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Post by lakon on Apr 21, 2016 9:19:49 GMT -5
What we really need are dosing trials to determine the best time to take a dose per meal type, like MattB mentioned, the unwritten Afrezza manual. Have a fixed meal defined. Test Afrezza -15 min, 0 min, +15 min, +30 min, etc. from the start of the meal. Fit the insulin curve to the glucose curve. Theoretically, this could be done with all insulin types, but the time of action makes it far more challenging without Afrezza. It's RISC vice CISC in computing. I can get behind this kind of study, but the so called "The Superiority Study" to solve all of our problems, not so much. I think not "A [1] Study" can do what we need. I think many studies would help, but time and money (capital capital capital)... Also, I reviewed the referenced Humalog studies (thanks agedhippie), but I asked quite purposefully: Is Humulin superior to Humalog? I doubt the answer above. Granted, I did not have time to read every line again, but I thought studies showed Humalog superior to Humulin R... |
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Post by agedhippie on Apr 21, 2016 18:31:14 GMT -5
What we really need are dosing trials to determine the best time to take a dose per meal type, like MattB mentioned, the unwritten Afrezza manual. Have a fixed meal defined. Test Afrezza -15 min, 0 min, +15 min, +30 min, etc. from the start of the meal. Fit the insulin curve to the glucose curve. Theoretically, this could be done with all insulin types, but the time of action makes it far more challenging without Afrezza. It's RISC vice CISC in computing. I can get behind this kind of study, but the so called "The Superiority Study" to solve all of our problems, not so much. I think not "A [1] Study" can do what we need. I think many studies would help, but time and money (capital capital capital)... Also, I reviewed the referenced Humalog studies (thanks agedhippie ), but I asked quite purposefully: Is Humulin superior to Humalog? I doubt the answer above. Granted, I did not have time to read every line again, but I thought studies showed Humalog superior to Humulin R... It depends on the delivery but generally Humulin is inferior. There are exceptions like IV delivery. Diabetics can do curve fitting today. It's knowing how your personal metabolism works. This is very personalized which is why you often see YMMV in these discussions amongst diabetics. The problem is that a fatty meal will delay the glucose spike so it doesn't arrive at the right time. A meal with a high glycemic load will have the opposite problem. This is why you sometimes see people on Afrezza taking second doses as they don't hit the spike squarely. The only thing that will move doctors are studies as everything else is opinion in their view. |
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Post by mnkdnut on Apr 21, 2016 19:42:16 GMT -5
What we really need are dosing trials to determine the best time to take a dose per meal type, like MattB mentioned, the unwritten Afrezza manual. Have a fixed meal defined. Test Afrezza -15 min, 0 min, +15 min, +30 min, etc. from the start of the meal. Fit the insulin curve to the glucose curve. Theoretically, this could be done with all insulin types, but the time of action makes it far more challenging without Afrezza. It's RISC vice CISC in computing. I can get behind this kind of study, but the so called "The Superiority Study" to solve all of our problems, not so much. I think not "A [1] Study" can do what we need. I think many studies would help, but time and money (capital capital capital)... Also, I reviewed the referenced Humalog studies (thanks agedhippie ), but I asked quite purposefully: Is Humulin superior to Humalog? I doubt the answer above. Granted, I did not have time to read every line again, but I thought studies showed Humalog superior to Humulin R... It depends on the delivery but generally Humulin is inferior. There are exceptions like IV delivery. Diabetics can do curve fitting today. It's knowing how your personal metabolism works. This is very personalized which is why you often see YMMV in these discussions amongst diabetics. The problem is that a fatty meal will delay the glucose spike so it doesn't arrive at the right time. A meal with a high glycemic load will have the opposite problem. This is why you sometimes see people on Afrezza taking second doses as they don't hit the spike squarely. The only thing that will move doctors are studies as everything else is opinion in their view.
Could not agree more with that last statement. Prescribers and Payers both rely on the strength of clinical studies to decide on what to use. They rarely have time for discussions that begin with "the clinical study results are inconclusive, but...", especially when they have other treatments they have invested their time in. Either you show them evidence in a way that's accepted in the industry/community, or you face constant resistance. It's like trying to travel outside the US with just a birth certificate - the customs agents don't really care if you're an actual US citizen, they want a valid passport! I suspect MNKD will start to address this sooner with smaller scale studies that may not change the label, but get doctor's attention for a certain target segment of patients. And, the incentive of a lower price (if feasible) is always an attention getter. |
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Post by peppy on Apr 21, 2016 20:12:37 GMT -5
It depends on the delivery but generally Humulin is inferior. There are exceptions like IV delivery. Diabetics can do curve fitting today. It's knowing how your personal metabolism works. This is very personalized which is why you often see YMMV in these discussions amongst diabetics. The problem is that a fatty meal will delay the glucose spike so it doesn't arrive at the right time. A meal with a high glycemic load will have the opposite problem. This is why you sometimes see people on Afrezza taking second doses as they don't hit the spike squarely. The only thing that will move doctors are studies as everything else is opinion in their view.
Could not agree more with that last statement. Prescribers and Payers both rely on the strength of clinical studies to decide on what to use. They rarely have time for discussions that begin with "the clinical study results are inconclusive, but...", especially when they have other treatments they have invested their time in. Either you show them evidence in a way that's accepted in the industry/community, or you face constant resistance. It's like trying to travel outside the US with just a birth certificate - the customs agents don't really care if you're an actual US citizen, they want a valid passport! I suspect MNKD will start to address this sooner with smaller scale studies that may not change the label, but get doctor's attention for a certain target segment of patients. And, the incentive of a lower price (if feasible) is always an attention getter. So they are stupid? Blind? or stubborn? screencast.com/t/s71fZjKaDOyK screencast.com/t/BQ2WnilGfm
It sounds like an argument as to why idiocy should exist.
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Post by mnkdnut on Apr 21, 2016 20:49:27 GMT -5
Could not agree more with that last statement. Prescribers and Payers both rely on the strength of clinical studies to decide on what to use. They rarely have time for discussions that begin with "the clinical study results are inconclusive, but...", especially when they have other treatments they have invested their time in. Either you show them evidence in a way that's accepted in the industry/community, or you face constant resistance. It's like trying to travel outside the US with just a birth certificate - the customs agents don't really care if you're an actual US citizen, they want a valid passport! I suspect MNKD will start to address this sooner with smaller scale studies that may not change the label, but get doctor's attention for a certain target segment of patients. And, the incentive of a lower price (if feasible) is always an attention getter. So they are stupid? Blind? or stubborn? screencast.com/t/s71fZjKaDOyK screencast.com/t/BQ2WnilGfm
It sounds like an argument as to why idiocy should exist.
No, I'd say just time starved and under a lot of pressure to see lots of patients and make zero mistakes. At any one time, they probably have 2 dozen reps who want a slice of their time to explain some new treatment they should try. They have to have some darn good motivation to spend the time to understand something that may or may not help them or their patients. Studies published in the NEJM make it easy for them to decide to spend some time. Screenshots from twitter - not so much. I'm sure Michael Castagna gets it and will address it appropriately, but it won't be easy or fast. |
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Post by saxcmann on Apr 21, 2016 21:40:09 GMT -5
No, I'd say just time starved and under a lot of pressure to see lots of patients and make zero mistakes. At any one time, they probably have 2 dozen reps who want a slice of their time to explain some new treatment they should try. They have to have some darn good motivation to spend the time to understand something that may or may not help them or their patients. Studies published in the NEJM make it easy for them to decide to spend some time. Screenshots from twitter - not so much. I'm sure Michael Castagna gets it and will address it appropriately, but it won't be easy or fast. I don't post much but felt compelled here... Mnkdnut is 100% correct with his thread comments. Doctors need scientific results from studies not blog reports. Peppy...yes, doctors are stubborn as hell too! |
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Post by tayl5 on Apr 21, 2016 21:40:22 GMT -5
The legal aspect should not be underestimated. Nobody gets sued for following standard of care, even if it's years behind what's possible. This is particularly true if cutting-edge care requires a doctor to go off-label. Might work for an early adopter but the mass market don't play that.
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Post by agedhippie on Apr 22, 2016 12:57:18 GMT -5
Could not agree more with that last statement. Prescribers and Payers both rely on the strength of clinical studies to decide on what to use. They rarely have time for discussions that begin with "the clinical study results are inconclusive, but...", especially when they have other treatments they have invested their time in. Either you show them evidence in a way that's accepted in the industry/community, or you face constant resistance. It's like trying to travel outside the US with just a birth certificate - the customs agents don't really care if you're an actual US citizen, they want a valid passport! I suspect MNKD will start to address this sooner with smaller scale studies that may not change the label, but get doctor's attention for a certain target segment of patients. And, the incentive of a lower price (if feasible) is always an attention getter. So they are stupid? Blind? or stubborn? screencast.com/t/s71fZjKaDOyK screencast.com/t/BQ2WnilGfm
It sounds like an argument as to why idiocy should exist. Strictly speaking that second link show hypoglycemia. His level is 71 and has risen slightly from somewhere in the 60s. That is the sort of things that make endos and doctors twitchy. |
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Post by peppy on Apr 22, 2016 15:20:21 GMT -5
Strictly speaking that second link show hypoglycemia. His level is 71 and has risen slightly from somewhere in the 60s. That is the sort of things that make endos and doctors twitchy. strictly speaking it makes me twitchy as well. Ever look at what is considered a normal blood glucose level? 60 to 90 mg/dl I see the normal values have been upped for the glucose epidemic. for years the lab results said, 60 to 90 was a normal glucose. 1980's, 1990's. •A normal fasting (no food for eight hours) blood sugar level is between 70 and 99 mg/dL.
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Post by agedhippie on Apr 22, 2016 15:35:33 GMT -5
Strictly speaking that second link show hypoglycemia. His level is 71 and has risen slightly from somewhere in the 60s. That is the sort of things that make endos and doctors twitchy. strictly speaking it makes me twitchy as well. Ever look at what is considered a normal blood glucose level? 60 to 90 mg/dl I see the normal values have been upped for the glucose epidemic. for years the lab results said, 60 to 90 was a normal glucose. 1980's, 1990's. •A normal fasting (no food for eight hours) blood sugar level is between 70 and 99 mg/dL.
It is the sort of thing that has doctors saying that you get a good A1c by having lows. That's a bit unfair and you can do it with a CGM but I am not sure I want to do it off a meter alone. I know I dose far more aggressively when I am on my CGM because I can avoid lows better. |
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