuss with your vet, and if at all overweight, a weight loss program started, along with discussing your concerns about his change of behaviour since starting Prascend, and, if appropriate, his PPID diagnosis.

Belinda Adams

3/25/2018 10:42:32 pm

12,2hh pony 24yrs. Has had prascend successfully for almost 7 yrs but has started coughing when I syringe the 1mg dose each day. When I reduced and then stopped the dose for about 3 weeks her hair became very long and dry. I am having an uphill battle to keep weight on her and can only feed soaked, drained and then pour hot water on it otherwise she coughs and violently passes wind . Her last blood test was normal but by vet kept her on prascend at the same rate. I am considering trying alternative treatments in case the cough and flatulence are caused by the Prascend

The Laminitis Site

3/26/2018 10:32:33 am

This is something you need to discuss with your vet, and ideally have your vet present when you give the Prascend and she shows this reaction.

We have not heard of a link between Prascend and coughing.
Could it be the syringing that is causing the coughing and passing wind? Have you tried syringing a similar amount of liquid that doesn’t contain Prascend to see if it has the same effect?
Have you tried giving the Prascend at a different time of day, or using a different liquid (e.g. apple sauce, yoghurt…) to carry the Prascend?
The passing wind could be due to the coughing.
Can you give the Prascend without syringing it? Will she eat it in a treat, e.g. a slice of apple or a small square of jam sandwich or malt loaf? If you give it in a treat, it’s a good idea to give the treat without Prascend some of the time, as ponies sometimes associate the treat with the tablet and start to refuse the treat.

We are not quite sure if you are soaking, draining and pouring hot water on hay or Prascend? Pergolide is heat sensitive and should not be stored at temperatures above 25’C. Although the body is of course warmer than this, it may be best to avoid adding water hotter than 25’C to pergolide before administering it.

If it is hay that you are soaking, draining and pouring hot water onto before feeding to prevent coughing, then perhaps you should investigate whether there are any issues with the hay or how your pony eats hay, and again discuss with your vet.

There aren’t really any alternative treatments to pergolide that have been proven to help horses with PPID. Other dopamine agonists, such as bromocriptine http://www.thelaminitissite.org/b1.html , have been tried for horses, but pergolide seems to be the most effective.

As you saw a change in her hair coat when you took her off the Prascend, that may suggest that her clinical signs of PPID worsen if she is not treated, and is also likely to suggest a correct diagnosis of PPID. A reduced dose of Prascend may be possible if her ACTH levels are normal and her clinical signs of PPID are controlled. It has been suggested that horses with PPID may need a higher dose of pergolide initially to get symptoms under control, and that the dose may be able to be reduced after months/years of treatment once the PPID is controlled. It is also quite common for horses to need an increased dose during the seasonal rise, from around July to December, with the dose being reduced again around December.

Involve your vet with this problem, and hopefully you will be able to resolve it and continue to keep her PPID well controlled.

Sue McMurray

8/16/2019 07:12:53 pm

Our 23 years old Warmblood gelding has been on 2 Prascend tablets per day since June 2015. Our vet does a blood draw three times per year to check his ACTH numbers, which have stayed within the normal range of 9 to 35. He was scoped for stomach ulcers, and his IR was tested at University of California Davis Large Animal Hospital in March of 2018, both were nominal. He is barefoot, and on a trimming schedule every 6 to 8 weeks. He has had 4 hoof abscesses in the four years since his retirement in December 2014. He is allergic to seasonal midges, and receives 10 Cetirizine tablets (10mg tablets) twice daily during fly season. He is also completely body clipped from the Spring shed to mid-September, to help him feel more comfortable during the warm/hot months. He lives in a small pasture with generous shade and a small stables with his best friend, is fed 4 small meals per day (senior feed and alfalfa pellets), and has grass hay available 24/7. He has regular 6 months vet checkups for any dental work and for vaccinations and worming. Other than the midge allergy and the excessive coat, he is an active healthy old guy with a lovely topline.

So, what is the endgame on this? What happens to old PPID horses? Will there come a time when his ACTH numbers can no longer be managed? What happens then?

The Laminitis Site

8/19/2019 03:13:20 pm

Hi Sue

PPID doesn't necessarily get worse with age, once it is controlled by treatment. In fact, experts now suggest that the dose of pergolide/Prascend may be able to be reduced long-term:

Andy Durham suggested in a 2015 webinar that, for some horses, it may be that a higher dose of pergolide is needed initially to bring the PPID under control, and that that dose may then be able to be reduced. Hal Schott found that horses kept on a low dose of pergolide showed greater improvement after 2.5 years than after 6 months, so there does appear to be a long-term effect - see p19 https://sites.tufts.edu/equineendogroup/files/2013/10/Equine-Geriatric-Workshop-II-DRH-2014.pdf.

It sounds as if you are doing everything you can for him, by checking his ACTH throughout the year (ideally check ACTH in August to make sure it is controlled as we go into the peak of the seasonal rise), and checking his insulin to assess his laminitis risk (this should be either a resting insulin after he has been eating his normal hay or grass, or an oral sugar test if his resting insulin is normal and/or if he shows no clinical signs of insulin dysregulation). It's quite common for horses with PPID to need a slightly higher dose of Prascend through the seasonal rise (around August to November), with the dose being brought back to the lowest dose that controls clinical signs and blood hormone levels for the rest of the year.

Do you know why he had foot abscesses? In a horse with foot abscesses, we would want to eliminate laminitis (which could be sub-clinical) as a cause, ensure the diet was providing above minimum levels of essential nutrients, especially copper, zinc and selenium, and make sure the feet were kept well aligned and protected, perhaps with owners doing a small interim trim between professional trims, and using hoof boots with thick pads if soles became flat or a horse showed any discomfort on hard ground.

There are horses and ponies with PPID living quality lives into their 30s and 40s. From a 2014 webinar with Dianne McFarlane and Marian Little
https://thehorse.com/138221/managing-horses-with-ppid-equine-cushings/
Q. What is the life expectancy for a horse with PPID with/without medication?
A: Horses with PPID can live a long time and have a high quality of life if well managed and able to avoid infectious diseases and laminitis if they have insulin dysregulation. If PPID is well controlled with pergolide and good management, no reason they can’t live a long quality life, possibly into their 40s (Dr McFarlane knew a 45 year old with PPID) – PPID is not necessarily going to shorten life expectancy.

We hope your boy enjoys many more healthy years!

The Laminitis Site

Cindy Thompson

12/25/2019 02:25:12 pm

Hi - My 30 year old quarter horse recently started on 1 mg of prascend after being diagnosed with Cushing's after a minor bout of laminitis. That amount of prascend put him completely off his grain and he acted like he was in a drug induced stupor. My vet suggested cutting the amount to 1/2 tab to see how he did. After 5 days, he's better but still not eating his grain that well and just doesn't have his usual amount of energy. My vet said if he didn't respond in a few days to take him off of it completely and we would revisit in a few weeks once he wazs back to his normal self. Would you suggest starting him back on a lesser amount i.e. 1/4 tab and building that up to the full amount? Thanks for any thoughts and suggestions.

The Laminitis Site

12/26/2019 09:22:02 am

Hi Cindy

Prascend/pergolide should ideally be started at the lowest possible dose - 0.25 mg or 1/4 tablet - and built up over a few days. The ECIR Group suggests increasing by 0.25 mg every 3 days or so, the rate of increase will depend on no adverse effects being seen. ECIR Group members have also reported success when giving APF at the same time as starting pergolide.

When a horse has active laminitis which is thought to be caused by PPID, it is likely to be more urgent to increase the dose of Prascend/pergolide.

For horses that are eating hay ok but not their bucket feed, we've had success with some horses by changing the interval between giving the Prascend/pergolide and giving bucket feed - not the same pattern for every horse, some have liked their Prascend around the time of their bucket feed, others have liked it well away from their bucket feed. However, if you are seeing lethargy too then I suspect this is less likely to be relevant.

More information about starting Prascend/pergolide here:
http://www.thelaminitissite.org/articles/starting-pergolideprascend

Horses that have laminitis and PPID have insulin dysregulation, and it's important to control all the factors that contribute to EMS as well as medically treating the PPID, most importantly by feeding a diet with less than 10% combined sugar/starch, plus protein, minerals and vitamins that aren't provided by the hay/haylage, and gradual weight loss if necessary. All horses with laminitis should have x-rays taken and feet realigned and fully supported through the solar structures immediately.

Coral Mannion

1/4/2020 08:34:12 pm

My 27 year old welsh x was diagnosed with cushings in 2013. He’s been well managed. Last summer was the first summer he didn’t lose his coat. He doesn’t display any other signs. On NYE he stopped eating and now just picks at food. He has also started laying down a lot more. The vets seen him twice but is at a loss. Could it be caused by this medication?

The Laminitis Site

2/6/2020 11:21:25 am

We see some horses with PPID that have an increased dose of pergolide for the seasonal rise and show signs of going off feed, lethargy or mild diarrhoea as we come out of the seasonal rise if their dose isn’t reduced. However, you say that he didn’t lose his winter (?) coat last summer, which may suggest that his PPID was not fully controlled and that he may need an increase in his dose. His recent ACTH tests should help you and your vet decide whether his dose is about right or could be reduced or increased.

Generally pergolide/Prascend seems to be an extremely safe medication and we hear of very few side effects as long as the dose is kept as low as possible, at the level that controls clinical signs and blood hormone levels, with adjustments as necessary through the year.

It’s important to look outside of PPID when horses are showing any clinical signs of illness. The clinical signs of PPID, with the exception of the long curly coat that doesn’t shed, can all be due to other illnesses. Work with your vet to monitor his vital signs closely, have full blood tests and other diagnostic tests run if appropriate, keep a diary noting any change. If he is lying down a lot more, could he have laminitis that hasn’t been diagnosed, or if he has some arthritis, is he finding it harder to get up?

Is he happy to eat hay/haylage/grass but just not bucket feed, or has he gone off all feed and is he losing weight? Check that his diet is providing everything he needs appropriate for his age and that he is happy to eat everything (offering each item in his bucket feed separately can help identify something a horse doesn’t want to eat) - http://www.thelaminitissite.org/diet.html.

Sarahkate

6/6/2020 10:48:08 pm

DESPERATE FOR HELP. Large mini/small pony, all metabolic labs are off the charts bad but he has no outward PPID appearance except very mildly cresty neck. When acquired he was completely sound, energetic, I had him xrayed and blood work as a precautionary baseline, he had no rotation or signs of laminitis then but the awful lab results from Cornell University. Vet insisted that due to lab results despite being asymptomatic he had to be started on Pergolide. But after just two doses he got very hot feet and a mild colic (no feed change - his grazing was already closely managed, he was not being given grain, hay is Teff (1.5% NSC tested), no weather change - nothing). He was so painful he would barely stand much less walk. We took appropriate measures (ice, DMSO drench twice) plus vet said to stop the pergolide and switched him to Metformin for the EMS and Equioxx for pain. After two months he's finally walking out sound with minimal Equioxx dose, with no heat in his feet. However new lab results have not improved one bit. So now the vet wants to put him back on Pergolide tablets and if he colics again vet wants him to get the Pergolide via daily injection. I am scared to death that he will react adversely again with the Pergolide esp. now that he is comfortable standing and walking (and still has sleek and slick summer coat). Vet says his bad labs mean he has to be euthanized if I don't agree to put him back on Pergolide and threatened to "turn me in" to animal control (I'm in USA west coast area) if I don't agree to do either. I don't know who to ask about this and I do not do Facebook so hoping someone can help here. I tried to figure out joining the ECIR group but it's sort of impossible for me as I'm not a computer genius. My farrier who was trained in Europe for laminitis and founder management is extremely concerned and does not understand why the vet is insisting on my pony being given something that already created a severe laminitis attack with months of vet bills and pain for this lovely pony. Surely there must be something in this whole world of amazing pharmaceuticals that can be used more safely? Can anyone comment or send me somewhere for guidance?

The Laminitis Site

6/7/2020 01:28:11 am

To our knowledge it is an owner's choice whether to treat PPID or not. It is only the clinical signs/diseases that may be due to PPID, such as laminitis or an infection, that may have welfare implications if not treated.
There are several reasons why ACTH could be high, other than PPID: http://www.thelaminitissite.org/ppid-faq/does-a-high-acth-result-mean-my-horse-has-ppid, and clinical signs of PPID must be present for a diagnosis of PPID.
A cresty neck is a sign of insulin dysregulation and therefore probably EMS, but not necessarily PPID. Controlling EMS/insulin dysregulation with a low sugar/starch diet, weight loss if necessary and exercise when able is necessary even if a horse is being treated for PPID.
Pergolide is extremely unlikely to cause laminitis. It would be possible for a pony to have an illness which caused colic and laminitis and possibly also abnormal blood results, and it could be coincidence for clinical signs of another illness to be seen at the same time as starting pergolide.
Generally a horse should not need pain relief for more than a few days after endocrinopathic laminitis. A more severe laminitis can be an indication of sepsis-related laminitis, or significant uncorrected changes to the feet.
As adverse reactions are likely to be to the active ingredient - pergolide - if a pony was showing adverse reactions to pergolide, it is unlikely to be any better if pergolide was given by injection rather than orally. Significant adverse injections to pergolide are generally very rare, pergolide is generally an extremely safe drug when given at the correct low dose.
It is important to have a vet with whom you can discuss your pony's care reasonably. If that isn't your current vet, it may be time to change. We are aware of cases (in Europe) where a vet has called in animal welfare officers because an owner did not want to follow that vet's advice. As long as the owner is acting in the horse's best interests and can give evidence of a good treatment plan, the welfare officers are likely to be helpful.
If you would like to discuss your pony further, you might like to email info@thelaminitissite.org.

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Please report adverse reactions to Prascend

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