The Invokana didn't fail. It was the same through all the ups and downs. Something else was responsible.
--
Eleanor in PA

www.drkellon.com 
EC Owner 2001
The first step to wisdom is "I don't know."

Last night temperatures were in the single digits below zero, and Flea did surprisingly well.  He's actually outside walking around this morning, only slightly stiff.  He's still on Invokana but I did receive the Steglatro.  I won't start it until the Invokana is gone, but now I'm wondering if the Invokana actually failed or not - if he continues to do well,  would you advise that I keep him on it, or should I switch him over to be on the safe side?
--
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

Yes, you should halve the dose of Mov Ease but it does not replace ALCar.  Mov Ease addresses arthritis.
--
Eleanor in PA

www.drkellon.com 
EC Owner 2001
The first step to wisdom is "I don't know."

Happy to report that after less than 48 hours, Flea was back up and moving.  He's still obviously sore and stiff, but he's up more than down, and venturing out of the barn more often. 

Since I've been doubling up his ALCar and tripling his Devil's Claw, I'm running short on both.  I have enough DC to get me through until the new shipment arrives, but I'm very low on ALCar.  I have started adding in Mov-Ease and wanted to check on a few things.  The loading and maintenance dose is 3 grams 2x daily/3 grams daily.  Is that for a full-sized equine, or any sized?  Flea being a mini, I'm never sure if I should halve a dosage.  Also, will the Mov-Ease replace the ALCar, or should I continue with both in addition to DC and j-herb?  These supplements have me completely confused, and the files I've read just make it less clear for me.
--
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

P.S.  PLEASE make sure the coronary band and frog tip are marked for the next films. If Flea has significant sinking a longer foot may be required.
--
Eleanor in PA

www.drkellon.com 
EC Owner 2001
The first step to wisdom is "I don't know."

Jennifer,

When a trim causes pain it is often because altered mechanics make abscess collections mobilize so I would poultice his feet for a few days, preferably with Numotizine. Can't say much else without films. I've never heard anyone, vet or owner, say gabapentin worked.
--
Eleanor in PA

www.drkellon.com 
EC Owner 2001
The first step to wisdom is "I don't know."

Yesterday Flea walked out of the barn and stood with his buddy eating hay - for the first time in probably three weeks!  I was so happy; he was walking much, much better and looking bright.  My trimmer came out and I was shocked by the hoof growth he's had since his last trim in late December.  I couldn't get him to stand so I could inspect the bottoms of his hooves when I would change his boots because he was so sore, and I only saw the outside/top portion of his hoof, really.  The hoof walls were incredibly tall, and his heels have prolapsed.  My trimmer did what she could (he was not cooperative because he didn't like putting full weight on either front - he was much better for his hinds) and is coming back in two-week intervals until his hooves are under control again. We'll do rads probably in April (I'm tapped out financially right now).

For the first time I can recall, Flea was incredibly sore after his trim.  As soon as we finished, he laid down and that night I could see that he had just moved back into the interior of the barn little by little as evidenced by the nests he makes laying down. I gave him a double dose of alcar and a triple dose of Devil's Claw.  I asked my trimmer if she expected him to be this sore due to his feet being so overgrown, and she suggested trying gabapentin for the pain.  From what I've read here, it doesn't really do much because it's not well absorbed in horses.  Should I just continue with what I'm giving him now, and assume he'll feel better soon?

--
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

Thanks, Kirsten!  I did a search and saw so many different doses that I wasn't sure.  I'll see if increasing the amount helps.
--
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

https://ecir.groups.io/g/main/message/272774

--
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

There is a wide range of Devil's Claw doses reported in the literature, from 2-40 g/day for normal size horses, so the safety margin is quite high.

--
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

Just to throw this out there...I ordered Steglatro today from PricePro and was told that for the Australian pills it's a 6-week shipping time, and for the UK pills it's 6 weeks or longer.  The UK pills are affected by the Royal Mail cyberattack.  I had a flashback to when I started Flea on Invokana during the height of the pandemic, and shipping was 8-10 weeks.  So it looks like we're on Invokana for at least another month or two. 

In better news, Flea came through the bitter wind chills ok.  We were in the -40s overnight and into the next day, and he definitely felt it, but he's recovering quickly.  Still laying down a lot, but his appetite is good and he's passing manure and peeing.  The devil's claw (extract) doesn't seem to be working as quickly as I'd hoped; I may increase it if there's no risk. 

--
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

No need to taper. Give him double the human dose twice a day to start.
--
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."

The Devil's Claw extract powder is here; it's a human product and I cannot find dosing instructions in the files.  Can anyone help me there? 
Flea has only had 3 meals (1.5 days) with Tylenol in them, so I'm not sure if he needs to be tapered off of it?  I'm assuming not.

--
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 don't think so; I have only given him 2 doses, this morning and tonight.  The vet gave him the shot of bute after taking blood Monday.  He didn't get anything prior to that other than j-herb and maybe 2 doses of alcar.
--
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

In doing a little more research, the elevated bilirubin, primarily indirect, could very well be coming from the Tylenol:

https://link.springer.com/article/10.1007/s40278-016-23190-1

https://www.researchgate.net/publication/348611336_Acetaminophen_elevates_unbound_bilirubin_levels_by_the_glucose_oxidase-peroxidase_method

Indirect/unbound/unconjugated bilirubin is used as a marker of Tylenol (aceptaminophen) liver toxicity:

https://www.clinicaltherapeutics.com/article/S0149-2918(15)00476-2/fulltext

--
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."

Thank you so much, Dr. Kellon.  I know everyone wants a piece of your time and I'm always humbled by how much you do to help as many of us as you can.

I'm positive he's getting the Invokana - I hand feed it every single morning and he's never rejected it.  I'll continue with the jiaogulan.  His feet were very warm when my vet was here the other day, which is why my vet suggested taking off the socks and leg warmers but keeping the boots on for support.  With the cold coming, I'm going to dress him to the nines!  Devil's claw should be here tomorrow.

I'm a little less shaken as he seems to be even more comfortable today.  He was up and actually came outside for a short while.  He stands to eat and oh boy, does he eat...he's been licking his bowl clean the past few days; I think he likes the alcar.  I haven't noticed any jaundice, but I'll look a little closer when I go down to the barn tonight. 
--
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

All of his liver enzymes were normal; only bilirubins somewhat elevated, especially indirect. This is most commonly seen when they are not eating well. Was he? Are the whites of his eyes jaundiced?

The FFW is likely from the high fiber in your hay. Try adding half a cup of wet psyllium to meals. Doubling probiotic won't help.

Are you positive he was getting the Invokana?  No reason you can't switch to ertugliflozin. You can continue Invokana in the meantime and Tylenol is not an NSAID but is toxic to the liver. Most (90%) of the SGLT action in the kidney is SGLT2. Invokana inhibits both SGLT1 and SGLT2 but is predominantly SGLT2.

Tylenol alone is not likely to have much effect on him. You can probably get Devil's Claw at a local drug store but I wouldn't stop Jiaogulan. The insulin could be up because of cold and you can't rule out cold and it's effects on blood flow as a factor here.

You don't have to discourage his movement but by all means keep him out of that wind chill. If you have a drug store or health food store with herbals you can probably find Devil's Claw and I would also look for a standardized Ashwagandha and start that at 2X human dose to protect against cortisol surges in severe weather.
--
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."

Thanks for splitting this out, Cass!
--
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

Dr. Kellon, if you get a chance could you review the CBC panel I uploaded to my case history file?  It's the one labeled 2023 01 30 CBC and Insulin.  My vet is a little concerned about the elevated bilirubin levels, and I want to be sure what I'm doing isn't contributing to that. 

Since this is now identified as laminitis due to insulin elevation and not cold-induced pain, here's my plan - please let me know if I should tweak anything.

*  Vet wants me to temporarily give him 5 tabs 500 mg Tylenol to reduce pain 2x daily; will do until I get Devil's Claw.
* J-herb - in the files under Pain Relief it's noted that "once heat and pounding pulses are present [j-herb] will likely be ineffective, may worsen pain...I avoid these with acute laminitis".  I will discontinue j-herb until this laminitic event is resolved.
* AAKG - can worsen inflammation, so I will discontinue.
* ALCAR - will continue to give this for neuropathic pain.
* Devil's Claw - will get my hands on some and introduce it to diet; I've tried phyto-quench and despite many attempts, he flat-out refuses it.
* Equine Generator probiotic - thinking about doubling his dose of this to support GI tract, but unsure if it's necessary.
* Other supplements are Vt. Blend, spirulina powder, salt, vit E, l-carnitine which I will continue to give.

* Switching from Invokana to Steglatro - this is the big one; my vet is concerned that the Invokana has stopped working, or Flea's system isn't processing it correctly.  Something to do with the SGLT1 upregulating it?  It's all Greek to me.  My biggest question is until I can switch, should I continue with the 130mg dose of Invokana?  Especially if I'm giving him Tylenol temporarily?

The hay is tested and below 7% ESC+starch, other than that he gets 1/4 cup Stabul1 mixed into a mash of ODTBC, so I won't change that. 

He's in boots and blanketed with a heat lamp in one room that he seems to like to lay under; wind chill values will be in the -30s Friday and Saturday.

I'm wondering about locking him in his little stall; he's moving around as evidenced by his "nests" in the shavings but should I discourage that?  He is having a lot of gas and although his stools are normal, there's a lot of liquid coming out with them (FFW).

Thank you for putting up with all my questions.  You'd think that after going through this all before I'd be better prepared, but I keep learning better ways to manage these events, and just want to keep him safe and comfortable.

--
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