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Post by peppy on Mar 28, 2018 7:02:57 GMT -5
ok. So this physician was concerned about the absence of insulin with afrezza? Help me aged. [Love the picture  ] She was concerned about people getting sloppy because Afrezza was so effective Her scenario is this I think. Suppose you cannot be bothered with the hassle of dosing (why bother, you will end up in the 400s but you can clean up the resulting high later, Afrezza is fast). Depending on where you are with your basal, and how long ago you last took Afrezza, you might not have enough insulin in your system to suppress ketosis and could slide into DKA. At that point taking Afrezza to drop back to normal quickly could be potentially lethal. It's less of a problem with RAA because it is much more work to get back to normal so you avoid that sort of behavior and that slower drop reduces (but does not eliminate ) the risk. Afrezza gives you more freedom, but that freedom can give you the illusion of more control than you have. so let's talk/type about this then aged. I am a poor lamb who has lost my way. Her blood glucose is 226. What are her cells burning for ATP? (fat? the result? ketones?) She has insulin on board.  |
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Post by agedhippie on Mar 28, 2018 7:25:37 GMT -5
so let's talk/type about this then aged. I am a poor lamb who has lost my way. Her blood glucose is 226. What are her cells burning for ATP? (fat? the result? ketones?) She has insulin on board. If she has insulin onboard she will be burning glucose for energy, she just has more glucose than she needs. Insulin suppresses ketosis so ketones from burning fat is not an option. It's not the question  , but at 226 she would almost certainly be to low to start generating diabetic ketones regardless. |
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Post by bill on Mar 28, 2018 10:17:10 GMT -5
If that were what doctors believe they would now be prescribing Afrezza to all their patients that are with insurers that cover it, which the script numbers clearly indicate is not the case. Whether price is or isn't a major issue, few doctors currently believe that Afrezza is a superior prandial insulin. I have recently become aware or understood something my son's endo recently tipped me off to. She was worrried about potassium levels. it is in the black box though I pooh poohed it. and may be it is just pooh pooh but, for cases in which a T1D self treats with a fast and effective insulin like afrezza (and lets face it- all diabetes is treated outside the clinical setting except for DKA and complications) there is a temptation to let ones glucose control go out the window, pre-emtively speaking, becuase you know that if you are at 400 you can just take 3 or 4 eights and get back into range. Problem is, if you spend any length of time in DKA, for which a reading of 400 for 6 hours or so would probably qualify, you now have a K+ ion imbalance. Ion potential is how your body maintains the voltage for keeping your heart beating (or something like that). Extended DKA masks a K defeiciency becasue the blood ph drives all K into circulation on one side of the potential barrier. Taking Afrezza quickly moves insulin out of blood into the cells which is good, but the switch raises te risk for fibrillation. The risk for this on injectable is somewhat less, so not sure how fair it is to make a comparison. but this may be one reason for hesitation onpart of some endos to prescribe afrezza. You might also ask how many physicians are even aware of this. You might prefer not to know the answer, for a variety or reasons....(?) Try asking your MD... - Why would someone who understands Afrezza and the damage of glucose spikes go out of their way to let their blood sugar spike at all, no less for hours? One of the advantages of Afrezza is that you can take it when you start your meals or shortly thereafter. There's absolutely no reason why someone on Afrezza ought to have spiked glucose readings for extended periods of time. Afrezza is not designed to reduce spikes, though it does a good job. It's designed to avoid spikes. As a side note, there's nothing tragic about going into atrial fibrillation. As long as you return to a normal sinus rhythm within 24 hours, there's little risk of a blood clot. Most folks will realize they're in atrial fibrillation because it induces a fight or flight reaction which gets them to a doctor or hospital to figure out what's wrong. |
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Post by agedhippie on Mar 28, 2018 13:39:39 GMT -5
- Why would someone who understands Afrezza and the damage of glucose spikes go out of their way to let their blood sugar spike at all, no less for hours? One of the advantages of Afrezza is that you can take it when you start your meals or shortly thereafter. There's absolutely no reason why someone on Afrezza ought to have spiked glucose readings for extended periods of time. Afrezza is not designed to reduce spikes, though it does a good job. It's designed to avoid spikes. The short answer is because you can. The difference between the early adopters and most others is that the early adopters are heavily focused on looking for a solution for something (non-diabetic numbers, no hypos, no spikes, and so on.) They are prepared to put in the work, to watch their CGMs closely, and to take those follow up doses. Consequently they get excellent results. Now you have everyone else. Typically they want diabetes to have as little impact on their life as possible. It's why in Type 2 pills are popular and diet and exercise is not. It's why like most other Type 1s I don't do follow up boluses as I should, why I don't use my CGM, and why I find it hard to care about spikes. Right now I avoid going high because it is a pain to have to get back to normal, if it was trivial I could easily understand the attraction of ignoring bolusing and straightening things out later - especially for kids who don't want to appear different. The mistake a lot of people make on this board is thinking that diabetics want to work at maintaining control - they don't. For the vast majority one pill a day and poor control trumps six inhales a day and good control. People like the JDRF know this and it's why they spend so much effort on the closed loop AP. Sorry - that turned into a bit of a rant. The points hold though. |
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Post by bill on Mar 28, 2018 14:32:17 GMT -5
- Why would someone who understands Afrezza and the damage of glucose spikes go out of their way to let their blood sugar spike at all, no less for hours? One of the advantages of Afrezza is that you can take it when you start your meals or shortly thereafter. There's absolutely no reason why someone on Afrezza ought to have spiked glucose readings for extended periods of time. Afrezza is not designed to reduce spikes, though it does a good job. It's designed to avoid spikes. The short answer is because you can. The difference between the early adopters and most others is that the early adopters are heavily focused on looking for a solution for something (non-diabetic numbers, no hypos, no spikes, and so on.) They are prepared to put in the work, to watch their CGMs closely, and to take those follow up doses. Consequently they get excellent results. Now you have everyone else. Typically they want diabetes to have as little impact on their life as possible. It's why in Type 2 pills are popular and diet and exercise is not. It's why like most other Type 1s I don't do follow up boluses as I should, why I don't use my CGM, and why I find it hard to care about spikes. Right now I avoid going high because it is a pain to have to get back to normal, if it was trivial I could easily understand the attraction of ignoring bolusing and straightening things out later - especially for kids who don't want to appear different. The mistake a lot of people make on this board is thinking that diabetics want to work at maintaining control - they don't. For the vast majority one pill a day and poor control trumps six inhales a day and good control. People like the JDRF know this and it's why they spend so much effort on the closed loop AP. Sorry - that turned into a bit of a rant. The points hold though. Not a rant at all, good discussion. I think you may have made an interesting point with regards to controlling spikes. Suppose there were scientific evidence that said that each glucose spike experienced by a PWD costs them an average of "x" days of life expectancy and increases the likelihood of a serious diabetic complication by "y" percent. How large would "x" and/or "y" have to be for you (and others) to change your behavior? At the most basic level, insulin is insulin. Controlling diabetes is all about trying to manually balance glucose and insulin using different pharmaceuticals taken in different amounts at certain times during the day. Up until Afrezza became available, the pharmaceuticals that did the best job of controlling diabetes were the ones that were the most challenging to dose along with a substantial risk of hyperglycemia, and the ones that were easiest to dose were the ones that were least effective and most likely to result in long-term complications. An Afrezza claim-to-fame could be is that it can be used to produce much better results than the previously best pharmaceuticals, with less risk using a more straightforward dosing regimen. If true (which I think it is), then the next question is "by how much." If every glucose spike cost you a week of life expectancy and increased the probability of diabetic complications by 10%, almost everyone would want to avoid spikes at all costs. Those values are undoubtedly too high, but how high would they need to be for most PWDs to desire Afrezza? Thoughts? |
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Post by bill on Mar 28, 2018 14:46:36 GMT -5
BTW, the human body and mind are amazing creations. We are all world-class compensators to varying degrees. I suspect one of the hurdles that Afrezza needs to surmount is the one raised by agedhippie, i.e., PWDs do not incur obvious consequences from glucose spikes and even high HbA1c values don't cause obvious discomfort or overt symptoms, initially. As humans we instinctively assume that what I'm doing can't be that bad if I don't experience any immediate consequences.
OTOH, if you know that every spike has a downstream cost and you objectively know that cost, you can make a value judgment about whether you're willing to pay the price.
In many ways getting PWDs to switch to Afrezza is similar to getting people to cease smoking. Everyone knows smoking is bad for you and the more you smoke the more likely that you'll develop cancer or other complications. With enough education many people quit, but others still smoke, however they've made an intellectual decision to accept the consequences; a higher probability of health problems at some point in their lives.
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Post by goyocafe on Mar 28, 2018 14:56:11 GMT -5
BTW, the human body and mind are amazing creations. We are all world-class compensators to varying degrees. I suspect one of the hurdles that Afrezza needs to surmount is the one raised by agedhippie, i.e., PWDs do not incur obvious consequences from glucose spikes and even high HbA1c values don't cause obvious discomfort or overt symptoms, initially. As humans we instinctively assume that what I'm doing can't be that bad if I don't experience any immediate consequences. OTOH, if you know that every spike has a downstream cost and you objectively know that cost, you can make a value judgment about whether you're willing to pay the price. In many ways getting PWDs to switch to Afrezza is similar to getting people to cease smoking. Everyone knows smoking is bad for you and the more you smoke the more likely that you'll develop cancer or other complications. With enough education many people quit, but others still smoke, however they've made an intellectual decision to accept the consequences; a higher probability of health problems at some point in their lives. Interesting! How about a countdown counter on your device that speeds up with every spike and while high (above 6.5 or whatever is agreed to be the high water mark for excursions). |
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Post by akemp3000 on Mar 28, 2018 15:29:55 GMT -5
This has been a valuable discussion. It seems another piece of the coming paradigm shift will come from glucose monitoring and their promoters educating the public-at-large to become much more concerned about spikes than about their A1c. This education will benefit the general population...not so much BPs and their traditional standards of care!
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Post by agedhippie on Mar 28, 2018 18:45:54 GMT -5
The short answer is because you can. The difference between the early adopters and most others is that the early adopters are heavily focused on looking for a solution for something (non-diabetic numbers, no hypos, no spikes, and so on.) They are prepared to put in the work, to watch their CGMs closely, and to take those follow up doses. Consequently they get excellent results. Now you have everyone else. Typically they want diabetes to have as little impact on their life as possible. It's why in Type 2 pills are popular and diet and exercise is not. It's why like most other Type 1s I don't do follow up boluses as I should, why I don't use my CGM, and why I find it hard to care about spikes. Right now I avoid going high because it is a pain to have to get back to normal, if it was trivial I could easily understand the attraction of ignoring bolusing and straightening things out later - especially for kids who don't want to appear different. The mistake a lot of people make on this board is thinking that diabetics want to work at maintaining control - they don't. For the vast majority one pill a day and poor control trumps six inhales a day and good control. People like the JDRF know this and it's why they spend so much effort on the closed loop AP. Sorry - that turned into a bit of a rant. The points hold though. Not a rant at all, good discussion. I think you may have made an interesting point with regards to controlling spikes. Suppose there were scientific evidence that said that each glucose spike experienced by a PWD costs them an average of "x" days of life expectancy and increases the likelihood of a serious diabetic complication by "y" percent. How large would "x" and/or "y" have to be for you (and others) to change your behavior? At the most basic level, insulin is insulin. Controlling diabetes is all about trying to manually balance glucose and insulin using different pharmaceuticals taken in different amounts at certain times during the day. Up until Afrezza became available, the pharmaceuticals that did the best job of controlling diabetes were the ones that were the most challenging to dose along with a substantial risk of hyperglycemia, and the ones that were easiest to dose were the ones that were least effective and most likely to result in long-term complications. An Afrezza claim-to-fame could be is that it can be used to produce much better results than the previously best pharmaceuticals, with less risk using a more straightforward dosing regimen. If true (which I think it is), then the next question is "by how much." If every glucose spike cost you a week of life expectancy and increased the probability of diabetic complications by 10%, almost everyone would want to avoid spikes at all costs. Those values are undoubtedly too high, but how high would they need to be for most PWDs to desire Afrezza? Thoughts? The problem is that diabetes is a game of inches. If spikes were the only thing shortening your life then each spike may shorten your life by about 1.5 hours (back of the envelope math). In the end that adds up and you land up a ten years short on average. Of course there are a number of things that shorten your life and spikes are just one. I think if it was a day per spike I would definitely be better behaved. Less than that I would probably fall back on thinking it's not that much. I sort of do this already with my A1c - if I go over 7.0 then I change what I am doing, if I am under 6.5 then I don't change. If I am between those points I worry a little and don't do anything about it. The elephant in the room is that identifying the causes of complications is not that far removed from witchcraft. Nobody can say for sure what impact spikes have - are they major or minor? Right now what they know from the DCCT trials is that A1c accounts for about 11% of the microvascular risk in diabetics, they have no idea what causes the other 89% of the risk. Currently the theory is that the 89% is due to spikes, but there is no solid proof, it's just a guess (probably accurate). |
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Post by sayhey24 on Mar 28, 2018 19:05:51 GMT -5
Bill - my thoughts on your question "Those values are undoubtedly too high, but how high would they need to be for most PWDs to desire Afrezza?"
Most PWDs will do what their doctors tell them. Even when they have heard of afrezza and know the benefits of afrezza, if their doctor says no afrezza for you, the PWD goes along with their doctor.
Prior to CGMs it was easy for the PCP to hide behind the numbers because for the most part no one really knew what a PWDs AGP was. Now with the Libre getting the AGP is really easy but how many PCPs have even prescribed a Libre let alone afrezza? If they did and saw the post meal spikes their patients where having and how metformin and the other antiglycemics where just masking the problem, many may actually be interested in learning more but right now most PCP are pretty clueless. With that said the Libre and afrezza are like peanut butter and jelly as each sells the other, just saying.
IMO until the IWatch CGM (or other similar device) is available and everyone starts understanding BG like they do steps walked or heart rate the PWD is just going to keep doing what their doctor tells them. At this point in time few understand BG let alone what a non-diabetic range is and its importance. Most PWDs think an A1c of 7 is pretty good and thats an average 154mg/dl while probably spiking 200+ for hours.
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Post by mytakeonit on Mar 28, 2018 20:40:46 GMT -5
"Most PWDs will do what their doctors tell them. Even when they have heard of afrezza and know the benefits of afrezza, if their doctor says no afrezza for you, the PWD goes along with their doctor."
That is true. I have several diabetic friends that are using insulin and I tell them to ask for Afrezza. They say no ... they won't tell their doctor what to do. I send them info showing them the benefits of using Afrezza ... same story. It's pretty sad when they won't even ask about it. Hopefully, they won't be in much worse shape when their docs finally learn about Afrezza and recommend/prescribe it.
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Post by nylefty on Mar 28, 2018 21:44:56 GMT -5
"Most PWDs will do what their doctors tell them. Even when they have heard of afrezza and know the benefits of afrezza, if their doctor says no afrezza for you, the PWD goes along with their doctor." That is true. I have several diabetic friends that are using insulin and I tell them to ask for Afrezza. They say no ... they won't tell their doctor what to do. I send them info showing them the benefits of using Afrezza ... same story. It's pretty sad when they won't even ask about it. Hopefully, they won't be in much worse shape when their docs finally learn about Afrezza and recommend/prescribe it. In other words, advertising may be of little help |
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Post by mytakeonit on Mar 29, 2018 1:58:48 GMT -5
Advertising will help ... but, probably Dr. Kendall talking to these endos will help a LOT MORE !!!
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Post by digger on Mar 29, 2018 8:51:37 GMT -5
Advertising will help ... but, probably Dr. Kendall talking to these endos will help a LOT MORE !!! Neither salespeople nor Dr. Kendall will have any effect on the core problems of cost and insurance coverage. On the other hand, "brotherm" posted elsewhere a link to a new fiasp study -- clinicaltrials.gov/ct2/show/NCT03450863. They're basically just using fiasp as the prandial insulin and the freestyle libre in 684 subjects. All they're basically measuring is A1c and patient satisfaction at the end of six months. That is exactly the kind of study MNKD wll need to do to gain real insurance coverage. |
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Post by kite on Mar 29, 2018 8:55:02 GMT -5
Advertising will help ... but, probably Dr. Kendall talking to these endos will help a LOT MORE !!! Neither salespeople nor Dr. Kendall will have any effect on the core problems of cost and insurance coverage. On the other hand, "brotherm" posted elsewhere a link to a new fiasp study -- clinicaltrials.gov/ct2/show/NCT03450863. They're basically just using fiasp as the prandial insulin and the freestyle libre in 684 subjects. All they're basically measuring is A1c and patient satisfaction at the end of six months. That is exactly the kind of study MNKD wll need to do to gain real insurance coverage. Exactly. MNKD should copy this same study. |
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, but at 226 she would almost certainly be to low to start generating diabetic ketones regardless.
