Insulin still high


Gymah
 

We just rechecked the insulin on my pony, and it came back at 1200 pmol/L (normal is 28-390). She's been on metformin since the beginning of the year, and while it did work to bring her insulin levels down into the normal range at first, her insulin has just been getting steadily worse now. I know that this is a common phenomenon with metformin. 

I unfortunately can't do the other drug (invokana) as it's too expensive.

My vet is thinking that we should just take my pony off of the metformin since it's no longer working. 

Right now, my pony is the best/ most comfortable she's been since being diagnosed with laminitis in December. But since her insulin is so high, is it likely that she'll have another relapse? 

Her diet is as "tight" as it can be (the hay we're using has the analysis up in her photo album, and I still soak it before feeding). Is there nothing else that can be done to keep the insulin down?

At this point I just really want to get her through the spring and summer without having another relapse, and think about putting her down at the end of the summer so she doesn't have to go through another flare up in the fall/ winter.
--
Helene A. in BC 2021
Photo album:
https://ecir.groups.io/g/CaseHistory/album?id=271068
Case history:
https://ecir.groups.io/g/CaseHistory/files/Helene%20and%20Rosie


Eleanor Kellon, VMD
 

I wouldn't stop the metformin because there is some evidence it helps with neuropathic pain so may be contributing to her comfort even though the  insulin is still high.

Have you looked into empagliflozin?

Are her minerals balanced?

Have you done a domperidone stimulation test for PPID or considered treating with pergolide during the seasonal rise. Winter/cold induced pain can be managed.
--
Eleanor in PA

www.drkellon.com 
EC Owner 2001


Gymah
 

I hadn’t looked into empagliflozin, but I just did a quick search on it, and it doesn’t seem too effective? 

https://holistichorse.com/api/amp/health-care/possible-dangers-of-velagliflozin-in-horses-get-the-facts/

She has been tested and diagnosed with Cushing’s in 2018 (although I don’t know what test they did). She’s on 1/2 a pill of pergolide now (her acth levels have remained low on this dose, so we’ve never increased it). Could increasing her pergolide help? Would I go up to 3/4 of a pill or a whole pill? I imagine Doing 3/4 of a pill would be difficult/ hard to get that exact amount
--
Helene A. in BC 2021
Photo album:
https://ecir.groups.io/g/CaseHistory/album?id=271068
Case history:
https://ecir.groups.io/g/CaseHistory/files/Helene%20and%20Rosie


Sherry Morse
 

I would take that article with a healthy grain of salt and wouldn't hesitate to try it even if it did stop working eventually.




 

Hi Helene,
Your case history indicates Rosie is getting 1mg of Prsscend currently.  Her blood tests show her ACTH was well controlled by the dose of pergolide she was on two months ago.  While.you shouldn’t expect that adding more pergolide will in any way normalize the insulin, it’s possible it would help.  If you want to try increasing her pergolide, going to 1mg sounds reasonable if your vet concurs.  If you decide to increase by 0.25mg, you can dissolve 1/2 tablet in a small amount of water and give half with her regular dose one day and the other half the next.  
--
Martha in Vermont
ECIR Group Primary Response
July 2012 
 
Logo (dec. 7/20/19), Tobit(EC) and Pumpkin, Handy and Silver (EC/IR)

Martha and Logo


 
 


 

 This study reported at the National Institute of Health showed good results in ponies:  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6136744/

We need Dr Kellon’s input on the appropriate dose before you can make a reasoned decision. Invokana may be less expensive if you compare Jardiance to Invokana from PriceProPharmacy.com at the same 0.3mg/kg dosage. 
-
Cass, Sonoma Co., CA 2012
ECIR Group Moderator
Cayuse and Diamond Case History Folder                
Cayuse Photos                Diamond Photos


TERRI JENNINGS
 

The cost of Invokana is also less if you’re willing to order the larger pills and split them up.  I thought I wouldn’t be able to afford to put my ponies on it, but once I checked the price and figured out how to split the pills, it’s much less than I thought it would be. 
--
Terri Jennings with Teeny, Finn and Elliott
Arcata, CA
https://ecir.groups.io/g/CaseHistory/files/Terri%20and%20Teeny
Joined 2019


Eleanor Kellon, VMD
 

I meant ertugliflozin, not empagliflozin. Sorry. Dose of that being used is 0.05 mg/kg. We had one member try empagliflozin and it stopped working after 3 weeks.
 
--
Eleanor in PA

www.drkellon.com 
EC Owner 2001


Gymah
 

Terri (or anyone  else), if you don't mind me asking, how much do you spend on Invokana a month?
--
Helene A. in BC 2021
Photo album:
https://ecir.groups.io/g/CaseHistory/album?id=271068
Case history:
https://ecir.groups.io/g/CaseHistory/files/Helene%20and%20Rosie


Gymah
 

Thanks Dr. Kellon!
I'll mention the ertugliflozin to my vet and see if he's able to prescribe it/ figure out what the cost would be. It seems to be in the same drug class as Invokana? Is it just a slightly less expensive version? 
--
Helene A. in BC 2021
Photo album:
https://ecir.groups.io/g/CaseHistory/album?id=271068
Case history:
https://ecir.groups.io/g/CaseHistory/files/Helene%20and%20Rosie


Gymah
 

Also, how long does everyone soak their hay for? I've been soaking it for an hour, but my vet suggested I could try soaking it longer. Would I be able to soak it overnight (~11hrs) for the morning feed?
--
Helene A. in BC 2021
Photo album:
https://ecir.groups.io/g/CaseHistory/album?id=271068
Case history:
https://ecir.groups.io/g/CaseHistory/files/Helene%20and%20Rosie


Eleanor Kellon, VMD
 

Yes, same class, same precautions. Cost is going to vary depending on where you live and what is available. For example, I was told in AU that pergolide and ertugliflozin have about the same cost.
--
Eleanor in PA

www.drkellon.com 
EC Owner 2001


Nancy & Vinnie & Summer
 

At pricepropharmacy.com I order a three month supply of 300mg invokana (shipped from england) I had my vet put on the rx that I use 1 pill per day.  But I do split the pills with a pill cutter to 150mg.  This lasts me 5 months with the cost with shipping and e-check discount it costs a total of $285.00. Monthly this works out to a cost of $47.50.

Hope that helps. It truly has been a lifesaver in spite of the challenges we have had with it. :)
--
Nancy and Vinnie and Summerat pru
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


Nancy & Vinnie & Summer
 


 

Helene,
The monthly cost of Invokana (there is no generic available to me) depends on the dose and the weight of the equine. It's most economical to buy the 300 mg tablets and cut them with a pill cutter. Ninety 300 mg tablets costs about $280 with shipping to the USA.

Just as an example, if Rosie's weight is 600 lb≈272 kg, and if her dose is 0.6 mg/kg, then her dose would be 163 mg or half a 300 mg tablet. For $280, you would get 180 day supply for about $1.56/day. If she were on a lower dose, your cost would be proportionately less.

https://www.pricepropharmacy.com/product/invokana/

To find other pharmacies, check https://www.pharmacychecker.com 
--
Cass, Sonoma Co., CA 2012
ECIR Group Moderator
Cayuse and Diamond Case History Folder                
Cayuse Photos                Diamond Photos


Kirsten Rasmussen
 

Hi Helene,

Considering Rosie's ACTH was too high in Dec 2021 on 0.5 mg, I would say she needs a higher dose of pergolide.  I would try 1mg.  Remember that ACTH is only 1 of the insulin-raising hormones that are elevated with PPID.  We don't know if the other hormones are more elevated and helping drive the high insulin, but pergolide has an effect on all the associated hormones so with a PPID horse increasing pergolide to see if there's an improvement in insulin is always an option.  You want to keep ACTH in the low-middle of the reference range of 2.4-10.2, YEAR ROUND (ie, it's not ok for Rosie's ACTH to go above 5 or 6 pmol/L, even in the fall/seasonal rise).  Test again in early August to make sure it's not climbing (and if it is climbing then you have time to increase the dose).

Also, your hay is probably a little high in ESC and starch than reported since it's an NIR test, so it's good you are soaking it.  And if you are not feeding balanced minerals, a deficiency in Mg in particular can also affect insulin resistance.  We always recommend having minerals balanced to your hay, but if you choose not to do that you could add magnesium oxide.

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


Kirsten Rasmussen
 

Soaking hay for longer periods may not help much.  What you CAN do is change the soaking water and do a second soak.  A second soak with clean water will pull out more sugars.

Also, are you rinsing your beet pulp well after soaking?  The rinse water should run clear before you feed it.

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


Eleanor Kellon, VMD
 

Nancy,

Did you get his triglyceride results?

--
Eleanor in PA

www.drkellon.com 
EC Owner 2001


Nancy & Vinnie & Summer
 

Not yet Dr K, I am waiting on my vet to send me the forms.for the blood pull. Will follow up with her and will try to get the pull done early next week.

He is doing great though!!
--
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


fullcirclefarmhorses@...
 

Hi Gymah,
I pay $125/month for Invokana.  I use PricePro Pharmacy in Canada and the meds ship from the UK.  It takes about 3 weeks to arrive.  I just started it on 4/11 and just got the results from yesterday’s bloodwork.  It is working!  Ava’s insulin was in the 240 range and it’s now at 47.  Her glucose was high and it’s now within the normal range.  It was my last option and I feel so blessed it is working!  
--
Heather W in WI 2022
https://ecir.groups.io/g/CaseHistory/files/Heather%20and%20Ava
https://ecir.groups.io/g/CaseHistory/album?id=273564