Ertuglifozin v. Metformin


misglen
 

My equine vet has suggested trialling Max on Ertuglifozin. It seems to be recently available here in Australia and there has been some publicity about it.  Max’s insulin came back on 30/7 at 79 (tested 4 hours after feed, but access to hay). Max has his first bout of laminitis, seemingly after I added an unsuitable feed to his diet.  That has now been removed and he is on the emergency diet, confined to rubber lined stable/breezeway, with soaked hay.  He has improved over the last few days, still has some heat in his feet, but moving better, pulses seem softer, and down to 6ml of Bute per day to taper off after another few days hopefully.
Given I’m certain that this first laminitis was caused by the Lupinpak feed I added to his diet a month or so ago, and I’ve always managed him as an at risk horse for 13 years without issue, I’m hoping I can go back to managing Max without meds.
Should I try that first, and then Metformin if required, leaving the Ertuglifozin for the third step for the first two aren’t  effective? Is it likely for me to get Max back to managing with diet and environmental only, or will drugs be required now he’s had a laminitic episode???
I don’t want to medicate him if I don’t have to, but obviously will if needed?
--
Michelle & Max
Yarra Valley, Victoria, Australia
Thank you
Joined 2022
https://ecir.groups.io/g/CaseHistory/files/Michelle%20and%20Max
https://ecir.groups.io/g/CaseHistory/album?id=277108


Eleanor Kellon, VMD
 

First thing I would do is test for PPID. First laminitis later in life often means early PPID. Do a TRH stimulation test, if available. His test was in the high normal range.I wouldn't go right to ertugliflozin without retesting his insulin. The LupinfPak is low sugar and starch. At 8% fat it is more than we would recommend but I don't know if that alone could push him over the edge in one month.
--
Eleanor in PA

www.drkellon.com 
EC Owner 2001


Kirsten Rasmussen
 

Hi Michelle,

Assuming he doesn't have PPID and just has EMS, there's a very good chance you can manage Max through diet and exercise alone.  It might mean you have to make more dietary changes, such as sourcing a lower sugar hay or even soaking it, and get him into regular workouts once he's recovered from this episode.  If that insulin result is for blood pulled while he is on the Emergency Diet then you will definitely need to look for a different hay if you want yo avoid drugs.  My horse first tested with a similarly high insulin at around 80 uIU/mL on a soaked hay full of clover (11% ESC + starch).  I put him an unsoaked lower sugar grass hay (7% ESC + starch) and insulin came down to the low 40's.  I started soaking the low sugar hay and got him trotting 3x a week for 20 min, and that brought insulin down into the teens.  Through this 2-year process he also lost about 200 lbs, which undoubtedly helped.

I wouldn't leap to Ertugliflozin unless Max had intractable high insulin, meaning diet and exercise and Metformin didn't work.  It seems like a miracle drug but it is very new in horses and there is the potential for serious side effects.  I don't know about Australia but in Canada it is also very expensive.  As Max ages you might find his EMS gets harder to manage, at which time the meds may be needed.

Agree that you need to investigate the possibility of PPID because that really does require medication (pergolide or Prascend).

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


Maxine McArthur
 

<Do a TRH stimulation test, if available>


Michelle, if your vet does do a TRH stim please let us know the details, as it is not available here.
--
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

 


misglen
 

Thank you Dr Kellon, he was tested for PPID first, I’ve uploaded the test result in his Case History, it was negative at 23.3 so my vet then did the insulin test. Unfortunately he hasn’t been able to find a lab here in Australia that does the TRH test, as I asked for that to be done also?
--
Michelle & Max
Yarra Valley, Victoria, Australia
Thank you
Joined 2022
https://ecir.groups.io/g/CaseHistory/files/Michelle%20and%20Max
https://ecir.groups.io/g/CaseHistory/album?id=277108


misglen
 

Hi Kristen the bloods were taken for the insulin test before I started the emergency diet.  My vet is coming back tomorrow to re-check Max so perhaps I should get another insulin test done to see if the level has come down? 


if anyone knows a lab in Australia that will do a TRH test I’d love the details so I could get one done… we seem to be on a backwater in that regard!
--
Michelle & Max
Yarra Valley, Victoria, Australia
Thank you
Joined 2022
https://ecir.groups.io/g/CaseHistory/files/Michelle%20and%20Max
https://ecir.groups.io/g/CaseHistory/album?id=277108


misglen
 

PS it’s in my Case History but I forgot to add in above, I was giving him 3\4 cup of stabilised RBO fir a week or two  along with the Lupinpak…. Too much far from what I know now 
--
Michelle & Max
Yarra Valley, Victoria, Australia
Thank you
Joined 2022
https://ecir.groups.io/g/CaseHistory/files/Michelle%20and%20Max
https://ecir.groups.io/g/CaseHistory/album?id=277108


Maxine McArthur
 

Michelle, as far as I know it's not a laboratory issue with the TRH stim--it's the fact that vets have to buy an entire very expensive vial of the material, which they may not use all of, and therefore it's a huge loss for them. They can't afford to do it, at least that's per my vet. Unless they pass on the expense to the owner. She did say that Charles Sturt Uni at Wagga might be able to do it but I would probably need to take the horse there, and she wasn't sure. That's why I asked you to let me know if you find any vet in Victoria who does it. 

--
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

 


misglen
 

Hmm, that makes sense.  What a shame, when its a very useful alternative test.  My gut instinct is that Max is early PPID, as nothing else explains his abnormal sweating which only started this autumn,and his late coat shedding for the last year or two.  And as Dr Kellon said above, the insulin is high, but its not hugely high.  I just don't trust the ACTH test results, but what am I supposed to do, its really frustrating.
--
Michelle & Max
Yarra Valley, Victoria, Australia
Thank you
Joined 2022
https://ecir.groups.io/g/CaseHistory/files/Michelle%20and%20Max
https://ecir.groups.io/g/CaseHistory/album?id=277108


Maxine McArthur
 

Michelle, I would discuss your concerns with your vet, as they are allowed to trial pergolide/Prascend based on symptoms even if the test is equivocal. My mare tested only at the top of the normal range but her anhydrosis, lethargy, poor coat and skin issues without any other obvious cause prompted us to try her on medication and she improved, so my vet is quite happy to keep her medicated now. 

--
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

 


misglen
 

I'm going to do exactly that Maxine, thank you for reinforcing my gut instinct - vet is due back tomorrow so will discuss a Prascend trial.  I really don't want to treat him for IR as a primary issue if its actually PPID causing the problem.

Thanks so much!
--
Michelle & Max
Yarra Valley, Victoria, Australia
Thank you
Joined 2022
https://ecir.groups.io/g/CaseHistory/files/Michelle%20and%20Max
https://ecir.groups.io/g/CaseHistory/album?id=277108


Kirsten Rasmussen
 

My vet is coming back tomorrow to re-check Max so perhaps I should get another insulin test done to see if the level has come down? 
Yes, absolutely!  You want to see what effect the diet changes have had.  Ask for insulin and glucose.

The alternative to a TRH Stimulation test is the domperidone stim test, OR to test ACTH at the peak of your seasonal rise when not on pergolide.  Early PPID horse will have an exaggerated response to the rise, but may test normal the rest of the year.
--
Kirsten and Shaku (IR + PPID) - 2019
Kitimat, BC, Canada
ECIR Group Moderator
 
Shaku's Case History
Shaku's Photo Album


Kirsten Rasmussen
 

An insulin of 80 and an ACTH of 23 likely means he has EMS.  He may also have early PPID.

I would cut out the added oil if you haven't already.  We need to keep fat minimized in the diets of EMS horses.  And switch the carrot treats for celery...they love it and it's safe!  You should add a source of omega-3 fatty acids and vitamin E .  An 1100 lb horse with EMS/PPID needs about 1 cup of ground flaxseed (4 oz) and 2000 IU vitamin E (mixed with a small amount of oil, or fed as human grade gel caps containing oil) to meet their needs.

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


misglen
 
Edited

Hi Kirsten, thanks for, I stopped the oil a couple of weeks ago, I just had a feeling about it, that it wasn’t right. 

I bought some celery on the weekend and Maxie LOVES it, I give him a couple of bits a day and he thinks it’s a huge treat.

I’ve got him on the emergency diet, but I can’t get him to eat any type of magnesium, he thinks it’s poison.  Any suggestions??

my vet came and saw him tonight, and we both can see some improvement in Max - he is moving a little easier, and in the stable (stable comfort flooring and thick granulated pine sawdust) he is moving almost normally. We have taken bloods and will test again for insulin to see if there is any improvement after a week on soaked hay and no grass.  My vet is certain Max is IR and not Cushings, we had a good chat about it and I’m happy with his advice.  I expressed my concerns about going straight to Ertuglifozin, and because there has been some improvement we’ve decided to try Metformin from tomorrow and reassess at the end of the week. We are going to drop his Bute down to 5ml per day from 6ml and see how that goes.  I’ve ordered some Cloud Therapy Boots on my vets advice so hopefully they will help also.
Max is being a very good patient and I’m very proud of him.  

Thanks everyone for your advice and support, it’s so very much appreciated. 
--
Michelle & Max
Yarra Valley, Victoria, Australia
Thank you
Joined 2022
https://ecir.groups.io/g/CaseHistory/files/Michelle%20and%20Max
https://ecir.groups.io/g/CaseHistory/album?id=277108


Sherry Morse
 

Hi Michelle,

Just a reminder that for laminitis due to elevated insulin NSAIDs are not the answer and he should be weaned off of the Bute ASAP to avoid other issues related to being on long term NSAIDs.  You can read about how to taper off here: https://ecir.groups.io/g/main/files/Pain%20Medication%20and%20Alternatives/How%20to%20Taper%20Off%20NSAIDs.pdf




misglen
 

Thanks Sherry, we are weaning him down off Bute, we want to get him off it asap.  Reduced the dose down again this morning, and he’s moving quite well tonight, so fingers crossed we are on The right track.
--
Michelle & Max
Yarra Valley, Victoria, Australia
Thank you
Joined 2022
https://ecir.groups.io/g/CaseHistory/files/Michelle%20and%20Max
https://ecir.groups.io/g/CaseHistory/album?id=277108