Date
1 - 9 of 9
Flea is getting bad again, advice? (Invokana)
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Jennifer Murphy
I've emailed Dr. Kellon but I'm sure she receives hundreds of emails every day, so while I wait I was hoping for some advice, specifically from others who have their equines on a flozin drug and have experienced setbacks.
Flea's most recent bloodwork from 10/25 shows ACTH at 35.9 pg/mL, up from 25.3 in July. Insulin is at 135.82 ulUmL, up from 68.35 in July. Triglycerides were 78 in July, 82 in October. (I need to put those new numbers in my case history.) In April I bumped up the pergolide from 2 tabs to 2.5 tabs as ACTH was 36.4, against the recommendation of my vet. I wanted to bump him up again after his October results, but my vet thinks he's on too high of a dose already. My farrier agrees, and says per Tufts ACTH limits go up to 80 during the seasonal rise, so he's well within controlled range. My understanding is that is for normal horses, not PPID diagnosed horses. Both think his ACTH is perfect for this time of the year. I know Kirsten said in my previous thread that she would have increased the pergolide again in July, but I honestly thought it was fairly decent, so that's on me. My farrier is convinced the ACTH has nothing to do with the insulin spike, and that Flea's recent weight gain is responsible. My vet thinks he's not getting his pills (he is, I hand feed them every day). I've had issues with hay this year - low ESC+starch, but low cal and not very palatable. I've switched to a hay that agrees with both mules, but in the past few weeks I've watched Flea become lethargic, his belly looks bloated (he has the donkey A frame look), and now he's in visible pain walking. The day we did the bloodwork/rads/trim he had a slight pulse in one foot, but nothing alarming. He was walking fine, but turning was becoming difficult. I was told to cut back his hay, put it back into nets, get the weight off, don't increase his meds. Other than the hay, he gets about 1.5 cups of soupy mash of ODTBC, which is poured over 1/4 cup Stabul 1 with his vitamins, salt, l-carnitine, vit E, & probiotic. At night he gets the same except no E or l-carnitine, instead he has spirulina powder and J herb. 100 mg of Invokana in the morning, 2.5 mg Prascend in the evening. The hay he's on he's been getting for about a month, so I don't think it's a matter of abrubt change in forage. He's also showing signs of FFW again. I've put him back in boots and he is barely walking. My gut feeling is to increase pergolide to 3mg, but is it too late? What about cutting back the hay - is that smart or not? Should I increase the Invokana slightly? Swap him over from ODTBC to beet pulp? I hate that he's feeling so poorly after he was doing so incredibly well, and I'm torn between two different schools of thought. I just want him to be happy. -- 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 |
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Jennifer, I can tell you from personal experience Vinnie's ACTH has never matched his physical symptoms. So this year even though we tested well within normal ranges, I kept upping his dose to keep his ACTH in the mid teens. You can see my CH how it trended. Vinnie is now on 11.5mg Compounded Pergolide and his ACTH is at 18.
Hope that helps. Thanks Nancy -- 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 |
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Hi, Jennifer.
Your gut feeling is correct. It is NOT too late to control PPID with an increase in pergolid. It is the first step to addressing fall laminitis. Obesity does NOT cause high insulin or laminitis. It is a symptom, not a cause. You really need to update your Case History. As for changing the diet, I don't even know which hay you are feeding. It would also be helpful to see a current photo of Flea along with any new radiographs. I do have unfortunate experience with laminitis in a horse on Invokana. Laminitis pain can really reduce movement and possibly calorie needs, BUT fine-tuning a feed reduction for Flea is Dr Kellon's domain. I do know you need to use extreme care in reducing feed for weight loss in a mule and that a crash diet is the worst plan because of the risk of hyperlipidemia. I'm sorry that you're getting incorrect advice about the effect of uncontrolled PPID on insulin. I understand why you're getting the erroneous information. PPID is a complicated condition that affects multiple hormone regulation mechanisms. The details are laid out here: https://www.ecirhorse.org/physiology-ppid.php Excessive production of cortisol caused by uncontrolled PPID can increase insulin resistance. I suspect Invokana cannot compensate for that increased insulin resistance. I'm sure Dr Kellon can explain more clearly. ECIR suggests tight regulation of PPID all year long, including during the seasonal rise by targeting ACTH in the high teens to very low 20's. That's my goal with my horse on Invokana. -- Cass, Sonoma Co., CA 2012 ECIR Group Moderator Cayuse and Diamond Case History Folder Cayuse Photos Diamond Photos |
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It's true ACTH could go as high as 80 in older horses without PPID but that doesn't mean it's harmless. Animals with a history of seasonal rise laminitis are doomed to repeat it unless their ACTH is controlled - an indicator of pituitary control in general.
IMO, the only correct dose of pergolide is the one that controls PPID. We have had horses on much higher doses than 2.5 and in the UK BI recommends Prascend up to 5 mg - with no justification for the upper recommendation being 2 mg here. Since Flea has gained weight, his Invokana dose maybe too low; e.g. if he weighs 450, he should get 125 mg. If the new hay (did you test it?) is making him bloated and sore, go back to the old hay. I would also increase both meds. Eleanor in PA www.drkellon.com |
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Jennifer Murphy
I've updated my case history and added photos to the album; body shots and hoof photos as best as I could manage today. I will try again to get better photos, but these will have to do for now.
I've increased pergolide to 3 mg and am free-feeding hay again unless instructed otherwise. He is getting the VT White Farm hay (wet chem analysis in my case history folder). He and my healthy mule both experienced bloating and FFW on the CC Farm hay (wet chem analysis in my case history folder), and Flea started gaining on that. They've been on the VT hay for just over a month, both had the FFW clear up as soon as I switched, Flea's reappeared just this past week but seems to be clearing up now. They clean this hay up and the healthy mule's bloat went away. Flea has always had that bloated look a little. In the photos from the side it looks like he has a funny-shaped belly, almost like an edema in front of his sheath area - this is just the ridiculously long hair that he won't allow me to clip! Interestingly enough, if I calculate his weight using heart girth/length as a horse (via EquiMed weight calculator), he estimates at 358 lbs but using just the heart girth it estimates at 429 lbs. If I use a donkey calculation, he comes out at 462 lbs. Using the donkey sanctuary calculator he's about 440 lbs. Measurements in inches are heart girth 51.75, length 44, and height 39. I last used a weight tape to estimate his weight, and he was 420, so somewhere between 430 - 462 would be my guesstimate. Any suggestions as to a good weight for him would be appreciated! As of this morning, he is walking much better and I took his boots off. We'll see how he is by the end of the day. I suspect I'll just have to wait and see what his next bloodwork looks like, but I'll take any advice for getting his weight down. Would higher-calorie hay in less quantity be better? Or just less of the hay he's getting? -- 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 |
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Hi Jennifer
I wanted to share this article from Dr Kellon about hay belly. I'm going through the same thing with my EMS TWH. He's dealt with high fiber fractions (ADF and NDF) before, but this year is different. I do find Sonny gets the FFW when he finds weeds he should not have had. I'm pretty much following the recs outlined in this article . https://drkhorsesense.wordpress.com/2020/11/19/avoiding-hay-belly/ I think raising the pergolide was a good idea, given his top line. Those short muscles take a beating when PPID is not well controlled. I'm still trying to get my arms around the Invokana feeding regimen so am looking for ward to info from others, especially Dr Kellon. I believe I read you have custom balanced the hay which is good. The iron in the VT White Farm would need tight copper and zinc to balance. -- Nancy C in NH ECIR Moderator 2003 ECIR Group Inc. President 2021-2022 HOW TO SEARCH THE ARCHIVES: https://ecir.groups.io/g/main/wiki/1993 |
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I don't see any glaring differences between those two hays to explain the FFW. A preservative is one possibility.
Agree Flea's ideal weight is probably around 400 but with all the hair it's difficult to assess body condition. The abdomen also looks more like there is excess fluid rather than bloat. What is his deworming routine? I would take Invokana up to 125. -- Eleanor in PA www.drkellon.com |
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Jennifer Murphy
Nancy - I've been spoiled with fairly consistent hay from the same source over the years, but this year has definitely been an odd one. Any hay I've tested has been less than spectacular. I wonder if a second cut would be a better choice and if it tests well I could mix it with what I have on hand?
Dr. Kellon - My deworming routine is admittedly lacking; the last time the mules were dewormed was fall of 2021, with Ivermectin. Would Zimecterin Gold be a safe choice, and should I have a fecal egg count done prior? Per the article Nancy linked, both prebiotics and probiotics are suggested. Flea gets Bio-Vet Equine Generator 2x/day currently. I do have psyllium husk on hand so I could start giving him that in the morning instead of the probiotic; is this given for a short period of time, or is this something I should plan to add to his diet permanently? The article states 8 oz psyllium husk moistened - is that the dose for any equine, or would Flea warrant a half dose? Thank you all for your input, it's much appreciated! Flea has been out of boots all day and is moving much better. Fingers crossed it stays that way. -- 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 |
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Definitely go ahead with ZimectrinGold deworming for them. Yes, halve the psyllium dose for Flea and you can give it with the probiotic. Use only until manure normalizes.
-- Eleanor in PA www.drkellon.com |
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