?Will pulmonary drug delivery achieve rich promise?

[peppy]

yep, more concentrated.

If basal insulin has been titrated to an
acceptable fasting blood glucose level,
but A1C remains above target, consider
advancing to combination injectable
therapy (Fig. 7.2) to cover postprandial
glucose excursions. Options include
adding a GLP-1 receptor agonist (27) or
mealtime insulin, consisting of one to
three injections of rapid-acting insulin
analog (lispro, aspart, or glulisine) administered
just before eating.  ( Here is our in?)

 A less
studied alternative, transitioning from
basal insulin to twice-daily premixed
(or biphasic) insulin analogs (70/30 aspart
mix, 75/25 or 50/50 lispro mix),
could also be considered; pharmacodynamic
profilesmake them suboptimal to
cover postprandial glucose excursions.
Bolus Insulin
Some individuals with type 2 diabetes
may require bolus insulin dosing in addition
to basal insulin. Rapid-acting analogs
are preferred due to their prompt
onset of action after dosing. The FDA
recently approved a more concentrated
formulation of rapid-acting insulin analog,
U-200 (200 units/mL), dosed 15 min
or immediately prior to a meal.
Regular human insulin and human
NPH-Regular premixed formulations
(70/30) are less costly alternatives to
rapid-acting insulin analogs and premixed
insulin analogs, respectively,
but their pharmacodynamic profiles
make them suboptimal

Page 58 care.diabetesjournals.org/content/suppl/2015/12/21/39.Supplement_1.DC2/2016-Standards-of-Care.pdf

[cm5]

Yes, it should be an "in"----as Afrezza would be considered to be in this group.

Standards lag, and there was no effective communication/education/discussion under the Sanofi reign, so now this can be addressed effectively.

[agedhippie]

Thinking about this a bit more - the problem with the current concentrated insulin (U-500) is that it is Regular and not rapid. This is painful to use as you need to pre-bolus and it's longish acting. The market is more or less owned by Lilly with their Humulin R U-500.

The nice thing here is that the label works for us because Afrezza is taken as non-inferior to the analogs and it is already established that analogs are superior to Regular. By equivalence this would make Afrezza U-500 superior to Humulin U-500.

(And pre-mix insulins are an invention of the devil with no place in modern diabetes treatment - it's impossible to get good control with them)