FAO Dr Kellon - INVOKANA advice following latest blood test results


jenny.comish@...
 

Hi there,

it would be great if Dr Kellon could advise on this. I've got 3 sets of questions:

- Invokana and whether to start using it immediately given new blood results (my case history is up to date).
- Acetyl-L-Carnitine and how much to give.
- His feet and high heels.

My vet had agreed to putting Dewi on Invokana, but I think is procrastinating because it's not something he's used before. Dewi's latest insulin results are 42.5. He was on Metformin at the time but isn't any longer. In January his insulin was 173 and that was without Metformin. He did pick up whilst on the Metformin and became quite lively, albeit still lame but definitely an improvement. Since coming off the Metformin about 3 weeks ago he has had a couple of days where he looked worse (lying down more and not wanting to pick his feet up to have his boots on). But he's picked up again and generally he's a lot more perky and today was trotting about the arena (he's not on pain relief) and lost both of his hoof boots because of his cavorting! He is still lame however and is not good on a hard surface without the boots and he still seems to have a raised pulse in his right fore, which is his worst foot. 

Dewi has been struggling since last June and I don't know whether to say to my vet to get him on the Invokana asap because he is clearly not going to get better on his own or whether insulin of 42.5, whilst not normal, is massively improved and so I should wait to see if his increased movement will begin to help him further and he will come right on his own? 

I'm also unclear as to whether Invokana is something he would be on forever or if it's a short term drug? And do I put him back on Metformin? (I don't know how his insulin is since coming off it on 17th April). 

I'm also a bit worried about his feet - very high heels (I've added some new photos dated 3rd May). I'm trying to trust in the process that my trimmer is explaining to me - she says she's getting the toes back and allowing the heels to come down by themselves (she did take a little off the heels last time). She said it's important to not just slice his heels down due to causing pain his his deep digital flexor tendon. But it would be great for another set of eyes to look at the photos if possible - or should I post separately FAO Lavinia?

Thank you very much for reading.

Jenny
--
Jenny Comish
England, UK
Dewi Case History: https://ecir.groups.io/g/CaseHistory/files/Jenny%20Dewi
Dewi Photos: https://ecir.groups.io/g/CaseHistory/album?id=257833


Sherry Morse
 

Hi Jenny,

If Dewi was improved on the metformin why was he taken off of it?  Are you still using the same trimmer as when Lavinia did markups for you previously?  His trim is not doing him any favors which is probably a large part of why he is happier in boots.  The trim can also be causing him pain which will push the insulin level up.    Letting his heels get so tall that there's excessive pressure being put on the internal structures of his hoof is just as bad as saying they should be allowed to become underrun to help something else. 

I'll leave it to Lavinia to make specific comments on the trim.





Lavinia Fiscaletti
 

Hi Jenny,

Your instincts are correct regarding the trim.

Agree with everything that Sherry has mentioned. There appears to be a lot of excess overall foot length, not just the heels. You can't deal with toe length in a vacuum. Heels do not magically just "come down" on their own, the trim needs to set up the mechanics for them to relax into a more upright configuration while not allowing them to become worse.

Dewi didn't have any excess heel height back in Feb when the rads were done, he had excess overall hoof length, which appears to have increased. There was no reason to be concerned about the DDFT as it was perfectly well aligned before. All you that was needed was to maintain the balance that already existed and shorten the vertical height of the entire hoof capsule evenly, then back up the toes. Instead, the heels have been allowed to get even taller and more underrun. It appears as if the only thing that is making ground contact at this point is the walls all the way around, so he is being supported completely on them without benefit of the sole and frog aiding in the support.

The trimmer is correct that when heels have been really high for a long time you may need to bring them down slowly but regularly, in small increments, so that the DDFT has time to adjust, but that wasn't the situation with Dewi.

Need to measure both the collateral grooves at their deepest point toward the back of each foot (want 1", no more), then measure them at the tip of the frog (want 3/4" depth, no more). Lower then entire foot where needed to achieve this, which will have the added benefit of aligning the entire foot further back under the bony column. Then add a rocker to the back of each heel.

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


jenny.comish@...
 

Thank you both so much for your super quick comments. In answer to your question Sherry about the Metformin, my vet didn’t see it as a long-term medication, just something to get his metabolism going. And I’ve read it tends to stop working. So my vet said to stop it after about 7 weeks of being on it and see how he is. Apart from those coupe of ‘off’ days, he seems about the same now as when he was on it. I’m happy to put him back on it again (apart from the cost - £72 per month, which I think is about £99 dollars 😬). But the tricky thing is I don’t know if his insulin is worse or not since coming off it - I guess I should blood test again? But I am getting seriously broke from all the blood tests etc....

The other thing is that if I really ought to be getting him on Invokana, should that be used on its own without Metformin? I don’t want to pay out for a month’s supply of Metformin if really he’d be better off just going on the Invokana. 


I’m not using the same trimmer any more no. I’m quite stressed about his feet. It’s all turning into a bit of a nightmare. It feels like the only way to sort this is to quit my day job and train to be a trimmer. I find all the Pete Ramey articles and trimming advice overwhelming and I was hoping I could trust in the trimmer who offered to help me to know what they are doing but clearly not. It seems Dewi is now even worse off than in February. 


I think I need to find someone who is willing to look at the advice I get from this forum - most won’t taken any proper notice and think they know best. 


Thanks again, I really appreciate it.

Jenny
--
Jenny Comish
England, UK
Dewi Case History: https://ecir.groups.io/g/CaseHistory/files/Jenny%20Dewi
Dewi Photos: https://ecir.groups.io/g/CaseHistory/album?id=257833


Kirsten Rasmussen
 
Edited

Hi Jenny, 

Sorry to see Dewi's trim has gone off the rails.  :(   Many of us have had to pick up the rasp and learn to trim ourselves.   It is not easy at first, but you wouldn't be the first one to struggle through it.

I also wanted to say that as long as Metformin is working (given his history, an insulin of 42.5 uIU/mL is awesome!) and he is feeling better, it's the safer and cheaper medication option.

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


jenny.comish@...
 

Thanks Kirsten 😊. What’s making me unsure what to do as regards the Metformin is that clinically he now seems about the same as when he was on it - so do I keep paying out for it without really knowing if I am wasting my money. This is why I wonder if I should blood test again - if his insulin has gone up then start the Metformin again. Does this sound like a plan? 


But the other thing is that after 7 weeks of being on the Metformin he was still not right - definitely way better, but still lame. So how long do I leave him like that for as I don’t know if he will come good on his own whilst on the Metformin? Is it possible that with the kick start to his metabolism that the Metformin was hopefully giving him that over time the increased movement he is capable of doing will then in turn reduce his insulin and maybe the Invokana won’t be needed?  


On the trimming front I am seriously tearing my hair out! 😡😤 Did you manage to learn from reading things and advice given here? 


Jenny
--
Jenny Comish
England, UK
Dewi Case History: https://ecir.groups.io/g/CaseHistory/files/Jenny%20Dewi
Dewi Photos: https://ecir.groups.io/g/CaseHistory/album?id=257833


Sherry Morse
 

Hi Jenny,

Metformin does stop working for some horses over time, however it doesn't seem that was the case for Dewi.  Invokana is the choice for horses who don't respond well to metformin (or who it stops working for) - again, that doesn't seem to be the case with Dewi.

As far as being able to tell if it was effective - the only way to assess that would be to repeat the bloodwork under the same conditions as when he was on it and see if it's gotten worse or not.  If it's gotten worse that would indicate he should be put back on it.

All of that aside though, he's still not going to be sound with the trim the way it is now and pain can increase insulin so you're stuck in a bit of an endless cycle right now.




jenny.comish@...
 

Thanks Sherry I will get more bloods done whilst off Metformin - like you say it is the only logical thing to do. 👍
--
Jenny Comish
England, UK
Dewi Case History: https://ecir.groups.io/g/CaseHistory/files/Jenny%20Dewi
Dewi Photos: https://ecir.groups.io/g/CaseHistory/album?id=257833


Eleanor Kellon, VMD
 

Jenny,

You would have to check UK prices but  here Invokana is much more expensive. Your vet is right about the metformin but for some horses it works long term. For now, I would watch him carefully and if he backslides decide which one to try.

ALCar dose is 1 g/100 lb of body weight = 2.2 g/100 kg.

His feet have become deformed since January/February. It's not just high heels. The entire hoof is much too long and underrun. It's like walking on stilts. They are putting very abnormal forces on the hoof structures.
--
Eleanor in PA

www.drkellon.com 
EC Owner 2001


jenny.comish@...
 

Thanks for responding Eleanor. Is an insulin result of 42.5 acceptable even though it is not normal, I.e. will it be likely he will continue to be laminitic with insulin at that level?

Thanks for the ALCAR info. If he were yours would you have him in anything for pain such as Devil’s claw or Boswellia? He has previously been on a Devils Claw herbal supplement but it was hard to tell if it was helping. 


Yes after just 3 trims his feet have become a mess. I think I need to seek out someone else to help me ASAP. 


Jenny 
--
Jenny Comish
England, UK
Dewi Case History: https://ecir.groups.io/g/CaseHistory/files/Jenny%20Dewi
Dewi Photos: https://ecir.groups.io/g/CaseHistory/album?id=257833


Kirsten Rasmussen
 

An insulin of 42.5uIU/ml is below the zone where acute laminitis seems to occur (e.g., >80 uIU/ml, although the actual number will vary depending on the insulin assay so its hard to compare directly), but it is still within the sub-clinical laminitis zone where its high enough to compromise lamellar integrity.  Its not ideal and it can easily shoot up from there to a more dangerous level.  My horse had an insulin of ~41 last July when the vet visited, and 3 weeks later with no change in management he had an acute laminitis after he managed to sneak a few lbs of hay testing 9.9% s/s from his companion (I wasn't able to see what his insulin was when that happened, but it was like a trigger event and even after I blocked his access to that hay, it continued; the only thing I could do to stop the acute laminitis was to start soaking his usual low s/s hay).  But for Dewey, its a good sign the Metformin and everything else you are doing was helping.  If you can afford to test bloodwork then sure, see where he's at now before you put him back on Metformin.  As Sherry and Dr. Kellon said, until that trim is fixed, he is still going to be sore no matter what his insulin is.

As for learning to trim, I bought a rasp and Pete Ramey's Under the Horse dvds and book, as well as Jaime Jackson's dvd and book.  And I paid for a couple consults with Jenny Edwards of All Natural Horse Care where she provided markups and a 1 hr phone conversation to go over what needed to be done (very similar to what Lavinia does here).  Also used HoofHelpOnline for a few months.  Having the markups was really good though because they were specific to Shaku and his issues.  And learning more about the internal hoof structures from Pete Ramey's dvds was also helpful.  With Dewey's current situation, you probably need some consults if you are thinking of trying to trim him yourself.

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


jenny.comish@...
 

Thanks for sharing the info about your horse Kirsten. It’s of particular interest seeing as your horse’s insulin level was similar to Dewi’s. It’s a relief to hear that his insulin is not in the major danger zone, but still one to watch. I’ve just spoken with my vet and he feels that if Dewi is still looking quite perky and is moving more, hold off putting him back on the Metformin as he finds they become non-responsive to it. He thinks put him back on it again maybe in a couple of weeks. Not sure if this is good advice or not...?

On the trim front, I am more than happy to learn but I massively struggle with time. You’ve done so well Kirsten doing all that learning. Do you maintain your horses’ feet all by yourself without ever getting anyone out? 

For now I’ve left a message with a local farrier that comes recommended by my vet - but who knows what they will actually be like! 
--
Jenny Comish
England, UK
Dewi Case History: https://ecir.groups.io/g/CaseHistory/files/Jenny%20Dewi
Dewi Photos: https://ecir.groups.io/g/CaseHistory/album?id=257833


Kirsten Rasmussen
 

Sorry, I never seem to spell Dewi's name correctly!

I shared that info about Shaku so that you know how easy it is for some horses to tip the scale over to overt laminitis.  I thought Shaku was doing well, until he wasn't! 

I think your vet's advise is fine, but testing his insulin again now that he's off Metformin might help you make a decision of whether he should be back on it.  It's true that it loses effectiveness in horses with time.

As for trimming, hopefully you can find a professional that can help with Dewi's hooves.  Whoever you get, they might do better or feel more confident to have a set of new lateral rads to work from so they know where his coffin bone is in there.

I didn't have the option of calling in another trimmer.  I think that's the case for the other self-trimmers on this forum (there's quite a few!).  You just try your best.  My first trim was based on the markups Jenny Edwards gave me.  It was quite drastic.  I learned as I went after that, and am still learning.  It was very frustrating for the first year because Shaku had trouble holding his feet up and I had no one to turn to for help, but now 4 years later I am very comfortable trimming my own horse.  My advise if you are going to try is get a set of new markups (possibly rads if you can afford them), a good quality (professional) rasp, and do a LITTLE bit every single day until they look like the markups...that way it's not as overwhelming and you won't do any harm in one trim.

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