Is anyone in the UK using Invokana


jenny.comish@...
 

Hi all,

if there is anyone in the UK using Invokana please can you let me know? Dr Kellon has sent my vet details about it but he is seems hesitant to pursue using it before knowing who else in the UK is using it.

I’m quite desperate as my IR pony appears no better after 2 weeks on Metformin so Invokana is our last hope I think. 


Thanks

Jenny
--
Jenny Comish
England, UK
Dewi Case History: https://ecir.groups.io/g/CaseHistory/files/Jenny%20Dewi
Dewi Photos: https://ecir.groups.io/g/CaseHistory/album?id=257833


LJ Friedman
 

remember to test for triglycerides. offer your vet a hold harmless agreement regarding invokana?  
--
LJ Friedman  Nov 2014 Vista,   Northern  San Diego, CA

Jesse( over the rainbow) and majestic ‘s Case History 
Jesse's Photos

 


jenny.comish@...
 

Thanks for your reply. I know nothing about Invokana and it’s risks as the information has only been sent to my vet. Is testing for triglycerides something you do before using Invokana? Please can you explain by what you mean by a ‘hold harmless agreement’? 
--
Jenny Comish
England, UK
Dewi Case History: https://ecir.groups.io/g/CaseHistory/files/Jenny%20Dewi
Dewi Photos: https://ecir.groups.io/g/CaseHistory/album?id=257833


LJ Friedman
 

If you search Invokana on this page you’ll see a horse had a health issue where checking triglycerides would have been helpful.  all horses starting invokana should test for triglycerides- before and continue to include triglycerides when you do labs.
--
LJ Friedman  Nov 2014 Vista,   Northern  San Diego, CA

Jesse( over the rainbow) and majestic ‘s Case History 
Jesse's Photos

 


LJ Friedman
 

hold harmless.   Your vet can draw up a letter that you sign. What it says is in legal terms that you cannot sue him malpractice etc. for anything connected to Invokana..  you release him of any liability connected to anything related to Invokana.
--
LJ Friedman  Nov 2014 Vista,   Northern  San Diego, CA

Jesse( over the rainbow) and majestic ‘s Case History 
Jesse's Photos

 


Nancy C
 

Hi Jenny

Here is a recent post from Dr Kellon on Invokana and Triglycerides.  She outlines what you should be doing with your vet.  I'm sure she has told your vet this as well.

https://ecir.groups.io/g/main/message/262445

"Hold harmless" info here. This is a UK source.

https://www.lawdepot.co.uk/law-library/faq/hold-harmless-agreement-faq-united-kingdom/#.YFOLBeYpDXQ

FWIW -- In my experience with a half-dozen vets, I have not actually ever had to sign anything.  I have just indicated that this is the apporach I wanted to take for my horse, and that I would sign some thing if they wanted.  Most of them went along with me.

--
Nancy C in NH
ECIR Moderator 2003
ECIR Group Inc. President/Treasurer  2020-2021
Join us at the 2021 NO Laminitis! Conference, August 13-15, ECIR Virtual Conference Room


jenny.comish@...
 

I’m just bumping this up in case there is anyone in the UK using Invokana that has missed it. However my vet is saying ‘no’ to using it as it’s not licensed. He spoke with a vet at Liphook Equine hospital about it and that was their conclusion. Unless I can find a UK case study I can’t see how I will persuade him. The result of this might end up being Dewi is put to sleep as he just isn’t getting much better - he is on Metformin at the moment and has been for 2 and a half weeks. I would say he looks perkier (he was actually bucking in the arena the other day!) but when he walks he is crippled and has been for months now. 
--
Jenny Comish
England, UK
Dewi Case History: https://ecir.groups.io/g/CaseHistory/files/Jenny%20Dewi
Dewi Photos: https://ecir.groups.io/g/CaseHistory/album?id=257833


Caroline
 

Sorry, I'm not using it but there are uk studies on it's use in people.  https://www.diabetes.co.uk/diabetes-medication/invokana-canagliflozin.html might help.  Vets can prescribe unlicensed medicines.  Some species literally do not have any licenced meds, and it's up to the vet to bridge that gap.  The cascade stops them prescribing human drugs where there is a species licensed version, but that's not the case here.  Have you spoken to any other vets that might be more willing to work with you?  
--
Caroline
Spalding, Lincolnshire, UK
September 2019
https://ecir.groups.io/g/CaseHistory/files/Caroline%20and%20Evan
https://ecir.groups.io/g/CaseHistory/album?id=231916


Eleanor Kellon, VMD
 

No, it's not licensed but neither was pergolide until a few years ago. It's perfectly legal to prescribed a drug being used in humans if there is no veterinary alternative. Invokana is approved for human use in the UK. You are supposed to be informed of risks and to sign a consent form.

BTW, metformin isn't  licensed for horses either.
--
Eleanor in PA

www.drkellon.com 
EC Owner 2001


LJ Friedman
 

following this thread, you can’t completely fault your vet for not prescribing Invokana as he did speak to a specialist and they didn’t give “a move forward answer.”answer. Additionally, to think about putting your horse to sleep because you can’t get the Invokana would be awful. What I did, and what I suggest you do, is just get Invokana anyway you can. And then after testing, show the results to your vet and I’m sure he will prescribe it. 
is there no one in UK that can loan you 30 tablets? 
--
LJ Friedman  Nov 2014 Vista,   Northern  San Diego, CA

Jesse( over the rainbow) and majestic ‘s Case History 
Jesse's Photos

 


LJ Friedman
 

If I didn’t mail out the invokana , I wasn’t using it for another member, I would gladly mail you 30 tablets if I had them. Perhaps a member in the US can mail you 30 tablets.???
--
LJ Friedman  Nov 2014 Vista,   Northern  San Diego, CA

Jesse( over the rainbow) and majestic ‘s Case History 
Jesse's Photos

 


Eleanor Kellon, VMD
 

LJ,

I can't recommend that approach. Invokana is a new medication, incompletely studied in horses (and horses are not people, very different metabolism). It must be used only under the direction and supervision of a veterinarian who understands the metabolism, can set up appropriate testing schedules and monitor the horse. If the veterinarian is reluctant even with signed informed consent forms, try to find another that is not.
--
Eleanor in PA

www.drkellon.com 
EC Owner 2001


Lorna Cane
 

Hi Jenny,

Would you be able to take a video of his walking ?

Hang in. Keep breathing.

--

Lorna  in Eastern  Ontario
2002
Check out FAQ : https://www.ecirhorse.org/FAQ.php


Eleanor Kellon, VMD
 

LJ,

Sending medication like that is both illegal and dangerous.
--
Eleanor in PA

www.drkellon.com 
EC Owner 2001


Eleanor Kellon, VMD
 

Jenny,

In addition to signing the consent form for "off label" use of a medication, you can specifically offer to sign a form that absolves your veterinarian of any fault in the event of an adverse outcome. When the alternative is euthanasia, that is entirely reasonable. You can also work together to determine a timeline for when you will "pull the plug".

Again, many medications are legally prescribed for horses when there is no species specific approval. That includes metformin and the Glyburide that Liphook has used. Whether or not someone in UK has used it is irrelevant.

All of that said, no medication is a magic bullet. You still have to control PPID if that is present, maintain an appropriate diet and a good trim.
--
Eleanor in PA

www.drkellon.com 
EC Owner 2001


Caroline
 

I found this  https://sites.tufts.edu/equineendogroup/files/2020/09/200592_EMS_Recommendations_Bro-FINAL.pdf
There is a recommendation for Invokana for horses where metformin doesn't work.  Andy Durham from Liphook is a member of the group that published it, so either your vet didn't speak to him or there is some other reason that it's not recommended.
Hope this helps
--
Caroline
Spalding, Lincolnshire, UK
September 2019
https://ecir.groups.io/g/CaseHistory/files/Caroline%20and%20Evan
https://ecir.groups.io/g/CaseHistory/album?id=231916


jenny.comish@...
 

Thanks Eleanor and sorry I have been so slow to respond. My vet has spoken with Andy Durham at Liphook and seems more prepared to consider writing me a prescription for Invokana. But Andy said he has never used Invokana. Andy Durham’s advice is to blood test Dewi one hour after different meals to see what is triggering him. But Dewi is only on soaked hay and unmolassed beet pulp to carry his minerals so I don’t know if that is worthwhile? I guess we could take blood an hour after his beetpulp but could that be a trigger? It’s low ESC and starch. 


He has already had a blood test done whilst on hay (unbeknown to my vet as I ignored the advice to starve) although it was done in the morning and Dewi had run out of hay when I arrived, so I wonder if a test done in the afternoon would be better when he has been consistently eating? 


 My vet also wants to blood test him while he is still on Metformin but wants me to fast Dewi first (arghh!). I presume that is an incorrect approach and I should feed him his usual hay ration? 


Thanks 


Jenny
--
Jenny Comish
England, UK
Dewi Case History: https://ecir.groups.io/g/CaseHistory/files/Jenny%20Dewi
Dewi Photos: https://ecir.groups.io/g/CaseHistory/album?id=257833


Kirsten Rasmussen
 

Another factor here is PPID.  Is Dewi on pergolide/Prascend and if so can you add it to your Case History?  You'll want to retest his ACTH 3 weeks after being on the full dose to make sure it is helping.  Uncontrolled PPID could really be compounding the high insulin, so you need to make sure this is under control.

Your vet probably just wants Dewi's insulin results to be comparable, so if he thinks you have fasted him in the past he is going to want you to continue to fast him for bloodwork so the numbers can be compared.  Again, point him to the EEG document saying testing should be done non-fasted, on pasture or hay only and tell him that's how Dewi needs to be tested going forward, so that you can see how his diet is influencing his insulin.  Yes, it would be nice to test after a specific meal to see if the beet pulp is a trigger, but testing is also expensive so that may not be something you want to pursue.

--
Kirsten and Shaku (IR) - 2019
Kitimat, BC, Canada
ECIR Group Moderator
 
Shaku's Case History
Shaku's Photo Album


Eleanor Kellon, VMD
 

I don't see the value to fasting insulin. He shouldn't have insulins that high even in you fed him a bucket of sweet feed so the diagnosis is made already. It's reasonable to remove anything that drives him higher but you would need before and after feeding tests to know that.  On the other hand, he has to eat something and if your diet is already rock bottom S/S there's no place to go with diet since you are already soaking hay.

You can't tell if Metformin is helping if you fast him first. The whole point is to control his insulin response to eating.

I saw in his record there were 2 low insulins. Were those fasting? Since he's a pony, he may be in the group where high insulin and glucose are related to high levels of incretin https://wp.me/p2WBdh-yE . Also see https://journals.physiology.org/doi/full/10.1152/ajpendo.00362.2015?rfr_dat=cr_pub++0pubmed&url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org . These ponies have increased absorption of glucose from the gut and therefore increased insulin. Their response on intravenous testing is normal so they don't really have insulin resistance.

In the end, it doesn't really matter for you and Dewi since he ends up with high insulin and laminitis. The Invokana will work whether he has IR or abnormal incretin and glucose absorption.
--
Eleanor in PA

www.drkellon.com 
EC Owner 2001


jenny.comish@...
 

Thanks Kirsten and Eleanor. He’s not on medication for PPID at present. Although ACTH has been a little high, my vet wants to be sure it’s not due to stress from the laminitis rather than ongoing high ACTH. But he has said we can try Cushings meds but not yet.

He has seen the EEG document but I don’t know how much of it he’s read. It’s driving me nuts that he keeps going  on about fasting! He just says Dewi should not have high insulin if he’s been fasted.


The problem is the last time I ignored the fasting instruction and he could tell from the results that he must have eaten hay, so it’s making it quite awkward! But if I fast when he is blood tested whilst on the Metformin it won’t be like for like with the last blood test where I didn’t fast him. My vet is from a farm and equine practice and I just think he’s not kept up with the latest thinking. But he is making more effort than Three Counties Equine Hospital ever have (my last vets) - he seems to want to try to get to the bottom of this and help Dewi. 


Eleanor the 2 low insulin results were from non-fasted tests. 


As regards Invokana, did the info you sent my vet lay out the success rates so far with other horses and the risks? I’ve not had a chance to ask him about the details as he is so busy lambing and calving.  I just don’t want to agree to any medication blind sighted. 


Thanks very much.

Jenny
--
Jenny Comish
England, UK
Dewi Case History: https://ecir.groups.io/g/CaseHistory/files/Jenny%20Dewi
Dewi Photos: https://ecir.groups.io/g/CaseHistory/album?id=257833