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Post by stevil on Mar 9, 2023 20:09:02 GMT -5
Stevil - sorry if I hurt your feelings on points 1 2 and 3. I thought you were a young guy/gal? One thing you will learn is with age comes wisdom. I can definitely understand your new patient. First off he is a guy and he wants to totally ignore he has a health issue. I would think this is not unusual for T2s. Its a guy thing. Maybe not as much for the under 40 crowd but 50+ I would see it more the norm. I have already mentioned these T2 seminars are 70%+ women maybe closer to 80%. He can definitely contact me if you want. I can talk about my dad and how he thought having a coke at lunch gave him diabetes. I can also tell this guy how he had his first "known" heart attack at 62 and was gone by 70. Didn't hurt my feelings. BUT! I think I figured out the solution. To everyone but sayhey: (he's wrong about a lot... but also probably right about some things... proceed with caution if you choose to follow his line of thinking) To sayhey: I hope with age comes wisdom, although I hope it's just a little different than the kind you have. I hope that I choose to listen a little better before I speak, although... I think that's part of wisdom. IDK, not sure. I'm not old enough yet! Edit: Sorry, moderators. Forgot sarcasm wasn't allowed. Feel free to scrub this post if needed. |
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Post by sayhey24 on Mar 10, 2023 7:36:23 GMT -5
Stevil - sorry if I hurt your feelings on points 1 2 and 3. I thought you were a young guy/gal? One thing you will learn is with age comes wisdom. I can definitely understand your new patient. First off he is a guy and he wants to totally ignore he has a health issue. I would think this is not unusual for T2s. Its a guy thing. Maybe not as much for the under 40 crowd but 50+ I would see it more the norm. I have already mentioned these T2 seminars are 70%+ women maybe closer to 80%. He can definitely contact me if you want. I can talk about my dad and how he thought having a coke at lunch gave him diabetes. I can also tell this guy how he had his first "known" heart attack at 62 and was gone by 70. Didn't hurt my feelings. BUT! I think I figured out the solution. To everyone but sayhey: (he's wrong about a lot... but also probably right about some things... proceed with caution if you choose to follow his line of thinking) To sayhey: I hope with age comes wisdom, although I hope it's just a little different than the kind you have. I hope that I choose to listen a little better before I speak, although... I think that's part of wisdom. IDK, not sure. I'm not old enough yet! Edit: Sorry, moderators. Forgot sarcasm wasn't allowed. Feel free to scrub this post if needed. Stevil - being wrong about a lot of things is OK. Its part of the scientific method. You make hypotheses, you test them and you adapt. Its also a little funny as you sound like one of my kids who are probably around you age. They always tell me I am wrong until they tell me I am right. I am use to being wrong. When it come to afrezza and diabetes I really have very few original thoughts. Most of my nonsense is based on what Al Mann did and said. To be honest I did not understand a lot of the things he was saying at the time and in some cases it took me years to come to the "ah ha" moment. Other nonsense I have is based on studies I have seen or some personal experience. If you would like to identify the top thing I am wrong about - we can work on it. Let me know what it is. I know for years my kids told me how wrong I was about the covid research starting in the U.S. then being transferred to WIV and then being weaponized. For years I heard how it was from an undercooked bat burger and side of pangolin fries from the local wet market. This thread is about a theory on intestinal blockage and the question of can GLP1s be a contributing factor. I think they could be. I would say they are most likely not helping the situation. Should GLP1s be prescribed for glucose control - I would say since we have afrezza probably not. Should they be prescribed for weight loss? Its clear people stop eating and loose a lot of weight from starvation but its also becoming clear as soon as they stop taking it they put the weight back on and sometimes more. Are their intestines getting screwed up in the process - you say its from diabetes. I look at Richard Bernstein and say his intestines seem to have worked pretty well for a long time by keeping tight glucose control. BTW - let me give you some advice on the patient you suggested talk to me. What I have learned as a father was when the kids are about 7 or 8 they stop telling you things. As they go through high school and college it gets even worse. These days with the devices its probably a lot easier to figure out what they have been up to but a method which always works is to get their best friend and start questioning them. However your kid needs to be there when you are asking the questions. If not they will tell you nothing. Once you get them on a roll and get them laughing they pretty much will tell you anything. Even when your kid has done some really crazy/dangerous things. For that guy, its not me he needs to talk to. If he is married and has a caring wife (best friend) its his wife that someone needs to talk with. She will be the one who will make sure this guy is doing what he needs to do. That guy on his own listened to you for about 15 seconds and then shut your off. BTW - the 15 seconds came from training I was given in laying people off. After 15 seconds they stop hearing you so make sure you have everything written down in the brown envelope you are handing them. |
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Post by sportsrancho on Mar 10, 2023 10:07:21 GMT -5
Wow, so much truth in one post! #LifeLessons
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Post by agedhippie on Mar 10, 2023 11:51:37 GMT -5
This thread is about a theory on intestinal blockage and the question of can GLP1s be a contributing factor. I think they could be. I would say they are most likely not helping the situation. Should GLP1s be prescribed for glucose control - I would say since we have afrezza probably not. I was curious about the idea that GLP-1 and basal insulins don't handle TIR well for Type 2 diabetics so I went off and did some research. There is only one trial I can find that used CGMs and it is a sub-study of SURPASS-3 looking at treating people after oral meds no longer work (the point at which the Affinity-2 trial was set) and what their TIR looked like for 243 people over a year. What do we find? People on Mounjaro averaged 91% TIR (71-180), and 73% had a TIR of (71-140) after 52 weeks. On Tresiba people achieved 75% TIR. When the weekly basal insulins arrive you will be able to use either of these once a week for good TIR. This means we can bust two myths at once; GLP-1 obviously can control spikes, and basal insulin as a first step looks pretty good as well. Will those results persist forever? Probably not, but at this point we have no data one way or the other. So to answer your question as to whether GLP1s be prescribed for glucose control, that 91% TIR appears to validate the SoC choice. I confess, it wasn't what I had been expecting! |
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Post by sayhey24 on Mar 10, 2023 14:03:14 GMT -5
This thread is about a theory on intestinal blockage and the question of can GLP1s be a contributing factor. I think they could be. I would say they are most likely not helping the situation. Should GLP1s be prescribed for glucose control - I would say since we have afrezza probably not. I was curious about the idea that GLP-1 and basal insulins don't handle TIR well for Type 2 diabetics so I went off and did some research. There is only one trial I can find that used CGMs and it is a sub-study of SURPASS-3 looking at treating people after oral meds no longer work (the point at which the Affinity-2 trial was set) and what their TIR looked like for 243 people over a year. What do we find? People on Mounjaro averaged 91% TIR (71-180), and 73% had a TIR of (71-140) after 52 weeks. On Tresiba people achieved 75% TIR. When the weekly basal insulins arrive you will be able to use either of these once a week for good TIR. This means we can bust two myths at once; GLP-1 obviously can control spikes, and basal insulin as a first step looks pretty good as well. Will those results persist forever? Probably not, but at this point we have no data one way or the other. So to answer your question as to whether GLP1s be prescribed for glucose control, that 91% TIR appears to validate the SoC choice. I confess, it wasn't what I had been expecting! OK - I thought we already knew GLP1s are great for TIR which includes sleeping hours. TIR and post prandial glucose excursions are two separate discussions. The GLP1 users are being starved. All the food is stuck in their intestines and blocking things up and the pancreas is being tickled 24 hrs a day to squeeze out a little more insulin when it should be resting and recovering. If you are not eating and what you have is stuck in your intensives your PPG should not be rising that much - in theory, but rumor is they do see spiking to some extent but we need to "go to the tape". We need AGP results. I will also say you are seeing the spiking in your number of 91% for 180. These people are spiking over 180 for 9% of the time and that accounts for the 2 hour post meal period. This IMO is not very impressive for PPG control. Can you find some study showing AGPs of GLP1 users detailing what they ate and when? What do once a week basal shots have to do with this? Are you going to the CMS CGM discussion? The CMG vendors have to get the PWD on insulin asap. They can do the once weekly insulin or the daily or the afrezza. Only one will provide real time control. With any of them they have to jump the SoC past steps 2 and 3 which includes the GLP1. If and when this happens and they get prescribed afrezza and its properly dosed they won't be needing the GLP for TIR as a T2 because in theory once you get them back to their baseline with afrezza lets say 95 target in 2 hours their pancreas should produce enough insulin for fasting periods. |
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Post by agedhippie on Mar 10, 2023 15:39:00 GMT -5
OK - I thought we already knew GLP1s are great for TIR which includes sleeping hours. TIR and post prandial glucose excursions are two separate discussions. So it's agreed then that GLP-1 is good for TIR? We can stop now because that's the measure. You can invent other ones, but TIR and HbA1c are the only two the medical world cares about because their impact has been quantified. Doctors will absolutely take a 91% TIR number for a weekly shot to treat a T2, especially when you add weight loss and the cardiorenal benefits. It's hard to justify putting insulin in front of that unless the patient explicitly asks for it. |
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Post by sayhey24 on Mar 10, 2023 19:23:19 GMT -5
OK - I thought we already knew GLP1s are great for TIR which includes sleeping hours. TIR and post prandial glucose excursions are two separate discussions. So it's agreed then that GLP-1 is good for TIR? We can stop now because that's the measure. You can invent other ones, but TIR and HbA1c are the only two the medical world cares about because their impact has been quantified. Doctors will absolutely take a 91% TIR number for a weekly shot to treat a T2, especially when you add weight loss and the cardiorenal benefits. It's hard to justify putting insulin in front of that unless the patient explicitly asks for it. Aged - going forward - remember afrezza together with the CGM is "forward looking radar" - going forward for T2s it will be less about the SoC and less about time in range and more about the Abbott sales rep getting the Medicare PWD on insulin. Robert Ford may have just blown-up the T2 Industry. What did Robert Ford say in that interview? He wants $10B in CGM sales by 2025. How did he say he was going to get there? He said CMS was going to change the rules to allow single dose basal but then something happened and CMS changed the rules to allow "insulin treated". Believe it or not and as crazy as this may sound to you I believe I know what happened. Regardless, it happened and I was shocked and I lost a bet. The CMS rule does not say GLP1 treated or SGLT2 treated. Why not? It says insulin treated. Lets be realistic 91% TIR for a T2 is really not that good when you consider their bodies should still be making enough insulin during fasting to keep them flat at baseline. What this number is really saying is GLP1s suck at mealtime and the CGMs will show that. If you stop the spike and get the T2 back to baseline within 2 hourse their TIR should be near 100%. The thing is we never had T2s widely using CGMs and most are not even testing with a meter. While we are adding cardiorenal lets add blocked intestines and all the other bad things on the label. Why are they seeing cardiorenal benefits? Maybe because their BG is better than it was or so Rich Bernstein says. If Bernstein is correct then afrezza should make it even better. BTW - when did TIR become the new cool kid on the block? I think it was within the last few years when T1s starting adopting CGMs. For T2s they don't need to worry about things when they sleep. They only need to worry about things when they eat. For T2s it is not about TIR but rather PPG. |
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Post by agedhippie on Mar 10, 2023 20:02:31 GMT -5
So it's agreed then that GLP-1 is good for TIR? We can stop now because that's the measure. You can invent other ones, but TIR and HbA1c are the only two the medical world cares about because their impact has been quantified. Doctors will absolutely take a 91% TIR number for a weekly shot to treat a T2, especially when you add weight loss and the cardiorenal benefits. It's hard to justify putting insulin in front of that unless the patient explicitly asks for it. Aged - going forward - remember afrezza together with the CGM is "forward looking radar" - going forward for T2s it will be less about the SoC and less about time in range and more about the Abbott sales rep getting the Medicare PWD on insulin. The idea that you are going to get doctors to ignore the SoC because a rep asks nicely is a fantasy, but who am I to deprive people of their fantasies?  Let's be realistic, 91% TIR is amazing. Under similar circumstances Afrezza managed 62% TIR. The trials for the cardiorenal benefits are adjusted for the improved BG numbers and other factors, you would know that if you read the source material before you speculated. As to block intestines; it's right up there with amyloid deposits from injection sites - it's so rare nobody cares. |
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Post by longliner on Mar 11, 2023 5:02:19 GMT -5
Aged, I truly appreciate your posts, you claim to not have the time to work with a product like Afrezza. You say, "a busy diabetic just wants simplicity". You are the diabetic that researches everything related to this disease, that is admirable. You've seen the positive results Afrezza users are discussing. You, with a quick prescription, could share with us the results you experience. I'm not proposing you as a guinea pig, we are far past those days. Afrezza could be a valuable (or not) tool in your tool kit. I truly doubt cost is your barrier, if it is, I'll pay for it. You seem to have countless hours available to dispute every positive aspect of Afrezza as a viable treatment for this disease (I know, you say it really doesn't take much time) but let's take a quick look at Sayhey and your debate, plus the additional 5000 or so posts....the research you do must take a team, or maybe you truly do have that much time to dedicate to research? I suppose you will just continue to join in this conversation regarding a very positive advance in treating diabetes (both adult and pediatric) with your negative slant. I guess it all pays the same. . Although at some point, integrity may come into play? Oh yeah, Ozempic...throw it on Technosphere.  |
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Post by sayhey24 on Mar 11, 2023 7:36:15 GMT -5
Aged - going forward - remember afrezza together with the CGM is "forward looking radar" - going forward for T2s it will be less about the SoC and less about time in range and more about the Abbott sales rep getting the Medicare PWD on insulin. The idea that you are going to get doctors to ignore the SoC because a rep asks nicely is a fantasy, but who am I to deprive people of their fantasies? Let's be realistic, 91% TIR is amazing. Under similar circumstances Afrezza managed 62% TIR. The trials for the cardiorenal benefits are adjusted for the improved BG numbers and other factors, you would know that if you read the source material before you speculated. As to block intestines; it's right up there with amyloid deposits from injection sites - it's so rare nobody cares. What did Al Mann tell us? The medically correct way to treat the T2 diabetic is to treat the "post prandial glucose excursions". As I told Stevil I don't make this up. You can argue Al Mann was wrong but I would say don't go there. TIR is a T1 measurement. For T2s to properly treat them our focus is on PPG. If our fasting glucose target is between 85-95 and we can stop the post meal spike under 160 90% of the time and 100% of the time get them back to baseline in 2hours whats the 24hr TIR going to be? I have no idea where the 62% T2 afrezza number is can you provide a link so we can zapruder it. TIR is needed with T1s because of the sleeping hours and how things can go sideways. T2s don't have that issue. TIR is a T1 thing. Aged - when you say "The idea that you are going to get doctors", WRONG. I am not going to "Get Doctors" and neither is Mike nor MNKD. Robert Ford is on a mission to sell CGMs to the T2 market. He needs to get T2s on insulin ASAP. He could careless what insulin. That is counter to the SoC. The SoC will change over time but will be ignored short term on a growing basis. I know that goes counter to what we have discussed here for years and how important it was to get changes to the SoC for afrezza but this guy has a lot of money and a lot of studies for insulin; SGLT2s; GLP1s with his Libres. He is on a mission and Abbott is not little MNKD. Robert Ford just blew up the T2 industry. Will it be once a week basal or daily basal or mealtime afrezza? He does not care. All he cares about is getting that metformin user to be "insulin treated". However Mike needs to care. He needs to make sure afrezza is on the 2024 formularity and he needs to get some studies going which shows afrezza is the best "insulin treatment" for T2s including PPG control for GLP1 users. He also needs to keep a close eye on the SoC so the change is not limited to "once weekly insulin". It would also be nice if he tried to call Robert. In the end do we want to use the CGM as a "Rearview Mirror" for the T2s or do we want "Forward Looking Radar"? Mike needs to shape that answer. |
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Post by agedhippie on Mar 11, 2023 10:06:03 GMT -5
What did Al Mann tell us? The medically correct way to treat the T2 diabetic is to treat the "post prandial glucose excursions". As I told Stevil I don't make this up. You can argue Al Mann was wrong but I would say don't go there. TIR is needed with T1s because of the sleeping hours and how things can go sideways. T2s don't have that issue. TIR is a T1 thing. I am not going to "Get Doctors" and neither is Mike nor MNKD. Robert Ford is on a mission to sell CGMs to the T2 market. He needs to get T2s on insulin ASAP. He could careless what insulin. That is counter to the SoC. I will happily say that Al Mann was wrong since it's theory and not fact. There is no data to support this. If you think T2 diabetics do not have night time issues you have obviously never heard of dawn phenomenon. You will find the 62% number on Mannkind's web site (actually 62.5%.) I would certainly hope Robert Ford wants to sell CGMs. However, the target is $10B over the next 5 years (so 2028) as discussed that at the J.P. Morgan Healthcare Conference. That's 15% CAGR which given a global product is an easy reach. The $25B number by 2025 for Libre is fantasy. And the elephant in the room. There is no way Abbott direct their sales people to defraud Medicare which is what you are proposing. That's even assuming you could get the prescription past the insurer given that a lot of coverage requires prior approval or step therapy. This idea is a flight of fantasy, but by all means invest based on it.  At this point I think we are arguing in circles; I go by the data and you go by faith in your ideas. Those cannot be reconciled so I am going to drop this. Going back to the point of this thread - the risk of SBO with GLP-1. Just like amyloid deposits this is so rare that nobody cares, it does make a good headline though (Daily Mail - you do know their reputation don't you?). The clear benefits outweigh the risk and that's how medicine works. |
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Post by sportsrancho on Mar 11, 2023 12:05:23 GMT -5
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Post by stevil on Mar 11, 2023 15:26:22 GMT -5
Welcome to being a doctor š. These are considerations I make with each patient. There are never any absolutes in medicine. It is all risk/benefit analysis. Weāre playing the same waiting game with Afrezza, at least all of us but say hey. Medicine will never advance if weāre too afraid to take the first step. The only way we now know afrezza is *probably* safe is because we can look backwards and see that it is. Weāll do the same with GLP-1s. Sometimes we get it wrong. When that happens, you adjust. Itās why the first step for me when I treat diabetes is to address the underlying cause first. I stress diet and exercise changes, because THAT is the safest and best first line treatment for diabetes. Then we go from thereā¦ |
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Post by agedhippie on Mar 11, 2023 15:30:07 GMT -5
Aged, I truly appreciate your posts, you claim to not have the time to work with a product like Afrezza. You say, "a busy diabetic just wants simplicity". You are the diabetic that researches everything related to this disease, that is admirable. You've seen the positive results Afrezza users are discussing. You, with a quick prescription, could share with us the results you experience. I'm not proposing you as a guinea pig, we are far past those days. Afrezza could be a valuable (or not) tool in your tool kit. I truly doubt cost is your barrier, if it is, I'll pay for it. You seem to have countless hours available to dispute every positive aspect of Afrezza as a viable treatment for this disease (I know, you say it really doesn't take much time) but let's take a quick look at Sayhey and your debate, plus the additional 5000 or so posts....the research you do must take a team, or maybe you truly do have that much time to dedicate to research? I suppose you will just continue to join in this conversation regarding a very positive advance in treating diabetes (both adult and pediatric) with your negative slant. I guess it all pays the same. . Although at some point, integrity may come into play? Oh yeah, Ozempic...throw it on Technosphere. I think that Afrezza has a lot of positive aspects, I just don't think it is a magic bullet. Oddly if I went on a pump I would probably use Afrezza at meal times because I could let the pump handle what would have been the second dose. I feel that always taking a 12u cartridge for the meal would work well. Predictable absorption is another benefit. The negatives are the need for follow-on doses, the size of doses (I want bigger doses), and the cough maybe but I suspect that passes as I think it's technique. Usually where I object is when people make assumptions (all diabetics will want this), assign it unproven properties (this cures T2, but we can't prove it just trust us), or treat theories as fact and expect you to take it on faith (magical thinking). My work revolves around risk and that is highly data driven, if there is no data it's unquantifiable, so when claims are made without evidence it stands out to me. The other side of my work is that I enjoy researching and I know how to do it efficiently. So when someone makes a claim I will check it. The flip side is that I don't make claims unless I have evidence to support them because I assume people will fact check. If you look you will see that periodically I jump on people making negative comments when they are wrong as well. It's just that there are a lot more positive stories to examine than negative on this board so it looks like I am anti-Afrezza which is not the case. Ozempic on TS would be interesting, but the tricky bit would be making it last a week. |
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Post by agedhippie on Mar 11, 2023 15:51:08 GMT -5
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