Hi, Martha. Thanks for taking a look. On Invokana — After I received the lab report showing insulin of 183, I immediately restarted Invokana. Because appetite wasn’t perfect, I started at 150 mg, then 225 mg the next day and 300 mg the third. So she hadn’t been at the new target Invokana dose for many days before the latest blood draw.  

Another factor in this report (I forgot!) is that Invokana had not been given yet that day. So we’re seeing insulin 24 hrs after the most recent Invokana dose. 

But your point about looking at the symptoms and not just the labs is exactly what my vet said. Looking back over her insulin results, she has a history of high spring insulins. I need to chart them. 
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Cass, Sonoma Co., CA 2012
ECIR Group Moderator
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Hi Cass,
I looked at Cayuse’s CH when I saw it was posted and made the same observations as you.  Wasn’t there some discussion about the insulin possibly being high because she wasn’t getting invokana regularly?  I didn’t read back to check.

I wonder if there might be some value in doing a TRH stim test?  I realize this suggestion is the complete opposite of how we normally recommend the test be used.  Her ACTH values over time remind me of those of my pony, where I can’t depend on ACTH testing to tell the whole story.  The ACTH values are fairly consistent, which is a tribute to your attention to detail but it seems like they’re stuck where they are.  My pony is stuck at about 35.  Obviously there wouldn’t be any controls.  

I should add that I didn’t mean to include a 3 week pergolide withdrawal, which we do suggest in similar situations.  I never wanted to take my pony off pergolide to do that.
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Latest Cornell results just came in from May 17, and I put them into the CH. With a 2mg increase in pergolide and Invokana dosed at 300 mg/day:
•Insulin dropped to 78 from 183 uiu/ml.
•ACTH only dropped to 27.6 from 29.7 and it's still up from March. 
•Glucose was 109, slightly down from 111mg/dl. She had Stabul1 with BP an hour before the blood draw because the visit was 6-7 hours earlier I expected. Her CH shows other morning results in the +100 range over the years.

 It looks like PPID has a big impact on Cayuse's insulin that Invokana doesn't completely mitigate. Or PPID combined with a mare issue?

I will discuss another pergolide increase with my vets. Is there anything else to look at?
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Cass, Sonoma Co., CA 2012
ECIR Group Moderator
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