seekingalpha.com/article/2879736-mannkind-great-afrezza-word-of-mouth-but-prescriptions-wont-soar-right-away?auth_param=k9285:1ad2d9n:7e416525da6247f0610f26266dd0ef4c&uprof=45MannKind: Great Afrezza Word Of Mouth, But Prescriptions Won't Soar Right Away
Last week we learned about the quiet launch that MannKind Corp's (NASDAQ:MNKD) partner, Sanofi (NYSE:SNY) engineered for Afrezza, its inhaled super-fast acting insulin.
The drug launch was officially announced this morning, but investors should not expect to see an immediate surge in sales.
There are several reasons for this.
A Shortage Of Diabetes Specialists Limits Appointments
The first is that most family doctors do not prescribe fast acting insulin to their patients. If a patient needs it, they refer them to a specialist who treats diabetes, the endocrinologist.
However, endocrinology is one of the poorer-paying specialties because unlike many other specialists, endocrinologists do not perform procedures. Instead, they spend most of their time talking with patients, ordering tests, and helping them figure out how to fine tune their dosing. And because of the relatively low pay, there is a shortage of doctors going into endocrinology. As a result of this shortage, patients who need to use fast-acting insulin often have to wait as long as three months to get an appointment with an endocrinologist after they have been referred.
Even patients currently under the care of an endocrinologist will have to wait months to get an appointment where they can ask for Afrezza. That's because stable patients are usually only scheduled for quarterly or biannual appointments. And those scheduled appointments are often not with the endocrinologist but with the nurse practitioners many endocrinologists use to mange the care of their stable patients so that the doctor can concentrate on treating the newly diagnosed patients who are often in crisis. These nurse practitioners are unlikely to have the authority to change a patient's insulin from standard injected insulin to Afrezza.
So the patient who is a perfect candidate for Afrezza and hears about Afrezza today will often have to wait three months or more to get an appointment with the specialist who can prescribe it, no matter how much they may want to start using it.
This is why the launch has been so quiet and why any investor who expected to see a Superbowl ad for Afrezza does not understand the insulin market.
The many months that it will take until patients can get appointments with the doctors who prescribe Afrezza will allow time for the Sanofi sales force to educate those doctors, and ideally, their nurse practitioners, on how to prescribe Afrezza.
The Afrezza Doses Currently Available Are Too Low For Many Type 2s
The second reason that there will be a delay before we see the tidal wave of Afrezza prescriptions that investors are hoping for is that the currently available doses of Afrezza are not large enough to supply the needs of many people with Type 2. An insulin resistant Type 2 may need anywhere from three to ten times as much insulin as an insulin sensitive Type 1 or Type 1.5 person would need.
The currently available packages of Afrezza contain 4 and 8 unit cartridges. However, many people with Type 2 diabetes will need as much as 24 units of Afrezza for a single meal. At the currently provided doses this would require them to buy many boxes of Afrezza each month.
MNKD is addressing this issue and has applied to the FDA for approval of a 12 unit cartridge. When they are approved and manufactured, the typical Type 2 dose of 24 units per meal will be more affordable and much easier to prescribe.
Sanofi and MNKD understand both of these factors and therefore they prepared for a slow launch. They have stated in previous conference calls that Afrezza will be marketed first to influential, high prescribing endocrinologists. Once these influential doctors have had a chance to use Afrezza with some patients and to learn how well it works, they will, it is hoped, evangelize to other specialists and make presentations at conferences to general practitioners.
So the launch will be slow and that mass market advertising will not commence until there is a well-educated physician population able and willing to prescribe the larger doses that are not yet in production.
Word Of Mouth So Far Is Excellent
That's the "bad news." The good news is that you can't buy advertising that does what this image posted by@afrezzauser to Twitter does:
Let me explain what this is and why it is so powerful. This is a photo of the screen of a Dexcom Continuous Glucose Monitor System [CGMS]. What it is displaying is blood sugar readings taken every few minutes using blood taken from a little tube inserted for a week or two into the skin of the user's abdomen. You can't fake these readings and
afrezzauser is posting lots of them.
What this particular shot shows is a perfectly flat blood sugar completely within the normal range. This would be no big deal except that the person wearing this CGMS has Type 1 diabetes, a condition in which it is almost impossible to achieve blood sugars that flat.
afrezzauser has been tweeting his Dexcom screens since he got his prescription last week. Not all the graphs are flat, but they are all impressive. Before getting his Afrezza prescription,
afrezzauser had posted screens that were showing huge fluctuations from 50 to above 300, which was what he got with injected fast acting insulin. These looked like what most Type 1s see when they wear CGMS.
Dexcom graphs like this will impress anyone who has ever looked at a CGMS graph of a person with Type 1 diabetes. And
afrezzauser's results when he was taking only fast-acting insulin suggest that many people with Type 2 diabetes could get by just using frezza.
And yes, endocrinologists are very familiar with CGMS graphs. They will know what this means.
Meanwhile, highly influential diabetes blogger Amy Tenderich posted this article on her Diabetes Mine web today, entitled Welcome Afrezza Inhaled Insulin Gets Real . Again, you can't pay for promo like this.
Those naysayers who have been harping on how the Afrezza label prohibits claims that Afrezza reduces hypos, please note that the FDA doesn't prohibit bloggers from citing very well known endocrinologists who say that it does. (And
afrezzauser's graphs back him up!) And that he also says that Type 2s might not need long-acting insulin with Afrezza.
Of course, physicians aren't reading Twitter and they don't read the blogs of diabetes activists. They are going to be waiting to see what a few of their own patients, whose current CGMS graphs they are familiar with, experience with Afrezza.
It is only going to be after they see a couple more of their patients getting results like
afrezzauser's the enthusiasm will start to rise. And when the 12 unit cartridges become available and they see results like this with Type 2s who have been avoiding insulin until now, watch out!
Shorts Won't Give Ip Without A Fight
Short interested went up in January, not down. It stood at 76,855,622 shares on January 15. So you must brace yourself to see a slew of articles claiming that the number of prescriptions issued for Afrezza during the first month of the launch was lower than expected and show that it is a failure. The number may be low, but they show only that Sanofi and MannKind are doing exactly what they said they would do. I
And meanwhile, Afrezzauser's Dexcom charts show us that Afrezza, too, does exactly what Al Mann told us, all along, it would do.