I'm so frustrated.  For the first time in years Flea's ACTH numbers are within the reference range, so we're doing something right.  Unfortunately his insulin continues to test over 200.  The most recent blood work was done in September, before that August, and before that June. (CH is updated)

I've tested the hay, balanced minerals, have a farrier who follows ECIR protocol, have brought in a specialist vet to work with us...what am I missing?  I feel like I'm failing him.  He's been on Metfomin since June and over the past month I've been able to get him to finally eat his mash with the meds in it, so I know it's getting into him. I started him on ALCar and saw a great response; he seemed more loose and comfortable all over.  My farrier even commented that he's walking better than he has in a long time - he's no longer shuffling or humped up and doesn't look like every step is agony.  I put him on Spirulina and for the first time in years he didn't have missing patches of hair on his face from fly bites. My farrier is very happy with the new, healthy growth of his feet and especially his soles, even though we continue to fight his over long heels.

I was really hoping since externally things are looking much better that meant internally he was leveling out.  Is now the time to try a different approach? 

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

Hi Jennifer,
Have you been in touch with Dr. Kellon about using invokana?  I don’t have any personal experience with it but an increasing number of people seem to be using it when metformin isn’t helping to keep insulting values down.
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Ellen
Pal & Savvy
N. Alabama
Aug 2013
Case History 

If you want to try Invokana, ask your vet to contact me or send me their e-mail address and I'll send an information file. You will need to schedule an appointment to draw blood for a chemistry panel to check kidney function first and should also check insulin again at that time since you recently started ALCar.  The good clinical response is probably from ALCar effects on neuropathic pain but there may be an insulin effect as well. You can also send a duplicate insulin sample to BET at that time to compare results and we will pay for the handling, shipping and testing costs of the BET sample.
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Eleanor in PA

www.drkellon.com 
EC Owner 2001

I just spoke with my vet and she is ready to discuss switching to Invokana.  Dr. Kellon, you had emailed the information to her but she was skeptical of using it for some reason.  She had wanted to go with Velagliflozin instead, but I read as much as I could find about that on this site and it doesn't seem like it's the best option.  We also tried to get enough blood drawn to send to both testing labs the last two times, but getting blood from this little mule is an absolute nightmare.  We're lucky if we can draw enough for one lab sample, and it usually takes two or three needles and a dozen tries to find the vein.  These mules know just how to tighten their neck muscles to make it an extreme challenge!

I'll get some body shots today if I can, and we're actually scheduled to do updated radiographs in a few weeks.  There is a differing opinion between the two vets as to whether he is suffering from contracted tendons.  The specialist vet wants to do a tenotomy on both front legs, and my regular vet is absolutely opposed.

So if we go the Invokana route, can I wait to do the blood panels the same day as the radiographs, or is time of the essence in this case?  I don't want to change the date for radiographs as it coordinates with my next farrier appointment, so she can trim according to the radiographs as they're taken.  We've done this before and it's very helpful for the farrier.

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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

Remember, the next time you test for insulin at Cornell, have your vet write on the work order to please post the exact insulin number if it is over 200.
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LJ Friedman  Nov 2014 Vista,   Northern  San Diego, CA

Jesse and majestic ‘s Case History 
Jesse's Photos

 

To update this, I had decided to go the Invokana route, and my vet was out earlier this week to do bloodwork to check liver/kidney function before we started the new medication.  I asked her to also get ACTH and insulin just to see if we were staying ahead of the seasonal rise, and because I wanted to see if Flea's insulin was still over 200. 

Everything looks good, he's low in potassium, though.  His ACTH is actually down slightly from last month (will update CH when I get a minute) from 31.3 to 27.5, and his insulin is FINALLY lower at 147.45!  I'm very excited, and my vet and I agree that we should keep him on the Metformin for now to see if his numbers continue to decrease.  I just want to see if that's what others would do...sometimes I'm unsure of my decisions.

My vet recommended Purina Enrich to get more potassium into him, but I checked it out and it's too high in sugar and starch, and I don't like that high protein level for a mule.  Does anyone have any suggestions to increase his potassium level?  His current hay is at 1.90% potassium as fed, and I feed TC Timothy Balance Cubes as mash with Stabul 1 (small amounts), mixed with Vermont Blend, probiotic, ALCar, and a tiny smidge of flax. 

This week we also have an appointment for my vet and farrier to be at the barn together to do a trim in conjunction with radiographs, so I'm hoping we can get his feet a little more straightened out, too!
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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

Burdock root, black seed (nigella sativa) ceylon cinnamon fenugreek seed are good sources of potassium, bananas too
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- Frances C.
December 2017, Washington & California
Case history: https://ecir.groups.io/g/CaseHistory/files/Frances%20and%20Phoenix
Phoenix's Photo Album: https://ecir.groups.io/g/CaseHistory/album?id=12382

Hi Jennifer,

Need Dr. Kellon to chime in on this one.

Do you have a copy of the actual blood work results? If so, would you please upload it to your case history folder. If not, could you get a copy from your vet?

Generally, there is more than enough potassium in hay alone to meet daily requirements.

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

Is there a possibility that his diet is low in sodium and his kidneys are keeping it to maintain blood sodium levels while getting rid of potassium to compensate? 

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María Durán Navarro 
Dec 2017
Madrid (Spain)

Plutón´s Case History
Plutón´s Photo Album

Hi Jennifer

Would be great if we could see the blood work results. 

As Lavinia said, you have plenty of potassium in your hay. I would not look to feed more. If we can see exactly what the results were, Dr Kellon can give a read out on what -- if anything -- may be going on. Or at least where to look further.

If you are still using the salt block, make sure he is consuming at least one ounce per day. You need to determine the weight of the block, and how long it takes him to consume it. It might be better to add loose table salt, 1-2 ounce per day, to his meals. Start on the lower end b/c he may need to get used to it.
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Nancy C in NH
ECIR Moderator 2003
ECIR Group Inc. President/Treasurer  2019-2020
Join us at the 2021 NO Laminitis! Conference, August 12-15, Harrisburg, PA

Velagliflozin isn't available.

Could you post some current photos of her feet and body?

You can wait to draw the blood.
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Eleanor in PA

www.drkellon.com 
EC Owner 2001

Do you have the actual number on potassium? Hyperlipemia causes potassium to test lower.  Are you soaking your hay? I didn't see any glucose readings in your file. If that is high, excretion in urine carries K with it - although we haven't seen that as an issue in horses on Invokana.

Response to metformin usually decreases over time, not increases - but it's not impossible. If you are happy with progress to date no harm in continuing it but that insulin is still dangerously high.
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Eleanor in PA

www.drkellon.com 
EC Owner 2001

Frances,

All food contain potassium. None of those things will be of much good to a horse. 100 grams of burdock root contains only 1.2 % of the horse's daily potassium requirement.    Bananas are definitely not appropriate, far too  much sugar, and potassium still only 1.6%. Just one pound of her hay has over 8 times more potassium.
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Eleanor in PA

www.drkellon.com 
EC Owner 2001

Thank you Dr. K. Good to know
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- Frances C.
December 2017, Washington & California
Case history: https://ecir.groups.io/g/CaseHistory/files/Frances%20and%20Phoenix
Phoenix's Photo Album: https://ecir.groups.io/g/CaseHistory/album?id=12382

Hi Everyone! 

Jennifer- I have a horse that had ACTH well under control with Prascend- but still suffered from refractory insulin. Despite a strict diet of NuZu Stabul1 and Safe Starch Forage & absolutions ZERO access to grass/weeds) his insulin was still over 200. 

As a “Hail Mary”, we started Invokana in March of 2020. After a month of 1 tablet per day, his insulin dropped to 38- the lowest it’s been in years. 

I have had his kidney & liver enzymes checked & everything is within normal limits. His Triglycerides are slightly elevated. 

He is on 5mg Pergolide, 1mg Prascend & 1 invokana per day and is trimmed every 4 weeks. 

This medicine has saved his life along with all of the wonderful moderators & veterinarians associated with ECIR. We are so grateful!! 

Hope this information helps & watching him happily trot around & canter pain free makes it all worth while! 

 

 

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Adrienne & PJ
Atlanta GA 2018

I've added the CBC document to my folder, and updated my case history. 

Currently Flea has access to a plain salt block because he refuses his mash when I add salt.  I'm going to start adding a small amount and see if I can build it up.

One thing my farrier has called me out on is the fact that he gets no exercise.  Due to circumstances I don't care to get into, taking him out of his pen is not feasible.  I've been working on a track system, but it's not fenced yet.  I moved in 2018 and since that time he's been regulated to small dry lots where he doesn't move much, and I've noticed that has directly affected his health.  I'm hoping to get the track done before we get snow. 

Adrienne, that definitely helps! 
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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