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Post by cyn on Apr 4, 2017 13:45:40 GMT -5
Zuegirdor wrote ... "This flexibility and physiological adeptness, which injected lacks, is what also makes Endos nervous. There is too much explaining to patients, which takes time when you have 100-200 of them to treat-most of which are out of target and thus all these conversations are fraught with angst of failed therapies and low self esteem on the part of patients."
Zuegirdor, you are so correct to point out that Afrezza is a time management nightmare for Endos, despite all it's benefits. Clearly, Endos won't devote the time necessary to re-train "existing" patients, especially those patients with low self esteem and already stressed in patient-doctor titration conversations. As you (and others) have so correctly emphasized, Afrezza's dosing methodology requires a dramatic shift in mindset, customization and patient empowerment; and Endos just simply don't want to re-invest additional office hours in existing patients. Time is money ... and let's face it, the emphasis will always be on growing the "new' patient base while preserving the "status quo" on office time management where possible. Why should Endos duplicate valuable office time on "existing" patients when they don't have to? And, why should Endos expose themselves to added insurance paperwork (and scrutiny) to justify extra hours to shift patients to Afrezza? Imo, MNKD needs to find a way to incentivize Endos by somehow reducing the office time required to re-dose patients to Afrezza.... Perhaps some sort of "how to" short orientation film focused on Afrezza's dosing methodology (and distinctions to injectable insulin) to reduce dosage training time with the Endos. I seem to recall years ago before having a complicated surgery that I was required to view an orientation film before I met with the surgeon. This film headed off many of my questions and concerns, and unquestionably saved an immense amount of time with the surgeon. MNKD needs to find creative ways to make the dosage regime shift to Afrezza as uncomplicated "and" time-efficient for the Endos and their patients. GLTA Longs.
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Post by markado on Apr 4, 2017 15:44:56 GMT -5
Cyn,
While I agree with many of the barriers to adoption that you present on behalf of the Endo profession, the simple answer to "why should they?" is twofold: patient quality of life and patient satisfaction.
Being the most resistant Endo isn't going to bode well for career longevity. How many wagon wheel makers do you know? I wonder who the last orthodontist in America will be to adopt the Invisalign method of tooth alignment vs wires and spacers, etc.
Fear of irrelevance, in addition to every other form of demotivating influence, is also getting in the way of Afrezza adoption and prescription. But, if MNKD could show that treating a patient on Afrezza could potentially be less time intensive, therefore more profitable per patient, maybe that could allay some of the issues you describe. Though, I hardly think profit per patient should be an Endos primary motivation.
Mannkind is suffering a form of agency bias with the Endo community, but as agents of care, the Endo community is failing PWD's by not attempting to deploy it in every case where it currently proves most applicable and relevant, to give them an opportunity to possibly improve their quality of life, diabetic state and symptoms.
I believe the most successful Endos and true "specialists" in this field will add Afrezza to their portfolio of treatment options. The rest will be second class and remarkably replaceable via a PWD's next visit to a GP. So, if they're not going to adopt it, maybe their fear (even if subconscious) is reasonably justified.
This is just a perspective. But this situation has played out in many industries many times over since the inception of commerce and of medicine.
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Post by agedhippie on Apr 4, 2017 16:46:46 GMT -5
Cyn, While I agree with many of the barriers to adoption that you present on behalf of the Endo profession, the simple answer to "why should they?" is twofold: patient quality of life and patient satisfaction. Being the most resistant Endo isn't going to bode well for career longevity. How many wagon wheel makers do you know? I wonder who the last orthodontist in America will be to adopt the Invisalign method of tooth alignment vs wires and spacers, etc. Fear of irrelevance, in addition to every other form of demotivating influence, is also getting in the way of Afrezza adoption and prescription. But, if MNKD could show that treating a patient on Afrezza could potentially be less time intensive, therefore more profitable per patient, maybe that could allay some of the issues you describe. Though, I hardly think profit per patient should be an Endos primary motivation. Mannkind is suffering a form of agency bias with the Endo community, but as agents of care, the Endo community is failing PWD's by not attempting to deploy it in every case where it currently proves most applicable and relevant, to give them an opportunity to possibly improve their quality of life, diabetic state and symptoms. I believe the most successful Endos and true "specialists" in this field will add Afrezza to their portfolio of treatment options. The rest will be second class and remarkably replaceable via a PWD's next visit to a GP. So, if they're not going to adopt it, maybe their fear (even if subconscious) is reasonably justified. This is just a perspective. But this situation has played out in many industries many times over since the inception of commerce and of medicine. Ok, there are a few misconceptions here. Irrelevance and redundancy are not any sort of issue for endos. Not least because diabetes is only one of a whole slew of conditions they treat. Add to that the shortage of endos (they don't have juicy expensive procedures they can do - you don't get rich as an endo) as evidenced by how long it takes to see one. No, lack of business is not a fear. Time per patient. Your endo appointment may discuss insulin or your doses but that't usually the smaller part. I spend far more time talking about odd situations, or why I got a particular result. Then there is the whole knock on - in Type 1 it's auto immune (am I getting celiac disease, is my thyroid acting up, any neuropathy), and for Type 2 it's lipids and metabolism. Afrezza changes very little of that, certainly it wouldn't shorten appointment times. Agency bias, aka. consensus. Endos don't change treatments lightly, not least since diabetics are very resistant to change (says the poster child) and it's easy to make things worse. Putting someone on a different statin may have minimal down side, putting someone on an entirely different type of insulin may put them in hospital (this is one reason I don't think DTC has much effect). The same thing happened with the introduction of RAA, it took time and trial data to move people, that is still true. I can see Afrezza as part of the armory, the question is whether it's the main event or a side show bought out on special occasions. My endo won't prescribe it generally, but there is a couple of very specific cases where he has because the circumstance warrant it in his view.
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Post by peppy on Apr 4, 2017 19:44:44 GMT -5
Afrezza is different than subq insulin. Phase one and two and all. I wish MNKD would make a deal in Israel. Mango tells me Raphael Mechoulam, has several patents now for synthetic CBD compounds. That would be one deal MNKD could take. TEVA, it would seem to me teva could take over fast acting insulin human. human insulin does not require a prescription?
OK, my last barrage was delivered at light speed in case there were time constraints at your end. I need reiterate that titration is magic cepter of endocrinology practices. It casts a spell of logic and confidence over the proceedings in the endo's office. Only that spell does not protect the patient when he returns to his home and realizes that injected does not really "titrate" either. That is what hypos and 65% of patients out of target Blood Glucose means. tell the Dietician that his patients need faster, more phyisologically adept, injected insulin if they want to go around talking about "titratability". Truth is that the only way to titrate injected insulin well is by having Diabetics eat low carb. Great idea and everything, but it begs the point about the titratability of insulins. I am furious as you can tell. So as to titrating Afrezza. something we are realizing is that Afrezza also works best if you can start meal time dosing while in the 70-90 range, just like normoglycemic individuals. Chasing a high blood sugar at meals or any other time, will mean you will need to take more Afrezza. Its hard to find the motivation for this technique because Afrezza will correct you so fast if you blow it. But after a while you understand how much more efficient it is to stay in range. I think that is why you see Eric F, Sam F Cynthia R-K, Duckfiabetes and Afrezzaguy CGM traces in flatline. We just started doing that with my son this week end and whoa what a difference. He needs half as much Afrezza-which is big for us since wwe pay OUT OF POCKET for it and have frequently been running out. Now he stays in range (generally below 100)AND uses less Afrezza! The big take home for us was that the amounts needed to titrate change with the range you have set. we have been using Afrezza for him for three months and just now realized we were still under the Endo's spell. We believed that the 130 to 80 range they set for him as a 17 year old(was 180 to 80 a year ago) was reasonable. It may be for injected but it is all wrong for dosing Afrezza. It is OK to go to 130 or higher while on afrezza after a meal, but your range pre-meal and post digestion should be the same as a normoglycemic individual: 70 to 90! ITS WHAT THE BODY WANTS. And it is making a huge difference as we learned this weekend. My son did not get enthusiastic about follow up dosing until we saw this pattern working. Titration has less to do with this kind of control than timeing and setting the normal type of Fasting Blood Glucose targets THAT ONLY AFREZZA allows you to set (assuming you like to eat a conventional diet). Quote: start meal time dosing while in the 70-90 range, just like normoglycemic individuals. Chasing a high blood sugar at meals or any other time, will mean you will need to take more Afrezza. But after a while you understand how much more efficient it is to stay in range. I think that is why you see Eric F, Sam F Cynthia R-K, Duckfiabetes and Afrezzaguy CGM traces in flatline. Reply: Afrezza keeps your glucose level from going high in the first place.
Quote: It is OK to go to 130 or higher while on afrezza after a meal, but your range pre-meal and post digestion should be the same as a normoglycemic individual: 70 to 90! ITS WHAT THE BODY WANTS. And it is making a huge difference as we learned this weekend. He needs half as much Afrezza-which is big. Now he stays in range (generally below 100)AND uses less Afrezza! Reply: I always wondered how afrezzaguys cgm was such a nice wave. Thank you for figuring it out and telling us. Afrezza, keeps your blood glucose from going high in the first place. Feel the wave.
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Post by sportsrancho on Apr 4, 2017 20:17:04 GMT -5
Thank you for figuring it out and telling us. Afrezza, keeps your blood glucose from going high in the first place. Feel the wave.
What a valuable asset to this board!
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Post by sayhey24 on Apr 4, 2017 20:41:04 GMT -5
Cyn, While I agree with many of the barriers to adoption that you present on behalf of the Endo profession, the simple answer to "why should they?" is twofold: patient quality of life and patient satisfaction. Being the most resistant Endo isn't going to bode well for career longevity. How many wagon wheel makers do you know? I wonder who the last orthodontist in America will be to adopt the Invisalign method of tooth alignment vs wires and spacers, etc. Fear of irrelevance, in addition to every other form of demotivating influence, is also getting in the way of Afrezza adoption and prescription. But, if MNKD could show that treating a patient on Afrezza could potentially be less time intensive, therefore more profitable per patient, maybe that could allay some of the issues you describe. Though, I hardly think profit per patient should be an Endos primary motivation. Mannkind is suffering a form of agency bias with the Endo community, but as agents of care, the Endo community is failing PWD's by not attempting to deploy it in every case where it currently proves most applicable and relevant, to give them an opportunity to possibly improve their quality of life, diabetic state and symptoms. I believe the most successful Endos and true "specialists" in this field will add Afrezza to their portfolio of treatment options. The rest will be second class and remarkably replaceable via a PWD's next visit to a GP. So, if they're not going to adopt it, maybe their fear (even if subconscious) is reasonably justified. This is just a perspective. But this situation has played out in many industries many times over since the inception of commerce and of medicine. Ok, there are a few misconceptions here. Irrelevance and redundancy are not any sort of issue for endos. Not least because diabetes is only one of a whole slew of conditions they treat. Add to that the shortage of endos (they don't have juicy expensive procedures they can do - you don't get rich as an endo) as evidenced by how long it takes to see one. No, lack of business is not a fear. Time per patient. Your endo appointment may discuss insulin or your doses but that't usually the smaller part. I spend far more time talking about odd situations, or why I got a particular result. Then there is the whole knock on - in Type 1 it's auto immune (am I getting celiac disease, is my thyroid acting up, any neuropathy), and for Type 2 it's lipids and metabolism. Afrezza changes very little of that, certainly it wouldn't shorten appointment times. Agency bias, aka. consensus. Endos don't change treatments lightly, not least since diabetics are very resistant to change (says the poster child) and it's easy to make things worse. Putting someone on a different statin may have minimal down side, putting someone on an entirely different type of insulin may put them in hospital (this is one reason I don't think DTC has much effect). The same thing happened with the introduction of RAA, it took time and trial data to move people, that is still true. I can see Afrezza as part of the armory, the question is whether it's the main event or a side show bought out on special occasions. My endo won't prescribe it generally, but there is a couple of very specific cases where he has because the circumstance warrant it in his view. The one Endo at the ADCOM predicted Afrezza would crush his practice once it caught on. Most of his patients were out of control T2s. His prediction was the PCPs would start prescribing and afrezza would stop the progression. He voted yes T1 and yes T2 because he said it was the right thing to do. I guess time will tell if he was right. Its up to Matt and Mike to prove this guy right.
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Post by peppy on Apr 4, 2017 20:44:51 GMT -5
Ok, there are a few misconceptions here. Irrelevance and redundancy are not any sort of issue for endos. Not least because diabetes is only one of a whole slew of conditions they treat. Add to that the shortage of endos (they don't have juicy expensive procedures they can do - you don't get rich as an endo) as evidenced by how long it takes to see one. No, lack of business is not a fear. Time per patient. Your endo appointment may discuss insulin or your doses but that't usually the smaller part. I spend far more time talking about odd situations, or why I got a particular result. Then there is the whole knock on - in Type 1 it's auto immune (am I getting celiac disease, is my thyroid acting up, any neuropathy), and for Type 2 it's lipids and metabolism. Afrezza changes very little of that, certainly it wouldn't shorten appointment times. Agency bias, aka. consensus. Endos don't change treatments lightly, not least since diabetics are very resistant to change (says the poster child) and it's easy to make things worse. Putting someone on a different statin may have minimal down side, putting someone on an entirely different type of insulin may put them in hospital (this is one reason I don't think DTC has much effect). The same thing happened with the introduction of RAA, it took time and trial data to move people, that is still true. I can see Afrezza as part of the armory, the question is whether it's the main event or a side show bought out on special occasions. My endo won't prescribe it generally, but there is a couple of very specific cases where he has because the circumstance warrant it in his view. The one Endo at the ADCOM predicted Afrezza would crush his practice once it caught on. Most of his patients were out of control T2s. His prediction was the PCPs would start prescribing and afrezza would stop the progression. He voted yes T1 and yes T2 because he said it was the right thing to do. I guess time will tell if he was right. Its up to Matt and Mike to prove this guy right. sayhey, any of this on video (You tube?) or a website?
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Post by sportsrancho on Apr 4, 2017 20:52:25 GMT -5
Ok, there are a few misconceptions here. Irrelevance and redundancy are not any sort of issue for endos. Not least because diabetes is only one of a whole slew of conditions they treat. Add to that the shortage of endos (they don't have juicy expensive procedures they can do - you don't get rich as an endo) as evidenced by how long it takes to see one. No, lack of business is not a fear. Time per patient. Your endo appointment may discuss insulin or your doses but that't usually the smaller part. I spend far more time talking about odd situations, or why I got a particular result. Then there is the whole knock on - in Type 1 it's auto immune (am I getting celiac disease, is my thyroid acting up, any neuropathy), and for Type 2 it's lipids and metabolism. Afrezza changes very little of that, certainly it wouldn't shorten appointment times. Agency bias, aka. consensus. Endos don't change treatments lightly, not least since diabetics are very resistant to change (says the poster child) and it's easy to make things worse. Putting someone on a different statin may have minimal down side, putting someone on an entirely different type of insulin may put them in hospital (this is one reason I don't think DTC has much effect). The same thing happened with the introduction of RAA, it took time and trial data to move people, that is still true. I can see Afrezza as part of the armory, the question is whether it's the main event or a side show bought out on special occasions. My endo won't prescribe it generally, but there is a couple of very specific cases where he has because the circumstance warrant it in his view. The one Endo at the ADCOM predicted Afrezza would crush his practice once it caught on. Most of his patients were out of control T2s. His prediction was the PCPs would start prescribing and afrezza would stop the progression. He voted yes T1 and yes T2 because he said it was the right thing to do. I guess time will tell if he was right. Its up to Matt and Mike to prove this guy right. I remember that day well!
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Post by sayhey24 on Apr 4, 2017 21:10:28 GMT -5
The one Endo at the ADCOM predicted Afrezza would crush his practice once it caught on. Most of his patients were out of control T2s. His prediction was the PCPs would start prescribing and afrezza would stop the progression. He voted yes T1 and yes T2 because he said it was the right thing to do. I guess time will tell if he was right. Its up to Matt and Mike to prove this guy right. I remember that day well! It was 3 years ago. It seems like yesterday. I was about 10 feet from that guy. That endo's comments and those from the Dr from NC I will never forget. Usually after awhile you start thinking something can't really be this good. The crazy thing is afrezza keeps looking better and better. There a session at this years ADA meeting - should T2s be using CGMs. Are these people kidding me. Every T2 should immediately be put on afrezza with a cloud connected CGM with a tele-coach. In 3 to 6 months many of those T2s would be in remission.
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Post by brentie on Apr 4, 2017 21:28:01 GMT -5
The one Endo at the ADCOM predicted Afrezza would crush his practice once it caught on. Most of his patients were out of control T2s. His prediction was the PCPs would start prescribing and afrezza would stop the progression. He voted yes T1 and yes T2 because he said it was the right thing to do. I guess time will tell if he was right. Its up to Matt and Mike to prove this guy right. sayhey, any of this on video (You tube?) or a website? www.youtube.com/watch?v=ylin1ZSDo0oand www.youtube.com/watch?v=aSRnq35QUnk
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Post by mango on Apr 5, 2017 0:08:59 GMT -5
Cyn, While I agree with many of the barriers to adoption that you present on behalf of the Endo profession, the simple answer to "why should they?" is twofold: patient quality of life and patient satisfaction. Being the most resistant Endo isn't going to bode well for career longevity. How many wagon wheel makers do you know? I wonder who the last orthodontist in America will be to adopt the Invisalign method of tooth alignment vs wires and spacers, etc. Fear of irrelevance, in addition to every other form of demotivating influence, is also getting in the way of Afrezza adoption and prescription. But, if MNKD could show that treating a patient on Afrezza could potentially be less time intensive, therefore more profitable per patient, maybe that could allay some of the issues you describe. Though, I hardly think profit per patient should be an Endos primary motivation. Mannkind is suffering a form of agency bias with the Endo community, but as agents of care, the Endo community is failing PWD's by not attempting to deploy it in every case where it currently proves most applicable and relevant, to give them an opportunity to possibly improve their quality of life, diabetic state and symptoms. I believe the most successful Endos and true "specialists" in this field will add Afrezza to their portfolio of treatment options. The rest will be second class and remarkably replaceable via a PWD's next visit to a GP. So, if they're not going to adopt it, maybe their fear (even if subconscious) is reasonably justified. This is just a perspective. But this situation has played out in many industries many times over since the inception of commerce and of medicine. Ok, there are a few misconceptions here. Irrelevance and redundancy are not any sort of issue for endos. Not least because diabetes is only one of a whole slew of conditions they treat. Add to that the shortage of endos (they don't have juicy expensive procedures they can do - you don't get rich as an endo) as evidenced by how long it takes to see one. No, lack of business is not a fear. Time per patient. Your endo appointment may discuss insulin or your doses but that't usually the smaller part. I spend far more time talking about odd situations, or why I got a particular result. Then there is the whole knock on - in Type 1 it's auto immune (am I getting celiac disease, is my thyroid acting up, any neuropathy), and for Type 2 it's lipids and metabolism. Afrezza changes very little of that, certainly it wouldn't shorten appointment times. Agency bias, aka. consensus. Endos don't change treatments lightly, not least since diabetics are very resistant to change (says the poster child) and it's easy to make things worse. Putting someone on a different statin may have minimal down side, putting someone on an entirely different type of insulin may put them in hospital (this is one reason I don't think DTC has much effect). The same thing happened with the introduction of RAA, it took time and trial data to move people, that is still true. I can see Afrezza as part of the armory, the question is whether it's the main event or a side show bought out on special occasions. My endo won't prescribe it generally, but there is a couple of very specific cases where he has because the circumstance warrant it in his view. What is being rich? Happiness and Health. Onto the rich you are referring to: average Endocrinologists make over 200K. They have no financial worries. Also, like I have tried pointing out before: • Now, let me show evidence ONCE again, that Big Pharma influences the clinician's medical decision making: • This Endocrinologist says 90% of T2D are managed by primary care. So, what is his rolewith Eli Lilly and diabetes? To "educate" these people on Eli Lilly's behalf, everything being biased efucation of course, and is paid by Eli Lilly to do so. He directly influences the medical decision making of primary care clinicians. • And in the same article: Payments to doctors from drug companies scrutinized• How trustworthy is Eli Lilly? 🐵🙈🙉🙊 Eli Lilly Pleads Guilty in Largest Qui Tam Healthcare Case in History
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Post by tingtongtung on Apr 5, 2017 0:15:05 GMT -5
Just 3 years!!
Watched the videos again. I have a hard time understanding how this drug can keep on failing to get enough attention. Sanofi sabotaged Afrezza, insulin cartel, shorts, etc, etc.. I used to believe earlier. But, it's too far fecthed, I guess.
* Patients dont know about Afrezza. * Dosing seems to be a rocket science (10 min into meal, at 70-90 BGL, so on and on). I'm not taking a pot shot at some of the people here. It's just that there are several opinions, and MNKD doesn't seem to suggest the "Best practice". I'm not a Dr. May be if the instructions are simpler to follow, Drs will prescribe it, and patients will follow it? Since the hypo events are almost negligible with Afrezza, why not suggest 12 units for all as the starting dose, and then tune it down? * Insurance and availability.
Mike is a great guy (even Matt), and he can individually deal with every single new patient every week - looking at the NRx numbers. So, what exactly is going on with sales force? Why is it failing so miserably? If you look at some of the posts here, they are advertising/selling/promoting Afrezza better than MNKD.
It's already April. How much money is left now? They didn't even dilute and raise some money with RS. Now, it's just ~40 cents above $1.
Come on MNKD!!
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Post by mango on Apr 5, 2017 0:35:02 GMT -5
* Patients dont know about Afrezza. Agree. Disagree. Insurance is part of The Fundamental Problems of Healthcare. Mike is a cool dude. Hard worker too. Good heart. Matt too. Times infinity.
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Post by peppy on Apr 5, 2017 7:45:52 GMT -5
Just 3 years!! Watched the videos again. I have a hard time understanding how this drug can keep on failing to get enough attention. Sanofi sabotaged Afrezza, insulin cartel, shorts, etc, etc.. I used to believe earlier. But, it's too far fecthed, I guess. * Patients dont know about Afrezza. * Dosing seems to be a rocket science (10 min into meal, at 70-90 BGL, so on and on). I'm not taking a pot shot at some of the people here. It's just that there are several opinions, and MNKD doesn't seem to suggest the "Best practice". I'm not a Dr. May be if the instructions are simpler to follow, Drs will prescribe it, and patients will follow it? Since the hypo events are almost negligible with Afrezza, why not suggest 12 units for all as the starting dose, and then tune it down? * Insurance and availability. Mike is a great guy (even Matt), and he can individually deal with every single new patient every week - looking at the NRx numbers. So, what exactly is going on with sales force? Why is it failing so miserably? If you look at some of the posts here, they are advertising/selling/promoting Afrezza better than MNKD. It's already April. How much money is left now? They didn't even dilute and raise some money with RS. Now, it's just ~40 cents above $1. Come on MNKD!! You know I am frustrated that afrezza isn't selling. I now pin it down to insurance coverage, a change in insulin, and whatever it is with the endo's/is it the standard of care? afrezza works totally different than subq rapid acting. subq rapid acting let's glucose go way up and brings it down. Afrezza stops blood glucose from going up in the first place. (You can see I am still trying to work this through) Physicians at some level seem to be tied to the standards of care, because the standards of care in what insurance covers. Then as aged points out, afrezza is non-inferior, so insurance will choose the cheaper non inferior.
As Mango pointed out on another thread, the diabetic standards of care are written by people that have worked in the industry. at lilly, novo, etc.
If physicians are so smart, as we all have been sold, physicians can figure out afrezza. MNKD stock has allowed me to learn, "The racket"
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Post by peppy on Apr 5, 2017 8:22:55 GMT -5
Thank you Brentie. I hold you in high esteem. From the approval testimony 2014.
The speaker did not go on to say, "Afrezza as a treatment for type two will require a change in the standards of care so that the insurance companies cover type two's with a mealtime insulin with out having to go through monotherapy, dual therapy, and triple therapy prior to mealtime insulin." "you will be needing a really good health care policy." www.screencast.com/t/nOwBa4aaA
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