Every thing You Must Know (and Extra) About Afrezza Inhaled Insulin
by Gary Scheiner MS, CDCES
Certainly one of my favourite guidelines of diabetes administration is “If it ain’t broke, don’t repair it”. This adage has gotten me out of loads of family chores and a few difficult appointments with shoppers who had been in search of absolute perfection with their diabetes administration. However I’ve to confess, “ain’t broke” is a relative time period. Who’s to say what is really “not damaged”? In spite of everything, if issues could be made higher or simpler, why not give it a strive?
For the previous 5+ years, I’ve been very happy with the open-source (DIY) Loop hybrid closed loop system. I discover it versatile and straightforward to make use of. It additionally produces nice-enough glucose ranges and makes diabetes fairly simple to dwell with. However for the great of science, I’m at all times keen to strive an alternate.
Lately, a analysis research known as “INHALE-3” was introduced on the American Diabetes Affiliation’s Scientific Classes. It confirmed comparable A1c and time-in-range between customers of AID (automated insulin supply) programs and regimens that make the most of injected long-acting insulin and Afrezza because the bolus insulin.
Afrezza, developed and marketed by MannKind Company, options recombinant human insulin in dry powder kind (known as Technosphere) and a whistle-like machine for inhaling it. It’s accepted for adults solely and isn’t for use by people who smoke or individuals with persistent lung illness.
As soon as within the lungs, Afrezza absorbs shortly into the bloodstream. By avoiding the necessity to take in by the fats layer under the pores and skin, Afrezza begins working inside a few minutes, peaks in about half-hour, and clears in about 90 minutes (the length is barely longer at bigger doses). That is greater than twice as quick as conventional “rapid-acting” insulin (aspart, lispro and glulisine), which takes practically quarter-hour to begin working, peaks in 60-90 minutes, and lasts a full 3-5 hours. The brand new “ultra-rapid” insulins (Fiasp and Lyumjev) are only some minutes quicker than fast insulin.
Anybody who has heard me converse is aware of that I wish to put the time period “fast performing insulin” in quotes (like I simply did right here) as a result of it’s a lie. Speedy insulin is simply extra fast than “common” insulin. It comes nowhere near matching the velocity of insulin produced by the pancreas.
I knew from prior expertise that Afrezza works a lot quicker than fast insulin, so I made a decision to make use of it as my unique bolus insulin for 2 weeks. It was an amazing studying expertise.
Right here’s what I found.
The Basal Behind the Bolus
Let’s get this out of the way in which first. No person with T1D can get away with utilizing simply Afrezza. A basal insulin can be required.
Over the 2 week interval, I attempted a couple of completely different approaches to basal insulin simply to see if one labored higher than the others. And I discovered that it does matter. When utilizing injected basal insulin (within the type of Tresiba/degludec), I discovered that my glucose ranges had been very unstable – particularly in the course of the instances when my basal is generally at its highest and lowest. I used to be always rising within the early a part of the night time and dropping within the afternoon.
So I went again to utilizing my pump system for basal supply solely, and entered my carbs and Afrezza doses manually into the Loop app.
Making use of Afrezza
The Afrezza bolus course of is pretty easy.
Load a cartridge (the scale of somewhat greenhouse from Monopoly) into the whistle-like inhaler, put the mouthpiece in your mouth and inhale slowly.
It took a couple of days to grow to be snug with the inhalation course of. At first, I’d cough proper after each inhalation. Generally, a cloud of “insulin smoke” would come out of my mouth, which made me fear that I didn’t obtain the complete dose. It additionally made me fear that folks round me might breathe in “second hand” insulin. However now I’ve the process down fairly good. A sip of water beforehand and inhaling with rather less pressure works rather well.
The insulin cartridges come labeled as 4, 8 and 12 models.
I say labeled, as a result of they don’t really work like 4, 8 and 12 models of the insulin we’re used to utilizing. They work extra like 2.5, 5.0 and seven.5 models, respectively. Should you want greater than 7.5 models, you may load one other cartridge and do a second inhalation proper after the primary.
Determining the suitable doses takes some trial and adjustment. I began out with the bottom (2.5u) cartridges and elevated from there – utilizing a small/medium/high-carb meal strategy. For correcting excessive glucose values, I solely used the low (2.5u) cartridges, as this is sufficient to decrease me about 150 mg/dl based mostly on my sensitivity to insulin.
Dosing in increments of lower than 2.5 models requires the “Tony Montana” strategy, based mostly on Al Pacino’s character in the film Scarface.
One should separate the tiny insulin-containing chamber from the remainder of the cartridge, faucet the powder onto a clear floor, cut up it into two halves with a bank card, scoop one of many halves again into the chamber, and snap it again into the remainder of the cartridge… all with out coughing or sneezing all of it into oblivion. It really works, however it is extremely inexact, tedious, and fully off-label.
Due to its fast peak and clearance, the timing of Afrezza additionally required some changes. After practically 40 years of being advised, “Take your insulin earlier than you eat!”, I realized that you may’t try this with Afrezza. Doing so will often trigger a low shortly after (or throughout) the meal.
Actually, most meals consisting of low-to-medium glycemic-index meals require a modest dose with the meal and a second dose two hours later. That is as a result of prolonged digestion that takes place. Only a few meals are completed digesting in 90 minutes; any digestion that takes place after 90 minutes will trigger a delayed rise until a second dose of Afrezza is given.
Prime-Line Outcomes
Keep in mind that that is an “N” of 1: It’s inappropriate to attract agency conclusions from a really small pattern measurement. Nonetheless, my general glucose management was worse when utilizing Afrezza in comparison with my regular AID system. My customary time-in-range of 75-80% went all the way down to about 65%, and my common went from 141 to 157 mg/dl. There was no important change within the frequency/length of hypoglycemia, though my lows had been extra extreme with Afrezza – principally from making an attempt to right highs with a dose that was greater than I seemingly wanted.
One space that improved was my post-meal glucose.
I often have cereal within the morning, and it was good to not spike as much as 200+ mg/dl quickly after consuming. I don’t often spike that top after different meals and snacks, however even these had been higher with Afrezza. Nonetheless, I did must take a second dose of Afrezza after nearly each lunch and dinner, until the meal was very low in each fats and protein.
One different space of enchancment with Afrezza was with post-meal train.
I typically work out 1-2 hours after breakfast or dinner, so my glucose often begins out somewhat on the excessive facet after which drops considerably. With Afrezza, I went into the exercises with higher management and didn’t drop practically as a lot for the reason that bolus was nearly fully gone in the course of the exercise.
Who can profit most from Afrezza?
Based mostly on the advantages and disadvantages related to Afrezza, I imagine that sure individuals are optimum candidates:
These with extreme, untreatable needle phobia (conserving in thoughts that basal insulin will nonetheless should be taken)Anybody with widespread lipodystrophy, for whom injected insulin is very unpredictablePeople whose diets are comparable day-to-day, constantly low in fats, and excessive in rapidly-digesting (excessive glycemic index) carbohydratesThose preferring to train 2-4 hours post-meal and have a tendency to expertise hypoglycemiaThose who battle with extreme post-meal glucose spikes regardless of making use of methods to mitigate the rise (earlier bolusing, use of ultra-rapid insulin, consuming slower-digesting meals, post-meal bodily exercise, and so on…).
Even in case you don’t fall into one in all these classes, it might nonetheless be price having Afrezza out there. These are a number of the conditions wherein Afrezza could come in useful:
Fixing very excessive glucose levelsBolusing for very-high-glycemic-index meals/snacksCovering meals when pre-bolusing shouldn’t be possibleAddressing hyperglycemia brought on by a pump/infusion website malfunction, or any time dehydration is current (dehydration impairs insulin absorption under the pores and skin)Protecting meals or fixing hyperglycemia an hour or two previous to train
Curiously, the INHALE-3 research discovered that in a single day management was superior in individuals who used an AID system in comparison with Afrezza with injected basal insulin. However take into account the opportunity of combining the 2 regimens: automatically-adjusted basal insulin from a pump, bolusing with the pump for “typical” meals, and Afrezza to cope with the highs, super-fast-acting meals, and previous to exercises.
Our understanding of Afrezza grows every day. You probably have any questions, be happy to succeed in out to me or anybody on the Built-in Diabetes Providers medical crew. And if in case you have expertise with Afrezza and want to share any suggestions/methods, please achieve this! All of us do greatest after we work collectively.