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Post by pat on Dec 2, 2018 6:00:09 GMT -5
Great post. Thank you.
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Post by falconquest on Dec 2, 2018 9:28:37 GMT -5
stevil The time has come. You now get to prescribe. The standards of Care in what ever speciality/disease you end up in written. The revolving door of patients coming in. Now you get to see. These patients, the ones that will become yours, over time; you will get the visual, the lab results, the x-rays. Come back and let us know. - These pills/medications worked the patient got better. -These pills worked for this, caused that, new pills for that.... Come back and let us know, did the health of these people improve? I know you have read every word on the package insert of every prescription you give out, you know the organs that will be affected. That is part of the job description. I was at Mayo a few years ago, I watched the people come in the door. These people did not look well. Peppy, Not yet. I can't prescribe anything until June, but even then, I will need my supervising physician to sign off on it. I don't yet know where I'm going for residency, although I have been given a few winks from my top choice, but it's not a given that I will be able to prescribe Afrezza. I have already seen a lot of people have success with metformin and the GLP-1's. The nice thing about the latter (Trulicity) is that they only require a once/week injection schedule. Compliance is a huge hurdle with the diabetic population. Many don't care about their disease, others just are either uninterested or incapable of understanding the severity of their disease. I kid you not, I once spent 30 minutes counseling one of my patients in the hospital and at the end of it, she still didn't understand what glucose was or how/why her levels were so high. And I did my best to simplify it. Level of education is a hurdle. As awful as you and everyone else think it is (and I agree it is unfortunate), there is only a limited amount of time you get to spend with each patient as a physician. In my observation throughout the past year and a half, there seems to be a correlation between education level and glucose control. The more educated typically earn more money, buy healthier food, have better access to healthcare, and understand the importance of seeing their physician regularly and are able to interpret what their doctor tells them and make better choices because they understand the consequences of their decisions. I haven't looked it up to see if anyone has studied this, but what this means (again from my experience) is that diabetes is more of a disease of the poorly insured and less compliant, at least for the type 2 population. The issue that the majority of people on here don't seem to understand is that even though Afrezza may be the best solution for diabetes, it isn't the best solution for every person with diabetes. You can have the best drug in the world, but if people won't take it as they're supposed to, it isn't going to work all that well. Therefore, I've actually become a bigger fan of bariatric surgery (gastric sleeve) and GLP-1 use. Insurance coverage is still an issue with those, but they are so wonderful because they require less compliance from the patience to be effective. On top of this, I did a presentation in front of residents and supervising physicians last week, and had incredible difficulty compiling compelling trial data for the use of Afrezza for better glucose control. I found that I was forced to explain the science and why Afrezza "should" work better because the available trial data just does not support the use of Afrezza over other insulins. At best, Afrezza spent 9 fewer minutes every day in hypoglycemic ranges and less weight gain than RAAs with 1-2 hours more "in range" so an argument could be made for the use of Afrezza in those experiencing difficult control with multiple severe hypoglycemic events. At that point, safety takes precedence to overall magnitude of reduction, since Afrezza lowered A1c less than RAAs in nearly every arm that has been studied. At the end of the day, doctors are currently taught to treat to a number, not for control. I will do my best to convince my supervising physician to allow me to prescribe Afrezza, but the residency I'll hopefully be practicing at is in a very large hospital in a metropolitan area with the homeless and impoverished making up the majority of the patient population. Insurance will be an enormous hurdle. Going back to my previous example, counseling will be an enormous hurdle. I will get dinged in my residency if I spend too much time with my patients. Part of my education is learning how to be efficient. Then, once I start practicing independently, I'll have a tremendous debt burden that has been accruing interest since the day I stepped foot onto my medical school campus. As much as I want to help my patients, I first have an obligation to my family. Insurance doesn't pay you for spending longer than they deem necessary for an office visit. I can sometimes justify a higher level of billing if I document properly, but that takes even more time since thorough documentation takes considerably longer than normal documentation. For those who want to throw stones because of this, I would highly encourage you to tell your employer you don't want 20% of your paycheck every week. I will do my best for every one of my patients that I see. But my best will be different for each of them because you need to tailor care to what is attainable for each of them. Not every patient wants the best care. Not every patient is willing/able to do what is necessary to get the best results. The trick is to figure out what will be best for them and to work as hard as I can to help ensure they get what they want and need to achieve their goals. stevil, I sincerely congratulate you for the time, effort, and investment you (and your family) have made in your profession. I can't help but shake my head however at our system of health care in this country. You have a great deal of debt and therefore are forced to comply with insurance standards to have any chance of paying off that debt. As the husband of a prospective PhD in a helping profession I am just amazed at how helping professionals work incredible hours for meager pay. Wonder why there's a mental health crisis in our country? Look at the emphasis on mental health by insurance companies. Look at how many long hours dedicated professionals work for the aforementioned meager compensation. I am impressed by the manner in which stevil approaches patient care, it's too bad our system won't allow him to be the Physician he wants to be, uuggghh!
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Post by stevil on Dec 2, 2018 15:25:57 GMT -5
Thanks for the kind words, falcon. It's been by far the hardest thing I've ever done, and I still have residency to look forward to, but it's already been so rewarding to play the very small part I have thus far in caring for patients. I can't imagine how much better it will be when I get to be the one dictating care.
Kudos to your SO for being persistent and going til the end. It takes a true passion to reach a PhD. I'm glad you get to play a part in it. There's no way I'd have gotten through school without my wife. She deserves more than her half of the credit.
I'm glad my debt burden is so high. At times it was the only thing keeping me moving forward. All in all, physicians live comfortably. If I really want to sell out and work endless hours, I've heard stories of every specialty making over 5-600k. The money is there if you know how to play the game and find it. I personally don't care to work that hard, but I will not ever be among the working poor, regardless. From what I've heard of PhD work, though, a good salary is not always guaranteed outside of teaching. Your SO is the one who should really be getting a pat on the back. I'm glad you seem to be understanding and appreciative of the effort it takes to reach that goal. Kudos to you also for being so supportive and being a good partner and teammate!
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Post by falconquest on Dec 2, 2018 16:33:54 GMT -5
Thanks for the kind words, falcon. It's been by far the hardest thing I've ever done, and I still have residency to look forward to, but it's already been so rewarding to play the very small part I have thus far in caring for patients. I can't imagine how much better it will be when I get to be the one dictating care. Kudos to your SO for being persistent and going til the end. It takes a true passion to reach a PhD. I'm glad you get to play a part in it. There's no way I'd have gotten through school without my wife. She deserves more than her half of the credit. I'm glad my debt burden is so high. At times it was the only thing keeping me moving forward. All in all, physicians live comfortably. If I really want to sell out and work endless hours, I've heard stories of every specialty making over 5-600k. The money is there if you know how to play the game and find it. I personally don't care to work that hard, but I will not ever be among the working poor, regardless. From what I've heard of PhD work, though, a good salary is not always guaranteed outside of teaching. Your SO is the one who should really be getting a pat on the back. I'm glad you seem to be understanding and appreciative of the effort it takes to reach that goal. Kudos to you also for being so supportive and being a good partner and teammate! .....and thank you for yours. It has certainly been a journey (and still is). As for "selling out" I would advise that you pursue what feels right for you. Take the path that provides the most rewards that are non-monetary. Although, if that path includes monetary rewards that's fine. Just don't sell out and pursue something purely for monetary gain. Our entire health care system is based on dollars when it should be based on patient outcomes. There is a little girl out there who no longer suffers from epileptic seizures due in large part to intervention provided by my wife. Knowing that is a significant reward in itself! |
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Post by brotherm1 on Dec 2, 2018 20:54:00 GMT -5
I think management is doing OUTSTANDING and worth every penny they are getting - which includes part of the money I’ve sunk into the equity of this company. I’m not challenging anyone’s right to post anything anywhere. I’m explaining what I perceive to be a concerted effort to undermine the ability of the company to finance itself through the use of disinformation. If you’re a fan of Matt remain so. If I question it’s motives it’s my right to do so. Is the falcon in your screcar n name related to USAF academy by chance? If that’s too personal feel free not to answer. There is a long history here of accusing those who post a realistic (and potentially negative sounding) view that they are undermining the company. That was the basis for my post. It's always communicated as some kind of "short seller conspiracy" which I find rather silly. Does anyone really believe they can undermine the share price by posting on a message board? Conversely, all the positive posts in the world will not cause the share price to rise. As for my screen name, I don't mind the question. It is a reference to the name of my sailboat. Yes. These unrealistic and unbridled posts by shorts on this board do affect the share price. Posting stuff like the company is going bankrupt and even messaging others of the same is damaging. :Some even sold at the time because of that. Posting things like “The Market” looks at mnkd in the light of other insulin companies that make over $50 million per week to put mnkd in a dim light is not realistic. He throws the negative slanted hyperbole in there in almost every post. I’ll never forget the nonsensical post matt posted saying 10,000 scripts per week would not bring mnkd to profitability. From a guy that says he was a ceo of a nasdaq listed pharma, that nonsense unfortunately carries a lot of weight to many and unecessarily unerves those here who have a large investment in mnkd. MNKD shareholders are mostly retail. Where do potential new investors learn about MNKD? They google and find a few sights such as this one, stock twits, yahoo and from friends who found it in these places. Not much else out there. |
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Post by pat on Dec 3, 2018 7:33:07 GMT -5
Agreed Brotherman. Thanks for the post. This thread was starting to make me feel like a heel.
Maybe that’s the point...lol...black helicopters are circling my house and getting through the tin foil.
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Post by peppy on Dec 3, 2018 7:46:47 GMT -5
There is a long history here of accusing those who post a realistic (and potentially negative sounding) view that they are undermining the company. That was the basis for my post. It's always communicated as some kind of "short seller conspiracy" which I find rather silly. Does anyone really believe they can undermine the share price by posting on a message board? Conversely, all the positive posts in the world will not cause the share price to rise. As for my screen name, I don't mind the question. It is a reference to the name of my sailboat. Yes. These unrealistic and unbridled posts by shorts on this board do affect the share price. Posting stuff like the company is going bankrupt and even messaging others of the same is damaging. :Some even sold at the time because of that. Posting things like “The Market” looks at mnkd in the light of other insulin companies that make over $50 million per week to put mnkd in a dim light is not realistic. He throws the negative slanted hyperbole in there in almost every post. I’ll never forget the nonsensical post matt posted saying 10,000 scripts per week would not bring mnkd to profitability. From a guy that says he was a ceo of a nasdaq listed pharma, that nonsense unfortunately carries a lot of weight to many and unecessarily unerves those here who have a large investment in mnkd. MNKD shareholders are mostly retail. Where do potential new investors learn about MNKD? They google and find a few sights such as this one, stock twits, yahoo and from friends who found it in these places. Not much else out there. quote: I’ll never forget the nonsensical post matt posted saying 10,000 scripts per week would not bring mnkd to profitability. reply: In all fairness (and we know the way I feel) I do not remember this post. Just sayin. |
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Post by sayhey24 on Dec 3, 2018 8:24:31 GMT -5
Stevil - you said you "had incredible difficulty compiling compelling trial data for the use of Afrezza for better glucose control. I found that I was forced to explain the science and why Afrezza "should" work better"
Thats really a shame. There are a zillion studies associated with the damage 140+ sugars cause after 2 hours from neuropathy to heart attacks. Since afrezza is the only diabetes treatment to bring PWDs back to baseline in the 2 hour period, explaining why its a game changer should be a no-brainer. The STAT results are pretty clear. afrezza stands alone and all it takes is a little puff.
GLP1s can't do this nor metformin. Both just mask the issue and hope the broken pancreas has time to catch up before the next meal. Over time what we know is both typically fail. Worse than that are side effects.
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Post by peppy on Dec 3, 2018 8:42:04 GMT -5
Stevil - you said you "had incredible difficulty compiling compelling trial data for the use of Afrezza for better glucose control. I found that I was forced to explain the science and why Afrezza "should" work better"
Thats really a shame. There are a zillion studies associated with the damage 140+ sugars cause after 2 hours from neuropathy to heart attacks. Since afrezza is the only diabetes treatment to bring PWDs back to baseline in the 2 hour period, explaining why its a game changer should be a no-brainer. The STAT results are pretty clear. afrezza stands alone and all it takes is a little puff.
GLP1s can't do this nor metformin. Both just mask the issue and hope the broken pancreas has time to catch up before the next meal. Over time what we know is both typically fail. Worse than that are side effects.
, you told me why it was a game changer. With Afrezza, the diabetic gets "the first phase." You were still in medical school when you told me. Later when Matt B, mattdownunder, tried afrezza, he documented the first phase in a video. Stevil, especially the type two's need the first phase, correct? Although, it doesn't hurt to turn off the type ones liver from making more glucose at mealtime.  |
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Post by agedhippie on Dec 3, 2018 9:56:04 GMT -5
Stevil - you said you "had incredible difficulty compiling compelling trial data for the use of Afrezza for better glucose control. I found that I was forced to explain the science and why Afrezza "should" work better"
Thats really a shame. There are a zillion studies associated with the damage 140+ sugars cause after 2 hours from neuropathy to heart attacks. Since afrezza is the only diabetes treatment to bring PWDs back to baseline in the 2 hour period, explaining why its a game changer should be a no-brainer. The STAT results are pretty clear. afrezza stands alone and all it takes is a little puff.
GLP1s can't do this nor metformin. Both just mask the issue and hope the broken pancreas has time to catch up before the next meal. Over time what we know is both typically fail. Worse than that are side effects.
The problem is that there are no quantified results of the impact of Afrezza in the long term. Afrezza returns you to the baseline in two hours taken properly. The question is in the real world will it be taken properly, and if so by how many and for how long. This is complicated by the use of HbA1c as a proxy for the likelihood of complications, one day it will be TIR but the data is not there yet. Without a pivotal trial it is going to be a game of inches. GLP-1 is the perfect drug for the patient population that Stevil is talking about. This is a group that struggles to take drugs daily and you are asking them to take a changing dose of Afrezza every time they eat and to test and possibly follow up an hour later. That is to much of a load, they will not be able to deal with that. Taking a GLP-1 dose every Sunday is far more achievable. It doesn't matter how wonderful a drug is if people do not take it. |
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Post by agedhippie on Dec 3, 2018 9:59:46 GMT -5
Later when Matt B, mattdownunder, tried afrezza, he documented the first phase in a video. Stevil, especially the type two's need the first phase, correct? Although, it doesn't hurt to turn off the type ones liver from making more glucose at mealtime. I don't think the argument is which is the better option, the argument is which one is the patient going to take - Afrezza 3 to 6+ times a day with a varying dose, or a GLP-1 with a fixed dose once a week? Stevil is saying for his patient population the answer is the later. |
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Post by mango on Dec 3, 2018 12:02:14 GMT -5
What's the stats on GLP-1s keeping people from developing chronic diabetes-related conditions? What's the stats for people on GLP-1s having to require increasing step therapy? These people have a problem with regulating their glucose. Afrezza takes care of that. Argue all day about this or that, but what are you doing by negatively reinforcing by giving the medically incorrect treatment? Someone complained about a person not understanding after a 30 minute glucose explaination, well take more time to help them understand. Days, weeks, months—does it really matter? That's not an excuse that works for me. You either want the best for people or don't. The choice is yours. That's my opinion. You don't have to like it, and I'm not looking for a reply full of excuses and reasons why you don't.     |
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Post by peppy on Dec 3, 2018 12:58:50 GMT -5
GLP-1, it's easy, once a week injections. The physicians like it. Trulicity. Eli Lilly. Dulaglutide activates the GLP-1 receptor, a membrane-bound cell-surface receptor coupled to adenylyl cyclase in pancreatic beta cells. Dulaglutide increases intracellular cyclic AMP (cAMP) in beta cells leading to glucose-dependent insulin release. Dulaglutide also decreases glucagon secretion and slows gastric emptying.In the four Phase 2 and five Phase 3 randomized clinical studies, at baseline, 50 (1.2%) TRULICITY-treated patients had mild renal impairment (eGFR ≥60 but <90 mL/min/1.73 m2), 171 (4.3%) TRULICITY-treated patients had moderate renal impairment (eGFR ≥30 but <60 mL/min/1.73 m2), and no TRULICITY-treated patients had severe renal impairment (eGFR <30 mL/min/1.73 m2). In a 52-week clinical trial, 270 (71%) TRULICITY-treated patients had moderate renal impairment (eGFR ≥ 30 but <60 mL/min/1.73 m2) and 112 (29%) TRULICITY-treated patients had severe renal impairment (eGFR ≥ 15 but < 30 mL/min/1.73 m2) [see Clinical Studies (14.3)]. No overall differences in safety or effectiveness were observed in this study. 6.2 Postmarketing ExperienceThe following additional adverse reactions have been reported during post-approval use of TRULICITY. Because these events are reported voluntarily from a population of uncertain size, it is generally not possible to reliably estimate their frequency or establish a causal relationship to drug exposure. • Anaphylactic reactions, angioedema [see Contraindications (4), Warnings and Precautions (5.6), Patient Counseling Information (17)]. • Increased serum creatinine, acute renal failure or worsening of chronic renal failure, sometimes requiring hemodialysis [see Warnings and Precautions (5.5) and Patient Counseling Information (17)].WARNING: RISK OF THYROID C-CELL TUMORSSee full prescribing information for complete boxed warning. • Dulaglutide causes thyroid C-cell tumors in rats. It is unknown whether TRULICITY causes thyroid C-cell tumors, including medullary thyroid carcinoma (MTC), in humans as the human relevance of dulaglutide-induced rodent thyroid C-cell tumors has not been determined (5.1, 13.1).• TRULICITY is contraindicated in patients with a personal or family history of MTC and in patients with Multiple Endocrine Neoplasia syndrome type 2 (MEN 2). Counsel patients regarding the potential risk of MTC and symptoms of thyroid tumors (4, 5.1).
pi.lilly.com/us/trulicity-uspi.pdf========================================================================================My words, keep thinking this is the way to go. EASY. Once a week. My fav: Dulaglutide causes thyroid C-cell tumors in rats. It is unknown whether TRULICITY causes thyroid C-cell tumors, including medullary thyroid carcinoma (MTC), in humans as the human relevance of dulaglutide-induced rodent thyroid C-cell tumors has not been determined (5.1, 13.1). This is a difficult one. hmmm, NO. 
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Post by xanet on Dec 3, 2018 14:10:12 GMT -5
What's the stats on GLP-1s keeping people from developing chronic diabetes-related conditions? What's the stats for people on GLP-1s having to require increasing step therapy? These people have a problem with regulating their glucose. Afrezza takes care of that. Argue all day about this or that, but what are you doing by negatively reinforcing by giving the medically incorrect treatment? Someone complained about a person not understanding after a 30 minute glucose explaination, well take more time to help them understand. Days, weeks, months—does it really matter? That's not an excuse that works for me. You either want the best for people or don't. The choice is yours.That's my opinion. You don't have to like it, and I'm not looking for a reply full of excuses and reasons why you don't. Mango, if you have done some work in populations similar to those stevil is referring to, I really would love to hear your ideas about overcoming the barriers to adoption of Afrezza in these populations. For me, working with these populations was extremely challenging. Without a strong, persistent support system, the effects of poverty, mental illness, drug addiction, homelessness, etc., are not easily overcome. You can give people the best medicine available for their condition, but you can't make them take it. Then what have you really given them? Will you be there to remind them to take each puff? Sure, someone may be able to set up a program that works, but that is something much larger than one person and requires a tremendous dedication to reach a particular population. Do you have that dedication? I think a lot of people have the heart, but who has the resources and time? This is a problem that goes way beyond diabetes. |
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Post by mango on Dec 3, 2018 14:24:24 GMT -5
What's the stats on GLP-1s keeping people from developing chronic diabetes-related conditions? What's the stats for people on GLP-1s having to require increasing step therapy? These people have a problem with regulating their glucose. Afrezza takes care of that. Argue all day about this or that, but what are you doing by negatively reinforcing by giving the medically incorrect treatment? Someone complained about a person not understanding after a 30 minute glucose explaination, well take more time to help them understand. Days, weeks, months—does it really matter? That's not an excuse that works for me. You either want the best for people or don't. The choice is yours.That's my opinion. You don't have to like it, and I'm not looking for a reply full of excuses and reasons why you don't. Mango, if you have done some work in populations similar to those stevil is referring to, I really would love to hear your ideas about overcoming the barriers to adoption of Afrezza in these populations. For me, working with these populations was extremely challenging. Without a strong, persistent support system, the effects of poverty, mental illness, drug addiction, homelessness, etc., are not easily overcome. You can give people the best medicine available for their condition, but you can't make them take it. Then what have you really given them? Will you be there to remind them to take each puff? Sure, someone may be able to set up a program that works, but that is something much larger than one person and requires a tremendous dedication to reach a particular population. Do you have that dedication? I think a lot of people have the heart, but who has the resources and time? This is a problem that goes way beyond diabetes. Maybe so maybe not. But we're not EVEN giving them the best treatment, xanet. What the are you arguing exactly? Gianrico Farrugia, M.D at Florida Mayo Clinic would disagree with you here. And there is only one medically correct treatment for prandial, and that is, as of 2014—Afrezza. As Dr. Gianrico Farrugia puts it—It's about putting the patient first, and doing what is best for the patient, best for the provider and best for the payer. That is Afrezza. You can argue against it, but it is what is best for the patient and puts the patient first. |
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