Why Afrezza retention is low and what to do about it...

[bill]

Apologies if this has been discussed previously or discussed in the VDEX literature or postings. Moderators can feel free to delete my thread if so... The below is based on what I've read on this board over the past few years since I'm not diabetic...

I'd like to hypothesize that Afrezza retention with T1 users (even those equipped with a CGM) is compromised because of their life-long use of subcutaneous RAA insulins. This class of users have undoubtedly experienced hypoglycemic episodes, and are very likely to be concerned about hypos when switching to Afrezza. As a result, without guidance to the contrary, when first using Afrezza they:

• Dose (pre-Bolus) before eating to ensure they don't spike high during their meal which diminishes Afrezza's effectiveness
• Use less rather than more insulin so they don't experience hypos post-meals
• Are reluctant to take follow on doses because of they don't want to stack and go hypo--particularly overnight

The net result is that they believe Afrezza doesn't work--and they have the CGM data to prove it!

My recommendation is that new T1 patients be told they will need to aggressively dose Afrezza to get best results, i.e.,--(perhaps while also noting that Afrezza is likely to appear ineffective using an initial conservative dosing procedure)

• Dose during or after meals
• Use more than you believe is necessary
• Be willing to take a follow on dose that's dependent on the type of meal and the current CGM profile

Bottom line; tell new Afrezza T1 patients to expect that Afrezza may initially appear to be ineffective until they get comfortable using a more to much more aggressive dosing profile than would seem prudent.

T2 patients, on the other hand, have no experience with RAAs, so they are not biased towards any particular dosing profile. OTOH, they don't have the advantage of having CGMs to see what's happening.

My recommendation is that MNKD partner with one or more CGM vendors to arrange a new-T2-Afrezza patient 3-month CGM lease program so T2's can see the real-time behavior of Afrezza and learn how to maximize its effectiveness. After 3-months the CGM partnership could allow the users to purchase their CGM at a discounted price, or return it in favor of using less-expensive blood glucose monitoring technologies. MNKD could reduce the end-users costs by discounting Afrezza for new T2 patients for some period of time; at least 3 months, perhaps a year.

The bottom line here is that within 3 months the T2 patients should experience very good blood glucose control and be informed enough to make a go-forward decision with their physician(s) on whether to stick with Afrezza and/or their CGM use. Whether they continue or not, they will have their 3-month Afrezza/CGM baseline in hand to measure how well their blood sugar can be controlled.

Just my two cents!

[lennymnkd]

My recommendation is that MNKD partner with one or more CGM vendors to arrange a new-T2-Afrezza patient 3-month CGM lease program so T2's can see the real-time behavior of Afrezza and learn how to maximize its effectiveness. After 3-months the CGM partnership could allow the users to purchase their CGM at a discounted price, or return it in favor of using less-expensive blood glucose monitoring technologies. MNKD could reduce the end-users costs by discounting Afrezza for new T2 patients for some period of time; at least 3 months, perhaps a year.


Read more: mnkd.proboards.com/thread/11376/why-afrezza-retention-low#ixzz5uABtVcqY IF NOT THAT EXACT SENARIO... some form of alliances with CGM companies should be in order .. the technology is just too perfect .. the synergies are a dream ..

[rtmd]

Jul 19, 2019 16:38:18 GMT -5 bill said:

Apologies if this has been discussed previously or discussed in the VDEX literature or postings. Moderators can feel free to delete my thread if so... The below is based on what I've read on this board over the past few years since I'm not diabetic...

I'd like to hypothesize that Afrezza retention with T1 users (even those equipped with a CGM) is compromised because of their life-long use of subcutaneous RAA insulins. This class of users have undoubtedly experienced hypoglycemic episodes, and are very likely to be concerned about hypos when switching to Afrezza. As a result, without guidance to the contrary, when first using Afrezza they:

• Dose (pre-Bolus) before eating to ensure they don't spike high during their meal which diminishes Afrezza's effectiveness
• Use less rather than more insulin so they don't experience hypos post-meals
• Are reluctant to take follow on doses because of they don't want to stack and go hypo--particularly overnight

The net result is that they believe Afrezza doesn't work--and they have the CGM data to prove it!

My recommendation is that new T1 patients be told they will need to aggressively dose Afrezza to get best results, i.e.,--(perhaps while also noting that Afrezza is likely to appear ineffective using an initial conservative dosing procedure)

• Dose during or after meals
• Use more than you believe is necessary
• Be willing to take a follow on dose that's dependent on the type of meal and the current CGM profile

Bottom line; tell new Afrezza T1 patients to expect that Afrezza may initially appear to be ineffective until they get comfortable using a more to much more aggressive dosing profile than would seem prudent.

T2 patients, on the other hand, have no experience with RAAs, so they are not biased towards any particular dosing profile. OTOH, they don't have the advantage of having CGMs to see what's happening.

My recommendation is that MNKD partner with one or more CGM vendors to arrange a new-T2-Afrezza patient 3-month CGM lease program so T2's can see the real-time behavior of Afrezza and learn how to maximize its effectiveness. After 3-months the CGM partnership could allow the users to purchase their CGM at a discounted price, or return it in favor of using less-expensive blood glucose monitoring technologies. MNKD could reduce the end-users costs by discounting Afrezza for new T2 patients for some period of time; at least 3 months, perhaps a year.

The bottom line here is that within 3 months the T2 patients should experience very good blood glucose control and be informed enough to make a go-forward decision with their physician(s) on whether to stick with Afrezza and/or their CGM use. Whether they continue or not, they will have their 3-month Afrezza/CGM baseline in hand to measure how well their blood sugar can be controlled.

Just my two cents!

You couldn't do any of that without permission from the FDA. Good luck with that.

[rtmd]

Jul 19, 2019 17:04:25 GMT -5 lennymnkd said:

My recommendation is that MNKD partner with one or more CGM vendors to arrange a new-T2-Afrezza patient 3-month CGM lease program so T2's can see the real-time behavior of Afrezza and learn how to maximize its effectiveness. After 3-months the CGM partnership could allow the users to purchase their CGM at a discounted price, or return it in favor of using less-expensive blood glucose monitoring technologies. MNKD could reduce the end-users costs by discounting Afrezza for new T2 patients for some period of time; at least 3 months, perhaps a year.


Read more: mnkd.proboards.com/thread/11376/why-afrezza-retention-low#ixzz5uABtVcqY IF NOT THAT EXACT SENARIO... some form of alliances with CGM companies should be in order .. the technology is just too perfect .. the synergies are a dream ..

Insurance companies don't even like covering CGMs for T1s. Good luck with trying to convince them to pay for T2 CGMs.

[joeypotsandpans]

Jul 19, 2019 18:18:10 GMT -5 rtmd said:

Jul 19, 2019 17:04:25 GMT -5 lennymnkd said:

My recommendation is that MNKD partner with one or more CGM vendors to arrange a new-T2-Afrezza patient 3-month CGM lease program so T2's can see the real-time behavior of Afrezza and learn how to maximize its effectiveness. After 3-months the CGM partnership could allow the users to purchase their CGM at a discounted price, or return it in favor of using less-expensive blood glucose monitoring technologies. MNKD could reduce the end-users costs by discounting Afrezza for new T2 patients for some period of time; at least 3 months, perhaps a year.


Read more: mnkd.proboards.com/thread/11376/why-afrezza-retention-low#ixzz5uABtVcqY IF NOT THAT EXACT SENARIO... some form of alliances with CGM companies should be in order .. the technology is just too perfect .. the synergies are a dream ..

Insurance companies don't even like covering CGMs for T1s. Good luck with trying to convince them to pay for T2 CGMs.

The insurance companies have no issues whatsoever covering the 14 day Libre, that is all that is needed for the T2's to monitor their BG throughout the day/night in a very efficient manner. 

[bac]

Thread title begins:  "Why Afrezza retention is low"

Anyone know how to calculate Afrezza retention rate from Symphony scripts?
What is the (non-VDEX) Afrezza retention rate?

[mnholdem]

Jul 19, 2019 17:34:34 GMT -5 rtmd said:

Jul 19, 2019 16:38:18 GMT -5 bill said:

Apologies if this has been discussed previously or discussed in the VDEX literature or postings. Moderators can feel free to delete my thread if so... The below is based on what I've read on this board over the past few years since I'm not diabetic...

I'd like to hypothesize that Afrezza retention with T1 users (even those equipped with a CGM) is compromised because of their life-long use of subcutaneous RAA insulins. This class of users have undoubtedly experienced hypoglycemic episodes, and are very likely to be concerned about hypos when switching to Afrezza. As a result, without guidance to the contrary, when first using Afrezza they:

• Dose (pre-Bolus) before eating to ensure they don't spike high during their meal which diminishes Afrezza's effectiveness
• Use less rather than more insulin so they don't experience hypos post-meals
• Are reluctant to take follow on doses because of they don't want to stack and go hypo--particularly overnight

The net result is that they believe Afrezza doesn't work--and they have the CGM data to prove it!

My recommendation is that new T1 patients be told they will need to aggressively dose Afrezza to get best results, i.e.,--(perhaps while also noting that Afrezza is likely to appear ineffective using an initial conservative dosing procedure)

• Dose during or after meals
• Use more than you believe is necessary
• Be willing to take a follow on dose that's dependent on the type of meal and the current CGM profile

Bottom line; tell new Afrezza T1 patients to expect that Afrezza may initially appear to be ineffective until they get comfortable using a more to much more aggressive dosing profile than would seem prudent.

T2 patients, on the other hand, have no experience with RAAs, so they are not biased towards any particular dosing profile. OTOH, they don't have the advantage of having CGMs to see what's happening.

My recommendation is that MNKD partner with one or more CGM vendors to arrange a new-T2-Afrezza patient 3-month CGM lease program so T2's can see the real-time behavior of Afrezza and learn how to maximize its effectiveness. After 3-months the CGM partnership could allow the users to purchase their CGM at a discounted price, or return it in favor of using less-expensive blood glucose monitoring technologies. MNKD could reduce the end-users costs by discounting Afrezza for new T2 patients for some period of time; at least 3 months, perhaps a year.

The bottom line here is that within 3 months the T2 patients should experience very good blood glucose control and be informed enough to make a go-forward decision with their physician(s) on whether to stick with Afrezza and/or their CGM use. Whether they continue or not, they will have their 3-month Afrezza/CGM baseline in hand to measure how well their blood sugar can be controlled.

Just my two cents!

You couldn't do any of that without permission from the FDA. Good luck with that.

Of course you could. As a physician/clinic you are not bound to the FDA label like drug manufacturers. Several PB posts have documented doctors even prescribing Afrezza off-label to minors.

[rtmd]

Jul 20, 2019 8:29:49 GMT -5 mnholdem said:

Jul 19, 2019 17:34:34 GMT -5 rtmd said:

You couldn't do any of that without permission from the FDA. Good luck with that.

Of course you could. As a physician/clinic you are not bound to the FDA label like drug manufacturers. Several PB posts have documented doctors even prescribing Afrezza off-label to minors.

Yes, the doctors could, but Mannkind, as I understand it, is limited to promoting what is said on the insert -- the same reason they can't promote pediatric use of afrezza.

[mymann]

Make it simple as possible. Doctors are lazy and trying to see patients every 5 minutes is how they can pay their overhead. If anything, most doctors don't really understand how to prescribe even simple insulin takes too much time.

[sweedee79]

Rentention is low cuz docs are stuck in our present SOC.. no matter what anyone says they will be scared of hypos and lawsuits so won't prescribe proper dosing.. or a doc will prescribe without taking the time to really understand.. or it's too expensive ..

In any case Mnkd isn't getting the job done.. so they need to try something different..

[mymann]

Go after new docs, young energetic young doctors are open to new and innovative treatments. As they start settling up their practices wanting to be busy, they will try different approaches until they get so busy and gets burned out what ever it takes to get rid of the patients quickly will be their satisfaction of being successful. It is about what is right but how many patients they can see.

[mymann]

Don't give too much credit to Doctors doing the right thing. It's about not getting sued and making money.

[mymann]

One more thing. Most Doctors don't like using new drugs just hitting the market. Old faithful drugs that maybe work or not effective will be first choice because if most Doctors are using it, it will keep you out of trouble.

[Deleted]

Jul 20, 2019 14:15:55 GMT -5 mymann said:

One more thing. Most Doctors don't like using new drugs just hitting the market. Old faithful drugs that maybe work or not effective will be first choice because if most Doctors are using it, it will keep you out of trouble.

Doctors are regular people too.  There are some that will try NEW THERAPIES and some will NOT.  It depends on the doctor.  If a doctor has a patient (T1 or T2) STABLE around 7.5 they are not going to switch until the doctor is 100% positive the switch is appropriate and warranted.  In regards to Afrezza that will be after a conservative doctor has enough experience and that could take 12-18 Mos.  

[Deleted]

Jul 20, 2019 13:52:09 GMT -5 sweedee79 said:

Rentention is low cuz docs are stuck in our present SOC.. no matter what anyone says they will be scared of hypos and lawsuits so won't prescribe proper dosing.. or a doc will prescribe without taking the time to really understand.. or it's too expensive ..

In any case Mnkd isn't getting the job done.. so they need to try something different..

Very True...I saw my PCP last week and gave him the article about New Type 2's going on Afrezza which could be a cure.  He was very interested.  FDA and ADA need to come together and make changes to the SOC but that will only happen when there's enough proof Afrezza + CGMs really help the patient.