Inhaled Insulin: If You’re Too High, Take a Hit of This!

Rapid-acting insulins like Humalog or Novalog generally take 30 minutes or so to start working, but Afrezza kicks in almost immediately and is out of your system in an hour and a half. It addresses an important unmet need in people with type 1, and it can be a good option for people with type 2 who don’t want to take an injection.

 

Video transcription:

STEVE:

Hello Nation. Today we’re going to be talking about Afrezza. I’m here with my good friend and colleague, Jeremy Pettus. We recently had a huge webinar, over 2000 people, 38 countries, every state in the country, and one of the most common questions we had was about Afrezza, from both people with type 1 and type 2 diabetes. There’s a lot of stuff on our website about it, and the TCOYD book, but we’re going to talk about it some more.

JEREMY:

I have a list of questions here to make sure we cover everything and we’ll just ping it back and forth. I want to just start with the basics. What is Afrezza?

STEVE:

Afrezza in its simplest form is inhaled insulin. The insulin is in a powder form. It’s in these different little packets and there are 3 different sizes (doses) – 4, 8 and 12, and we’ll talk about dosing in a second. They simply pop in this little device, you close it, breathe in, and that’s it. And the cool thing –

JEREMY:

Yeah, that was my second question, why is it cool?!

STEVE:

I beat you to it! I’m being very serious when I say this – it really addresses an unmet need in type 1 diabetes because it has a rapid onset of action (within 10 minutes) and it also has a pretty nice peak, but the key is, and a lot of people don’t realize this, it gets out of your system super quickly. So what happens is, your post-meal blood sugars are better and you have less delayed hypoglycemia. I think one of the biggest frustrations for people with type 1 is that the subcutaneous insulin is just too slow.

JEREMY:

When we think about our rapid-acting insulins – Humalog, Novalog –  it takes 30 minutes or so for it to even start working, it peaks in about an hour and a half to two hours, and then it hangs around for 4 or 5 hours. If you compare that to Afrezza, it starts working almost immediately, it peaks in about 30 minutes or so, and then it’s out of your system in an hour and a half. It’s much more rapid-on, rapid-off, which is the main benefit for type 1s. We’ve all had those frustrating stubborn highs that just won’t come down, so to have something that you can hit those stubborn highs with quickly, bring them down and then you get about your business, vs the typical thing with is bolus, bolus, bolus, and then maybe like in 4 hours you eventually go crashing down low. It’s a huge pain.

STEVE:

Yeah, stacking our dose. We really discovered how slow subcutaneously injected insulin was when we got our CGM devices. Everyone kept saying, hey, my insulin’s bad. It’s not working. So this has made a huge difference for a lot of people in terms of improving their time in range (the percent of time between 70 and 180).

Regarding people with type 2 diabetes, the insulin action curve in folks with type 2 is different than in type 1s mainly because folks are heavier, there’s insulin resistance, there’s a whole bunch of other reasons, but folks with type 2 aren’t used to taking shots, they don’t like taking shots (not like we do) but if you’re a type 1, you’ve had to take shots since the day you were diagnosed so it’s not a big deal. It’s really the time course of action for us type 1s and the ease of administration for folks with type 2 because a lot of folks with type 2 need mealtime insulin, but it’s very difficult for them to put that into their daily routine.

JEREMY

Yeah, so why it’s cool…for type 1s, it’s really the rapid-on, rapid-off. It’s a real quick hit, then out of your system. For type 2s I think it’s the novelty of it being inhaled. If you start mealtime insulin and you’re type 2, it’s an option of not doing another injection. So I’ll talk more specifically about how to dose this. It comes in 3 doses as Steve mentioned: 4 units, 8 units and 12 units. One of the most important things, if not THE most important thing to know, is that there’s a conversion factor, so 4 units of Afrezza is not the same as 4 units of Humalog or Novalog. There’s a ratio of about 2 to 1, meaning that 4 units of Afrezza is more like 2 units of Humalog or Novalog. That’s very important to know because if you don’t know that, you’ll underdose yourself. So that’s step 1. And what I tell my type 1s what to do when they first start taking it, I recommend that all my type 1s be on a continuous glucose monitor, that they pick a time that their blood sugar’s high, and they just start with 4 units to inhale and they just see how it affects their blood sugars. If you have a CGM you can see how quickly it brings it down, how much of a drop you get out of 4 units, so you can kind of have a correction factor, and that’s a really good place to start.

STEVE

Yeah that’s a great way to start – you use it as a correction dose. And I think having a CGM, which is the standard of care for folks with type 1, it just makes it so much easier, and like everything else, it affects everyone differently, and it may affect you differently depending on the day of the week.

JEREMY:

I tell people, whatever you’re on, stay on that for now. If you’re on multiple daily injections or a pump, stay on that. Don’t make any radical shifts to doing Afrezza all the time in the beginning. Just get familiar with how quickly it works with the corrections, and then you might start gravitating towards using it at mealtimes. Nothing can combat that post-meal spike like Afrezza, especially when you’re eating a good amount of carbs. And because it works so quickly, you actually can inhale it right when you sit down to eat, or even 10 minutes or so after you eat, which is very different than what we would tell people with Humalog or Novalog, dosing 30 minutes or so before a meal.

STEVE:

Yeah, who remembers to take insulin 30 minutes before you eat? It’s a very good technique and if you can remember, that’s awesome, but the timing with Afrezza is much more convenient, and anything that’s more convenient is going to help you improve your time in range.

JEREMY

I find that when I start patients on it, they come back and tell me, I just like it for corrections, or I loved it for corrections so I started using it for mealtimes, and I was on a pump but now I want to come off of a pump and use Afrezza for every meal and every correction. There’s no wrong way to do it and there are a lot of different opportunities. How do you use it Steve, and how do your patients use it?

STEVE

First of all, what you said is exactly right. Everybody uses it according to their own regimen. I’m on one of these hybrid closed loop systems where the CGM data goes to my pump and the pump gives me insulin automatically, modulates my basal rate, and a lot of the really smart software engineers will say hey, (inhaled insulin) is going to mess up your algorithm, but from my personal experience, it doesn’t mess up my algorithm at all. I take it on top of the insulin that’s in my pump. When? When I’m eating something that I know is going to jack up my blood sugars, something rich in carbohydrates, and all the time, probably once or twice a day to correct for a high. When my blood sugars are heading toward that 180 and I don’t want it to wreck my time in range, I’m getting out the Afrezza. A lot of my patients, they may take it as their only mealtime insulin, and they use one of the injectables – Tresiba or Toujeo as the baseline.

JEREMY

I find that a lot of my patients will use it with their pumps, actually. For those highs, when you’re 300, it can bring it down so quickly. On top of that though, you can get really sophisticated, take it at the start of a meal, and then take a few units through your pump also to cover the fat and the protein that might come a little bit later.

STEVE

The other thing I’ll mention too is, because it gets out of your system quickly, if you do have a meal that’s heavy in protein and fat, you may need what we call a follow-on dose, where you’re still in the desirable range and then the trend arrow of your CGM goes up maybe an hour and a half later – take another hit.

JEREMY

A few practical things about starting it. If you do start it, you do have to get what’s called an FEV1 (Forced Expiratory Volume 1) meaning you have to billow into a little device as quick as you can, and it just tells you if your underlying lung function is normal. People ask, why do I have to do that? Well there’s no evidence that Afrezza causes any lung damage, but we do this to make sure you don’t have any underlying acute asthma or COPD, it shouldn’t be used in smokers, you have to get that test when you start, then after 6 months and then every year thereafter. It’s not a full lung test – it should literally just take one second.

STEVE

It’s not a pulmonary function test – a lot of doctors have the little device in their office. If you’re a current smoker, you have bad asthma, or bad COPD, it’s not the right insulin for you.

JEREMY

The point is that it’s a very unique insulin. There are a lot of different ways to use it and providers and patients need to know more about it because in our opinion, it’s very under-utilized.

STEVE

A lot of doctors don’t know about it. So that’s why we educate folks living with diabetes at TCOYD so you can bring it up and talk to your caregiver about it.

JEREMY

There’s lots of information on the TCOYD website, and in the TCOYD book, and we’re going to do a whole dedicated session on Afrezza at our ONE conference coming up October 3rd (2020). Lots of information on Afrezza. That’s all I got!

STEVE

So long nation!

JEREMY

So long!

20 Comments
  1. What if my endocrinologist does not want to prescribe it. I am type 1 and am use Lyemjev insulin in a Omnipod pump. My latest A1c was 6.5. I told my Dr. I want to use Affrezza to treat my highs above 200 that take awhile to bring down and sometimes take a long time to treat and require extra insulin. She commented she had never used Affrezza and did not recommend I use 2 different kinds if insulin. What can I do? I want the best control i can get.

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    How can we get this inhaled insulin approved by more insurance companies. I’m type 2 and I’m terrified of needles, I can’t take the metformin or the other prescribed drugs, they make me feel very sick and nonfunctional. I would love to try the inhaled insulin. I’ve never used insulin because of my fear of needles. My A1C is at 14 right now, early this week my glucose was at 464. The crazy part is, I didn’t/don’t have any symptoms. Had it not been for the blood work last week, I wouldn’t have known it was that something was wrong.
    I was diagnosed with diabetes Jan of 2019, my A1C was at 13.8, by April 2019 I had gotten it down to 6.5 with diet and exercise because the metformin made me so sick, I had tried it for 2 weeks. I’m back to diet and exercise which I plan on keeping up this time, I have to. I tried the metformin again and the same results, I can’t live like that.
    I really wished I could try the inhaler out. For now I will keep eating all low glycemic index foods until I’m healthy again.

  3. Thank you for this, Steve and Jeremy…but why didn’t you address the overwhelming problem with Afreeza, which is it’s frequent inability to get properly inhaled, in which case it doesn’t work? I tried it for a month, and found that the inhalation was suspect due to the powder attaching to the roof of my mouth, and/or the back of my throat, and/or my tongue, and/or my esophagus…which then prevented some or all of the powder from reaching deep into my lungs, so the blood sugar reduction was muted or eliminated entirely. If you are taking it successfully and avoiding this issue, HOW ARE YOU INHALING it so perfectly?

    • Scott…thanks for the comment. Believe it or not you are the first person/patient that has told me it is a major issue. Every once in a while folks say the effect was not as much as usual, but that’s pretty rare and I speak to a ton of folks who take Afrezza. Maybe there is an anatomical issue, but who knows. Send me an email and I can put you in touch with someone from Mannkind. My email address is steve@tcoyd.org.

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    I was in the trial back in 2005 for the inhaled insulin to treat my type 1 diabetes.
    Michelle

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    Thanks you guys for your great info and education on how Afrezza can help us T1Ds. Very good!

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    Ok but if it’s safe it should be safe for all copd or not. And I’m sure they’ll tell you why not to think that way.. lot why that’s not valid .. yet …History has taught us the only thing inhaled should be air. Anything else causes a problem eventually… I’m not willing to take a hit and see after 10 years it caused a problem

    • I understand your concern, and if you have a history of COPD and or Asthma…not indicated. At least I can tell you there has been close scrutiny of adverse affects by the FDA and so far none. Many other meds are given through inhalers as well, from glucagon to steroids. Stay healthy and thanks for your comment.

  7. Loved your visual! You rock!
    I tried Afrezza, but it caused me to cough a lot, so I stopped.

    • Thanks for sharing your experience – it’s important to listen to your body and use what works the best for you.

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    Thank you for this detailed information. My endo mentioned Affreza to me but wants to wait until my pneumonia is clear before starting me on this to treat highs.

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    I am interested in Afrezza for my teenage son who is Type 1. He likes to snack and sometimes forgets to Bolus. Having something to bring his levels down quickly would be great. Is Afrezza approved for kids under 18?

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    I was diagnosed with Type 2 in April. I’m not seeing an endocrinologist, only a physician assistant. He has me on metformin (500mg twice daily). I have changed my diet completely to a very, very low carb diet and was able to get my a1c from 11.8% to 6.7% in three months. I just started using a CGM trying to learn more about my diabetes and what foods/activities adversely affect my glucose. I’m learning so much, but I’m also learning that metformin may not be working for me and I’m also learning that I have some gluconeogenesis going on. But what I’m also learning is that while I was hoping to go back to a little bit “normal” diet, once I start trying to eat more “normal” foods (think basic things like a small serving of plain cheerios in almond milk or a small handful of popcorn or a few onion rings) my glucose goes up and is affected the next day and on and on and if I continue it compounds on itself. The only way I’ve found I can keep my glucose in normal range is I have to eat very low carb and do a lot of intermittent fasting (because of Dawn Phenomenon and Feet-to-the-Floor Phenomenan every single day) So now I have heard about Afrezza and watch this video and wonder, is this something for someone like me?! How can I find out? I’m not on insurance. But I’m willing to pay to live more “normally”. Am I a candidate? How can I find out if I am? The physician assistant I see didn’t even know he needed to prescribe the CGM and thought I could just find one to buy online! That tells you how much he knows about all of this. I’ve only been to see him twice. Once for the diagnosis and then the follow up 3 months later. I see him again in November. As far as I know, there is one endo in my town and he’s an elderly gentleman. Would he even know about all of this? Thank you so much for sharing this information!

    • Afrezza is approved for both people with type 1 and type 2 diabetes. It will bring your blood sugar down from a high, and it will also prevent spiking when you eat. You can learn more about assistance programs for Afrezza here: https://www.insulinsavings.com

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