Ertugliflozin

[Srhorselady]

Way to go Junior and Exvet!

[khall]

Yay Junior!

Metabolic wise Joplin insulin is good and she’s lost a bit of weight. Gaila looks perfect weight wise but we’re checking her acth levels did a stim test last week see if her ppid is managed. Especially with the seasonal rise coming. My sports vet suggested a glp1 instead of Flozen rather not have her founder. She’s now in the dry paddock though there is some grass out there. Mostly eating hay though. Will recheck both insulin in a month.

Well shoot got stim test results back and on the generic prascend form Gaila is not regulated at all. So switching back to original prascend and upping her dose. No wonder her insulin is high. So weird because she looks fantastic

[khall]

New drug Gaila is on is bexagliflozin It’s a glp1 drug I’m getting quite the pharmacy going!

Having some conflict between the Ecir group and my sport vet who btw was a farrier before becoming a vet. Ecir promotes compounded pergolide over prascend and my sport vet says nope and my holistic chiro vet and my local vet. They all feel like prascend is better at controlling symptoms. My sport vet says he sees much less ppid induced laminitis since prascend has been in use. Sigh. Have multiple vets is not always a good thing. Now my sport vet did say he’s finding the new generic prascend is not as effective in controlling ppid as prascend itself so switching back to original prascend.

Cha Ching!

[exvet]

Well no surprise that you get multiple different views = that's why I broke down and contacted Dr. Kellon. I will say that the risk of variation between doses of anything compounded is frightfully high. Hopefully the change in meds will be helpful.

[Josette]

exvet and Khall - thank you for these helpful updates. I've decided to contact my vet sooner rather than later for repeat labs. Physical appearance is so deceiving as we've learned and blood work will help guide medication and supplement changes. Exvet looking forward to good news for Junior's labs.

[exvet]

Well disappointed and not disappointed. Kidney values still all normal but slightly creeping up for what that is worth. Liver values that were abnormal are steady, no better and no worse. Triglycerides are still normal but those too are creeping up...........insulin is down a little from last time but not at their lowest which was after the first 2 weeks of treatment. He was 46.5 last time and now is 42.2; so, better but of course I would love to see it lower. What this means is I will go another month on the Ertugliflozin without a dosage change and remeasure. I will also keep him on the PP Metabolic Advanced Care.

[Josette]

exvet - it is good news that his other labs are stable and still within normal range. The lower insulin drop is also good news too because it went down showing that Junior is responding to all your health management. IMO you are certainly on the right track. Best Wishes!!

I actually dread repeating my guys labs (my fear issues) but we will see as he has a complex management situation.

[exvet]

As for all of us, the big gray area is when should I start to wean him down on the Ertugliflozin and is the PP metabolic advanced really helping. Too fearful and too superstitious to stop the Advanced since it's not causing colic and he's eating it. I will be discontinuing the InsulinWise and not purchasing more based on what Dr. Kellon said; however, do I wean him off or not? I guess I will because it won't likely hurt. I do feel that though his labs are stable that I need a plan to reduce the dose of Ertugliflozin and see if I can keep the Insulin down to 40 or below. It's an arbitrary number and I'm simply trying to find and walk the fine line. I'll feel a bit better about it once we get moved into our new place (September is the target) because there I will have better control in preventing his suicide attempts. I also will feel better when I see that first set of 'normal' radiographs.

[Josette]

Lab tests update - I had my vet stop by to repeat our blood work and review my feeding regimen. I'm very relieved to report his labs have improved further compared to his April report. I feel the recent increase in his Prascend medication to 1.5 tablets daily with diet adjustments show this good response. Last year, while I was trying to figure out hay follage products - I was feeding mixed chopped alfalfa timothy at lunch. He got soaked timothy hay cubes at breakfast and dinner. When I did labs (Nov or Dec) his Insulin result was just over 100 where I PANICKED. I forgot the ACTH result but I immediately stopped feeding the chopped alfalfa mix hay. I believe this lowered his Insulin value in his March labs (before we increased the Prascend dosage - April labs show after Prascend medication was increased).

August Glucose - 91 March Glucose - 80
August ACTH - 36 April ACTH - 96.3 March ACTH - 241
August Insulin - 28.3 April Insulin - 39.3 March Insulin - 53.13
August Leptin - 15.78 March Leptin - 25.86
August T4 - 1.73 March T4 - 2.47


Hopefully some of these details might help anyone with their management issues. I got my vet's office to release these labs before my vet has the chance to discuss with me. I'm guessing we will keep our feeding and medication regimen the same for now. I'm looking forward to hearing her feedback as I had mentioned the various supplement products to her.

[khall]

I just retested my two’s insulin. Unfortunately I’m not sure how good the information from the test results are. My local vet is now doing the tests in-house using Truforma machine. My sport vet says these particular machines do not give reliable results but ecir group says they do.
Joplin was at 38 up from 28 that was sent to Cornell
Gaila was down to 57 from 78. Joplin on half dose flozin Gaila on 1 1/2 prascend and glp1

I don’t know what to think or do. My sport vet is too far away to run tests reliably for me unless I pay part of their trip fee when they are in our area. He uses a snap test that he has determined gives reliable results. I had been preferring to send mine to Cornell using my local vet so I was getting consistent testing using same lab.

I also need to retest Gaila’s acth after switching back to prascend from generic form and upping her dosage. Which we will be doing first of September sending blood up to sport vet when Chex goes back up for ear surgery. He’s got we think sarcoids/swelling both ears after he had been treated several years ago with chemical injections in his ears.

Trying to make the best decisions for both of mine health wise. Switching up their diet right now seeing if they will eat Vermont blend vitamin mineral supplement. Tried mad barn Joplin said nope.

[Josette]

I forgot to mention that my guy also dropped some weight which I think is reflected in his decreased Leptin value.

Khall - all my lab testing is done at Cornell - but they are basically local to us being one state over. I think exvet's feedback for generic or compounded product versus Prascend is right on. Hopefully you will see some improvement switching back to Prascend.

My fall challenge last year was the giant bumper crop of acorns from all the oaks in my largest front paddock (almost an acre). I had to give up and move my guy to the smaller back turnout after I removed 6 large wheel barrows. Love the cool shade in the summer months but some years they really dump the acorns. We shall see this year after all the rain.....

[exvet]

So Juniors radiographs don't look too bad. He still has pretty significant rotation but he's growing a fair amount of hoof wall, still has plenty of sole and there is no highlight or evidence of 'itis' in his capsule. He's been moving very sound, almost too sound blasting around and doing his own version of tempi changes. All of his values that were abnormal have now normalized EXCEPT his insulin which went higher than what it was during the active phase of his laminitis. This time it came back at 64.9 - total bummer. Since his diet hasn't really changed except I'm no longer soaking his Teff per Dr. Kellon (and I have since drawing blood added a couple of amino acids) I strongly suspect that this is due to the compounding pharmacy and likely variation pill to pill of the ertugliflozin. All I can do is keep treating the horse in front of me. He's happy and thrilled to be ridden, walk only. I do think the daily walking is what has helped grow foot. If his insulin remains high in another month, I may try invokana since it can be prescribed extra label and there's better control over manufacturer consistency, that is if I can afford it.

[Srhorselady]

Exvet (and others with ponies) this is just a FYI. I tried and tried (pre ertug… days) to get Peanut’s insulin (half Welsh half Arab) down into the normal range with a variety of diets and supplements. It would go up and down a little but after years my Vet and I finally agreed that her normal was in the 60s. My vet commented that most of the ponies she tested were in that range although the horses went lower into the regular ranges. This was using Cornell lab. Good luck.

[Srhorselady]

Oh. She had NO laminitis or other symptoms during this period.

[Josette]

Exvet - I'll defer to your medical expertise but this may be of interest to your situation. When my guy had the very elevated insulin late last year - my vet started him on Thyro-L along with his diet changes. He was on Thyro-L for about 7-8 months until I recently weaned him off after we increased his Prascend. (objective was short term use only of Thyro-L to help metabolic status)

I did an AI query asking for Thyro-L increasing insulin sensitivity. See response below.

Increases Insulin Disposal: Research published via PubMed demonstrates that levothyroxine sodium directly enhances the rate of insulin disposal and can trigger a greater than twofold increase in a horse's insulin sensitivity.

Boosts Metabolic Rate: It provides a supplemental source of thyroxine (T4), which tissues convert into active T3. This shifts a sluggish metabolism into overdrive, forcing the body to utilize fat and lipids more effectively.

Reduces Laminitis Risk: By artificially driving down serum insulin levels and shrinking stubborn fat pads (like a cresty neck), it helps pull horses out of the high-danger zone for developing endocrinopathic laminitis.

[khall]

Exvet glad Junior is staying sound. Ugh on the insulin though. Remind me did you test him for cushings? We did Joplin because of her insulin issues. She was fine thank goodness.

I’m finding help from both my sport vet and the ECIR group. Sent blood to sport vet from Gaila and her insulin was 38. She is still on glp1 too. She’s fat though!! Trying to find a good vitamin and mineral supplement or balancer for my 2 that they will eat and went to Triple Crown 30% balancer. They both started porking out again but especially Gaila. I had tried the Vermont blend recommended by ECIR both said no thank you. So spoke to mad barn another one recommended by ECIR. Gaila is eating it Joplin says nope. Sigh. Joplin has been on platinum for years but it has cane molasses in it. The only other supplement they recommend is California trace. I hate to buy something they won’t eat. At least Vermont blend was small tried size. ECIR actually recommends balancing to the hay you feed but I feed such a mix especially between the 2 of them don’t see how it would work.

Got to reach out to local vet again to see if she will ship the blood to Cornell for me otherwise may see about a different local vet. One I don’t really use but…

[goldhorse]

Khall, California Trace will ship a 1 lb sample for the cost of priority mail. ECIR recommends the Plus version but you still will have to add magnesium.

I entered Piggy's diet into MadBarn thinking I would get a computerized readout. Instead I got a response from Eleanor Kellon and we went back and forth a few times until we were able to settle on an appropriate local hay for him. The stuff that I had been feeding was way too high on protein even though NSC was below 10%. So I got a free consult! I think if you buy a product from MadBarn you can get a free hay balancing. I just signed up for her class on nutrition since I'm a science nerd and want to be able to do this myself.

As for the new hay, he quickly looked less puffy like he had lost all over inflammation. New bloods will be taken this week.

[khall]

Thanks goldhorse. I will definitely order some for my 2.

Got insulin and acth back on Gaila both are wnl. So yay! Going into the seasonal rise happy about that.

And my local vet while snarky about it will send my blood samples off to Cornell. I’ll take the snark and thanked her for agreeing to my request.

[blob]

Khall--did you do the regular vermont blend or the vermont blend pro?

I'm asking because for whatever reason the pro requires a much smaller amount of the supplement. I couldn't get mine to eat the regular vermont blend and i think it's because of just how MUCH of it they had to get. But with vermont blend pro it's such a small amount both happily eat it, probably don't even notice it in there.

MM gets VBP with just hay pellets and RP with beet pulp (he's not on a diet, but can't have anything pelleted without getting gassy/colicky).

[Dapple Field]

Just a quick FYI. For those of you who are using InsulinWise, it comes in a pelleted form. My mare would leave the granular form in the bottom of her feed tub and happily cleans up the pelleted form.

[khall]

Blob I’m pretty sure it was regular Vermont blend. Amount didn’t mater though both left everything. Joplin is quite picky about her vitamin mineral supplements. She’s still eating the TC balancer so I’ll leave it at that until I can try California trace. Her weight is ok and I’ll pull her insulin this week or next. Gaila is eating the madBarn just fine and immediately dropped the weight from the TC. Weird because she was on it before going on prascend and looked fabulous. Quit eating it when I put her on ppid meds but then once she regulated was eating it again then porked out. Weird what cushings does.

M

[goldhorse]

I got Piggy's blood work back. His non-fasting insulin has fallen to 27. Pick me up off the floor. But his ACTH and post stimulation ACTH are greatly increased from the results in August when they were in the normal range. So I presume he's fully in the fall surge. My local vet will be consulting with UC Davis as to what to do and how much to increase his Prascend.
New diet:
Low sugar Orchard grass hay at $24/bale NSC 9.26%; Crude Protein 11.87% both based on dry matter (Just looked and the price went up to $26!)
California Trace Plus
Omega Horseshine
2000 IU Natural Vitamin E from UltraCruz
Magnesium to balance the high Calcium in the hay

[Josette]

FYI as I'm making my worm medication purchase I did this query for senior horse care with Cushing's and/or IR. (AI reply below)

For a senior horse diagnosed with Cushing’s disease (PPID) and Insulin Resistance (IR), Ivermectin 1.87% (such as [Zimecterin](https://animalhealth.boehringer-ingelhe ... /dewormers) or IverCare) is generally the safest baseline paste dewormer. [1]
However, managing horses with metabolic issues requires a highly cautious approach to deworming because their compromised immune status and unstable insulin levels alter standard guidelines. [2, 3]
## The Praziquantel Precaution
Standard equine rotation typically relies on combination pastes containing praziquantel (like [Equimax](https://www.petcircle.com.au/product/eq ... rmer-paste) or [Zimecterin Gold](https://animalhealth.boehringer-ingelhe ... terin-gold)) to target tapeworms in the fall. [1, 3]
For a horse with IR, veterinary experts note a precaution with praziquantel, as it has been linked to a potential hyperglycemic response. If your senior's insulin levels are currently high or uncontrolled, veterinarians often recommend bypassing praziquantel entirely. Instead, a veterinary-guided protocol using pyrantel pamoate (such as Strongid) can safely be used to cover tapeworms without spiking insulin. [4, 5, 6]
## Customizing the Plan for Metabolic Seniors

* Expect a Higher Parasite Load: Research indicates that horses with PPID typically have higher fecal egg counts and a faster egg reappearance rate after treatment than their healthy peers because their immune systems are suppressed. [7, 8]
* Mandatory Fecal Egg Counts (FEC): Never blanket-deworm a metabolic senior. You must use biannual FEC tests to check exactly what they are shedding. Because of PPID, your horse may need to be classified and treated as a "high shedder" even if they previously required minimal deworming. [2, 7, 9]
* Moxidectin Caution: Avoid using moxidectin (Quest) in senior metabolic horses unless explicitly instructed by your vet. Moxidectin is stored in body fat; senior horses with muscle wasting from Cushing's or unstable body condition scores from IR face a much narrower safety margin, raising the risk of accidental toxicity. [4, 10]

To ensure the safest plan, let me know:

* Are your horse's Cushing's and IR currently controlled with medication (like Prascend) and diet?
* What was the result of their most recent Fecal Egg Count (FEC)?

Knowing this will help determine if a simple ivermectin dose is enough or if a custom metabolic protocol is needed.

[exvet]

Well bad news, though Junior's overall blood work looks good, his insulin was in the mid 70s, the highest it's ever been. He's on hay with an overall ESC + starch of 5.5%, ration balancer that is very low sugar, the SGLPT, yada yada. He's lost more weight and has stayed sound but again this means it's only a question of when his laminitis relapses not if. I will repeat his ACTH stim despite having been normal in the spring because of this unfortunate update and the fact that it's fall. I'm anticipating it will come back 'normal' but then what? I know there's no point in getting advice from the guru's until I repeat the test for PPID. I also know that the senvelgo that Boerhinger makes in this country for diabetic cats recently got approved for use in horses in the UK that are EMS.....so maybe I will be able to access a SGLPT that isn't compounded.

[khall]

Exvet have you thought about putting Junior on prascend despite his ppid acth test results?

I got insulin results back on Gaila and Joplin
Gaila is at 39 she’s is now only on 2 mg prascend. No glp1 meds. She is on dry lot low nsc hay and madbarn. She lost weight when I switched from balancer by TC to madbarn and she’s being worked regularly. Her acth is wnl now too.

Joplin is at 29. She’s still on balancer because she won’t eat mad barn goes out for no more than 2 hours in the morning on tested hay, is fat sigh. Works hard. 5/6 days a week.

Most worried about these two while I’m out for surgery but especially Joplin who gets fat on air.