Dixie updated case history


terrieheining
 

Have just uploaded updated case history and would appreciate any thoughts on the last few items in the comments section please.  

After being on Metformin for a month Dixies insulin was down to 15 so we stopped the Metformin and tested again after 2 weeks and insulin was back up to 59.  Rather than go back onto Metformin, my vet preferred to start Ertugliflozin which brought the insulin back down to 18, however Dixie is now quite lethargic, not wanting to leave her stable, and laying down a lot.  She has 24/7 access from her stable to a small dirt yard.  I have tried letting her out into a very small paddock in a closed muzzle for a short time, with 2 shetlands for company and she has no interest in their company either, just wants to return to her stable.    Her diet is very tightly controlled, she eats all of her food, she is not losing weight, manure and urine appear normal, she is drinking normally.  While on the Metformin she was really perky, whinnying when anyone came into sight, out in her yard watching what was going on, since Ertugliflozin she is just flat.   Should I put her back onto the Metformin, is it wise to chop and change?  It seemed a reasonable idea to go to the Ertugliflozin as I believe that the Metformin would stop working eventually, and obviously the diet was not controlling the insulin without the medications, now I don't know which way to go for the best as Dixie was much happier when on the Metformin.

Also my trimmer noticed bruising on all 4 hooves 3 weeks ago and asked me to stop the Jiaogulan.  Dixie was most uncooperative at that trim so I also put her back on 4 tbsp of Devils Claw.  Dixie also had slight bleeding from one hoof while being rasped, which my trimmer had never experienced before.  At the latest trim earlier this week the bruising had reduced, however there was slight bleeding from all 4 hooves this time.  It is not profuse and stops within seconds, however my trimmer advises that there should not be any blood vessels anywhere near where she is working, and this had also happened on a couple of non PPID/IR horses being trimmed for seedy toe and hoof crack issues within the last couple of weeks.  Could this be a result of the very hot and humid conditions we have had for the past few weeks as the other horses have nothing in common with Dixie, or is it just a coincidence?

Many thanks
--
Terrie H in Australia 2021
Case history: https://ecir.groups.io/g/CaseHistory/files/Terrie%20and%20Dixie
https://ecir.groups.io/g/CaseHistory/album?id=268416





Sherry Morse
 

Hi Terrie,

Were she mine I'd go back to metformin as long as she is willing to take it and it works for her.  As far as her feet - I'm not sure why your trimmer asked you to stop Jiaogulan - did she offer an explanation?  As a former laminitic pony she needs the help to grow out a new hoof and as long as the trim is in order it shouldn't be an issue.  It sounds like areas that have previously been a problem are growing out which is a good thing. 

Can you take current hoof pictures and add them to your album when you have a chance?



Kirsten Rasmussen
 

Hi Terrie,

I hope Dr Kellon will also comment because I'm not sure, but since Ertugliflozin is in the same class of drugs as Invokana and we know Invokana can cause high triglycerides, have you been monitoring triglycerides?  She doesn't sound like she has many signs of hyperlipidemia, but lethargy is definitely one of them.

The blood oozing, her sore hooves and the bruising combined with low insulin to me suggest she is working out some abscesses or collections, in which case I would not stop the jiaogulan.  If the jiaogulan is causing bleeding then your trimmer would be trimming into the corium where the live blood vessels are, which she almost certainly is not doing.  Her sore hooves could also explain the lethargy and change in behaviour.

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


terrieheining
 

Thank you Sherry,  
Neither my trimmer nor my vet have any experience with Jiaogulan, so I guess it was just that I had explained that it was to increase the blood flow to the hooves when I started to give it to Dixie, and now we have all hooves oozing blood so it seemed a reasonable request to stop it to see if the oozing stopped, which it has not.  I will take some new hoof photos asap.

--
Terrie H in Australia 2021
Case history: https://ecir.groups.io/g/CaseHistory/files/Terrie%20and%20Dixie
https://ecir.groups.io/g/CaseHistory/album?id=268416







terrieheining
 

Thanks Kirsten,

My vet will contact Vetnostics to find out how to get triglyceride levels as it is not a listed test here.  She is also contacting Dr David Rendle who is the vet pioneering Ertugliflozin to get as much information as possible.    I had no trouble giving the Metformin to Dixie so going back to that will not be a problem, nor will restarting the Jiaogulan.  It is a big learning curve for everyone over here who is trying to help Dixie and I must admit when I saw the seeping hooves my own initial reaction was panic.  I agreed to swapping over to the Ertugliflozin as I thought that Metformin always stops working eventually, however now that seems to have been yet another poor choice on my part.  Hopefully whatever is going on right now is fixable.

--
Terrie H in Australia 2021
Case history: https://ecir.groups.io/g/CaseHistory/files/Terrie%20and%20Dixie
https://ecir.groups.io/g/CaseHistory/album?id=268416







 

Hi, Terrie.
Please do add photos of hooves oozing blood as soon as possible. Ertugliflozin-like drugs aren't an instant fix for trim issues or for PPID. PPID must remain controlled with pergolide even during the seasonal rise. As for the trim, it can take many months, a year or more, to re-align the coffin bone within the hoof capsule. During that time, abscesses are more common than not. Remember that the collections within abscesses are usually walled off within the hoof capsule. Whatever oozes out is old material. The same is true for bruising we see at the sole level: that bruising occurred many months ago. 

It's not clear that Ertugliflozin was a bad choice on your part or that it is responsible for the problems you're seeing. Do not give metformin while you're giving Ertugliflozin. We have no proof the combination is safe in equines.  Another member here has a pony on Ertugliflozin/Steglatro with dramatic results. Others of us are treating our equines with Canagliflozin (Invokana), a drug in the same family. In most cases, it reduces insulin to a safe zone. In the case of my own horse, insulin dropped from over 100 to the 20's. 

Critical feeding information is sent to the veterinarians and members who start Invokana. The elements of the diet (hay and pelleted feed) should be safe for an equine with EMS with ESC+Starch less than 10% combined. HOWEVER most equines on Invokana should be free-fed: there should be no diet restriction in the amount of hay they have access so. Soaking to lower ESC below 10% may be unnecessary.

Please read Dr Kellon's message describing elevated Triglycerides and Canagliflozin (Invokana) advising as follows: "Dietary adjustment could also be useful – specifically adding generous beet pulp. Beet pulp fermentation generates large amounts of acetate which can replace glucose in energy generation. Allow free choice safe hay unless the horse needs to lose weight. I do not recommend starting formal exercise when on this medication."
https://ecir.groups.io/g/main/message/263668 

We monitor our horses on Canagliflozin using urine test strips to check for urinary tract infections (which should be negative) and for glucose clearance (which should be high). When we run blood tests, we also check triglycerides which are part of a veterinary lipid panel. One member's horse suffered from hypertriglyceridemia and was hospitalized. For many of the rest of us, free-feeding hay and adding large quantities of beet pulp to the diet have kept triglycerides within a reasonable range. 

--
Cass, Sonoma Co., CA 2012
ECIR Group Moderator
Cayuse and Diamond Case History Folder                
Cayuse Photos                Diamond Photos


Lavinia Fiscaletti
 

Hi Terri,

No beating yourself up about things that are in the past - you can't change them, so just concentrate on the things you CAN do.

Given the amount of laminar wedge and sinking Dixie is dealing with, it is highly likely the seepage you are seeing is just old, walled-off collections of trapped material that needed to drain out. Even tho it can be a heart-pounding moment when you trim into one of those pockets, your trimmer is correct that she was nowhere near the actual blood supply.

Metformin doesn't always stop working, although the tendency does exist. If it is working for Dixie, there is no need to change until/if it stops working. Metformin is a much simpler drug to use than the class of drugs containing  Ertugliflozin, as these require more frequent blood testing, urine testing/monitoring and and dietary monitoring to be sure they are working as intended.

--
Lavinia, George Too, Calvin (PPID) and Dinky (PPID/IR)
Nappi, George and Dante Over the Bridge
Jan 05, RI
Moderator ECIR


Eleanor Kellon, VMD
 

The horse on canagliflozin that was hospitalized was hospitalized for colic and happened to have elevated triglycerides at the same time which may or may not have been related.  Other components of the hyperlipidemia syndrome in ponies and minis, especially poor appetite, are absent. This is consistent with other reports about hypertriglyceridemia in EMS horses.
--
Eleanor in PA

www.drkellon.com 
EC Owner 2001


Nancy & Vinnie & Summer
 

I just want to clarify, Vinnie presented as a colic, but when he got to the hospital they didn't feel ge was a colic, they hospitalized him for Hypertriglyceridemia/hyperlipidemia and was treated for the latter.
--
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


Eleanor Kellon, VMD
 

That's true, Nancy, but his symptoms/signs never aligned with hyperlipidemia syndrome and the staff there at UC Davis were surprised by that.
--
Eleanor in PA

www.drkellon.com 
EC Owner 2001


Nancy & Vinnie & Summer
 

I think UCD were perplexed only because as severe as hypertriglyceridemia as he was, 1100 on admission, over 1500 the following day while on IV glucose and heparin therapy that he was still consuming food. They had me send everything he was eating at home.becuaee they thought he wasn't getting enough DE. But ruled that out and co concluded it was because of the canagliflozin.

He was symptomatic in the sense that he was starting to decline in many ways and they felt his life was at risk resulting from the hyperlipidemia.  

I still feel Vinnie is more hypersensitive to this medication than most of the other horses that are on it.  I have wondered if this is because he is Arabian?

I am trying different feed combinations to get to that sweet spot that others have found where his insulin is controlled and his TG are normal or just above normal. :)
--
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


terrieheining
 

Hi Nancy,  
I am unsure if your post is intended to highlight how serious uncontrolled triglycerides can become for Dixie, or is a response to Dr Kellons previous comment, but either way,  my vet will be here in a couple of hours to take blood to send away for analysis, so  please be assured that we are taking immediate steps to get on top of this.  My vet, my trimmer and myself on Team Dixie are all totally committed to doing everything we can for her with the knowledge, advice and support of the ECIR group forming an essential part of the very steep learning curve involved in the process.  Dixies diet has been balanced by Carol Layton and everything is weighed with no deviation from the set ingredients and amounts.  It now appears that as Dixie has no access to any pasture at all,  while she is on Ertugliflozin free choice hay should be available, so I will need to run this by Carol to ensure that doing that does not upset the balance of all the other ingredients in her feed regime.  Seems an easier option to just stop the Ertugliflozin and go back onto the Metformin, which was controlling the insulin and Dixie was happy.  My young vet recently attended a seminar on Ertugliflozin which was presented as a game changer for lean IR horses and that was the only reason that we swapped over from the Metformin.  "If it ain't broke, don't fix it" seems a fitting remark in hindsight.  Many thanks for your interest.


--
Terrie H in Australia 2021
Case history: https://ecir.groups.io/g/CaseHistory/files/Terrie%20and%20Dixie
https://ecir.groups.io/g/CaseHistory/album?id=268416







Eleanor Kellon, VMD
 

Nancy,

They were right about the DE because it's the loss of calories/glucose in urine that causes this problem. Metabolic syndrome itself can cause elevated triglycerides and be completely asymptomatic even with triglycerides over 5000 mg/dL https://pubmed.ncbi.nlm.nih.gov/23663085/ and may have these levels for a prolonged period of time. Vets freak out over elevated TG because basically all we are taught is the syndrome in ponies and minis. This is very different and not life threatening. Because triglycerides are not part of routine chemistry screens we are likely missing a large number of animals with elevated levels. I'm not suggesting it should be ignored.  High TG are a sign energy balance is off. Even horses that haven't eaten for a few days - e.g. before and after colic surgery - have levels 8 to 10 times normal.

There are other Arabians on SGLT2 inhibitors with no unusual sensitivity.
--
Eleanor in PA

www.drkellon.com 
EC Owner 2001


Nancy & Vinnie & Summer
 

Thanks Dr Kellon. Is there a chance the group is working in a new feed protocol for horses on SGLT2 inhibitors? I think it would be super helpful. I know my journey has been trial and error and am still trialing and erroring:)

I am now using a 9.9 esc+ starch hay mixed with an 8.4 esc+starch at a ratio of 50/50 free fed.  I max out RSR BP at about 3lb dry weight but am trying to add in feeds that are beet pulp based like triple crown senior to use as a taste temptor at a cup per feeding of beet pulp. I am also using stabul 1 at about 3 cups per feeding. And about 4 to 5lb of odtbc balance cubes with a about 2.cups of timothy pellets and a handful of cavalor fiberforce.  This is to support his 150mg of Invokana (canagliflozin) every other day.  New labs will tell me how this is working in about a week.

Thanks so much for all you do.

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


terrieheining
 

Attention Lavinia please.

Blood test results came back yesterday and Dixies triglycerides are very high, so Ertugliflozin is stopped and we will restart the Metformin in a week. I will upload a copy of the report when it comes through from my vet. My  dietitian has approved ad lib Teff hay with increased Speedibeet and Hygain Zero to build Dixie up again. 

I have shown the responses from the group to my trimmer and she advises that she has trimmed through pockets of necrotic material previously but has never had bright red blood seeping through before so maybe rogue vascularisation?  She has asked my permission to continue to rasp (within reason) if the bleeding starts again at next weeks trim to try to locate the source so I want to trust her judgement despite my overwhelming urge to stop the process as soon as the seeping starts.  What are your thoughts on this please and is this something you recommend? I will take photos/video of the bleeding if it happens again and add to the Case History.

I have re-started the jiaogulan as removing that was a knee jerk reaction to the unexpected blood seepage and it looked guilty sitting there in its jar with a label saying that it increased blood flow to the hooves.  

My thanks to the group for their support and guidance along this very bumpy road.

 

--
Terrie H in Australia 2021
Case history: https://ecir.groups.io/g/CaseHistory/files/Terrie%20and%20Dixie
https://ecir.groups.io/g/CaseHistory/album?id=268416







Maxine McArthur
 

On Tue, Jan 25, 2022 at 11:04 AM, terrieheining wrote:
I have shown the responses from the group to my trimmer and she advises that she has trimmed through pockets of necrotic material previously but has never had bright red blood seeping through before so maybe rogue vascularisation? 
Terrie, I have seen red in the white line at the toe on Indy a couple of times at a routine trim. It wasn't not seeping but it was definitely red. There's a photo in her album here: https://ecir.groups.io/g/CaseHistory/photo/933/9551?p=Created%2C%2C%2C20%2C2%2C80%2C0
We assumed it was an area that had bruised and then grown down, as Lavinia says. 
Let us know if/when you get photos. 
 
--
Maxine and Indy (PPID) and Dangles (PPID)

Canberra, Australia 2010
ECIR Primary Response

https://ecir.groups.io/g/CaseHistory/files/Maxine%20and%20Indy%20and%20Dangles 
https://ecir.groups.io/g/CaseHistory/album?id=933

 


Eleanor Kellon, VMD
 

It's definitely not rogue vascularization.  The bleeding comes from tearing of the sensitive/live laminae. Until the  mechanics of the hoof are corrected, that tearing is going to continue and set back healing efforts.
--
Eleanor in PA

www.drkellon.com 
EC Owner 2001


Eleanor Kellon, VMD
 

As another note on the blood, true vascularization only occurs in living tissue and where there are vessels there are always nerves.  If there is no pain response in this area, it's not live tissue.
--
Eleanor in PA

www.drkellon.com 
EC Owner 2001