After Flea's last hiccup, I did what Dr. Kellon suggested and dewormed him.  I also increased his Prascend to 3 mg/day.  He slowly rebounded and was doing well, then we had an unusual warm spell and he actually acted sore in the warmer temperatures.  I booted him and in a few days, he seemed fine again.  We've had another round of unusually mild temperatures and on 12/31 Flea seemed very sore.  I put him back in boots and he seemed better, then this morning he was so crippled up he almost fell trying to back up.  This is the worst I've seen him since he's been on Invokana.  I suspect he may have been eating some dried-up weeds near the fence - I saw the other mule pulling at them last week.  I am going to clear them out today.  Over the last week or so, he's started to get that low-slung pot-belly look again, too.  I've put his thermal socks on in addition to his boots.

Dr. Kellon had suggested bumping him up from 100 mg/day of Invokana to 125 mg/day.  I had wanted to see if the increase in pergolide and deworming helped without having to increase the Invokana, so I never did that.  This morning I tried splitting a pill and ended up with more thirds than quarters, so he received approximately 130 mg.  If that increase is enough, how soon will I see his symptoms subside?  If I'm increasing Invokana, do I also need to increase the amount of L-carnitine he gets?  Also, should I deworm him again?  I gave him Ivermectin spring and fall of 2021, but then my routine lapsed, so this fall dose of Zimectrin Gold was the only time he was dewormed in 2022.  I'm not sure if it's worth getting a fecal done, is that recommended?

--
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

Just wanted to add that I've been in touch with my vet and she's coming tomorrow morning to do bloodwork.
--
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

I think that is a very good idea. 

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

Snickers' Case History
Snickers' Photo Album

I agree blood results will point you in the right direction.
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Eleanor in PA

www.drkellon.com  BOGO 2 for 1 Course Sale Through End of January
EC Owner 2001
The first step to wisdom is "I don't know."

Since I won't know the results of the bloodwork until mid to late week, can someone answer the questions from my first post? 

If that increase [of Invokana] is enough, how soon will I see his symptoms subside?  (from 100 mg to +/- 130 mg)
If I'm increasing Invokana, do I also need to increase the amount of L-carnitine he gets? 

He seems a little bit better but is still barely walking.  My vet was very disappointed by how bad he was; he can't turn, he's treading, and his legs are shaking.  I've put him in full winter laminitis regalia; socks, boots, legwarmers.  His appetite is still good.  I was hoping to never see him struggle like this again...I feel like I've failed him.

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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

Jennifer,

Where are you keeping your Invokana? It has to be protected from cold. I'd go so far as to ask the Post Office to hold a shipment for pick up rather than have it sit in a cold mail box.
--
Eleanor in PA

www.drkellon.com  BOGO 2 for 1 Course Sale Through End of January
EC Owner 2001
The first step to wisdom is "I don't know."

Dr. Kellon - my mother lives in an attached house and is fanatical about getting the mail as soon as it's delivered, but to be on the safe side I'll have the post office hold it in the future during cold weather.  Once it arrives, I keep it in the house so it's not exposed to cold after delivery.

--
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

OK, so that's not likely the issue. Sorry if I asked this already but have you checked the urine for glucose recently?  How are you giving the Invokana?
--
Eleanor in PA

www.drkellon.com  BOGO 2 for 1 Course Sale Through End of January
EC Owner 2001
The first step to wisdom is "I don't know."

If his insulin is still in acute laminitis range on these results you could switch to ertugliflozin. We haven't had any failures with canagliflozin/Invokana but it's bound to happen some time.

Is he on Jiaogulan?
--
Eleanor in PA

www.drkellon.com  BOGO 2 for 1 Course Sale Through End of January
EC Owner 2001
The first step to wisdom is "I don't know."

I give him the pill by hand every morning in a small piece of carrot to be sure he eats it.  I've never been able to get a urine sample.  He is on jiaogulan.  Tonight he got down to roll and I was surprised that he was able to get right back up.  He is still visibly sore and walking is difficult, but he's a tiny bit more mobile.  Would it be safe to increase to 150 mg until we get the results back, or should I just hold tight with the 130 mg?

--
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

Just hold at the 130.
--
Eleanor in PA

www.drkellon.com  BOGO 2 for 1 Course Sale Through End of January
EC Owner 2001
The first step to wisdom is "I don't know."

-Why haven’t been able to get a urine sample? If worse comes to worse, you can dip it right on the ground where the urine accumulates?
LJ Friedman  Nov 2014 Vista,   Northern  San Diego, CA

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

 

It's not accurate to sample from the ground.
--
Eleanor in PA

www.drkellon.com  BOGO 2 for 1 Course Sale Through End of January
EC Owner 2001
The first step to wisdom is "I don't know."

Just got off the phone with my vet and his insulin is 86, which for Flea doesn't correspond with the extreme discomfort he's been showing.  Sunday he was so sore he couldn't bend his off-front leg.  I increased his j-herb and he seems to feel a little more comfortable.  Today he stands square but is still shuffling and treading.  His ACTH was 39, which I wasn't expecting with the recent bump up from 2.5 to 3 mg of Prascend.  My vet didn't like that dose at all - she's not convinced the ACTH is a factor.  Triglycerides were within normal range.

Based on what we saw when Flea first went on Invokana and it halved his insulin in 24 hours, she thinks his insulin was probably much higher than 86 the day before we did bloodwork, as that's when I increased his dose from 100mg to +/- 130mg.  I'm to keep him on 130mg and we're going to do another round of bloodwork to see where his insulin is on Tuesday of next week.  I'll update his case history as soon as I have a copy of the bloodwork.

--
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

Case history is updated with the new blood work.  I'm thinking the recommendation would be to increase the pergolide again, and I don't know if I should do a .5 mg or 1mg increase.  
ACTH 39.6 pg/mL
Insulin  85.52 ulU/mL

Try 3.5 mg.
--
Eleanor in PA

www.drkellon.com  BOGO 2 for 1 Course Sale Through End of January
EC Owner 2001
The first step to wisdom is "I don't know."

Happy to report that Flea is finally moving well.  He's not 100%, but he's nowhere near as sore as he was.  He started acting more like himself and had better forward movement on Saturday, but I was holding my breath hoping it wasn't a fluke.  He's better each day.  As soon as he could move better, he headed straight to the area by the fence where a weed has been greening up under the snow that I noticed my other mule trying to get.  I identified it as Motherwort, and I have done the best I could to cover what was near the fence so neither of them can get it.  I smothered it in dirty shavings and urine-soaked manure for now, and they are leaving it be.  Once the ground thaws I'll be able to dig it out and get rid of it once and for all.  I honestly think that may have been the culprit behind this setback, but I'll never know for sure.

I'm very thankful for the guidance and support from members, admin, and of course, Dr. Kellon.  Now if I can keep Flea out of mischief, I may be able to get him through the rest of the winter without issue.
--
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

They keep us on our toes, that's for sure. Just remember everyone that there's always an answer. We may not know it at the time but never stop searching.
--
Eleanor in PA

www.drkellon.com  BOGO 2 for 1 Course Sale Through End of January
EC Owner 2001
The first step to wisdom is "I don't know."

My vet was just here to recheck insulin and offered either the traditional Cornell test or the test with the Stallside Insulin test that she should have by this evening.  I asked for both, so we could see the results and judge for ourselves how accurate the new test is and if I want to use it again in the future.  I did see this report, as well :
https://thehorse.com/1119267/scientists-validate-stallside-insulin-test-for-horses/
We'll see!  I figured it would be worth trying, at least.  :)
--
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

The study comparing it to RIA at Cornell is out https://journals.sagepub.com/doi/epub/10.1177/10406387221142288 . Long story short, the test can only read insulin between 40 and 60uIU with good correlation with Cornell values. Above and below that they diverge with mean error of 10.5%, range of -30.1 to 50.9%. (Correct me if I'm wrong Dr. Gustafson!)
--
Eleanor in PA

www.drkellon.com  BOGO 2 for 1 Course Sale Through End of January
EC Owner 2001
The first step to wisdom is "I don't know."