Demand

[od]

I just returned from high-volume New York City (upper east side) CVS.  Question to pharmacist friend - "Are you seeing demand or interest in Afrezza?"  Answer - head-shaking no.  It was too busy for a conversation, but the answer was a surprise.

Thinking about it, it is unlikely interested patients were able to get an appointment with their provider the same week they learned Afrezza was available (especially considering the New York City blizzard non-event closed most practices on Tuesday).  I think it wise to keep the bar low on first set of NRx numbers; if they are great, rejoice, but if not, I do not believe it is a negative indication.

No postion in MNKD or SNY (at this time).

[mrmookie123]

I think we should give it some time until we worry about script #'s etc. Hasn't even been officially launched yet. It will take some time until the entire diabetic community catches on to this thing... PATIENCE !! My Pharmacist has never heard of it, am I worried, Heck no.

[dreamboatcruise]

For sure there were few scrips written the first week. A vast majority of patients have NOT heard it is available because no patient marketing is happening yet. Early on it will more be doctors discussing it with select patients they feel would really benefit. A doctor is unlikely to call up a patient to set a new appointment just for this, so it likely will only occur at whatever the next scheduled appointment is... though those are likely fairly frequent for a target patient of Afrezza... poorly controlled diabetes. Then there is also the fact that no drug company would have enough sales reps to visit all doctors in a single week... that would be crazy staffing since they would be terribly underutilized in that case. Perhaps some of the docs could comment on how often they see particular sales reps... once every couple of months... once every month? At best I'd think it would take a month for sales reps to cover everyone... and then probably another couple of months before docs would have seen the subset of their patients they are most interested in having as early adopters. All told it seems like this process will be rather slow for at least 3 or more months.

So the numbers undoubtedly will be low. The key will be comparing the weekly numbers with a meaningful yardstick. To me that would be the weekly uptake rate for Novolog or Humalog at their launch. An insulin product isn't like a new allergy pill... it will take time. I sure hope someone has access not only to the Afrezza weekly numbers but also to those other prandial insulin historic data.

[od]

Jan 31, 2015 16:40:26 GMT -5 dreamboatcruise said:

For sure there were few scrips written the first week. A vast majority of patients have NOT heard it is available because no patient marketing is happening yet. Early on it will more be doctors discussing it with select patients they feel would really benefit. A doctor is unlikely to call up a patient to set a new appointment just for this, so it likely will only occur at whatever the next scheduled appointment is... though those are likely fairly frequent for a target patient of Afrezza... poorly controlled diabetes. Then there is also the fact that no drug company would have enough sales reps to visit all doctors in a single week... that would be crazy staffing since they would be terribly underutilized in that case. Perhaps some of the docs could comment on how often they see particular sales reps... once every couple of months... once every month? At best I'd think it would take a month for sales reps to cover everyone... and then probably another couple of months before docs would have seen the subset of their patients they are most interested in having as early adopters. All told it seems like this process will be rather slow for at least 3 or more months.

So the numbers undoubtedly will be low. The key will be comparing the weekly numbers with a meaningful yardstick. To me that would be the weekly uptake rate for Novolog or Humalog at their launch. An insulin product isn't like a new allergy pill... it will take time. I sure hope someone has access not only to the Afrezza weekly numbers but also to those other prandial insulin historic data.

Yes, sensible, not magical, thinking.  Though full-blown marketing has not begun, I believe enough patients are currently aware of availability to overdeliver on SNYs intial projections. That said, launching any product is a process, and patience is key.

[mike0475]

See my post in communication with mnkd.. if pfeffer is that accessible..he replied to my email. its not officially launched..joint pr to come

[robsacher]

od,

afrezzauser's twitter numbers are going up a lot now that he is using Afrezza and writing about his experience. He now has almost 500 followers. At this rate if he keeps documenting his daily use, in a month he may have 5,000 followers. I also saw that there is discussion about Afrezza on the American Diabetes forum pages.

RS

[mannmade]

After so many years of waiting the excitement around launch is very understandable, especially with all the positive chatter and news starting to break... However I think we all just need to Relax over first year sales numbers. I think it's pretty obvious why numbers for actual sales will likely be on the low side for the first six months or so. And this may actually be a good thing as otherwise a worse problem could be not having enough supply for demand. The most important numbers will be the % QxQ results each quarter for the first full 12 months of sales. And possibly the additional currency or value that can be applied to any technisphere deal(s) that are announced, depending on how they are recieved.

We have to remember that although Sanofi/Mannkind can't say it publicly/legally, Afrezza is a all new "FIRST IN CLASS" drug, the only ULTRA RAPID ACTING Insulin therapy for diabetics featuring "fast in/fast out" PK (the only one available to closely mimic the human body's own timing of insulin secretion) and which may effectively lead to a de facto cure of diabetes (The Holy Grail) by eliminating or greatly reducing the long term degenerative effects of diabetes due to the now very possible ability to raise basal insulin dosing to reduce FG levels to a more normal range as a result of significantly reducing the occurrence of sever hypos and start treating to zone instead of to a specific number such as Hba1c levels.

This is as I have been saying for some time what Al Mann has always believed and I do too, especially if the results posted by Sam are any indication of things to come for the diabetics of the world. However, it is indeed a revolution and a significant shift in the current paradigm for treating diabetics so it will take time, with proper thought and DD put into each patients and doctor's decision about whether to adopt a regimen of treatment based on Afrezza and/or Afrezza with Basal, (depending on whether T1 or T2)

So imho, Afrezza really is a paradigm shift in the treatment of diabetes for so many reasons such as looking to become the first line of therapy replacing Metformin etc in T2's, etc... With all of this in mind we have to understand that it will take time for the doctors and diabetics of the world to wrap their collective arms around these concepts after all it directly effects their bodies and not those of us who live a life free of this terrible disease...

[rockyp]

Here is an anecdotal data point.

The mother of my son’s friend is an endo. She mentioned today that she had been visited by a Sanofi rep this week and the rep was specifically talking about Afrezza. She said the rep was very excited about Afrezza and appeared to be very well informed. The rep was not pushing Afrezza in conjunction with any other drugs.
I had spoken with her a few months back, and at that time she wasn’t familiar with Afrezza and seemed rather cool to the idea of it, partially because she was familiar with the shortcomings of Exubera.
Today she had a very different outlook about Afrezza. She was impressed with the small size and ease of use of the inhaler. She said that roughly half of her type 2 patients who are supposed to take prandial insulin do not. She said the non-compliance is particularly high at lunch, when people tend to be out and about. (We are in NW Phoenix near Sun City, so I think she probably has a fair amount of elderly patients, FWIW.) She thinks the non-compliance is due to a combination of things such as forgetting to take the pen with them when they are out, the social stigma of injecting, or difficulty in injecting themselves if they are used to their spouse helping them (to either mechanically manipulate the pen or simply to read the numbers that indicate the size of the dose dialed in on the pen). She believes that if they had Afrezza available it might help improve their compliance number.
I asked if she had the FEV1 measuring device in her office. She said she did not, but indicated she would refer the patient to get that measurement taken and that would be “money well spent” for the patient, based on the potential benefits of Afrezza.

[joeypotsandpans]

Jan 31, 2015 17:27:34 GMT -5 robsacher said:

od,

afrezzauser's twitter numbers are going up a lot now that he is using Afrezza and writing about his experience. He now has almost 500 followers. At this rate if he keeps documenting his daily use, in a month he may have 5,000 followers. I also saw that there is discussion about Afrezza on the American Diabetes forum pages.

RS

Rob, keep in mind there is a decent percentage of his followers that are not diabetic but follow for "other interests", between all the investment forums on MNKD there are quite a few that are following as we all do. I rec'd second hand information from a very reliable source that one of the sales reps plans on scheduling 40 physicians/endo's a week, ones that are highly visible to diabetics....so hopefully that is where the biggest effect takes place as they get introduced and educated by that rep times all the others. No doubt Sam is getting attention as seen in Diatribe via Kelly Close so it is getting attention on all fronts. As far as appointments to see doctors, in some cases depending on the health plan it can take weeks, if one has not been scheduled ahead of time. Mine stated they would refer me to an endo so that adds to the time element as well.

[mannmade]

Jan 31, 2015 17:48:42 GMT -5 rockyp said:

Here is an anecdotal data point.

The mother of my son’s friend is an endo. She mentioned today that she had been visited by a Sanofi rep this week and the rep was specifically talking about Afrezza. She said the rep was very excited about Afrezza and appeared to be very well informed. The rep was not pushing Afrezza in conjunction with any other drugs.
I had spoken with her a few months back, and at that time she wasn’t familiar with Afrezza and seemed rather cool to the idea of it, partially because she was familiar with the shortcomings of Exubera.
Today she had a very different outlook about Afrezza. She was impressed with the small size and ease of use of the inhaler. She said that roughly half of her type 2 patients who are supposed to take prandial insulin do not. She said the non-compliance is particularly high at lunch, when people tend to be out and about. (We are in NW Phoenix near Sun City, so I think she probably has a fair amount of elderly patients, FWIW.) She thinks the non-compliance is due to a combination of things such as forgetting to take the pen with them when they are out, the social stigma of injecting, or difficulty in injecting themselves if they are used to their spouse helping them (to either mechanically manipulate the pen or simply to read the numbers that indicate the size of the dose dialed in on the pen). She believes that if they had Afrezza available it might help improve their compliance number.
I asked if she had the FEV1 measuring device in her office. She said she did not, but indicated she would refer the patient to get that measurement taken and that would be “money well spent” for the patient, based on the potential benefits of Afrezza.

Your story mimics exactly the experience I had with a friend of mine who is one of the leading diabetic care GP's in SoCal.  From my previous post I mentioned that he gave me what amounted to the "Short Thesis on Non-Adoption" aka reasons why Afrezza will not be a blockbuster.  After being called on by his sanofi rep earlier this week he sent me an unsolicited note to say how cool Afrezza was and so really easy to use.  Looks like sanofi knows what they are doing and we can put to bed another short argument that Sanofi is not properly supporting Afrezza.  Eg; AF they only gave Afrezza one slide so they must not care about it... Slowly but surely ("don't call me Shirley" circa:07.02 80 "Airplane") the noose is getting tighter around the shorts' necks... 

[notamnkdmillionaire]

It is clearly obvious that many who poo poo Afrezza either know nothing about it or quicky think it is an Exubera clone and use that as a misinformed reference point to make a very uneducated opinion on it. Once these people actually see Afrezza in the flesh and actually study what it is and how it works, they will have that epiphany moment and say to themselves, "OMG, this is going to change how I treat my patients and for the better!" That's my story and I am sticking to it. I cant wait to see Jim Cramer finally give a detailed analysis of MNKD and say, "Hey folks, MNKD's Afrezza and their technosphere is a game changer. Buy with wild abandonment. Oh, and those that follow Adam Feuerstein, I just fired his incompetent ass."

[od]

Apologies folks. I forget that I am communicating with a mature group here. When I masochistically look at YMB I can't break the urge to infuse some reality/sanity. No need on this ProBoard.

[od]

Jan 31, 2015 17:48:42 GMT -5 rockyp said:

Here is an anecdotal data point.

The mother of my son’s friend is an endo. She mentioned today that she had been visited by a Sanofi rep this week and the rep was specifically talking about Afrezza. She said the rep was very excited about Afrezza and appeared to be very well informed. The rep was not pushing Afrezza in conjunction with any other drugs.
I had spoken with her a few months back, and at that time she wasn’t familiar with Afrezza and seemed rather cool to the idea of it, partially because she was familiar with the shortcomings of Exubera.
Today she had a very different outlook about Afrezza. She was impressed with the small size and ease of use of the inhaler. She said that roughly half of her type 2 patients who are supposed to take prandial insulin do not. She said the non-compliance is particularly high at lunch, when people tend to be out and about. (We are in NW Phoenix near Sun City, so I think she probably has a fair amount of elderly patients, FWIW.) She thinks the non-compliance is due to a combination of things such as forgetting to take the pen with them when they are out, the social stigma of injecting, or difficulty in injecting themselves if they are used to their spouse helping them (to either mechanically manipulate the pen or simply to read the numbers that indicate the size of the dose dialed in on the pen). She believes that if they had Afrezza available it might help improve their compliance number.
I asked if she had the FEV1 measuring device in her office. She said she did not, but indicated she would refer the patient to get that measurement taken and that would be “money well spent” for the patient, based on the potential benefits of Afrezza.

Excellent news.  There are many reasons Exubera failed, but it is well documented that lack of spiromenters, especially in endo practices, was a significant factor.  Of course, before and after Exubera there was no need for endos to have the device, but there is now.  I have read that part of SNY detailing is explaining how lung function testing is reimbursed and that it more than pays for the spirometer investment.  What is confounding is that spirometer penetration in IM practices is less than 40% and there are many reasons beyond Afrezza lung function testing that it should be 100%.

[jpg]

Jan 31, 2015 21:36:03 GMT -5 od said:

Jan 31, 2015 17:48:42 GMT -5 rockyp said:

Here is an anecdotal data point.

The mother of my son’s friend is an endo. She mentioned today that she had been visited by a Sanofi rep this week and the rep was specifically talking about Afrezza. She said the rep was very excited about Afrezza and appeared to be very well informed. The rep was not pushing Afrezza in conjunction with any other drugs.
I had spoken with her a few months back, and at that time she wasn’t familiar with Afrezza and seemed rather cool to the idea of it, partially because she was familiar with the shortcomings of Exubera.
Today she had a very different outlook about Afrezza. She was impressed with the small size and ease of use of the inhaler. She said that roughly half of her type 2 patients who are supposed to take prandial insulin do not. She said the non-compliance is particularly high at lunch, when people tend to be out and about. (We are in NW Phoenix near Sun City, so I think she probably has a fair amount of elderly patients, FWIW.) She thinks the non-compliance is due to a combination of things such as forgetting to take the pen with them when they are out, the social stigma of injecting, or difficulty in injecting themselves if they are used to their spouse helping them (to either mechanically manipulate the pen or simply to read the numbers that indicate the size of the dose dialed in on the pen). She believes that if they had Afrezza available it might help improve their compliance number.
I asked if she had the FEV1 measuring device in her office. She said she did not, but indicated she would refer the patient to get that measurement taken and that would be “money well spent” for the patient, based on the potential benefits of Afrezza.

Excellent news.  There are many reasons Exubera failed, but it is well documented that lack of spiromenters, especially in endo practices, was a significant factor.  Of course, before and after Exubera there was no need for endos to have the device, but there is now.  I have read that part of SNY detailing is explaining how lung function testing is reimbursed and that it more than pays for the spirometer investment.  What is confounding is that spirometer penetration in IM practices is less than 40% and there are many reasons beyond Afrezza lung function testing that it should be 100%.

Having been around when Exubera came out I can, with a high degree of confidence, say the sprirometry thing was a very minor part of it's failure. We all know the lists of 'sins' so I won't go over it again but again lack of spirometry in endo offices was not even in the 'top 5' reasons for its failure.
I agree spirometry is clinically very useful but I don't know why IM practices should necessarily all have spirometers? Peak flow works just as well for a lot of the asthmatic stuff and has the added advantage of being easily tested (and therefor comparable) by the patient themselves. Agreed that if all MDs had spirometry it would make prescription of Afrezza slightly easier but I really doubt it will be a significant barrier for getting Afrezza prescribed. They really aren't that hard to get done and often in the same building and even on the same day.

[mnholdem]

I can already begin to see how word of mouth about the benefits of Afrezza with spread via the internet. 

simplyilka.com/2015/01/30/need-know-story-inhalable-insulin-Afrezza/

Patients won't demand what they don't know about. Folks like Ilka and afrezzauser, who are spreading the word, will soon number in the hundreds, then thousands, maybe tens of thousands.

Afrezza demand will start out slow but, like an avalanche, you will not be able to stop this on its way to becoming a blockbuster.