|
|
Post by sayhey24 on Sept 14, 2018 5:35:10 GMT -5
Never posted before as only observed and love the potential of Afrezza. That being said I have been ICU nurse for 20 yrs and witnessed(no exaggeration) 100's of pt's go low after follow up dose of aspart per MD order c blood glucose ranging from 200-250. Brutal diabetics or insulin resistant ones have bad swings. Many times wake pt up to give D50 iv in the 20's after follow doses were administered 4hrs previous. Learned to never give any insulin to someone after 2100 unless familiar c their case. Would go against MD orders for safety of pt. Reason, the tails on any SQ insulin could be dangerous to fatal. Seen it and witnessed 3 tragic results. Of course these pt's had high co-morbidities but still rough on psyche. Never been able to administer afrezza as not accepted common practice yet for tx, but dearly wished had as the quick action and clearance would have made many of our nights in ICU less stressful. And I can't tell you stress that brutal diabetics can pose to a nurse. Afrezza would be a godsend to ICU pt's capable of inhalation as no near the fear of tails. Sorry for rant but recently retired from hospital and 99% of anyone had no clue of afrezza or cgm's. Tried to talk to MDs and mostly said would look into it when accepted practice. Georgia - thank you for your post. While this may be you first post here it may well be one of the most significant posts I have read. Hopefully Aged and others take the time to understand what you are saying. Hopefully Mike Castagna and Dr. Kendall also get the opportunity to read this.
The great hope is Dr. Kendall can get the medical politicians to update the T1 standard so its reflects your experiences and includes afrezza for front line prandial and rescue use sooner than later and your old MD friends will have the time to look into it as it is "accepted practice".
|
|
|
|
Post by agedhippie on Sept 14, 2018 8:09:02 GMT -5
Never posted before as only observed and love the potential of Afrezza. That being said I have been ICU nurse for 20 yrs and witnessed(no exaggeration) 100's of pt's go low after follow up dose of aspart per MD order c blood glucose ranging from 200-250. Brutal diabetics or insulin resistant ones have bad swings. Many times wake pt up to give D50 iv in the 20's after follow doses were administered 4hrs previous. Learned to never give any insulin to someone after 2100 unless familiar c their case. Would go against MD orders for safety of pt. Reason, the tails on any SQ insulin could be dangerous to fatal. Seen it and witnessed 3 tragic results. Of course these pt's had high co-morbidities but still rough on psyche. Never been able to administer afrezza as not accepted common practice yet for tx, but dearly wished had as the quick action and clearance would have made many of our nights in ICU less stressful. And I can't tell you stress that brutal diabetics can pose to a nurse. Afrezza would be a godsend to ICU pt's capable of inhalation as no near the fear of tails. Sorry for rant but recently retired from hospital and 99% of anyone had no clue of afrezza or cgm's. Tried to talk to MDs and mostly said would look into it when accepted practice. I am not sure about your ICU, but my brother is an ICU team leader in a UK teaching hospital and when I asked him about this he said that for the most part the patients on his unit would not be in a condition to use an inhaled insulin and they would rather manage it via the lines anyway. They also use continuous glucose monitoring so unexpected lows do not happen. I am curious as to why you have to wake a patient to give them D50. Can't you just use the established lines as with everything else? Edit: Actually on reflection I am not sure why you do not deliver insulin via the IV since you have the lines in rather than SQ. If you do that it acts and clears even faster than Afrezza. |
|
Deleted
Deleted Member
Posts: 0
|
Post by Deleted on Sept 14, 2018 8:43:39 GMT -5
Matt - the problem with this study was not the design. The problem is the multi-hour tail of the RAA past 2hours after a meal when the prandial should be done.
What you are suggesting is exactly what the lady from the FDA review team at the ADCOM proposed to one of the participating Affinity1 doctors who did achieve remarkable A1c reduction compared to the other trial groups. In fact she accused him of cheating because he encouraged follow-up dosing of afrezza which was allowed but just not done by most while he did not have the RAA PWDs do follow-up dosing.
She suggested if he had encouraged the RAA PWDs to follow-up dose they would have gotten results as good as afrezza. The good doctor looked her square in the eye and said he if did what she was suggesting he would have KILLED his patients. His tone literally caused her to tear-up. That long tail is useful for meals, and bad for corrections. Getting good results in STAT is dependent on a follow up dose - that is producing a 4 hour tail from the meal which is the same as RAA. Frankly is a doctor thinks that tell his patients that using a correction with RAA will kill them I would advise those patients to find a competent endo who is capable of telling them how to do corrections (even if this one does have a nice flair for melodrama). I would suggest that perhaps the lady on the ADCOM team was tearing up with frustration rather than regret. Ultimately however, arguing that using a correction will kill them is not going to do anything at all for your credibility with Type 1s, or with endos. It simply makes them wonder what else you got wrong. So what you are saying is that a patient who begins their meal at 7pm would be advised by a competent endo to do a follow up dose at 8:30 or 9pm with an RAA and to advise otherwise would make the endo incompetent? How late into the evening do you regularly use a follow up dose of RAA? |
|
|
|
Post by agedhippie on Sept 14, 2018 10:27:52 GMT -5
That long tail is useful for meals, and bad for corrections. Getting good results in STAT is dependent on a follow up dose - that is producing a 4 hour tail from the meal which is the same as RAA. Frankly is a doctor thinks that tell his patients that using a correction with RAA will kill them I would advise those patients to find a competent endo who is capable of telling them how to do corrections (even if this one does have a nice flair for melodrama). I would suggest that perhaps the lady on the ADCOM team was tearing up with frustration rather than regret. Ultimately however, arguing that using a correction will kill them is not going to do anything at all for your credibility with Type 1s, or with endos. It simply makes them wonder what else you got wrong. So what you are saying is that a patient who begins their meal at 7pm would be advised by a competent endo to do a follow up dose at 8:30 or 9pm with an RAA and to advise otherwise would make the endo incompetent? How late into the evening do you regularly use a follow up dose of RAA? What I am saying is that a competent endo would advise that it is possible and you could consider it as an option. A lot of what a good endo does is judge how much effort you want to put into managing your diabetes and work out what will have the most impact within that parameter. The evening meal is the odd ball though because you typically told to correct at bed time so it's easier to just correct at that point rather than correct at 9pm and again at 11pm (back to the previous point about how much effort do you want to put in). I test and correct at bed time every night with a target of 120 and deducting 10% of my dinner dose for margin. There is a natural dip in the middle of the night (2am - 4am for me) where your basal glucose drops and if you have your basal insulin wrong you can get into trouble with that. |
|
Deleted
Deleted Member
Posts: 0
|
Post by Deleted on Sept 14, 2018 11:30:11 GMT -5
So what you are saying is that a patient who begins their meal at 7pm would be advised by a competent endo to do a follow up dose at 8:30 or 9pm with an RAA and to advise otherwise would make the endo incompetent? How late into the evening do you regularly use a follow up dose of RAA? What I am saying is that a competent endo would advise that it is possible and you could consider it as an option. A lot of what a good endo does is judge how much effort you want to put into managing your diabetes and work out what will have the most impact within that parameter. The evening meal is the odd ball though because you typically told to correct at bed time so it's easier to just correct at that point rather than correct at 9pm and again at 11pm (back to the previous point about how much effort do you want to put in). I test and correct at bed time every night with a target of 120 and deducting 10% of my dinner dose for margin. There is a natural dip in the middle of the night (2am - 4am for me) where your basal glucose drops and if you have your basal insulin wrong you can get into trouble with that. Familiar with the Dawn Effect. When you say you correct at bed time, I am inferring by correct you mean dosing Novolog, Humalog or Apidra - are you not significantly concerned about a hypo while you sleep? |
|
|
|
Post by agedhippie on Sept 14, 2018 12:57:12 GMT -5
What I am saying is that a competent endo would advise that it is possible and you could consider it as an option. A lot of what a good endo does is judge how much effort you want to put into managing your diabetes and work out what will have the most impact within that parameter. The evening meal is the odd ball though because you typically told to correct at bed time so it's easier to just correct at that point rather than correct at 9pm and again at 11pm (back to the previous point about how much effort do you want to put in). I test and correct at bed time every night with a target of 120 and deducting 10% of my dinner dose for margin. There is a natural dip in the middle of the night (2am - 4am for me) where your basal glucose drops and if you have your basal insulin wrong you can get into trouble with that. Familiar with the Dawn Effect. When you say you correct at bed time, I am inferring by correct you mean dosing Novolog, Humalog or Apidra - are you not significantly concerned about a hypo while you sleep? Not even slightly  Ok - the less flippant answer... I use Humalog and dosing and testing is literally the last thing I do before I climb into bed. I am hypo-aware so I wake up if either my levels are changing fast and I am under 75. Very occasionally I might be in the 60s. A gentle drift into the 70s is fine though. If I am in the 70s and wake I eat 10g of glucose and go back to sleep. If I am in the 60s I eat 10g of glucose wait 10 minutes to make sure I am rising, and go back to sleep. Strictly you are told to eat 15g, but I find 10g puts me up about 35 to 40 points and I don't want to be chasing highs later. I find I end up in the 70s and wake about once a month or so. Dawn effect is a complete pain as there is no way to deal with it well except with a pump. I have seen people try and use NPH which has a profile like a switchback and try to position one of the peaks to catch the dawn spike. My endo said I could try it but he didn't advise it because it's easy to get a night time hypo is the peak gets mistimed. With a pump you drop your basal for the early part of the night, and ramp it up around 4am to deal with the incoming spike. This is generally true. If you are dropping or rising fast you have to account for lag in readings. Your meter is probably 5 minutes behind where you really are, and a CGM is around 20 minutes. The CGM compensates by using projections, but those break down when things are changing fast. For example I do not use my Dexcom if I am eating glucose because it will show me still falling even when I am rising. |
|
|
|
Post by babaoriley on Sept 14, 2018 15:38:32 GMT -5
Ingesting a bit of marijuana (now that's it's legal in California) just before I go to bed insures that I'm not significantly concerned about anything. 
Aged One, your response was very well written and cogent, not poking fun at you in the slightest! You're one sharp cookie!
|
|
|
|
Post by sayhey24 on Sept 14, 2018 18:52:50 GMT -5
Aged - maybe its time to give afrezza a try. Dosing with humalog and testing right before bed and then waking during the night for the low and then rising with high BG in the morning maybe is not the best approach.
A tandem and afrezza might do wonders, just saying.
|
|
|
|
Post by agedhippie on Sept 14, 2018 19:51:14 GMT -5
Aged - maybe its time to give afrezza a try. Dosing with humalog and testing right before bed and then waking during the night for the low and then rising with high BG in the morning maybe is not the best approach. A tandem and afrezza might do wonders, just saying. It's not a big deal, once a month or so I wake up in the night below 70. If you look at the CGM graphs of Afrezza users you see posted there are a lot of dips below 70 in them. And Afrezza is not going to fix dawn phenomenon. More to the point, if I used a Tandem pump to fix the dawn phenomenon (a good choice BTW) it would also catch that night time low before it happened and prevent it. I described the way old school pumps where you set basal profiles worked because I am more familiar with them. I should have talked about basals with the Tandem (as well the 670G) which don't need profiles, they have the CGM integrated and will automatically adjust. To be completely honest I cheat as well which is part of what I reluctant to give up. Take breakfast as an example; I eat around 8am and take insulin to cover the breakfast plus typically plus one unit to correct the dawn phenomenon rise, and then I cheat. I know that I am going to want a snack before lunch so I add that into the breakfast bolus, another two units. I am overdose, but rely on the long tail to cover provide that insulin later when I snack and would otherwise need to take more insulin. If I don't snack the insulin is still in the tail when I eat lunch around noon so I just subtract 2 units from my lunch time bolus (or roll it forwards for afternoon tea). You develop these tricks over the years as you tailor living with diabetes to minimize it's impact on your life. I am pretty certain if I had to correct for snacks it would never happen (ditto follow up dosing) and my numbers would get worse as a result. It's tricks like this and knowing my limitations that let me get the sort of TIR that I do get. This is true for a lot of long term Type 1s. On the other hand there are many who cannot get good results today and whom Afrezza is a godsend (Sweedee's father for one). It's why I never give fellow diabetics advice unless explicitly asked - and sometimes it's hard to tell the difference between a request and just venting. |
|
|
|
Post by sayhey24 on Sept 15, 2018 6:30:29 GMT -5
Aged - so let me get this straight. You are doing all this work and "its not a big deal". However checking BG 90 minutes after eating and taking a second puff if needed is SO hard few will ever use afrezza to get better control and fewer hypos?
With afrezza you don't need the tricks. The kids who will be starting on afrezza in the near future will hopefully never know or want to know about the tricks.
The tandem and afrezza is something to consider. It would provide better control and a lot less sleepless nights.
|
|
|
|
Post by lennymnkd on Sept 15, 2018 7:02:35 GMT -5
Aged not being a diabetic an listening to what you have to say ! Seems like you have a more difficult regimen than just getting on board with the progress that has been made in healthcare CGM/ afrezza... what am I missing !
|
|
|
|
Post by sportsrancho on Sept 15, 2018 7:51:37 GMT -5
A little reminder... keep it simple. The kids are happy!
|
|
|
|
Post by sweedee79 on Sept 15, 2018 8:29:04 GMT -5
I seriously don't know why anyone would want fake insulin injected into their body when they could inhale the real thing..
It isn't just that Afrezza works better.. it is better.. a healthier more natural treatment for diabetes..
|
|
|
|
Post by agedhippie on Sept 15, 2018 9:27:56 GMT -5
Aged - so let me get this straight. You are doing all this work and "its not a big deal". However checking BG 90 minutes after eating and taking a second puff if needed is SO hard few will ever use afrezza to get better control and fewer hypos? With afrezza you don't need the tricks. The kids who will be starting on afrezza in the near future will hopefully never know or want to know about the tricks. The tandem and afrezza is something to consider. It would provide better control and a lot less sleepless nights. Well, it's not as much work as I made it seem, I broke down the whole process so people could see the rationale and mechanics. In real life it boils down to; I am going to want a snack (or Starbucks) later tack on two units. The option is to set a timer for 90 minutes after breakfast stop whatever I am in the middle of, test, load the inhaler, take a puff, break it down and put everything away, carry on until the snack, then test again, load the inhaler again, puff, break it down and put everything away. I think going "Meh, dial in an extra two unit for that snack" when I am injecting anyway is simpler. Then there is the question of better control. That all comes down to the amount of effort you want to put in. I already comfortably exceed the TIR the compliant Afrezza users in STAT got so what's in it for me? Fewer hypos? Well you still get them, but anyway the promised reduction would amount to maybe one or two a month (I am going to tempt fate and say it is ages since I had a serious hypo). Afrezza does need tricks, all treatments need tricks. Dosing during the meal rather than before is a trick, the follow up dose is a trick. For me tricks are where you deviate from prescribed practice to get a better result, or to simplify your life. People have evolved a way of using Afrezza that is fairly different from the label - those are tricks, tricks are good. I did look into getting a Tandem pump not that long ago (I prefer the Dexcom CGM to the Medtronics) but their customer service were a complete nightmare and I decided to wait a year or two for the APs. |
|
|
|
Post by agedhippie on Sept 15, 2018 9:36:49 GMT -5
Aged not being a diabetic an listening to what you have to say ! Seems like you have a more difficult regimen than just getting on board with the progress that has been made in healthcare CGM/ afrezza... what am I missing ! It's not as bad as I made it seem. I went into all the details and justifications because I thought people might be interested. The short form is that I can add an extra couple of units to my regular breakfast bolus and let the long tail deliver it when it's needed so I don't need to take extra doses later. I think that some people are very happy with a CGM + Afrezza and I am genuinely happy for them - Type 1 sucks and anything that makes people happier gets my vote (Cue: enter babaoriley with the marijuana stage left). I just don't see the gain for me in changing. To be honest the second dose is the killer for me. |
|
