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Post by stevil on Jan 30, 2024 10:49:53 GMT -5
Try contacting your local Afrezza rep. Usually the cash program only works for people whose insurance doesn’t cover Afrezza at all but I’d imagine they could probably pull some strings to get it to you for $100/box if that’s still doable.
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Post by stevil on Jan 22, 2024 23:20:54 GMT -5
external-content.duckduckgo.com/iu/?u=https%3A%2F%2Ftse1.mm.bing.net%2Fth%3Fid%3DOIP.dB_YbeZi5rZ-z90PDEqeIAHaG6%26pid%3DApi&f=1&ipt=81314e796654bf4d89c231cc3486cf676a90ec214d8ba89fc216258ee560109d&ipo=imagesI don’t really care to refute every “point” you make because you constantly live in a world where sound, proven research is inaccurate because it doesn’t fit your narrative. Viruses have been around as long as humans have- they just now started to cause diabetes?! You can’t even use international travel as an excuse because there should be pockets of people in the past that had these viruses plaguing them before they airplanes made their diseases rampant. I’ll save you the trouble- they don’t exist. Then, how do you explain how low income people suffer most from diabetes? Must be the viruses only target them, ignoring the fact they don’t eat high quality food and are most prone to stressful lives and a high content of fast and cheap, processed foods. Looking at the linked graph… you really want to look at that graph and say a virus that came out in 2020 caused that slope?! I usually don’t like to argue like this because correlation does not equal causation, but tell me if this graph looks anything like the link above- cause they look awfully similar to me. external-content.duckduckgo.com/iu/?u=https%3A%2F%2Fupload.wikimedia.org%2Fwikipedia%2Fcommons%2Fthumb%2Ff%2Ffc%2FObesity_in_the_United_States.svg%2F1200px-Obesity_in_the_United_States.svg.png&f=1&nofb=1&ipt=7a4c2d107505660bee2809870dfd6f4e0f11f25c0130eabfb20cce7af9899cc0&ipo=imagesBtw, I never said obesity causes diabetes. I have patients with BMI over 50 with an A1c of 4.8. Not everyone gets it. In fact, this is probably even better proof that your virus theory is wrong- if it was caused by a virus, that guy was just lucky enough to have dodged it?! What about the other 250 million Americans that don’t have diabetes from COVID? There’s a genetic link and predisposition to diabetes. It’s probably why it runs in your family. Unless your family never came in contact with anyone else, why were they the only ones that got it? I think there are probably some people who get viral illnesses and then develop diabetes. These people probably have LADA and make up a very small subset of diabetes. But just in the way not all smokers get lung cancer, not all people that are obese get diabetes. There is a whole new field of epigenetics that look into this. I’d recommend doing some reading… I will admit I don’t fact check every source that I have been taught. I trust my medical education and I try my best to eliminate biases, intentional or otherwise, from the data I do look at. I’ve said about all I can say on this. I don’t really care to go line by line refuting you because as aged has said many times, your basic science is often way off and you don’t ever back down from your stances. I’ll spare others the grief of the constant back and forth and save myself a few headaches as well. People will choose who they will believe. You will choose who and what you will believe. You can literally find research to support anything. Some people have even sought out to prove that smoking is good for your health and have “evidence “ so support it.
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Post by stevil on Jan 22, 2024 20:50:44 GMT -5
I’m not so certain that giving people with diabetes insulin as the first step is “medically correct” yet. That cannot be stated as fact yet.
I often order fasting insulin on my obese/prediabetic patients to see how big their risk factor is of getting diabetes. Way more often than not, they’re not at an insulin deficit but they actually have hyperinsulinemia. This was talked about in the podcast I linked.
You could actually make the argument that targeting insulin sensitivity/resistance is actually “medically correct” since that’s actually the underlying problem, not an insulin deficit.
It’s actually not harmless to have people running around with excess insulin. Insulin is pro-inflammatory in excess (although, to be fair this is seen much more with long-acting insulin, maybe not Afrezza. However, a precedent has been set between the effects of exposure to insulin and inflammation).
All that to say- I’m not disagreeing with Bill, per se. I just don’t think anyone can say with certainty that the SOC is completely wrong and AFALAA is the for sure correct step. I think the SOC paints the general population with a broad brush instead of a more nuanced approach. I think as more is learned about diabetes, more individualized treatment will eventually emerge. I think the SOC will work for most and AFALAA will be better for some as well. I have some patients stable on metformin for 30 years. Others that rapidly progress in 3-5 years without insulin antibodies and don’t have LADA.
If Bill believes he has the answer, he absolutely should set out to prove it. Man(n)kind needs him to. Despite how some might read my thoughts, I actually view myself as an ally and friend to him and he was more than gracious to share his thoughts with me when I was first starting to use Afrezza. I just don’t share the same convictions… yet.
Type 2 diabetes hardly existed 50 years ago. It wasn’t a virus that increased incidence. It’s an unhealthy lifestyle. Humans used to need to do work to live. Now we sit and drive around in cars. We used to have a perpetual food shortage (unless you were royalty), now we all eat like kings with access to refined, ultraprocessed, calorie dense foods that lack the necessary fiber to tell our brains we’re not hungry. Our intestinal flora is disrupted as well as good bacteria cannot thrive when eating garbage for food.
As I have stated before, we should be clamoring to change the food pyramid and being advocates for exercise. I suspect a lot of people on this board may not feel as strongly about Afrezza if they were not invested in MNKD, or at least might have different priorities/viewpoints in this debate.
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Post by stevil on Jan 22, 2024 2:29:06 GMT -5
*don’t get any newly diagnosed type 2s on a CGM.
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Post by stevil on Jan 21, 2024 21:48:05 GMT -5
Mounjaro fixes the underlying problem of insulin sensitivity and takes no work by the person using it.
Healthiest? Diet and exercise, then Afrezza.
Most likely to succeed in reducing A1c with minimal effort and potentially no lifestyle change? Mounjaro.
I’m not necessarily disagreeing with Bill. I just have a different vantage point because I have only gotten 1 newly diagnosed type 2 diabetic on Afrezza, whereas VDex gets nearly all of their newly diagnosed patients on Afrezza.
I also don’t get any newly diagnosed type 2s except that one Afrezza user, so take my words with a different grain of salt. So while I don’t get to see CGM miracles all the time, I do see many patients successfully put their diabetes in remission without Afrezza. So I’d like to see it play out on a bigger scale to avoid statistical anomalies and selection biases.
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Post by stevil on Jan 20, 2024 15:01:51 GMT -5
I think that would be my preference in an ideal world- Mounjaro +Afrezza. However, you’re now talking around $3500/month for treatment. That’s not going to work if everyone does it.
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Post by stevil on Jan 19, 2024 22:55:01 GMT -5
You are missing the point - its not about making money. Its about breaking the insurance blockade and establishing the base. The $35 campaign only makes sense if the Cipla and kids trial data is a good as Mike has signaled. If they are then we have solved the multi-year Proboards discussion that afrezza does not have the "data" for doctors to prescribe. You also never give anything away for free which has value and afrezza has value. Even if you have people pay $1 that is significantly different than "free". Even in the days of AOL you got the CD for free but then you had to pay the $5 per month. Is $35 the right number IDK. Maybe its a little more or less but $35 is the current Medicare price for insulin. Its also the number Mark Cuban promised for CostPlusDrugs. From an ongoing business perspective, as long as BP has afrezza at 1k scripts afrezza is really not worth perusing. If it were not for Tyvaso DPI paying for the factory afrezza at 1k scripts a week even at the current $1000 a box pricing is a money loser. Even a bigger question for you is do you agree with Bill from VDex and think afrezza should be prescribed first or do you think the current T2 SoC is the right way to go? It has to be about making money when you're a publicly traded company not named Amazon. Let's say you build up the base for 50,000 people to get on Afrezza. What makes you think insurance is going to want to turn around and increase reimbursement from $35 to $1000 if they even decide to cover the patient going forward? I'd much rather they spend that minimum of $25 million of losses over a couple years designing a bomb ass study so they can actually continue getting the $1000 they're currently asking and then quickly turn 1000 weekly scripts into 50,000 once they become standard of care- if we're so sure the data will undeniably suggest that. To answer the last question- I honestly don't know. I don't really do any of my own research. I have to trust that the ones that do have done a good job. I can tell you I want to think like Bill does. I have some pretty amazing stories from diet/exercise, metformin, and Mounjaro all as monotherapy. Every one of those modalities got my patient from an A1c greater than 11 to putting their diabetes in remission. It's really hard to develop an informed decision when there isn't more than anecdotal evidence on Afrezza. I have just as many anecdotes with other medications. Do they stop the PPGE as well as Afrezza? No. But they also last longer and reduce the basal sugar better. The true SOC should be diet and exercise first, but no one really does that, so we throw medications at them.
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Post by stevil on Jan 18, 2024 22:51:04 GMT -5
I’m no engineer but I have been waiting for someone to use simple math to shut this conversation down. I guess I have to post after all.
$35 x 50,000 scripts nets you $1.75 million.
It’s been a while since ripano/kippy posted the weekly script numbers… I guess it’s been too long and everyone has forgotten this is about $250,000 short of what they were routinely getting with the current plan.
A better plan is to pay $250,000 (plus whatever expenses are incurred from all the extra manufacturing and labor) to give 49,000 scripts away?
Just poking fun. Carry on and on and on 😁
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Post by stevil on Nov 23, 2023 0:27:06 GMT -5
From Bill… “ I’ll confine my comments to Stevil’s recent post and our experience with Afrezza. In overview, I can confirm much of his experience with Afrezza. We at VDex have had many patients drop but it was almost always over the cost. Given Afrezza’s tier placement on most plans (if it’s even on formulary at all) it’s just not affordable for most people. Aside from the cost there is a learning curve with the use of Afrezza. As I may have said before we use the analogy of riding a bike. You don’t just give a kid a bike and tell him to go learn to ride. He’ll never do it. A parent puts the kid on the bike holds on to the bike to steady it till the child gains enough confidence to ride off on his own. Same with Afrezza. You’ve got to hold patients’ hand in the early stage and that is the reason for CGM. I don’t want to misinterpret Stevil but it sounds like many of his patients drop because of the hassle factor with CGM and multiple dosing per day. I’m not surprised by that. To enjoy wide acceptance among Type 2s (93% of the market) a therapy has to be cheap, easy, convenient, safe and MUST NOT make the patient feel lousy. Afrezza checks all those boxes AFTER getting past the learning curve, EXCEPT cheap. The multiple dosing and hassles with CGM really is part of the learning curve. We at VDex used to do multiple dosing, especially post-prandially. We don’t anymore because again, it’s a hassle. The better strategy we’ve found is to dose higher at the mealtime (because you really don’t need to worry about lows) and not worry about follow up dosing. There’s such a wide safety margin with the drug that If one doses 24 units instead of say 18, the patient won’t have a problem. The key is to dose the meal aggressively then forget it. You won’t need follow up doses. Less hassle. The only real problem with this approach is that it involves inhaling more powder and can cause a cough. Regarding CGM, we don’t use it continuously again because of hassle. The therapy needs to be easy. So CGM is used during learning phase (learning to ride the bike). Then forget it until perhaps annual assessment of patients’ BG profile. Once patients learn that they have three inhalations per day at mealtimes and NOTHING ELSE, they’re happy and compliance goes up. Last point, despite the popularity of Ozempic and similar drugs, they can’t compare to Afrezza. Not even close. It’s just that use of Afrezza is different and one has to learn. But then wasn’t bike-riding the same? And didn’t we all learn?” This is a unique challenge to Afrezza that MNKD needs to figure out how to solve. But it takes A LOT of resources to do it. I’m pretty sure I’ve understood Bill to say it’s taken a long time to dial in the secret sauce for Afrezza. The problem is, he had to teach himself. I’m having to teach myself with my patients. It’s hard for your patients to hear that you’re learning as they’re learning. It’s also hard to hold their hand when you have such limited access to care. Like I said, I’m booked out anywhere from 4-6 weeks minimum at my clinic. I wish I could hold my patients hand while they’re learning to ride the bike. This problem isn’t unique to my clinic- we’re actually much more accessible than many other practices in my area. Most are out 3 months. Afrezza demands very close initial follow up. There need to be clinics like VDEX that are dedicated to this training- or nurse educators from MNKD that can support this transition. Ultimately, I only had one patient quit out of sheer confusion /frustration. He was a fairly new diabetic and he was still trying to learn how to use novolog/humalog. In hindsight, I set him up for failure because he was still in the learning phase of those and then I tried to switch him to Afrezza. It confused the hell out of him- he had to unlearn everything he’d just learned and it was frustrating so he gave up and went back to novolog/humalog. His CGM looked like a sine wave bouncing up and down because I think he was overdosing on Afrezza, panicking because his CGM was freaking out because his sugar was dropping so quickly so he’d correct with sugar and do it all over again. MNKD has been trying and they now do offer an educator. This started at the beginning of this year. I take as much time as I can with my patients, but it’s incredibly difficult to train someone on the nuances of Afrezza in 20 minutes.
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Post by stevil on Nov 23, 2023 0:13:16 GMT -5
Stevil - are you breaking major news here? Did you just say your patients were seeing a 0.4-0.5% lower A1c when using afrezza than using what - Mounjaro? I am not sure what you are comparing afrezza to but if it’s GLP1s that is HUGE news. Can you clarify, please. Mike mentioned awhile back that the India trial could show results on par to GLP1s but 1/2% more is very significant if a head to head trial was done between afrezza and Ozempic/Mounjarno. Ah! The one time I don’t expect you to actually take my words for gospel you go and surprise me! I don’t actually compile the data and compare A1cs. Just off memory, the patients that stop Afrezza tend to get a higher A1c once they stop. Not all, but more than half. A lot of the patients that stopped were already on MDI and either replaced humalog/novalog with Afrezza entirely or just used it for corrections. These people were functionally type 1s because they were on basal/bolus as well as metformin, Jardiance, and trulicity. So it’s not really all that impressive. They could sneeze and their sugars would jump to the 300s. This is why they quit. I was really disappointed in one of them. He had been diabetic for a long time and he was almost in tears and thanked me for putting him on it after the 1 month follow up. He was a nurse and was one of the first people I felt comfortable enough to start on Afrezza. Maybe (probably) I’m still using training wheels, but Afrezza is much harder to use in advanced diabetes beyond just the inhalation count/cough aspect. You (the patient) actually have to understand diabetes and how your body responds to stress, exercise, high vs low glycemic foods, etc. because it is so precise and works so quickly, it takes a lot more monitoring. Humalog/novolog are a little easier because they’re so blunt. You aren’t trying to hit the bullseye, you’re just hoping to get close to the target. Anyway, to answer your question, as with all things diabetes, it really depends on the patient. I have had patients that put their diabetes into remission with just diet and exercise after having an A1c of 11. I’ve seen it many times with metformin as well. Putting diabetes into remission really isn’t that impressive for a good number of patients. It’s definitely not unique to Afrezza. It depends on where they are in their disease and how poor their health and habits are. I guess I haven’t answered the question yet. Hard to give thoughtful responses on a phone. In general the improvement was on people with advanced diabetes on MDI. There were a few with Ozempic. But generally, Afrezza was used in addition to the GLP-1s for postprandial corrections. And to be fair, I have had patients trade their Afrezza for Mounjaro and get over 1 A1c better. This goes back to my previous post to you. It wasn’t because Afrezza wasn’t working well- I gave them a tool they didn’t want to use. they just missed doses because they didn’t want to do it multiple times a day.
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Post by stevil on Nov 22, 2023 23:37:45 GMT -5
When Bill and Stevil mention cost being a major factor in discontinuation of Afrezza, I am just curious if these people did not qualify for the Afrezza Savings Card copay can be as low as $15-$35. Or Eagle Pharmacy savings program that is $99 for 1 month of 90 carts or $199 for 1 months of 180 carts. Did both VDex and Stevil use these services? If not, why not? If so, what went wrong? stevil sportsranchoMannkind has a very generous coupon card. If a patients insurance covers it, it’s never more than $35/month unless you order 5+ boxes a month. At that point, the patient isn’t a good candidate for Afrezza, at least not until they create an aero chamber for it where you can just let them inhale their dose over several minutes 🤣 I don’t recall the specifics but the maximum coverage is very high. So for people with high deductible plans with 💩 for pharmacy benefits (although those plans would then never cover Afrezza), the coupon card essentially absorbs the entire cost of the prescription and leaves just a $35 copay for it- as long as you send it through the specialty pharmacy. UBC automatically applies it for patients. Retail pharmacies don’t- they’d need to get the coupon card from their doctor or online. Idk who sends it to retail though. It’s way more convenient to just go through UBC. You do the prior auth on their website and then it gets shipped directly to the patient
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Post by stevil on Nov 21, 2023 23:36:53 GMT -5
Stevil - Wow! I don't know where to start but lets try here - "The other problem is information is nowadays too accessible". If thats a problem its only a problem for those trying to hide something. What happened to the info Josil use to have on the web about diabetes and viral infections? I haven't looked in a while but the last time I could not find it. It got scrubbed. For years Aged said over and over the reason he/she would not try afrezza is his/her endos said it would cause serious lung damage. It was just the other week I heard they stopped saying that 5 years ago. Really?. Here is what he/she just said "The fact that he/she for years said afrezza would cause serious lung damage?" No he did not, he just gave up correcting you because you refuse to listen. I have just debunked this statement literally days ago and yet here you are repeating the same stuff yet again." - Are you kidding me! Yes I was born but it was not yesterday. You ask - I don’t know why you feel pressured or responsible to find the root cause to fix the problem. The answer is that is what I do. Things to me have to make sense. I am the kind of guy when I drive down "Church Road" I ask where is the church. I was one of those guys who called bull on Covid coming from the under cooked bat burger when that was accepted truth. I am the kind of guy who asks why are we not giving people insulin when their bodies are no longer producing enough for their needs? Now, we can slap a CGM on them and watch their BG spike after meals so we give them metformin or better yet Ozempic so they don't eat as much - now that's brilliant. Lets mask the underlying problem. As you said too much information is a problem. We can also see we had a spike in diabetes when everyone was watching the numbers during Covid. We can again ignore that and pretend it did not happen. We can also ignore that we got a bunch of research money which allowed some good work including the autopsy of some pancreas and some fine pictures of three deferent types of beta cell clumps as a result. We can ignore that too as that may be too much info. Now for me this is a show stopper - "Lack of compelling information/data that Afrezza is superior to existing medications". Which medication - an RAA, an antiglycemic, which exactly? Afrezza crushes RAA's. We can measure those results with a CGM. There is not one antiglycemic which address the underlying problem - the body not making enough insulin for the body's need. Whether the body is "insulin resistant" or not we can slap a CGM on someone and see they have lost post prandial control. Again maybe we have to much information these days. We have Richard Bernstein as a living example of what happens when we do have great BG numbers. Is Bernstein an outlier at 89? I say no and Bernstein says no. We also have a ton of studies which have shown time and again, early insulin intervention has huge benefits. The goal regardless of the medication is blood glucose control. Can we do it with the Bernstein diet, yep. Can we do it with other insulins, yep. Does anything mimic first phase release like afrezza - nope. Afrezza makes the job much easier. Can you do it with metformin - nope nor the GLP1s if the people start eating again. On this one - At least half but probably closer to 75% of the patients I have started on Afrezza have made the decision to stop using it on their own. Thats not surprising. If you have not pointed them to afrezza direct at $99 they are paying too much. Is $99 too much, maybe for some. What are they paying for Ozempic? 80%+ stop using in 2 years. Now the big question - if you start the early T2 on afrezza do they even need it after 1 year? Should afrezza be available for $35 on Medicare with out pre auths - yep but the powers to be are doing all they can to stop it. Answering one question leads to 2 more. I would like to address your questions, if I can. Josil probably got scrubbed because they realized it wasn't accurate information. I don't live in a conspiracy theory world. I do think there are dark forces and absolute power corrupts absolutely, however, I'm not connecting the conspiracy theory dots that you are. I really don't understand why you're so fixated on this. It has no relevance to Afrezza. I am far from an expert on immunology- that's it's own beast. Do we know viruses cause disease? Absolutely. I think a better explanation for any increase in diabetes during covid would be better explained by people getting some nice stimi checks, eating a ton of fast food, not working or leaving their houses, being sedentary, being stressed, actually going to their doctors when they're sick because they don't do preventive checkups and now that they need medical care, it reveals all sorts of new things, etc. The vast majority of people I knew said they gained weight during the pandemic. Unhealth leads to diabetes. I think that's a way more plausible cause than covid, when again, we're injecting the very protein into people's bodies that causes all the harmful effects of covid, some up to 5 times now and they're still not getting diabetes. To be honest with you, though, it's not really an argument that I care to entertain because it doesn't interest me and I don't see any relevance to Afrezza. Not a hill I'm willing to die on and I'm probably the wrong person to engage/entertain the argument because I'd be just as content if covid did cause diabetes. For a while, yes, aged said there was concern about lung issues. I don't see him saying that anymore and actually see the opposite? I don't see conflict here. Do you just need him to admit his endo was wrong to move on? This is another one that confuses me... If finding the root cause of something is what you do, great! My follow up question for you would be- what has this done for you? Where have you gotten? Are you any closer to getting to that root cause than you were, say 7 years ago? Even if you find that elusive root cause, what will you do with it when you find it? What influence or ability do you have to then effect any change with the newfound information? I don't want to rob you of your joy, but unless you're more than "just an engineer" (which is not a slight, by the way)... good luck, I guess? We have had this argument so many times on this board I'm not even sure if it's worth addressing. In a perfect world where I could have my patients do exactly what I wanted them to do and cost were no issue, I would probably choose Afrezza for the vast majority, if not all, of my patients. I didn't say that Afrezza wasn't better than all other diabetes treatments- I simply said that MNKD has failed to prove that it is. Everything you state after my quote has not come from evidence you've gotten from MNKD. That's a problem, or a "root cause", if you will, for the lack of Afrezza's success. What literature are you citing when you say using Afrezza early in their disease will halt the progression of diabetes? Sure, we have literature on early, intensive insulin treatment. It's been a while since I checked, but I have never seen Afrezza listed in those studies. If you're going to change a paradigm in a long-established disease and its treatment, theoretical arguments aren't going to influence opinions. Doctors want to see evidence and data. I don't know what to tell you other than it doesn't exist outside of what VDEX has published, which, unfortunately, doesn't fit criteria for a reputable source in the medical community. A white paper has never been authoritative but is an idea that will hopefully sprout into a new study that confirms its findings. This just hasn't been done yet. I really don't know what there is to argue about. Nothing matters until this happens... It's just the way it is and denying it or saying it shouldn't be that way is just going to leave you banging your head against the wall for all of us to keep seeing. For the showstopper- Yes, I have several patients on Afrezza. A couple I have started early, and they have increased their dose since they started on it. I have 100s of patients at this point on GLP-1s. I think I have maybe 2, that I can think of, that have stopped treatment due to side effects. I have had several quit because their diabetes went into remission and they didn't want to take it anymore if they weren't diabetic. But I'm not quite at the 2 year mark yet at my practice, so maybe I need to give them more time... And, yes, I live in a high cost of living area with very good insurance coverage. Surprisingly, only about 15% of my patients were on medicaid and about 65% were commercially insured the last time I ran a report. $99 is too much for many of them. People just don't care about Afrezza the same way you do. They want the path of least resistance. Not to shame my patients, but in general, we're not talking about weekend warriors. While there are some unfortunate type 2s that do everything right when it comes to diet and exercise, the majority of people that get the disease didn't get it from making healthy choices. Half of my patients quit Afrezza on their own. The biggest issue was it was too much work to babysit their CGM with Afrezza. They got excellent results- they admitted as much. They just got tired of having to dose so many times a day when they could get 0.4-0.5% higher A1c with less than half the effort. Cost wasn't the issue for most of them. I think I only have 1 person right now that is using the cash program. MNKD covers all commercially covered Afrezza at $35/month with their coupon card. BTW, Mounjaro has a $25 coupon card for 3 months, which is much cheaper than what Afrezza would cost. These things don't matter to me, though. What matters to me is finding a plan that works for my patient. If I make them use Afrezza and they refuse to do it, you end up with an uncontrolled diabetic. I try to meet them where they are and give them the tools they're willing to use. The biggest problem I see you having is that people with diabetes don't always care about getting "the best" treatment. They care about good enough with the least amount of effort. I have said this many times in the past and I've been argued with probably every one of those times. I don't really see the point in arguing it. It just is what it is. Sometimes you have to accept things for what they are. Hopefully I have addressed everything you wanted me to.
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Post by stevil on Nov 21, 2023 22:54:04 GMT -5
Dr Stevil ; I’ll make it quick ! No disrespect, what is your number one reason for being on this Board .. you sound like a much to busy a guy to be here . No disrespect taken- and you don't have to call me Dr. My number 1 reason for being on the board is to educate people, I guess? I'm not really sure what the question is behind the question because I don't really think you're interested in the answer but are trying to take a jab? It's a shame to learn about all this stuff and not share it with others. I have no problem taking a back seat to aged (or anyone else)- as long as someone else makes sure accurate information is being shared. From time to time I chime when I can't sit idly on the sidelines anymore. Not sure if that answered your question, or the one behind the question. No, I'm not a paid short. Yes, I am an actual medical doctor.
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Post by stevil on Nov 21, 2023 10:04:54 GMT -5
I appreciate and respect your tenacity for pursuing your goals. You are clearly very driven.
I also appreciate acknowledging you’re an engineer and, in a way, “staying in your lane”. When I first joined this board, I remember one of the first things I noticed was doctors were bashed for being ignorant or lazy because they wouldn’t prescribe Afrezza. It was odd because it even seemed to garner support from past and present moderators. All that to say, I certainly don’t speak for all doctors and I double especially don’t claim to know everything or have all the answers. I don’t mind being challenged- the part that bothers me is when people partially educate themselves on a matter and then think they’re an expert because they know some things more than a doctor. It’d be akin to tearing out a page from a 10,000 page novel and flaunting that you know it better because you memorized that one page but can speak nothing about the other 9,999 pages. Doctors need to be challenged on certain things but - if it were me- I would approach it more with - “I found this. How would you explain x, y, or z since it doesn’t seem to follow a, b, or c.” I can’t tell you how many times in my personal and professional career I made a big stink about something only to later regret thinking I new what I was talking when I was able to look behind the curtain and see the bigger picture. Again, it’s not to say doctors or the profession of medicine is perfect and always correct. But it has been, and continues to be, that any failure regarding Afrezza does not fall on “us” but on MNKD for not giving us a good instruction manual to use their tool or providing a clear path to use it, even if “we” want to. From what I have seen of doctors, we crave knowledge and really want to help our patients. Mounjaro/Ozempic didn’t take a long time to catch fire. We can debate all we want about if it’s safe or not, but you’ve seen firsthand what happens when you hand a doctor excellent trial data with clear understanding on how to dose a medication to get a desired effect.
The other problem is information is nowadays too accessible. Especially now with chat GPT and AI. Without a skilled interpretation, you have no idea how to filter, or even trust that information to be correct. Hell, the part that sucks about medicine is you can even have medical trials share garbage conclusions. It even takes a good amount of skill to sort through trial data, find well vs poorly designed information, identify biases and see if they were thorough enough to correctly account for confounding factors. In a lot of ways, I love math and engineering a whole lot more than medicine. Numbers don’t lie. You can plug numbers in and find 3 different ways to verify it’s true, if needed. Unfortunately, medicine isn’t like that and that’s been one of my greatest struggles to help not only the people on this board understand but also now my own patients. I understand people want simple answers. Human beings are incredibly complex creatures. We live in an even more complicated environment with countless variables that need to be accounted for.
To get back to answering your question- I was responding to your question about how I seemed to take aged’s side of the argument. That was your claim, not mine. My posts speak for themselves regarding which issue(s) I’ve defended. Another part of aged’s, and now my criticism of your posts is that you receive an answer but seemingly immediately disregard it. This is proof to that end. You cannot recall which points of yours I have tried to refute. I don’t keep a log, but off hand, it was that you didn’t believe insulin resistance was a real phenomenon, you thought a diseased pancreas secreted ineffective goo rather than insulin, and you keep pounding the table on COVID being an underlying cause of diabetes. It could be a different protein than the spike protein (if COVID causes diabetes at all, which I don’t happen to agree with) that causes diabetes, but we’ve now vaccinated probably 300 million people with an mRNA vaccine that quite literally manufactures the spike protein to greater levels than many infections. And people are getting exposed and re-exposed to it - some as many now as 5 times. We’d expect a much greater number to be getting diabetes if COVID is the cause.
I also came to ages defense regarding the ELS claim you kept bringing up. He said he hasn’t been concerned about that for a long time. You kept pressing so I stepped in to correctly identify the early concern for IPF and lung malignancy because insulin was a growth hormone and Exubera started showing signs it may cause lung problems before it was taken off the market. Again, I place the blame for this long held failure to educate doctors on MNKD. I have worked closely with several reps. I have been given many company sponsored Afrezza information booklets. None of them explain the science of FDKP, how it passes through the alveoli intact and then dissolves once it crosses into the blood. I learned about all of this on this board. I also have been completely unaware of the decade plus of CT screenings that showed no structural damage except for on this board. None of my reps know anything about these studies. MNKD doesn’t disseminate any of this information in their doctor education material.
Finally, as though this post wasn’t already long enough and to tie it back to the beginning - I don’t know why you feel pressured or responsible to find the root cause to fix the problem. Unless you’re employed by MNKD, this isn’t really even your job to try and you’ll probably just annoy the people whose job it is to do this. I have essentially identified the root cause in my post above. I’ll also add:
1/2. Poor education for clinicians and poor support for patients that have issues. At least half but probably closer to 75% of the patients I have started on Afrezza have made the decision to stop using it on their own. It varies from not understanding how to dose to being too expensive to not wanting to stay on top of their disease when there are more convenient tools. I had a few stop because of the cough. I don’t have time in my schedule to babysit my patients and make sure they’re doing what they should. It often takes 1-2 months for my established patients to even get in to see me because I’m booked out so far. There aren’t any community resources to help people when they have a problem with Afrezza so they just stop using it and I find out at my next appointment they don’t want to use it anymore. This has since been somewhat addressed as they now have Afrezza trainers but they still haven’t fixed the clinician side of things.
3. Insurance reimbursement is abysmal. Every script I have written has required a prior auth. When you spend so much time charting, the last thing you want to do is spend an extra 5 minutes at the end of your day to spin a wheel and hope for the 40-50% success rate of your PA. Half to more than half of your time you’re wasting your time- and you know it. If I didn’t care enough about my patients, I’d give up. To be honest, it’s a constant battle I have with myself- if I’m prioritizing my family or my patients first. It can become moral injury when you do it too much.
4. Lack of compelling information/data that Afrezza is superior to existing medications. Is it better or does it just blend in and is it another tool in the toolbox. So far, MNKD hasn’t effectively differentiated it from other insulins other than its inhaled. Again, non of my reps seemed to know much about the STAT trial significance, although this was listed in the physician print out. They pushed the inhaled benefits rather than the hypoglycemic and weight benefit. I am not privy to their educational background, how MNKD trains their reps, etc. as we’ve seen, there is a high rep turnover. Are they not hiring quality reps? Are they not training them properly? Do they not stay around long enough to get the training? It could be any or all.
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Post by stevil on Nov 21, 2023 2:08:55 GMT -5
Say hey:
I disabled the “online now” feature a long time ago (looks like in 2016) when I was a med student and spent wayyyy too much of my time trying to temper the board’s enthusiasm (and getting nowhere). I guess it was my way of making myself less available, even though no one probably cared if I didn’t respond immediately.
And I don’t come to age’s defense. I just agree with just about all of his scientific opinions/facts. Aged has more patience and takes more time to develop thoughtful and research-based responses than I do. I appreciate someone doing that so I don’t feel a need to.
Sometimes the loudest voice on a board needs to be opposed in order to avoid the “illusory truth effect”, especially when onlookers can’t tell the difference between science and pseudoscience. The problem with logic is that you can have 2 sound arguments that reach different conclusions. The problem isn’t the argument itself, it’s the premise that needs to be truthful and meaningful in order to reach an accurate conclusion. I don’t always see that here, so I try to provide balance, as I always have from the beginning. I have no idea if people respect my opinion. But I do love truth and I will always defend her as much as I can, regardless of who says her name. It just happens to be aged as much as I see and pay attention.
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