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It could just be that item mods in general change item generation, but idk.
basically there are 13 different pill colors and at the start of a run random effects are assigned to each color, there are horse pill variants of each color that activate a more potent effect.
If they've updated the API to allow custom horse effects to be created then I would imagine it works just fine, unless you're referring to custom pill colors, but I'm not sure if that's a thing.
However, some custom pills are simply cards(such as the Daily Dose) and would have to have an exception created for them, which I am not going to go out of my way to do.