Hello,

I had been waiting for a warmer day to check Cadet's insulin and it finally went above 40 F last week.  His CH is up to date.  I was disappointed that his insulin had gone up since November; maybe because it was still too cold?  He has been sound at a trot on sand and grass since early December.  He is still wearing Cloud's 23 hrs/d, with socks and leg warmers depending on the temperature.  I hand walk him for 30 mins daily, usually with 5 minutes or less of gaiting and trotting.  When he plays in the outdoor arena with our other horses, he usually trots, canters, rears, and bucks without apparent soreness.  My farrier has been happy with his feet.

I'm hoping for some ideas to further lower his insulin.  I would like to increase his exercise, but with his insulin this high, would this cause him harm?  With our current boarding situation, I am unable to limit his hay consumption or soak his hay, but his weight is stable.  Is a higher dosage of Invokana an option, or a maybe try a different SGLT2 inhibitor?  His urine has never had more than 500 glucose, but the specific gravity is usually 1.000 or 1.010 on the dipstick.

I am afraid that there is ongoing damage to his feet and acute laminitis could recur at any moment.  My husband and I were hoping to move from Michigan to Washington this summer, but transporting him seems to be a huge risk unless we fly him out there.  I would guess that giving him daily medication would be problematic for a commercial shipper.  I am trying to find him a place at a boarding facility with track turnout to increase his movement; there are very few available.

I appreciate any suggestions and remain very grateful for the support of this group.
--
Aunna
October 2018
Oakland County, Michigan, USA
Cadet Case History:  https://ecir.groups.io/g/CaseHistory/files/Aunna%20and%20Cadet
Ruger Case History:  https://ecir.groups.io/g/CaseHistory/files/Aunna%20and%20Ruger

Cadet Photo Album:  https://ecir.groups.io/g/CaseHistory/album?id=84102

Could you please add Invokana date started and dose to your case history? How are you giving it and making sure he eats it all?
--
Eleanor in PA

www.drkellon.com 
EC Owner 2001

Sorry Dr. Kellon!  I didn't realize that info was not in his CH.  I will add it asap.  He started on 10/20/2020, 300 mg QD.  He gets it in a homemade flax pill pocket fed by hand by me.  I know he's getting it.
--
Aunna
October 2018
Oakland County, Michigan, USA
Cadet Case History:  https://ecir.groups.io/g/CaseHistory/files/Aunna%20and%20Cadet
Ruger Case History:  https://ecir.groups.io/g/CaseHistory/files/Aunna%20and%20Ruger

Cadet Photo Album:  https://ecir.groups.io/g/CaseHistory/album?id=84102

Are you storing it at “room temperature” (77 degrees). I failed to do that and it stopped working for my boys. I threw out all of the meds and started with fresh pills and it’s working again. 
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Terri Jennings with Teeny, Finn and Elliott
Arcata, CA
https://ecir.groups.io/g/CaseHistory/files/Terri%20and%20Teeny
Joined 2019

Hi Terri,

Yes, the medication is stored at home.  BTW, I checked the package insert and it states "This medication does not require any special storage conditions".  I order it through PriceProPharmacy and it comes from the UK.  Thank you!
--
Aunna
October 2018
Oakland County, Michigan, USA
Cadet Case History:  https://ecir.groups.io/g/CaseHistory/files/Aunna%20and%20Cadet
Ruger Case History:  https://ecir.groups.io/g/CaseHistory/files/Aunna%20and%20Ruger

Cadet Photo Album:  https://ecir.groups.io/g/CaseHistory/album?id=84102

The FDA monograph says to store it between 59 and 86F https://www.accessdata.fda.gov/drugsatfda_docs/label/2017/204042s026lbl.pdf .

His insulin (Idexx) is well below the estimated threshold for acute laminitis but I'm sure you would like to see it lower. Any change in weight, fat deposits, energy/attitude? I have no experience with doses higher than 300 mg but you could try 450 to see if that changes his urine glucose. I would wait to recheck insulin until the weather has  consistently warmed up.

The only failure to lower insulin I have seen to date is a horse that still tested over 200 but had complete resolution of laminitis and fat pads. Frustrating for the owner and vet but the horse is doing great. There are also instances where insulin dropped but not completely to normal (like your horse) or rose when diet was liberalized or ACTH not in control but none of them had any evidence of laminitis.
--
Eleanor in PA

www.drkellon.com 
EC Owner 2001

Thanks Dr. Kellon.  I guess I was more concerned about the Cornell insulin result.  I just submit to Idexx for interest.  His weight is stable, attitude good (similar to when his insulin was lower), and his minimal crest and supraorbital fat pads slightly less.  At least his PPID is well controlled.  Do you have any comment about increasing his (nonridden) exercise or the potential risk in transporting him cross country?

I'll plan on rechecking insulin when there is a consistent warm up before I consider a dosage increase.  As always, I really appreciate your input.
--
Aunna
October 2018
Oakland County, Michigan, USA
Cadet Case History:  https://ecir.groups.io/g/CaseHistory/files/Aunna%20and%20Cadet
Ruger Case History:  https://ecir.groups.io/g/CaseHistory/files/Aunna%20and%20Ruger

Cadet Photo Album:  https://ecir.groups.io/g/CaseHistory/album?id=84102

Were you ever able to find out what assay Idexx uses? We are seeing quite a few Cornell results that don't match the horse's clinical condition and are significantly higher than other labs.

Lunging isn't a good idea because of the higher forces on the inside leg. Handwalking is OK and so is turnout. The vigorous  playing is a good sign. He would be sore after that if anything is going on in his feet.

Flying would certainly be easier on him. By summer he will have many more months of good growth on his feet and may make  the trip by road uneventfully but commercial shippers tend to spend more hours on the road in a day and I  don't know how much you can rely on adherence to diet restrictions and meds.
--
Eleanor in PA

www.drkellon.com 
EC Owner 2001

The storage temperature issue came up with my post too so I went back and checked both my prascend and invokana storage temps. I can't recall what the actual temps were (about 77-80 deg F) but there was only a high temperature listed. There was no lower bound temperature given for storage.
--
Chemelle
Hillsboro, OR
2019
https://ecir.groups.io/g/CaseHistory/files/Chemelle%20and%20Andy 

https://ecir.groups.io/g/CaseHistory/album?id=94380

There should be a freezing precaution. Do a Google search for "Invokana freezing".
--
Eleanor in PA

www.drkellon.com 
EC Owner 2001

I was wondering about this too, since pricepropharmacy.com ships from UK and affordablerx ships from India and the packaging isn't temp protected.  Could we be getting product that in flight that could be less than optimal?
--
Nancy and Vinnie and Summer
Oakley, Ca
Joined Nov 2018
https://ecir.groups.io/g/CaseHistory/files/Nancy%20and%20Vinnie 
https://ecir.groups.io/g/CaseHistory/album?id=245855

Summer
https://ecir.groups.io/g/CaseHistory/files/Nancy%20and%20Vinnie/Summer 
https://ecir.groups.io/g/CaseHistory/album?id=249104

Dr. Kellon,

Thanks for the reassuring thoughts.  Like many of my colleagues, I find it hard to remain detached when I'm dealing with my own pets' health problems.  The Idexx assay is Millipore USA.  I have more details on it if you need them.
--
Aunna
October 2018
Oakland County, Michigan, USA
Cadet Case History:  https://ecir.groups.io/g/CaseHistory/files/Aunna%20and%20Cadet
Ruger Case History:  https://ecir.groups.io/g/CaseHistory/files/Aunna%20and%20Ruger

Cadet Photo Album:  https://ecir.groups.io/g/CaseHistory/album?id=84102