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Update on Cadet, slow/partial response to Invokana


riggslippert@...
 

Hello,

After rechecking Cadet's insulin and glucose on 10/12/20 and finding them higher than the previous levels (insulin 338.5 uIU/mL and glucose 210 mg/dL), in addition to his becoming much more footsore, I started him on Invokana on 10/20/20.  Recheck ACTH showed good control (18.5 pg/mL).  CBC and profile on 10/21/20 showed values within laboratory limits, including glucose.  His first week of Invokana was courtesy of Costco, then medication sourced from Canada obtained from pricepropharmacy.com.  It arrived 10 days after ordering with express shipping.  He responded well enough within 4 days that I was able to move him from a stall back to his dry lot.  For the next 10 days, his degree of soreness did not change (walking OK in Cloud boots, but obviously lame without, even on sand).  

His hay was retested on 10/17/20 and showed ESC of 5.5%, starch 1.7% (analysis in case history file).  He was trimmed on 10/26/20 and the trimmer saw no signs of sole bruising or event rings.  She did not feel radiographs were needed at the time.  On 10/31/20, urine showed glucose 500 mg/dL, no evidence of infection, and specific gravity of 1.020.  Recheck of insulin (Cornell) on 11/2/20 showed a decrease (101.6 uIU/mL) and glucose within range (98 mg/dL).

Today his lameness had finally improved, although he still walked short-strided without boots on sand.  I'm hoping this progress will continue.  He is scheduled to have radiographs next week.  I will take hoof pictures at that time to see if his trim can be improved.

Is it reasonable to hope that his pain will gradually resolve with continued Invokana therapy?  Because I still have no explanation for the drastic worsening of his hyperinsulinemia with adequate Prascend therapy, I would appreciate any additional suggestions that might help him.  I understand the Prascend and Invokana will be needed indefinitely.

As an aside, I spoke to the equine veterinarian at BI and he had no expectation that velagliflozin would be FDA approved anytime soon.  He recommended that horses on Invokana have serum triglycerides monitored, as there has been some suggestion that hyperlipidemia could be an adverse effect, especially if associated with reduced appetite.  Cadet's serum triglycerides were normal on 11/2/20.

As always, I am so appreciative of the amazing expertise and experience of this group!
--
Aunna
October 2018
Oakland County, Michigan, USA
Cadet Case History:  https://ecir.groups.io/g/CaseHistory/files/Aunna%20and%20Cadet
Ruger Case History:  https://ecir.groups.io/g/CaseHistory/files/Aunna%20and%20Ruger

Cadet Photo Album:  https://ecir.groups.io/g/CaseHistory/album?id=84102




Eleanor Kellon, VMD
 

Most horses max out the dipstick readings for glucose from early on but occasionally one is slow to respond. Since his lameness is improving I'm not concerned. He's right on schedule in that department, with an obvious improvement usually evident with a week and a half or so.

Yes, more improvement can be expected over time! Obviously trim still plays an important role, and position of the bone column, unresolved abscesses. You might want to consider restarting Jiaogulan now too.
--
Eleanor in PA

www.drkellon.com 
EC Owner 2001


riggslippert@...
 

Thanks Dr. Kellon!  I will try to check his urine again to see if the glucosuria has increased.  When would you suggest I check his insulin again?

Did you have any comments on the triglycerides monitoring?  It is not typically included in equine profiles at Idexx, although easy enough to add on.  By the way, the paired insulin from Idexx was 38.2 uIU/mL (range 4.5-20.0 uIU/mL).

Aunna
October 2018
Oakland County, Michigan, USA
Cadet Case History:  https://ecir.groups.io/g/CaseHistory/files/Aunna%20and%20Cadet
Ruger Case History:  https://ecir.groups.io/g/CaseHistory/files/Aunna%20and%20Ruger

Cadet Photo Album:  https://ecir.groups.io/g/CaseHistory/album?id=84102




Eleanor Kellon, VMD
 

Have you noticed any polyuria?


Is that insulin compared to the 101.6 from Cornell? Do you know what assay Idexx uses? As a client they may tell you.

I would plan to retest insulin at the 1 month mark.

There was no mention of triglyceride issues in the two papers published on velagliflozin in horses. In fact, they proposed it could lower them. You would expect them to go up if the animal is not eating, and especially high in donkeys, ponies and minis. Without more information I wouldn't worry about it.
--
Eleanor in PA

www.drkellon.com 
EC Owner 2001


Eleanor Kellon, VMD
 

Hi Aunna,

There is still a rather limited database on Invokana responses but there was one other horse that was slow to maximize the glucose dumping in urine but did eventually get there. I also did some digging on false negatives. Apparently it depends on the test strip (might want to try a different brand, maybe a glucose only dipstick) and major offenders for false low results are vitamin C and SG over 1.020 with alkaline urine. Refrigerated urine may give a false negative, as can use of aspirin or Tylenol and some antibiotics but I don't see where  those are a factor. At this point, I'm most suspicious of the SG being a factor. Has he increased his water intake? How much salt is he eating?

How's his comfort?

His films show the expect increased horn lamellar zone, very minimal rotation RF, probably none LF and sole  depth could be better but it's much better than many we see. Major issue to my eye is just that toes could come back a bit more.
--
Eleanor in PA

www.drkellon.com 
EC Owner 2001


riggslippert@...
 

I had to delete the original post due to problems with the links in the message.  I have recreated it here.

Thank you for your comments, Dr. Kellon.  I noticed polyuria in the first week, not since then, but I am only able to observe him for 2-3 hours/day.  I tested his urine again on 11/7/20.  SG lower (1.010), but glucose still 500.  I've updated Cadet's CH; the paired insulins on 11/2/20 were Cornell 101.6 uIU/mL and Idexx 38.2 uIU/mL.  I've emailed and called Idexx about the assay; no answer yet, but I'll keep on trying.  He is violently opposed to taking jiaogulan powder in any food and it was a huge fight to syringe it.  I've started him on human capsules (4100 mg) once daily.  I've also started him back on APF Pro, as he was refusing to eat his supplements (in TB cubes as carrier).  Does the APF Pro have any vascular benefits in his feet?  I had radiographs taken and took hoof pictures on 11/9/20.  Ill be asking for markups in a separate message.

Thank you again for your ongoing help!

Aunna
October 2018
Oakland County, Michigan, USA
Cadet Case History:  https://ecir.groups.io/g/CaseHistory/files/Aunna%20and%20Cadet
Ruger Case History:  https://ecir.groups.io/g/CaseHistory/files/Aunna%20and%20Ruger

Cadet Photo Album:  https://ecir.groups.io/g/CaseHistory/album?id=84102




riggslippert@...
 

Sorry, my SG value was in error--corrected in the recreated post.  I will check his next urine sample with an alternate method.  I've seen no obvious increase in his water intake, but again, limited time for observation and seven horses all drink from the same large trough.  He eats 2 Tablespoons of iodized salt/day as long as he eats his bucket feeds.  He is very gradually improving in his comfort, no spontaneous movement faster than a walk observed yet.
--
Aunna
October 2018
Oakland County, Michigan, USA
Cadet Case History:  https://ecir.groups.io/g/CaseHistory/files/Aunna%20and%20Cadet
Ruger Case History:  https://ecir.groups.io/g/CaseHistory/files/Aunna%20and%20Ruger

Cadet Photo Album:  https://ecir.groups.io/g/CaseHistory/album?id=84102