I just had Flea's fall bloodwork done, and it's not so good.  I had bumped him up .5mg in his Prascend dose this summer because his ACTH was too high in April, and it came down from mid 30s to mid 20s by July.  I had a nagging feeling it wouldn't be enough during the fall rise, and I think I was right.  Here are the last 3 test results:
April: ACTH 36.4/2mg Prascend  Insulin 58.26/100mg Invokana 
July: ACTH 25.3/2.5mg Prascend  Insulin 68.35/100mg Invokana
Oct: ACTH 35.9/2.5mg Prascend  Insulin 135.82/100mg Invokana

Triglycerides have been 99/78/82 respectively, so not too worried about that. 

My gut feeling is to increase the Prascend to 3mg, but at this point, it's the end of the rise so is it even worth it?  Clinically, Flea is doing great, but I have noticed weight gain (especially an exaggerated hay belly), listlessness, and a reluctance to move.  When he does walk or trot, he seems sound.  The farrier is happy with his hoof health, and both she and the vet were happy with his latest rads. 

My questions/issues are these:
*My vet seems to think I'm dosing too high with the pergolide, so I'm wondering if there is any research that agrees with the ECIR position of "the correct amount of pergolide is that which controls the ACTH"?  I agree because I've been the one to implement dosage increases over the years and I've seen the results, but my vet is not on board and wants me to reduce his dosage. 

*Is 35.9 pg/mL considered to be in the safe range at this time of the year?  Cornell's reference range remains 2-30, so I'm confused as to where it could be considered safe/controlled during the rise.

*I know I was overfeeding hay; it's low cal/low protein/low s&s so I think I felt ok free feeding it, but I've started weighing it to cut out extra.  I'm planning to re-test the hay to be on the safe side.  Is this plus the higher ACTH the probable trigger for his insulin spike?  During the seasonal rise, would an increase in the Invokana dose be reasonable, or is that playing with fire? Flea still tapes at about 420lbs and is getting 100mg Invokana daily.
--
Jennifer in NH
2020

CH - https://ecir.groups.io/g/CaseHistory/files/Jennifer%20and%20Flea

Photo album - https://ecir.groups.io/g/CaseHistory/album?id=251041&p=Name,,,20,1,0,0