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Post by alcc on Jul 3, 2014 16:35:12 GMT -5
Q: What percent of Type 2 patients are on prandial insulin? I know most Type 2s when they start on insulin get put on basal (plus oral) and only those with high A1c (>10%?) and FBG would be put on prandial. But I cannot get any statistics on this. Obviously, this is an important piece of data re Afrezza TAM. Any reliable info? Thanks.
Q: The last three days of orderly trading is impressive -- and surprising. So, for you technicians out there who obviously foresaw this development, what do you call this sort of pattern? Headless shoulder formation? Flat-line channel? And what does this pattern tell you about what action to expect next? (From a skeptic).
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Post by jpg on Jul 3, 2014 18:47:29 GMT -5
Q: What percent of Type 2 patients are on prandial insulin? I know most Type 2s when they start on insulin get put on basal (plus oral) and only those with high A1c (>10%?) and FBG would be put on prandial. But I cannot get any statistics on this. Obviously, this is an important piece of data re Afrezza TAM. Any reliable info? Thanks.
Without providing any hard numbers (sorry...): not that many type 2s are on prandial insulin and this is an important statistics because even with the type 1 and the relatively few type 2s on prandials big Pharma sells billions of the stuff. Most clinicians start basals when pills don't work anymore then add, as a last 'desperate' step prandial insulin. Now this is where this could get very interesting for us because the logical way of introducing insulin should be to start of with prandial insulin and do so as early as possible.The barriers to doing this are needles and the complexity of monitoring the 'fat tail effects' of available prandial insulins. What does Afrezza deal with so well? Exactly those 2 issues. Perfect for busy primary care MDs who want to do the right thing for patients but findtit very difficult to do because there had not been, till now, a good prandial insulin. Basically I am saying the way to look at this is: how many diabetics are not on prandials but could or should be? This is at least an order of magnitude bigger as a market then the direct head to head competition against currently available prandial injectable imsulins.
JPG
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Post by alcc on Jul 3, 2014 19:19:10 GMT -5
Introducing ultra rapid acting prandial early makes sense. We all buy this thesis. However, that requires a paradigm shift among clinicians? Also, yes, Afrezza does away with the needle, but not the finger prick. Not exactly pleasant.
I am trying to get a handle on Afrezza TAM (total available market). Type 1 prandial TAM looks to be about $6B based on Humalog and Novolog sales. Even if we take 1/3 of that share in 3 years, that's ~$2.5B (assuming decent growth). Assuming 25% net margins, that's "only" ~$630M, which has to be split somehow between company and partner. You see the problem. We need to grow the Type 2 prandial market.
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Post by liane on Jul 3, 2014 19:41:28 GMT -5
Very well said jpg - it's not the monster we see, but the one we don't.
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Post by jpg on Jul 4, 2014 0:21:30 GMT -5
Introducing ultra rapid acting prandial early makes sense. We all buy this thesis. However, that requires a paradigm shift among clinicians? Also, yes, Afrezza does away with the needle, but not the finger prick. Not exactly pleasant. I am trying to get a handle on Afrezza TAM (total available market). Type 1 prandial TAM looks to be about $6B based on Humalog and Novolog sales. Even if we take 1/3 of that share in 3 years, that's ~$2.5B (assuming decent growth). Assuming 25% net margins, that's "only" ~$630M, which has to be split somehow between company and partner. You see the problem. We need to grow the Type 2 prandial market. No I honestly don't see the problem. Medicine is all about paradigm shifts. Who used stents 20 years ago? Who gave antibodies for cancer 20 years ago? Who did laparoscopic 'everything' 20 years ago? Ultrasound for so much 'stuff' by intensivists, anesthesiologists, cardiologists, ER physicians. I could go n and on. Is diabetic management immune to change? I really doubt it. It is just there weren't any good treatments out there to shake up the status quo. Again I don't look at the current prandial insulin market as what MNKD will primarily upset. That is the tip of the iceberg. The big deal is the oral agent market that will or should eventually get displaced by Afrezza. I believe many (most?) of the currently available piils out there are being prescribed because insulin is so painful (not necessarily the injections themselves) and complicated to prescribe. Afrezza changes or has the potential to alter the equilibrium dramatically if the science and marketing post approval are done right. Those who blast A. Mann for whatever shortcoming they see (more a Yahoo MB and 'the other board' issue...) don't seem to understand that he deeply understands what studies need to be done to prove or show why prescribing a prandial insulin without a fat tail is or should be near first line in the management of diabetes. Look at the gestational diabetic algorithm for guidance to how I think diabetics should all be managed. Afrezza is a successful science project and the way to sell it to MDs and patients is, in my opinion, the continuation of this good science project (REMS in kids being a prime example of this) with savvy marketing. Hopefully our future partner will be half as scientifically savvy (so hope we don't end up with Lilly!) as A. Mann. Novartis being my top choice in this aspect and luckily Greenhill is big on Novartis. Glucose finger sticks are a different issue obviously but Afrezza (if used extensively and well) will or should also dramatically alter the way we view how often glucose should be measured. Afrezza would be a catalyst for implemantation of near continous monitoring 24/7 of sugar levels. Sometimes one catalyst has the potential to revolutionize a branch of medicine. If done right Afrezza could be that catalyst foe diabetic management. JPG
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Post by babaoriley on Jul 4, 2014 0:33:11 GMT -5
jpg, well said! You and afrezzamiracle are positively waxing poetic this evening! A great start to the 4th of July fireworks!
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Post by alcc on Jul 4, 2014 3:59:28 GMT -5
jpg, obviously I fundamentally agree with your point of view. I am in for the long haul. Of course paradigm shift occurs with regularity and is what constitutes progress. The "problem" I referred to is not our shared conviction but how analysts will start to model the company's numbers. We can talk all we want about the T2 iceberg and other blockbuster applications for Technosphere; however, we should (I sure hope so) start to see more analysts starting to follow the company (I am talking real analysts, as opposed to the moronic self-appointed SA types). Personally, I don't give much credence to analyst reports (I don't own a stock unless and until I feel I know more than they do). However, analysts will eventually be the ones who will drive the interest (and valuation) in the company for both institutional as well as street investors. That is the investing community/infrastructure we have to deal with. And analysts can only model based on available market size, competition, market share, channels, pricing structure etc. I can assure you they won't and can't account for paradigm shifts in their models. In their narratives, yes. Not in their models. That's the problem -- as I see it.
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Post by liane on Jul 4, 2014 5:03:27 GMT -5
alcc,
You're absolutely correct that the analysts will be slow on correctly valuing Afrezza and MNKD. But eventually (and this may take several years) the true market size will become apparent. That just makes MNKD a great buy for anyone willing to hold long term.
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Post by alethea on Jul 4, 2014 9:34:01 GMT -5
"Introducing ultra rapid acting prandial early makes sense. We all buy this thesis. However, that requires a paradigm shift among clinicians? Also, yes, Afrezza does away with the needle, but not the finger prick. Not exactly pleasant. "
I was diagnosed Type 2 ten years ago. I suffered the painful finger pricks for about 3 weeks until a pharmicist suggested a Freestyle meter suitable for forearm testing. I've been forearm testing for 10 years. Virtually painless. I don't understand why peope are are still pricking their fingers, especially Type 2's with little or no chance of dangerous hypoglycemic events.
Due to an insurance change, I now use Accu Chek Nano. It works well also.
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Post by jpg on Jul 4, 2014 14:20:50 GMT -5
alcc,
You have to also agree that an analyst who can't factor in revolutionary innovation into his model will not be a great help to investors. To use only one obvious example the analyst would have 'missed' Apple not once but 4 or 5 times. Great analysts should model these paradigm shifts in their model. Some great analysts probably don't because of career risk. Then again these great analysts probably find other employers who get it and use their talent? Making projections that deviate to much from the mean is as you know dangerous. Putting a band of possibilities of sales on a drug like Afrezza will give ridiculously high market caps if Afrezza takes a meaningful chunk out of the oral market. Imagine an analyst writing down future 5-10 year sales with a range of 1 billion to 20 billion. Who would believe and give him a second paycheque? There are obviously many moving parts in these types of mass market and time will hopefully prove us right no matter what the analysts say. Valuation always follows.
As for glucose monitoring: This is not an area I currently follow as an investor or as a physician for now but it seems there soon might be non invasive continous blood sugar monitoring that actually works. There are also permanently implanted sensors being worked on. All topic that could be interesting investment ideas for those with the time maybe?
JPG
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Post by alcc on Jul 4, 2014 16:47:32 GMT -5
jpg, I agree 100%. Of course most analysts missed Apples's run. And of course most of them jumped on that bandwagon with strong buys at the stock peaked. As I said, I have no respect for analysts. Still, for us, it is important to do our own analysis, break down current market size and growth opportunities in T1 versus T2, weigh risks versus opportunities, anticipate what models analysts will likely come up with, etc. A strong thesis is what supports a strong conviction and enables a "strong hand" imo. Thanks for your reply to my question re prandial insulin use for T2.
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