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Post by sportsrancho on Feb 6, 2017 20:29:57 GMT -5
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Post by peppy on Feb 7, 2017 9:11:07 GMT -5
Wow, this is a classic. An A1c 8.1 and the answer is more metformin. Lets do the same thing which has not worked and double down. It sounds like insanity to me. So, this is the situation Mike C. and his staff face with the medical community. I know this endo is not unique but is probably more typical than not. I sure hope that the new staff can tell the story. I looked at the starter kit and I saw no where that it is explained how afrezza is different and what to expect. The daily log in the kit is interesting as someone had in mind testing before and after meals and before bed. No where does it explain what to do or why second dosing is often needed. I sure hope they straighten out the documentation for the new guys so they can tell a compelling story of how different afrezza is from the RAAs and how similar it is to natural insulin release. www.afrezza.com/wp-content/uploads/2016/08/Afrezza-Patient-Starter-Kit.pdf Regarding afrezza dosing guide. Agreed, a better dosing guide is needed. The starter kit said the physician will complete the dosing guide.
They are lost. Matt's small, medium or large meal, and fat content of the meal assessment, and follow up doses, should be talked about. Hmmm, the physician to complete the guide.
subq fast acting there is a huge learning curve. hmmm
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Post by Deleted on Feb 7, 2017 9:52:42 GMT -5
Interesting comment above on telemedicine. Several companies working on kiosks to put into pharmacies or corporate offices for the sole purpose of telemedicine. In many cases, a face to face is not needed and as such, telemedicine takes costs out of the system.
On PBS Newshour last night, segment on healthcare costs and in Boston, one of the health systems now utilizes telemedicine. In preparation for a fee for outcomes vs fee for service, telemedicine Is a cost saver. In other cases, a nurse practitioner making house calls. Look at all the healthcare infrastructure. How much of it is actually needed, that is, can more patients get the healthcare they need via telemedicine. Segment talked about replacement for ACA or a world where Medicare looks to the fee for outcome model and health systems experimenting with new ways to deliver healthcare. AI investment in radiology is already significant.
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Post by kc on Feb 7, 2017 10:26:34 GMT -5
TeleMed is big. I have a Dr. Friend who see's patients all over Kansas using TeleMed. Many small towns don't have the healthcare doctors anymore and he sees them from his KC office. He has been engaged doing this for over 10 year.
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Post by lakon on Feb 7, 2017 11:44:44 GMT -5
TeleMed is big. I have a Dr. Friend who see's patients all over Kansas using TeleMed. Many small towns don't have the healthcare doctors anymore and he sees them from his KC office. He has been engaged doing this for over 10 year. Consider this: Many countries never had the healthcare doctors needed...but they have cell phones...just call the mobile doc... Consider this: Finding a really good doctor for your needs can be a real challenge for everyone. Why not use the power of modern communications and the Internet instead of settling for whomever happens to be nearby geographically?
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Post by peppy on Feb 7, 2017 11:48:51 GMT -5
Could 50 licensed physicians in the 50 states of the USA provide teleconferencing medical assessment for Afrezza? Laboratory work done at primary physicians office, spirometery and A1c, Seems like a low cost model.
Additionally support staff to teach dosing and dosing times, could start working with them at time of prescription.
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Post by peppy on Feb 7, 2017 12:14:56 GMT -5
Explaining to T2 coworkers of the benefits of Afrezza versus metformin is relatively easy, however, because our insurance currently does not cover Afrezza it is difficult for them to make the switch. Are there papers that spell out compelling reasons to switch? Paper spelling out compelling reasons. Mnholdem had this posted in resources.
Did you notice the guidelines require metformin used with all therapies? www.screencast.com/t/nOwBa4aaA
www.diabetesincontrol.com/early-short-term-intensive-insulin-causes-the-remission-of-type-2-diabetes/
Excerpts:
In early type 2 diabetes (T2DM), short-term intensive insulin therapy (IIT) for 2-4 weeks can decrease insulin resistance, reduce glucagonemia, improve β-cell function, and even induce a remission of diabetes that can last up to one year in some patients.
Data was evaluated from the placebo arm of a double-blind randomized controlled trial in which patients with early T2DM (≤7 years duration) underwent 4 weeks of IIT (basal detemir, bolus aspart), followed by placebo therapy for 48 weeks (n=25). Participants underwent an oral glucose tolerance test every 12 weeks, enabling serial assessment of insulin sensitivity, α-cell response, and β-cell function. Diabetes remission was defined as A1c<6.5% on no medication for T2DM.
For the study design, data from the placebo arm of the double-blind randomized controlled trial in which 25 patients within 7 y of T2D diagnosis received 4 weeks of intensive basal/bolus insulin therapy followed by placebo for 48 wk. An oral glucose tolerance test (OGTT) every 12 weeks used to assess insulin sensitivity and beta-cell function. Then diabetes remission was defined as HbA1c <6.5% with no T2D medications.
The results showed that at 48 weeks after stopping intensive insulin, 14 participants (56%) were in diabetes remission. At baseline, the remission group had shorter duration of diabetes (1.2 vs 2.6 y; p=.03), lower A1c (6.2% vs 7.1%, p=.006), and better β-cell function.
The 2 groups did not differ in clinical characteristics such as age, gender, ethnicity, pre-study diabetes treatment, body mass index, waist circumference, blood pressure, liver enzymes, or insulin sensitivity.
Then, in logistic regression analyses, shorter duration of diabetes supplanted baseline A1c (p=.24) and β-cell function (p=.19) as an independent predictor of remission at 48 weeks (OR, 0.22; 95% CI 0.05-0.92; p=.04)
At 48 weeks post-IIT, 56% of the participants remained in remission. Comparison of remitters to non-remitters revealed no differences in waist, body mass index, insulin sensitivity (Matsuda index), or glucagon profile, either at baseline or over 48 weeks. Compared to non-remitters, the remission group had lower baseline A1c (p=0.006) and better baseline β-cell function
The key determinant of the likelihood of inducing sustained drug-free diabetes remission with short-term IIT is early intervention, particularly within the first 2 years after diagnosis. And reversing or delaying type 2 diabetes may help prevent morbidity and reduce healthcare costs.
Read more: mnkd.proboards.com/thread/3407/blood-sugar-101-tell-diabetes#ixzz4Y1KlV7tu
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Post by lakon on Feb 7, 2017 12:48:14 GMT -5
Could 50 licensed physicians in the 50 states of the USA provide teleconferencing medical assessment for Afrezza? Laboratory work done at primary physicians office, spirometery and A1c, Seems like a low cost model. Additionally support staff to teach dosing and dosing times, could start working with them at time of prescription. My thought was that VDEX was going to use a business model like this one to scale up quickly. Send lab work to labs rather than PCP. Cut out all competitors by outsourcing to laboratories directly. (Possibly partner with labs.) Go for volume and scale up. A new business model is needed to reach the global patient population, and MNKD's passion is innovation so I hoped to no avail. It seems that MNKD cannot innovate where they would run afoul of the FDA. Some enterprising doctors certainly could. Simplify dosing, dosing times, and titration to get good averages. Then, improve. Something like Al said, dose 10-15 minutes into a meal. Dose again if a long/large meal, or slow to digest. Type 1's can read their meters and improve upon this starting point. Stay in range is the goal to reach non-diabetic numbers. MNKD needs to convince a small number (50-100) of doctors, preferably PCP's or endos in VDEX, to get a statistically meaningful number of PWD's to non-diabetic numbers. Statistically meaningful is only a few hundred. The doctors need to publish the results, even if average results are only near non-diabetic or pre-diabetic, the news would be HUGE! The endos will have more to worry about if this comes to pass...
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Post by peppy on Feb 7, 2017 12:54:04 GMT -5
I am working on dosing in a separate thread now. Could not be easier to dose afrezza compared to subq. I can not believe this non prescription is about safety any longer. Subq fast acting is chit.
How sweet is was when medicine just told them what to do and no one could see their blood glucose levels unless they checked, and checking could have never been good, why bother.
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Post by dreamboatcruise on Feb 7, 2017 13:27:19 GMT -5
Could 50 licensed physicians in the 50 states of the USA provide teleconferencing medical assessment for Afrezza? Laboratory work done at primary physicians office, spirometery and A1c, Seems like a low cost model. Additionally support staff to teach dosing and dosing times, could start working with them at time of prescription. My thought was that VDEX was going to use a business model like this one to scale up quickly. Send lab work to labs rather than PCP. Cut out all competitors by outsourcing to laboratories directly. (Possibly partner with labs.) Go for volume and scale up. A new business model is needed to reach the global patient population, and MNKD's passion is innovation so I hoped to no avail. It seems that MNKD cannot innovate where they would run afoul of the FDA. Some enterprising doctors certainly could. Simplify dosing, dosing times, and titration to get good averages. Then, improve. Something like Al said, dose 10-15 minutes into a meal. Dose again if a long/large meal, or slow to digest. Type 1's can read their meters and improve upon this starting point. Stay in range is the goal to reach non-diabetic numbers. MNKD needs to convince a small number (50-100) of doctors, preferably PCP's or endos in VDEX, to get a statistically meaningful number of PWD's to non-diabetic numbers. Statistically meaningful is only a few hundred. The doctors need to publish the results, even if average results are only near non-diabetic or pre-diabetic, the news would be HUGE! The endos will have more to worry about if this comes to pass... It seems like it would be very difficult for a company like VDEX to have a business model based on 1 or 2 doctors in each state. Not only would there be dealing with the regulatory agencies in 50 states, there would be a need to get "on network" with hundreds upon hundreds of different insurance plans (unless it is only indented for cash paying customers). Remember that VDEX was set to open their first office in NJ. I highly suspect that it was either regulatory or payer coverage that kept that from happening. Does anyone know which, if any, managed care payers cover VDEX? Problem is, most HMO plans won't cover prescriptions unless they've been written by one's primary doctor or through an approved referral, even if some people were willing to pay out of pocket for VDEX services. I've long expressed a hope that a VDEX or some other practice such as Sam Finta's doctor would generate publicity of a new better way of managing diabetes.
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Post by Deleted on Feb 7, 2017 14:19:22 GMT -5
peppy I don't know how T2s are supposed to get around doctor prescribing metformin.
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Post by sportsrancho on Feb 7, 2017 14:51:11 GMT -5
peppy I don't know how T2s are supposed to get around doctor prescribing metformin. There are doctors even if you are on Metformin prescribing Afrezza for corrections.
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Post by peppy on Feb 7, 2017 14:59:09 GMT -5
peppy I don't know how T2s are supposed to get around doctor prescribing metformin. To get Afrezza to treat his type 2 diabtes at this point, I think your friend would have to go toe to toe with the physician. Something like this. I am on metformin twice a day, and my kidneys are indicating signs of damage. Go over the lab work. Metformin then is to be lowered, we did that, my blood glucoses so high I am back on two doses a day, back to kidney problems as studies in normal subjects demonstrate that metformin is excreted unchanged in the urine and does not undergo hepatic metabolism (Their is the toe to toe. few can pull it off. The Vdex Dad and his son, pulled off a version of toe to toe)
Further it could be said, so my choices are to take out my kidneys with metformin. I ask you to treat my insulin resistance with insulin and I choose Afrezza. Afrezza is a different type of insulin. The big hit of insulin you get from afrezza stops the liver from the gluconeogenesis just like you are asking the metformin to do, but metformin is taking out my kidneys.
You have to hit the physician with Matt: www.screencast.com/t/pYQ4TMFaY and some real time glucose monitors and allow them to think about it. twitter.com/hashtag/afrezza
Your friend needs insurance coverage for the cost.
Have him go in with a copy of the FDA/package insert. www.fda.gov/ohrms/dockets/dailys/02/May02/053102/800471e6.pdf
www.screencast.com/t/sOKNOiafBBag
have the physician look at the description. "The Nitrogen Doc, that is a lot of protein being excreted from my kidneys. The damage." C4H11N5.HCL toe to toe.
BUN Blood urea nitrogen...What is his BUN?
Renal Insufficiency In patients with decreased renal function (based on measured creatinine clearance), the plasma and blood half-life of metformin is prolonged and the renal clearance is decreased in proportion to the decrease in creatinine clearance (see Table 1; also see WARNINGS)
(Lactic Acidosis)
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Post by mnholdem on Feb 7, 2017 17:18:20 GMT -5
I am working on dosing in a separate thread now. Could not be easier to dose afrezza compared to subq. I can not believe this non prescription is about safety any longer. Subq fast acting is chit. How sweet is was when medicine just told them what to do and no one could see their blood glucose levels unless they checked, and checking could have never been good, why bother. It's fantastic that the FDA has finally approved a DexCom continuous glocuse monitor (GCM) to be used for the purpose of dosing.
CGMs are so expensive that it is a BIG DEAL that patients might finally get better coverage. Whenever a good, affordable blood glucose monitor hits the market, however, it will change everything related to the treatment of diabetes, especially for T2 diabetes.
A1c will eventually become a meaningless measurement. It served it's purpose but has outlived its usefulness. Time-in-Range will likely become one of the most important KPIs in for measuring the effectiveness of treatment. At least I hope it will, because that would help put Afrezza in the spotlight.
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Post by cjm18 on Feb 7, 2017 17:40:41 GMT -5
I am working on dosing in a separate thread now. Could not be easier to dose afrezza compared to subq. I can not believe this non prescription is about safety any longer. Subq fast acting is chit. How sweet is was when medicine just told them what to do and no one could see their blood glucose levels unless they checked, and checking could have never been good, why bother. It's fantastic that the FDA has finally approved a DexCom continuous glocuse monitor (GCM) to be used for the purpose of dosing.
CGMs are so expensive that it is a BIG DEAL that patients might finally get better coverage. Whenever a good, affordable blood glucose monitor hits the market, however, it will change everything related to the treatment of diabetes, especially for T2 diabetes.
A1c will eventually become a meaningless measurement. It served it's purpose but has outlived its usefulness. Time-in-Range will likely become one of the most important KPIs in for measuring the effectiveness of treatment. At least I hope it will, because that would help put Afrezza in the spotlight.
Interesting that mannkind is doing time in range studies. And not a1c.
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