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Dear Drs. E&P,
If you’re on an AID system and your blood sugar is high and you take Afrezza, can the AID system react fast enough to NOT give you a correction bolus? Is it really okay to use Afrezza with AID systems?
Dr. Pettus:
Afrezza isn’t officially approved for use with hybrid closed-loop systems (also called AID systems), but Steve and I use Afrezza with ours all the time. Steve is looping with an Omnipod, and I use the Medtronic 780G.
We regularly use Afrezza ourselves, and we also suggest it to our patients who may benefit from it…mostly for those sticky highs.
Automated insulin pumps are constantly determining how much insulin you’re getting in a day, and they use that information to make auto corrections. The concern here is that if you’re taking a bunch of Afrezza and the pump doesn’t know it, will it mess up the algorithm?
Generally speaking, the answer is no. BUT each hybrid closed-loop algorithm works differently, and may respond differently.
There are a couple of ways to use Afrezza with a pump – for a mealtime bolus and for a correction dose.
How to Use Afrezza for a Mealtime Bolus
If you want to take Afrezza for a mealtime bolus, just don’t enter the carbs into your pump, and the pump won’t know you’re eating. The pump should adjust when it sees your blood sugars coming down.
Some systems let you enter the carbs and register that you are taking Afrezza like Loop, which is a non FDA-approved AID system. Twiist is an FDA-approved version of loop, and will have that function soon.
How to Use Afrezza for a Correction Dose
The other scenario (and the essence of your question) is, can you take Afrezza if your blood sugar is high and the pump is already trying to bring you back down?
I still say yes.
The corrections that these pumps make are generally pretty conservative. So you could take a small dose of Afrezza and yes, the pump may react to stop giving you insulin to help you avoid a low, but you can still always go low if you have too much insulin (Afrezza and/or subcutaneous) on board. But in general, we do not see lows when our patients use Afrezza for this purpose.
You’ll need to experiment to see what works for you. Afrezza works really well with these systems as a quick touch to correct your blood sugars. It gets into your system fast (it’s in your bloodstream in less than 1 minute and starts lowering blood sugar in about 12 minutes) and gets out of your system fast (typically in about 90 minutes or so).
When Afrezza Can Throw Off Your Pump
If you start to use Afrezza multiple times a day, then it might start to mess up the algorithm for the AID system because your total daily dose of insulin will be much lower than normal.
For example, if your total daily dose of insulin is usually 50 units through the pump and you start regularly taking 20 units of Afrezza and 30 units through the pump, the pump is going to think you’re much more insulin sensitive because it doesn’t know about the insulin coming from Afrezza.
There are a lot of theoretical disadvantages to taking Afrezza with a pump, but the reality is that Afrezza works really well with these systems. The algorithms are looking at your blood sugar three, four, and five hours ahead of time. They’re looking at your rate of change and projected blood sugar, and then they make adjustments.
If your blood sugar starts to come down because of Afrezza, your pump will adapt and reduce your basal. All of the AID systems seem to adapt well.
Dr. Edelman:
I second everything Jeremy said. We’ve been using Afrezza with our AID patients for years, and we haven’t seen any issues. Again, using Afrezza with an AID system isn’t officially approved by the FDA, but screw that! People do not like sticky high blood sugars that don’t respond to subcutaneous insulin, and Afrezza gets the job done!
Key Takeaway: Afrezza and AID Systems Generally Work Well Together
Even though Afrezza isn’t officially FDA-approved for use with automated insulin delivery (AID) systems, we use it ourselves, and we often recommend it to many of our patients who could benefit from it.
The main caution is if a big chunk of your daily insulin is coming from Afrezza. In that case, your pump may think you’re more insulin-sensitive than you are and adjust its algorithm. But generally speaking, Afrezza and AID systems work well together, and Afrezza can be a great tool in your diabetes toolbox.
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Thanks! I have a friend who uses it for meals before exercise, since it clears from the body much faster than injected insulin. Seems like a good idea but I haven’t done it.
Yes, it gets into your body fast and out of your body fast, so there are lots of ways to utilize it.
I use Twiist and Afrezza. Did not know that Loop accounted for Afrezza – it seems like you are saying this will be a feature not available now, but will be later?
You are correct….it will potentially be available in future updates of the twiist.
As ive gotten older (58 years with T1D), I’m increasingly prone to inexplicable spikes. Afrezza is making such a difference for me (and yes, I’m on a pump with Eversense 365 – which I also love). Thanks so much for this posting!
That’s awesome! And glad you’re loving the Eversense 365!
If Afrezza with a pump has not been FDA approved, will insurance still cover the cost, or will it require OOP purchase? As an older person with Medicare, so many of my healthcare decisions are influenced by insurance coverage.
I use a pump and at first my insurance denied coverage. However, I am not sure how, but my diabetes medical provider was able to get me Afrezza covered with my insurance. I am not saying all insurance would do that and I am not yet on Medicare.
Thank you for sharing – glad you were able to get it covered!
In Medicare, afrezza is covered through Part D, prescription benefits. Insulin for insulin pump is covered under part B, Durable Medical. Your pharmacy insurance doesnt need to know you are using a pump. (Omnipod and Twiist are exceptions and are completely Part D, pharmacy.). If you have not been getting pump insulin through Part D you and your pharmacy need to address this. It only took me two weeks and ten hours on the phone to get my Medicare Advantage program to understand this. (They apologized and sent several people to re-education camp. ).
It’s a great question, but it really depends. With some insurance companies you can get it, but others will give a push back. But keep advocating for yourself, and hopefully you will get it!
I just received my Afrezza 2 days ago and already in love with it. I’m currently on omnipod5(manual mode with eversense 365). I like the finetuning i can do with the pod, especially for activity, but considering taking a break for a while and switching back to tresiba. Would appreciate thoughts on figuring out basal rate again.
I did convince my endo to prescribe afrezza for me, but after 2 months, they’re still learning how to prescribe and clearly know less than me. So, i took the online consult option on getafrezza website and it worked really well – they helped figure out coverage, ordering it through their pharmacy, etc – best 25$ spent.
That’s great, so glad it worked well and you’re loving Afrezza!
Regarding your basal rate, in general, you look at your average total daily basal dose from your download, and divide it by 24, and start off with that. You can find a more detailed explanation of how to test and check your basal rate here: https://tcoyd.org/2023/06/how-to-set-and-test-your-basal-rate/