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Post by stevil on Aug 17, 2018 22:08:24 GMT -5
Episode 67 of AFP podcast addressed intensive insulin therapy for type 1's and the benefits of tight glucose control. No mention of Afrezza... stevil, I Have a question. when you were in medical school, did you get a course/lecture on how medical (pharmacy) insurance works? Just started my 4th year, so I'm technically still in school, but no... there is so much science to learn that medical schools don't have time to teach students how the real world works. There's a funny video that my classmates passed along to each other that does a good job of illustrating the disparity between each level... It's funny because a lot of the preceptors/attendings concede that we know a lot of the science better than they do, but they know the useful/important information 92834739 times better than we do. Much of the info they teach in medical school is superfluous but it has to be in order to lay a strong foundation. You always lay a foundation as wide or wider than the structure. Long story short, most of that stuff is learned in residency, if it will be learned at all. It depends on the personality of the physician- how much control they want over their practice and how hard they're willing to work to keep as much money as they can. Most docs I've worked with A) are in a group practice and can afford an office manager that does billing/coding for them, B) (the vast majority private practice) outsource it to a company to handle it for them or C) work in a hospital that has an entire division that works on this for them. Docs for the most part don't want to be bothered with not only learning billing/coding rules that change very frequently- and likely will continue to- then have to sit down after all their hard work for the day and make sure they're catching every piece of revenue that they can based on the work they performed. There are probably tens of thousands of codes to learn. Look up ICD-10/CPT codes if you want good bedtime material. Good coding/billing people usually pay for themselves and then some on top of the convenience of not having to perform the work. You would not believe how much paperwork and documentation docs have to do. We spend more time doing paperwork than we do seeing patients more often than not because you have to CYA for malpractice, as well as document properly for insurances to get paid for your work. Pharmacy insurance doesn't get touched at all. That's pharmacy's business to sort out. If a drug isn't covered, you either do a PA, or more often, just switch it to another, cheaper drug that is a generic. Usually the pharmacy helps out with what's on a patient's formulary when they call or fax to change the drug or for a PA request. That and if you ask a patient why they aren't taking their meds and they tell you it's because their medication is too expensive are the biggest two ways I can think of for doctors hearing about pharmacy issues. Otherwise, it's a completely separate field altogether.
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Post by peppy on Aug 17, 2018 22:31:42 GMT -5
stevil, I Have a question. when you were in medical school, did you get a course/lecture on how medical (pharmacy) insurance works? Just started my 4th year, so I'm technically still in school, but no... there is so much science to learn that medical schools don't have time to teach students how the real world works. There's a funny video that my classmates passed along to each other that does a good job of illustrating the disparity between each level... It's funny because a lot of the preceptors/attendings concede that we know a lot of the science better than they do, but they know the useful/important information 92834739 times better than we do. Much of the info they teach in medical school is superfluous but it has to be in order to lay a strong foundation. You always lay a foundation as wide or wider than the structure. Long story short, most of that stuff is learned in residency, if it will be learned at all. It depends on the personality of the physician- how much control they want over their practice and how hard they're willing to work to keep as much money as they can. Most docs I've worked with A) are in a group practice and can afford an office manager that does billing/coding for them, B) (the vast majority private practice) outsource it to a company to handle it for them or C) work in a hospital that has an entire division that works on this for them. Docs for the most part don't want to be bothered with not only learning billing/coding rules that change very frequently- and likely will continue to- then have to sit down after all their hard work for the day and make sure they're catching every piece of revenue that they can based on the work they performed. There are probably tens of thousands of codes to learn. Look up ICD-10/CPT codes if you want good bedtime material. Good coding/billing people usually pay for themselves and then some on top of the convenience of not having to perform the work. You would not believe how much paperwork and documentation docs have to do. We spend more time doing paperwork than we do seeing patients more often than not because you have to CYA for malpractice, as well as document properly for insurances to get paid for your work. Pharmacy insurance doesn't get touched at all. That's pharmacy's business to sort out. If a drug isn't covered, you either do a PA, or more often, just switch it to another, cheaper drug that is a generic. Usually the pharmacy helps out with what's on a patient's formulary when they call or fax to change the drug or for a PA request. That and if you ask a patient why they aren't taking their meds and they tell you it's because their medication is too expensive are the biggest two ways I can think of for doctors hearing about pharmacy issues. Otherwise, it's a completely separate field altogether. thanks stevil. Glad everything is moving along. and that's the way it is August 17, 2018.
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Post by stevil on Aug 17, 2018 22:58:41 GMT -5
Not all docs are like that. I'd say the majority that I've been involved with are though. By and large, there isn't a whole lot of innovation in pharmacy outside of the new up-and-coming monoclonal antibody drugs. Most of the drugs that have come out in the past several years are "me too" drugs... just different formulations within the same class. Small improvements or supposed fewer side effects, etc of the same general medication. There generally isn't a significant benefit between the new brand drugs and a cheaper generic of an older drug. Some drugs are worth the extra time to get authorized and time will be spent to secure it for the patient. Just depends on the nature of the doc and if the situation warrants the effort. Usually, if there is evidence that a specific drug is needed above others, they'll go the extra mile. If not, they'll just switch it to a different drug in the same class.
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Post by peppy on Aug 17, 2018 23:09:06 GMT -5
Not all docs are like that. I'd say the majority that I've been involved with are though. By and large, there isn't a whole lot of innovation in pharmacy outside of the new up-and-coming monoclonal antibody drugs. Most of the drugs that have come out in the past several years are "me too" drugs... just different formulations within the same class. Small improvements or supposed fewer side effects, etc of the same general medication. There generally isn't a significant benefit between the new brand drugs and a cheaper generic of an older drug. Some drugs are worth the extra time to get authorized and time will be spent to secure it for the patient. Just depends on the nature of the doc and if the situation warrants the effort. Usually, if there is evidence that a specific drug is needed above others, they'll go the extra mile. If not, they'll just switch it to a different drug in the same class. Stevil, I know this is off topic for this thread, what are you seeing with the MAB's, anything good? There is this new bio life by me, so busy. I am thinking they are doing the blood draw for the monoclonals. What results are you seeing?
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Post by peppy on Aug 17, 2018 23:11:18 GMT -5
Not all docs are like that. I'd say the majority that I've been involved with are though. By and large, there isn't a whole lot of innovation in pharmacy outside of the new up-and-coming monoclonal antibody drugs. Most of the drugs that have come out in the past several years are "me too" drugs... just different formulations within the same class. Small improvements or supposed fewer side effects, etc of the same general medication. There generally isn't a significant benefit between the new brand drugs and a cheaper generic of an older drug. Some drugs are worth the extra time to get authorized and time will be spent to secure it for the patient. Just depends on the nature of the doc and if the situation warrants the effort. Usually, if there is evidence that a specific drug is needed above others, they'll go the extra mile. If not, they'll just switch it to a different drug in the same class. so regarding afrezza, insurance isn't covering it. The for profit insurance we have here get kickbacks from pharm when their script numbers are hit.
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Post by babaoriley on Aug 18, 2018 0:19:17 GMT -5
Joslin's theory to answer the question "But why and how does it reduce insulin resistance, which as I understand refers to the fact that the cells which are receptors of the insulin don't want to let much of the insulin in?" is the resistance is viral based. The extra insulin allows for the displacement of what they call viral insulin-like peptides (VILPs) which are causing the resistance. Over time the displaced virus can't replicate and are destroyed resulting in reduced resistance. Joslin says they have identified four distinct viruses, so far. www.joslin.org/news/virus-can-produce-insulin-like-hormones-active-on-human-cells.htmlsayhey, under the above explanation, wouldn't any insulin displace the VILPs, then? But all types of added insulin doesn't result in reduced resistance, does it? Or was Joslin just talking about Afrezza having this effect? Many thanks to all who responded!!
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Post by mnholdem on Aug 18, 2018 5:16:56 GMT -5
I believe that the trial mentioned in the OP is the first using Afrezza inhalable insulin, which wasn't available for past clinical studies on early intensive insulin treatment. If RAA insulin can demonstrate these kinds of results (i.e. remission) it would beg the question of whether Technosphere insulin may demonstrate even better results. One important note. In a number of these trial papers, researchers have noted that patients in early stages of diabetes may be resistant to a treatment which involves multiple daily injections. This represents another distinct advantage that Afrezza may have over RAA insulin.
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Post by sayhey24 on Aug 18, 2018 8:17:17 GMT -5
Joslin's theory to answer the question "But why and how does it reduce insulin resistance, which as I understand refers to the fact that the cells which are receptors of the insulin don't want to let much of the insulin in?" is the resistance is viral based. The extra insulin allows for the displacement of what they call viral insulin-like peptides (VILPs) which are causing the resistance. Over time the displaced virus can't replicate and are destroyed resulting in reduced resistance. Joslin says they have identified four distinct viruses, so far. www.joslin.org/news/virus-can-produce-insulin-like-hormones-active-on-human-cells.htmlsayhey, under the above explanation, wouldn't any insulin displace the VILPs, then? But all types of added insulin doesn't result in reduced resistance, does it? Or was Joslin just talking about Afrezza having this effect? Many thanks to all who responded!! Any insulin will do. I am not aware of ANY large scale early insulin intervention study which has used afrezza. It would be nice if Duke and UNC start one. Joslin was not talking about afrezza at all. There are early insulin intervention studies dating back to the 1950's done by UpJohn. Insulin always wins.
The issue with insulin has always been; hypoglycemia; needles; social stigma of being at the end of the road. If these three things are solved all the oral agents are obsoleted. If you listened to the podcast cited above they make a comment the way to get best control is insulin.
The big question is does afrezza really solve the hypoglycemia issue? It clearly solves the needle issue and Hollywood made inhaling cool in the 1920's even when it was a paper stick lit on fire which turned to ash, so I have to believe Mike and Jeff Dachis can come up with a cool looking chrome inhaler to replace the disposable one.
If you take 2x the amount of afrezza than you should have how low will you go and how fast will you recover? Dr. Kendall is doing a dosing study now to try and answer that question. We should have some answers the medical community will accept soon.
The second big question is if Joslin is correct, how well would afrezza do if used as the first treatment for the T2s? Some of us think it would be a real game changer. Some of us think the best use for afrezza is with the prediabetics and early diagnosed PWDs. Simply taking a 4u with every main meal or big snack would have a huge impact at the very early stage of diabetes and the chance of hypoglycemia is near zero but we need to wait for the official results. Hopefully we should have them pretty soon.
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Post by MnkdWASmyRtrmntPlan on Aug 18, 2018 10:27:25 GMT -5
Episode 67 of AFP podcast addressed intensive insulin therapy for type 1's and the benefits of tight glucose control. No mention of Afrezza... I emailed afppodcast@aafp.org thanking them but that I was disappointed that inhalable insulin was not even mentioned, and that some believe there is more of a future in that for T1 mealtime treatments than in closed-loop systems. I will post any responses.
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Post by babaoriley on Aug 18, 2018 10:45:58 GMT -5
sayhey, under the above explanation, wouldn't any insulin displace the VILPs, then? But all types of added insulin doesn't result in reduced resistance, does it? Or was Joslin just talking about Afrezza having this effect? Many thanks to all who responded!! Any insulin will do. I am not aware of ANY large scale early insulin intervention study which has used afrezza. It would be nice if Duke and UNC start one. Joslin was not talking about afrezza at all. There are early insulin intervention studies dating back to the 1950's done by UpJohn. Insulin always wins.
The issue with insulin has always been; hypoglycemia; needles; social stigma of being at the end of the road. If these three things are solved all the oral agents are obsoleted. If you listened to the podcast cited above they make a comment the way to get best control is insulin.
The big question is does afrezza really solve the hypoglycemia issue? It clearly solves the needle issue and Hollywood made inhaling cool in the 1920's even when it was a paper stick lit on fire which turned to ash, so I have to believe Mike and Jeff Dachis can come up with a cool looking chrome inhaler to replace the disposable one.
If you take 2x the amount of afrezza than you should have how low will you go and how fast will you recover? Dr. Kendall is doing a dosing study now to try and answer that question. We should have some answers the medical community will accept soon.
The second big question is if Joslin is correct, how well would afrezza do if used as the first treatment for the T2s? Some of us think it would be a real game changer. Some of us think the best use for afrezza is with the prediabetics and early diagnosed PWDs. Simply taking a 4u with every main meal or big snack would have a huge impact at the very early stage of diabetes and the chance of hypoglycemia is near zero but we need to wait for the official results. Hopefully we should have them pretty soon.
Thanks, sayhey. The lessening of insulin resistance remains somewhat a mystery to me, as it appears on the surface that the extra insulin merely overwhelms the resistance, as opposed to actually lessening it. But if that virus has a part in it, or if it has something to do with the liver as Peppy pointed out, then I can see an additional reason why insulin should be the "first responder" for a new type 2 or a pre-diabetic individual. By the way, in contrast, but support, Spiro has maintained for years that Metformin is not a nice drug side effect wise.
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Post by agedhippie on Aug 18, 2018 11:19:24 GMT -5
... If you take 2x the amount of afrezza than you should have how low will you go and how fast will you recover? Dr. Kendall is doing a dosing study now to try and answer that question. We should have some answers the medical community will accept soon.
...
You already have those results from the Safety and Efficacy of Technosphere® Insulin Inhalation Powder (TI Inhalation Powder)When an Optimal Dose is Taken With Varied Carbohydrate Intake trial. The outcome at 50% for Type 1 was that everybody crashed ( Original Protocol Type 1 Diabetes Mellitus Technosphere Insulin Treated; 50% carbohydrate load was administered but not completed due to all subjects having hypoglycemia, 0% carbohydrate load was deemed unsafe by PI). It was a small trial though.
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Post by centralcoastinvestor on Aug 18, 2018 12:01:43 GMT -5
The question of how insulin resistance works is still confusing to me. I had a surgeon explain to me that diet was the principal cause of insulin resistance. That there was too much sugar on board in a persons body and that the pancreas was overloaded and could not deal with more sugars and more insulin would do no good. So how would Afrezza overcome that?
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Post by brotherm1 on Aug 18, 2018 12:13:47 GMT -5
Any insulin will do. I am not aware of ANY large scale early insulin intervention study which has used afrezza. It would be nice if Duke and UNC start one. Joslin was not talking about afrezza at all. There are early insulin intervention studies dating back to the 1950's done by UpJohn. Insulin always wins.
The issue with insulin has always been; hypoglycemia; needles; social stigma of being at the end of the road. If these three things are solved all the oral agents are obsoleted. If you listened to the podcast cited above they make a comment the way to get best control is insulin.
The big question is does afrezza really solve the hypoglycemia issue? It clearly solves the needle issue and Hollywood made inhaling cool in the 1920's even when it was a paper stick lit on fire which turned to ash, so I have to believe Mike and Jeff Dachis can come up with a cool looking chrome inhaler to replace the disposable one.
If you take 2x the amount of afrezza than you should have how low will you go and how fast will you recover? Dr. Kendall is doing a dosing study now to try and answer that question. We should have some answers the medical community will accept soon.
The second big question is if Joslin is correct, how well would afrezza do if used as the first treatment for the T2s? Some of us think it would be a real game changer. Some of us think the best use for afrezza is with the prediabetics and early diagnosed PWDs. Simply taking a 4u with every main meal or big snack would have a huge impact at the very early stage of diabetes and the chance of hypoglycemia is near zero but we need to wait for the official results. Hopefully we should have them pretty soon.
Thanks, sayhey. The lessening of insulin resistance remains somewhat a mystery to me, as it appears on the surface that the extra insulin merely overwhelms the resistance, as opposed to actually lessening it. But if that virus has a part in it, or if it has something to do with the liver as Peppy pointed out, then I can see an additional reason why insulin should be the "first responder" for a new type 2 or a pre-diabetic individual. By the way, in contrast, but support, Spiro has maintained for years that Metformin is not a nice drug side effect wise. Seems to me if what Peppy posted is correct that “Ectopic fat is defined as storage of TG in tissues other than adipose tissue, that normally contain only small amounts of fat, such as the liver, skeletal muscle, heart, and pancreas. Ectopic fat can interfere with cellular functions and hence organ function and is associated with insulin resistance”: then extraneous insulin does more than overwhelm insulin resistance, it keeps resistance from increasing by burning triglycerides that cause ectopic fat. And if used with low carb diets or fat burning diets and/or exercise to burn off current fat levels, extraneous insulin will actually decrease insulin resistance. But I’m still curious if Afrezza bypasses the liver to any degree and preclude the liver from making glucose, which if not burned, will turn into fat and create further insulin resistance? And/or does it possibly bypass the liver and preclude it from making glucose which would cause greater stress on the pancreas to produce more insulin?
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Post by mytakeonit on Aug 18, 2018 12:22:53 GMT -5
Makes sense to me ... I killed my liver long ago while in the military ... and I'm still considered a prediabetic.
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Post by centralcoastinvestor on Aug 18, 2018 12:32:48 GMT -5
The following is an except from an article in the Huffington Post:
However elevated sugar is only a symptom, not the cause of the problem. The real problem is elevated insulin unchecked over decades from a highly refined carbohydrate diet, a sedentary lifestyle and environmental toxins.
Most medications and insulin therapy are aimed at lowering blood sugar through increasing insulin. In the randomized ACCORD trial of over 10,000 patients, this turns out to be a bad idea.
i thought the ACCORD trial had to be suspended due to hypoglycemia being the problem and not the insulin.
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