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Post by hellodolly on Mar 21, 2019 5:16:55 GMT -5
Two points: Many PCPs refer patients to an endocrinologist and prevention is exactly what can result from early short term intensive insulin (STII) treatment, which enables over worked pancreatic beta cells to recover and for the pancreas to repair itself before it gets damaged beyond repair. Their have been several major that show 50% drug free remission for up to two years, during which time the patients will adopt additional preventive lifestyle changes. Prevention begins with early STII therapy, yet the ADA puts insulin as the last step of treatment. Often, by that time, the pancreas may have degraded to the point where it cannot be repaired. Then the patient has no choice but to take insulin for the rest of his/her life. A quick story: I spent last weekend at WDW with family in Orlando. It was a big get together, 30 or so of the clan. My nephew's wife is a doctor in upstate GA, outside of roam. She's new, maybe 5 years out of residency at UF (she's probably about 31-32 years old, very young). She picked the area after being recruited and loves the PCP role and the fact that she wants to be a 'family doctor' and watch families grow in small town USA. We've talked about Afrezza in the past and I brought it up to her again. She told me that she refers her patients to endo's and the insurance companies look at her as insignificant and hardly give her the "time of day" [her words] when she tries to battle for various coverage. I sent her the vids of Dr. Edelman, Afrezza Jake and Laura K. just to let her see the social media presence that is taking shape.
To your point, she does refer her patients to endos because she feels they have a better shot getting coverage for Afrezza and she avoids the battle in the trenches with insurance companies who pretty much don't give her the time of day. It's a shame.
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Post by sayhey24 on Mar 21, 2019 5:47:35 GMT -5
Stevil - why would the endo at this point in time be concerned about afrezza putting him out of a job? He already has the PWDs a patients.
The endo at the Adcom who made the comment about afrezza putting him out of a job was saying so because he saw a future where the PCP would prescribe afrezza as Step 1 for the T2s. He knew afrezza would stop the progression and by doing so the T2 PWDs would never need an Endo which were 90% of his business.
PCPs manage insulin already, not sure why an easier insulin would put endos out of a job. No one can predict the future with any certainty, but my crystal ball is telling me that Afrezza may eat a little into the endos schedules, but they've got lots of overflow to take from before they notice the difference. Afrezza seems nuanced enough that it may put off PCPs from trying to master it. If there's a sizeable market for VDex, endos have nothing to worry about, especially if Afrezza becomes first line (which I don't see happening). If that scenario played out, there would only be millions more to treat. PCPs probably wouldn't want to manage diabetes all day and would just refer out to the endos to take care of it. Prevention is the biggest threat to endos. If the dirty secret about how unhealthy the FDAs food pyramid is gets out, then they'd be in trouble. Otherwise, there will likely never be a shortage of patients, unless they saturate the market with NPs, PAs, or PCPs. All indications are pointing to that not being the case for the baby boomer generation and Gen X'ers. Even my generation of millennials still increased the growth rate. The demand for PCPs is higher than is currently being filled by the data I have seen. All signs are pointing to a shortage. Long story short, a shortage of PCPs means they're not going to want to turn into an endo and manage diabetes all day long. There will be plenty of job security for all parties involved. One thing Al told me when we were having a discussion about my condition was to keep an eye on the Joslin research and diabetes being viral based. If you buy into it being viral which I do, things like food are not the root cause but just create a greater demand on the body for additional insulin which the body can no longer make due to beta cell damage.
I also believe, the difficulty in titrating afrezza has been way over-hyped and with the Libre and connected care its really easy. Even without connected care, the Libre with Libreview is good enough to make titrating a snap. In the near future, I see the PCPs working with connected care monitoring services and once they do there is no need in most cases for the Endos as the T2s wont progress. In some cases they will improve.
As Fitbit, Apple and Google jump in the game with non-invasive "fitness" CGMs, everyone will be connected to their remote monitoring services.
What will also be interesting will be how the overall heath of these people improve and if they have a reduce need for their PCP. Start treating the early T2s and prediabetics and I think the reduced demand will be significant. There is something about blood and glucose levels, it affects all parts of the body.
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Post by matt on Mar 21, 2019 9:24:54 GMT -5
As Fitbit, Apple and Google jump in the game with non-invasive "fitness" CGMs, everyone will be connected to their remote monitoring services.
Monitoring alone does not fix the problem of non-compliance; it requires constant human follow-up to insure the patients actually adhere to the drug therapy. I was involved in one such project during the period when effective "cocktail" therapies were first becoming available for AIDS patients. Those early drugs had very tight dosing windows, a dose administered as little as a hour late could result in the virus spawning many new mutations. The major cost was not for the monitoring service, which was largely computerized and triggered a system update every time a pill bottle was opened, but in the human cost of trained nurses to call the patients when doses were missed. If insurance will not pay for a CGM, will they pay for the much higher cost of human interventions and coaching needed to make the monitoring effective? Monitoring gizmos are great for motivated patients that will use them as intended, but unfortunately that is not a good description of the majority of patients. |
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Post by prcgorman2 on Mar 21, 2019 11:30:01 GMT -5
Interesting observations Matt. I would have guessed PWDs wanted CGMs for the near-real-time visibility of BG without the hassle of finger pricks. I get from what you're saying that many PWDs may just guess at their BG based on how they're feeling. Can that really be true? I have just assumed that as insurance companies did due diligence (assuming they still do that) with actuarial analysis they would see the value of CGMs (and Afrezza). But even without insurance, we all know consumers continue to benefit from Moore's Law (although I think the "doubling" has probably slowed). i.e., digital devices continue to increase in capability and performance and decrease in cost. Remember TVs when they were CRTs? Anyway, like sayhey24, I've just assumed CGMs would become a de facto part of PWD life.
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Post by agedhippie on Mar 21, 2019 12:25:52 GMT -5
Interesting observations Matt. I would have guessed PWDs wanted CGMs for the near-real-time visibility of BG without the hassle of finger pricks. I get from what you're saying that many PWDs may just guess at their BG based on how they're feeling. Can that really be true? I have just assumed that as insurance companies did due diligence (assuming they still do that) with actuarial analysis they would see the value of CGMs (and Afrezza). But even without insurance, we all know consumers continue to benefit from Moore's Law (although I think the "doubling" has probably slowed). i.e., digital devices continue to increase in capability and performance and decrease in cost. Remember TVs when they were CRTs? Anyway, like sayhey24, I've just assumed CGMs would become a de facto part of PWD life. Ok, this might be me projecting what I do onto others, but the issue is that most people simply aren't that motivated. The big reason that I use a Dexcom rather than a Libre is because I can have my levels in the notification bar on my phone so every time I look at the phone. It turns out I look at my phone far more often than I can be bothered to scan the Libre. I only really scan the Libre when I would have done a finger stick anyway rather than periodically as I should if I want to be proactive. I would hazard that most PWD guess their BG based on how they feel. If you feel off you test, otherwise you assume it's more or less where it should be. That feeling not quite right is the prompt to test. Insurers hate CGMs with a passion because they are expensive to run which is why so few T2 have them. They fought against CGMs for years and it wasn't until they forced to do it by the trial data that they started to cover T1. Even then they were very restrictive for years. The Libre seems to have changed that a bit as it is cheaper for the insurer, but it lacks that push notification (although I am looking at the MiaoMiao which converts the Libre to a full CGM). Insurers are starting to offer services like Livingo which has coaching as well as a meter that reports numbers back to the cloud via the cell service. I politely declined since I don't want my insurers having any of my data as far as possible. |
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Post by sportsrancho on Mar 21, 2019 14:37:03 GMT -5
I agree. The kids though and the athletes are different they want it all.. the CGM the the Onedrop app...the iPhone. Afrezza!
And stuff that I don’t even know about:-)
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Post by prcgorman2 on Mar 21, 2019 16:00:30 GMT -5
Interesting observations Matt. I would have guessed PWDs wanted CGMs for the near-real-time visibility of BG without the hassle of finger pricks. I get from what you're saying that many PWDs may just guess at their BG based on how they're feeling. Can that really be true? I have just assumed that as insurance companies did due diligence (assuming they still do that) with actuarial analysis they would see the value of CGMs (and Afrezza). But even without insurance, we all know consumers continue to benefit from Moore's Law (although I think the "doubling" has probably slowed). i.e., digital devices continue to increase in capability and performance and decrease in cost. Remember TVs when they were CRTs? Anyway, like sayhey24, I've just assumed CGMs would become a de facto part of PWD life. Ok, this might be me projecting what I do onto others, but the issue is that most people simply aren't that motivated. The big reason that I use a Dexcom rather than a Libre is because I can have my levels in the notification bar on my phone so every time I look at the phone. It turns out I look at my phone far more often than I can be bothered to scan the Libre. I only really scan the Libre when I would have done a finger stick anyway rather than periodically as I should if I want to be proactive. I would hazard that most PWD guess their BG based on how they feel. If you feel off you test, otherwise you assume it's more or less where it should be. That feeling not quite right is the prompt to test. Insurers hate CGMs with a passion because they are expensive to run which is why so few T2 have them. They fought against CGMs for years and it wasn't until they forced to do it by the trial data that they started to cover T1. Even then they were very restrictive for years. The Libre seems to have changed that a bit as it is cheaper for the insurer, but it lacks that push notification (although I am looking at the MiaoMiao which converts the Libre to a full CGM). Insurers are starting to offer services like Livingo which has coaching as well as a meter that reports numbers back to the cloud via the cell service. I politely declined since I don't want my insurers having any of my data as far as possible. Very helpful reinforcement of Matt's points. Thank you agedhippie and sports.
This discussion reminded me of the Google work to build a CGM into a contact lense. I assumed it also had a Head's Up Display (HUD) of some sort built into it even if it was only a tiny dot showing green, yellow, or red. It also reminded me of the (ill-fated?) Google Glass eyeglasses which had a much more feature-rich HUD display and could in theory provide an easy at-a-glance BG reading for folks who live with eyeglasses on their face (like me). Technology to the rescue (eventually).
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Post by akemp3000 on Mar 21, 2019 16:07:35 GMT -5
It's threads like this that make this board valuable. Thanks for everyone's interesting input!
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Post by sweedee79 on Mar 21, 2019 16:24:04 GMT -5
I agree. The kids though and the athletes are different they want it all.. the CGM the the Onedrop app...the iPhone. Afrezza! And stuff that I don’t even know about:-) I couldn't agree more.. And IMO we need to get this peds trial done because it will be the kids that embrace Afrezza in a big way.. Just think of the things we could do with the dreamboat marketing to the under 18 demographic.. we could make it available in cool colors.. etc etc.. personalized..or an Indy race car dreamboat.. expand the technology..kids would love it.. Diabetes is never fun.. but why not lighten it up a bit.. plus no needles.. great insulin and good control.. perfect for kids who love technology.. |
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Post by sayhey24 on Mar 21, 2019 18:46:52 GMT -5
Interesting observations Matt. I would have guessed PWDs wanted CGMs for the near-real-time visibility of BG without the hassle of finger pricks. I get from what you're saying that many PWDs may just guess at their BG based on how they're feeling. Can that really be true? I have just assumed that as insurance companies did due diligence (assuming they still do that) with actuarial analysis they would see the value of CGMs (and Afrezza). But even without insurance, we all know consumers continue to benefit from Moore's Law (although I think the "doubling" has probably slowed). i.e., digital devices continue to increase in capability and performance and decrease in cost. Remember TVs when they were CRTs? Anyway, like sayhey24, I've just assumed CGMs would become a de facto part of PWD life. Ok, this might be me projecting what I do onto others, but the issue is that most people simply aren't that motivated. The big reason that I use a Dexcom rather than a Libre is because I can have my levels in the notification bar on my phone so every time I look at the phone. It turns out I look at my phone far more often than I can be bothered to scan the Libre. I only really scan the Libre when I would have done a finger stick anyway rather than periodically as I should if I want to be proactive. I would hazard that most PWD guess their BG based on how they feel. If you feel off you test, otherwise you assume it's more or less where it should be. That feeling not quite right is the prompt to test. Insurers hate CGMs with a passion because they are expensive to run which is why so few T2 have them. They fought against CGMs for years and it wasn't until they forced to do it by the trial data that they started to cover T1. Even then they were very restrictive for years. The Libre seems to have changed that a bit as it is cheaper for the insurer, but it lacks that push notification (although I am looking at the MiaoMiao which converts the Libre to a full CGM). Insurers are starting to offer services like Livingo which has coaching as well as a meter that reports numbers back to the cloud via the cell service. I politely declined since I don't want my insurers having any of my data as far as possible. My experience over just the last 2 weeks working with 3 new T2 Libre users is very much different.
First - the T2 has little need to keep looking at their reading ever few minutes. What they need to see is their profile while awake and their sleeping profile
Second - looking at meal time, 30/60/90/120 minutes after a meal and associated afrezza dose should do it
Third - After reviewing the profile and seeing a spike/dip they need to record what caused the spike/dip - what they ate, exercise, etc.
Fourth - Being obsessed and looking every few minutes during the day is not only a waste of their time but it is counter productive to the goal of afrezza which is to make them healthy and put more freedom in their live.
What I am seeing with the new users is a great deal of excitement and motivation. What they say is they had no idea how different foods affected them so much. The visual feedback is a huge motivator. The Libre is a game changer for them. I think I mentioned a friend of mine has a mom in India and we set her up on Nightscout so he can monitor her. She was running over 400. She thought prior to the Libre she had no sugar issues just "other" issues. We can't get her the afrezza over there but now she is on lantus which is a start. She is no way taking three shots a day plus the lantus. Its just not going to happen, sadly she would rather die.
One of the new Libre lady's is 60. Her dad died from diabetes complications including being an amputee. Her sister is a Step 3 T2 and is losing the battle. The Libre Lady had a 5.9 A1c. She asked the PCP for a Libre when her doctor told her her A1c was 5.9. Her doctor told her she did not need it and would not prescribe. We got her one and now she is amazed at what she is seeing and is putting a nice AGP history together to have a follow-up discussion with her doctor who clearly gave her bad guidance. Sadly, this PCP is typical. They really want to keep these PWDs in the dark.
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Post by sayhey24 on Mar 21, 2019 18:54:17 GMT -5
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Post by Deleted on Mar 21, 2019 19:17:44 GMT -5
I'm paying $32 (No insurance coverage) for the 14-Day sensor with a Manu Coupon of $25 from CVS. |
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Post by Deleted on Mar 21, 2019 19:18:53 GMT -5
I'm paying $32 (No insurance coverage) for the 14-Day sensor with a Manu Coupon of $25 from CVS. Here's a TIP - You don't need the Device if you have a smartphone. That will save you $80 |
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Post by agedhippie on Mar 21, 2019 20:28:07 GMT -5
Ok, this might be me projecting what I do onto others, but the issue is that most people simply aren't that motivated. The big reason that I use a Dexcom rather than a Libre is because I can have my levels in the notification bar on my phone so every time I look at the phone. It turns out I look at my phone far more often than I can be bothered to scan the Libre. I only really scan the Libre when I would have done a finger stick anyway rather than periodically as I should if I want to be proactive. I would hazard that most PWD guess their BG based on how they feel. If you feel off you test, otherwise you assume it's more or less where it should be. That feeling not quite right is the prompt to test. Insurers hate CGMs with a passion because they are expensive to run which is why so few T2 have them. They fought against CGMs for years and it wasn't until they forced to do it by the trial data that they started to cover T1. Even then they were very restrictive for years. The Libre seems to have changed that a bit as it is cheaper for the insurer, but it lacks that push notification (although I am looking at the MiaoMiao which converts the Libre to a full CGM). Insurers are starting to offer services like Livingo which has coaching as well as a meter that reports numbers back to the cloud via the cell service. I politely declined since I don't want my insurers having any of my data as far as possible. My experience over just the last 2 weeks working with 3 new T2 Libre users is very much different.
First - the T2 has little need to keep looking at their reading ever few minutes. What they need to see is their profile while awake and their sleeping profile
Second - looking at meal time, 30/60/90/120 minutes after a meal and associated afrezza dose should do it
Third - After reviewing the profile and seeing a spike/dip they need to record what caused the spike/dip - what they ate, exercise, etc.
Fourth - Being obsessed and looking every few minutes during the day is not only a waste of their time but it is counter productive to the goal of afrezza which is to make them healthy and put more freedom in their live.
What I am seeing with the new users is a great deal of excitement and motivation. What they say is they had no idea how different foods affected them so much. The visual feedback is a huge motivator. The Libre is a game changer for them. I think I mentioned a friend of mine has a mom in India and we set her up on Nightscout so he can monitor her. She was running over 400. She thought prior to the Libre she had no sugar issues just "other" issues. We can't get her the afrezza over there but now she is on lantus which is a start. She is no way taking three shots a day plus the lantus. Its just not going to happen, sadly she would rather die.
One of the new Libre lady's is 60. Her dad died from diabetes complications including being an amputee. Her sister is a Step 3 T2 and is losing the battle. The Libre Lady had a 5.9 A1c. She asked the PCP for a Libre when her doctor told her her A1c was 5.9. Her doctor told her she did not need it and would not prescribe. We got her one and now she is amazed at what she is seeing and is putting a nice AGP history together to have a follow-up discussion with her doctor who clearly gave her bad guidance. Sadly, this PCP is typical. They really want to keep these PWDs in the dark.
I think you missed the point with using the phone as a display device. You don't look at the phone to see your level, you see your level when you look at your phone. In other words you see your level as a by-product of normal phone use. Looking at your phone every few minutes just to see your level would be obsessive (ditto looking at your Libre every few minutes). We are going to have to differ on point two, but I think expecting that most people will test with their Libre every 30 minutes for a couple of hours every time they eat is unrealistic. On a good day I would expect them to do it once in that period, but mostly I would be shocked if they did it at all. I would expect them to test before they took the first dose of Afrezza and that would be it. Again, at this point it's all speculation in both directions because there is no comprehensive data available. |
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Post by agedhippie on Mar 21, 2019 20:57:44 GMT -5
Yeah, that's insurance fraud (although in this case I wish them well) so it's not going to scale to thousands of people. A good start would be to make Libre OTC like meters and not Rx. |
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