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Post by agusta on Mar 29, 2018 11:19:55 GMT -5
I have just returned from my new PCP. Was with the Cleveland Clinic, OH and they no longer accept my insurance "Medical Mutual" New PCP is with Southwest General Hosp./University Hospitals Cleveland. We went over my history and meds. Reviewed Diabetes meds: 1000mg Metformin - Glimepiride 2mg. Sugar runs 223..I own, not on top of following diet and too cold to walk the dog. Told me it will always get cold  Went on to ask him if he had ever heard of "Afrezza" eye's roll. Why do I ask he said. Explained did not like the side effects of Diabetes drugs. He asked if I knew this is not the first inhaled insulin and went into, briefly, Exhurbia (Sp?) Told me my pancreas is half as effecient since I was diagnosed 2 yrs ago...also that most people who can't manage this will need a basil insulin. Inhaled MAY and only May be an NICHE product and see's no reason why he or anyone would choose to prescribe. Please, before I hear it's my job to educate him - It would be better for a professional to teach University Health care systems and educate those doctors. I am not medically inclined to go toe to toe and he does not want to hear about it. Furthermore, my medical insurance does not cover. Just an update and wanted to share my experience today 3/29/18. My investment 6 figures at one time has me extremely nervous. Not meant to be doom and gloom - just real. Happy Easter. |
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Post by peppy on Mar 29, 2018 11:43:26 GMT -5
These physicians are a great disappointment.
This physician used the catch word, "Niche", which was a from a Goldman Sachs analyst.
Was this physician channeling Goldman Sachs?
Explain that!
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Post by ezrasfund on Mar 29, 2018 11:44:03 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."
I am surprised that there seems to be a consensus that Afrezza takes more "work" than using conventional prandial insulins. I recall hearing from patients that one of the benefits of Afrezza was that it took much less time and effort to manage diabetes, and that they no longer had to think about it all of the time. For example, patients don't need to plan what and when they will eat and take their insulin in advance and then be sure to adhere to the plan. Instead they take Afrezza at the start of the meal. Nor do they have as many worries about severe hypos and managing "insulin on board" hours after dosing. When long term T1 PWD like Paul Sparks say that Afrezza has changed their lives, this is what I think they are referring to. You can get good results with conventional insulins, but compliance is much more difficult.
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Post by agusta on Mar 29, 2018 11:49:30 GMT -5
Forgot to mention, my new PCP said he had heard that it's hard to figure out correct dosing and that was part of his issue.
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Post by peppy on Mar 29, 2018 11:56:51 GMT -5
Forgot to mention, my new PCP said he had heard that it's hard to figure out correct dosing and that was part of his issue. He heard huh? I would not want to go to this physician. I would if I needed an antibiotic, or a referral, or if I was dying and needed something. |
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Post by zuegirdor on Mar 29, 2018 12:32:51 GMT -5
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. Well everybody is different but I have noticed, in my home, a tendencyto revert to the pre diagnosis norm of eating whenever you want without worrying about insulin. Afrezza allows so much more flexibility in "meal planning" that it is possible to chase the high and have better a1c's. That is not a good reason to chase highs, and he seldom goes over 300, even less seldom stays over 300 more than an hour, but we are trying to let him learn independence so, mistakes will be made. |
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Post by joeypotsandpans on Mar 29, 2018 12:34:37 GMT -5
Forgot to mention, my new PCP said he had heard that it's hard to figure out correct dosing and that was part of his issue. Agusta, don't get too down as for every 5 obsolete physicians there is 1 new open minded young one entering the field. I met with my endo yesterday and she is young and eager to learn. Her last words as she was leaving the room "I love learning about new stuff". As with my new current primary who is also a year out of residency they are awed by Afrezza and show genuine excitement about it when I am discussing it and explaining the history behind it as well as the proper way to look at it from a dosing per individual perspective. Yes Peppy, it is the unusual case of the patient educating the physician and fortunately in my case my primary and endo are all ears and eyes. It helps tremendously that they can read the Libre live so that is a huge plus, my endo (I will refer to her in the future as endo1) said I am her only patient using Afrezza currently (that is because they are a UHC/OPTUM facility and I am the only one on Express Scripts, this was a follow up visit from when I was on previous insurance so I went with it). I actually have another endo appointment from the more recent referral next week (the insurance system is such a clusterphk that now I'm technically with two primaries and two endos until my current insurance figures things out...I'll wait until they do lol). Also it doesn't hurt to have one as a backup with respect to writing my script. My next set of labs were ordered by endo1 for May so we'll see how they compare with the first 2.9 point drop improvement from the last set. The appointment with endo2 next week should be interesting as he was the one that originally set me up with a set regimen of 8u at meal and 4u follow up dose 1 hr. after, he also wanted me to take the extended release Metformin before bedtime. He might fire me as a patient after I went rogue on his regimen and am taking care of my own dosing/titration to stay in range but hopefully when he sees my most recent lab results he will rethink the "set regimen" and understand that each individual needs what works best for them rather than some type of universal preset dosing (sorry for the run on sentences bad habits are hard to break). Endo1 was very receptive and understanding of the fact that it needs to be a much more individualized approach IMO. In summary, TG for Kendall's arrival to help Mike C with the paradigm shift  . All I can say is record short interest and these current prices....the gift that keeps on giving Have a great Easter weekend everyone!! |
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Post by peppy on Mar 29, 2018 12:41:14 GMT -5
Forgot to mention, my new PCP said he had heard that it's hard to figure out correct dosing and that was part of his issue. Agusta, don't get too down as for every 5 obsolete physicians there is 1 new open minded young one entering the field. I met with my endo yesterday and she is young and eager to learn. Her last words as she was leaving the room "I love learning about new stuff". As with my new current primary who is also a year out of residency they are awed by Afrezza and show genuine excitement about it when I am discussing it and explaining the history behind it as well as the proper way to look at it from a dosing per individual perspective. Yes Peppy, it is the unusual case of the patient educating the physician and fortunately in my case my primary and endo are all ears and eyes. It helps tremendously that they can read the Libre live so that is a huge plus, my endo (I will refer to her in the future as endo1) said I am her only patient using Afrezza currently (that is because they are a UHC/OPTUM facility and I am the only one on Express Scripts, this was a follow up visit from when I was on previous insurance so I went with it). I actually have another endo appointment from the more recent referral next week (the insurance system is such a clusterphk that now I'm technically with two primaries and two endos until my current insurance figures things out...I'll wait until they do lol). Also it doesn't hurt to have one as a backup with respect to writing my script. My next set of labs were ordered by endo1 for May so we'll see how they compare with the first 2.9 point drop improvement from the last set. The appointment with endo2 next week should be interesting as he was the one that originally set me up with a set regimen of 8u at meal and 4u follow up dose 1 hr. after, he also wanted me to take the extended release Metformin before bedtime. He might fire me as a patient after I went rogue on his regimen and am taking care of my own dosing/titration to stay in range but hopefully when he sees my most recent lab results he will rethink the "set regimen" and understand that each individual needs what works best for them rather than some type of universal preset dosing (sorry for the run on sentences bad habits are hard to break). Endo1 was very receptive and understanding of the fact that it needs to be a much more individualized approach IMO. In summary, TG for Kendall's arrival to help Mike C with the paradigm shift . All I can say is record short interest and these current prices....the gift that keeps on giving Have a great Easter weekend everyone!! Joey, what doses are you taking to keep your blood glucose where you want it? What are you finding you need for your meals? |
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Post by joeypotsandpans on Mar 29, 2018 13:25:53 GMT -5
Agusta, don't get too down as for every 5 obsolete physicians there is 1 new open minded young one entering the field. I met with my endo yesterday and she is young and eager to learn. Her last words as she was leaving the room "I love learning about new stuff". As with my new current primary who is also a year out of residency they are awed by Afrezza and show genuine excitement about it when I am discussing it and explaining the history behind it as well as the proper way to look at it from a dosing per individual perspective. Yes Peppy, it is the unusual case of the patient educating the physician and fortunately in my case my primary and endo are all ears and eyes. It helps tremendously that they can read the Libre live so that is a huge plus, my endo (I will refer to her in the future as endo1) said I am her only patient using Afrezza currently (that is because they are a UHC/OPTUM facility and I am the only one on Express Scripts, this was a follow up visit from when I was on previous insurance so I went with it). I actually have another endo appointment from the more recent referral next week (the insurance system is such a clusterphk that now I'm technically with two primaries and two endos until my current insurance figures things out...I'll wait until they do lol). Also it doesn't hurt to have one as a backup with respect to writing my script. My next set of labs were ordered by endo1 for May so we'll see how they compare with the first 2.9 point drop improvement from the last set. The appointment with endo2 next week should be interesting as he was the one that originally set me up with a set regimen of 8u at meal and 4u follow up dose 1 hr. after, he also wanted me to take the extended release Metformin before bedtime. He might fire me as a patient after I went rogue on his regimen and am taking care of my own dosing/titration to stay in range but hopefully when he sees my most recent lab results he will rethink the "set regimen" and understand that each individual needs what works best for them rather than some type of universal preset dosing (sorry for the run on sentences bad habits are hard to break). Endo1 was very receptive and understanding of the fact that it needs to be a much more individualized approach IMO. In summary, TG for Kendall's arrival to help Mike C with the paradigm shift . All I can say is record short interest and these current prices....the gift that keeps on giving Have a great Easter weekend everyone!! Joey, what doses are you taking to keep your blood glucose where you want it? What are you finding you need for your meals? Generally speaking it is case by case depending on meal and time of day. Remember I am not taking a basal or any Met. so depending on where I am prior to going to sleep and where I am in the am. I may take a correcting dose but mostly depending on meal it may be anywhere from 8-12u at meal and then if needed a correcting dose of 4-8u pro re nata. I take a PPI (Nexium) which greatly reduces my stomach acid so my food takes much longer than normal to break down and digest. If I eat a bagel and depending what I eat it with it can be a marathon lol and thus you can't just use a set dose and time like prescribing a drug "8 units 3X daily at mealtime" etc., this is what I was alluding to when I wrote the post about everyone is different regarding stage of disease, medications they are taking, diet, exercise, activity, etc. Everyone is so different you can't have a "set" dosing especially for T2's, you have to educate them to use as necessary as they track their BG...this is why the CGM's are paramount and revolutionary regarding real time management and compliance and how this is going to progress to the new standard of care as Kendall alludes to |
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Post by morfu on Mar 29, 2018 15:17:05 GMT -5
I have just returned from my new PCP. Was with the Cleveland Clinic, OH and they no longer accept my insurance "Medical Mutual" New PCP is with Southwest General Hosp./University Hospitals Cleveland. We went over my history and meds. Reviewed Diabetes meds: 1000mg Metformin - Glimepiride 2mg. Sugar runs 223..I own, not on top of following diet and too cold to walk the dog. Told me it will always get cold Went on to ask him if he had ever heard of "Afrezza" eye's roll. Why do I ask he said. Explained did not like the side effects of Diabetes drugs. He asked if I knew this is not the first inhaled insulin and went into, briefly, Exhurbia (Sp?) Told me my pancreas is half as effecient since I was diagnosed 2 yrs ago...also that most people who can't manage this will need a basil insulin. Inhaled MAY and only May be an NICHE product and see's no reason why he or anyone would choose to prescribe. Please, before I hear it's my job to educate him - It would be better for a professional to teach University Health care systems and educate those doctors. I am not medically inclined to go toe to toe and he does not want to hear about it. Furthermore, my medical insurance does not cover. Just an update and wanted to share my experience today 3/29/18. My investment 6 figures at one time has me extremely nervous. Not meant to be doom and gloom - just real. Happy Easter. Solution seems easy, send him a link to this very discussion.. everybody and especially a doctor is welcome to discuss here.. he and we might learn something! |
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Post by mango on Mar 29, 2018 15:17:30 GMT -5
Maybe this would be a great opportunity for Dr. Kendall to educate this person.
It's one thing being ignorant about something, it's another to be ignorant and then lie to the patient by spewing false & negative "facts" to undermind its therapeutic benefits. Then, prescribe Metformin. Did you ask him why he is prescribing a drug that literally causes beta cells dysfunction and death? The AMP kinase activator Metformin induces the inhibition of glucose-stimulated insulin secretion via down-regulating MafA—a key transcription factor for the insulin gene. Can't have an immature beta cell turn into a mature insulin producing beta cell without transcription factor MafA.
MafA regulates genes that are essential for beta cell function (Glucokinase, Glut2, Pdx-1, Nkx6.1, GLP-1 receptor, prohormone convertase-1/3 and pyruvate carboxylase) Additionally, MafA has a key role in regulating first-phase insulin secretion, and insulin granule functions.
Afrezza is important because the first-phase insulin response is required for maintaining beta cell function. When you have a FPIR it means you have beta cell memory (truly called metabolic memory of beta cell. Information is contained in calcium and beta cells will obtain, store and retrieve the metabolic information. This is why CaMKII is important. It prepares beta cells for the next high glucose exposure by positively expressing not only MafA but other proteins as well like glucokinase, the glucose sensor. CaMKII is a calcium sensor. So, without CaMKII activiation your beta cells are screwed). So MafA is vital for insulin granule priming and loading and preparing for the next acute increase in glucose levels (meals). Beta cell memory formation is dependent on CaMKII activation (glucose-induced intracellular calcium influx or cell membrane deploarization). How this relates to MafA is—CaMKII regulates the protein expression of MafA. Loss of FPIR means CaMKII is not being activated which means a key transcription factor for insulin gene is not being expressed which means your beta cells are producing LESS insulin when exposed to increased levels of glucose (like when you eat a meal).
Metformin induces beta cell dysfunction and death by facilitating MafA protein degradation.
When you restore the first-phase insulin reponse with Afrezza, you literally restore beta cell function.
Get a new dr.
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Post by MnkdWASmyRtrmntPlan on Mar 29, 2018 15:48:19 GMT -5
Mango, I love it when you use big words. That's a powerful condemnation of Metformin. One punch to the doctor. Second punch to Metformin. And a final punch to make Afrezza the victor! I haven't seen you posting as much as you used to. But, you are still doing your research. You should be a doctor (if you are not). It seems that is where your heart is. Keep up the good work. |
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Post by peppy on Mar 29, 2018 15:51:37 GMT -5
Maybe this would be a great opportunity for Dr. Kendall to educate this person. It's one thing being ignorant about something, it's another to be ignorant and then lie to the patient by spewing false & negative "facts" to undermind its therapeutic benefits. Then, prescribe Metformin. Did you ask him why he is prescribing a drug that literally causes beta cells dysfunction and death? The AMP kinase activator Metformin induces the inhibition of glucose-stimulated insulin secretion via down-regulating MafA—a key transcription factor for the insulin gene. Can't have an immature beta cell turn into a mature insulin producing beta cell without transcription factor MafA. MafA regulates genes that are essential for beta cell function (Glucokinase, Glut2, Pdx-1, Nkx6.1, GLP-1 receptor & GLP-1 signaling, prohormone convertase-1/3 and pyruvate carboxylase) Additionally, MafA has a key role in regulating first-phase insulin secretion, and insulin granule functions. Afrezza is important becauae the first phase insulin response is required for maintaining beta cell function. When you have a FPIR it means you have beta cell memory. This is vital for insulin granules priming and loading and preparing for the next acute increase in glucose levels (meals). Beta cell memory formuation is dependent on CaMKII activation (glucose-induced intracellular calcium influx or cell membrane deploarization). How this relates to MafA is—CaMKII regulates the expression of MafA. Loss of FPIR means CaMKII is not being activated which means a key transcription factor for insulin gene is not being expressed which means your beta cells are producing LESS insulin when exposed to increased levels of glucose (like when you eat a meal). Metformin induces beta cell dysfunction and death by facilitating MafA protein degradation. When you restore the first-phase insulin reponse with Afrezza, you literally restore beta cell function. Get a new dr. I am more unnerved by glimepiride. Apparently the PCP can understand the dosing. |
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Post by agedhippie on Mar 29, 2018 16:45:57 GMT -5
I am more unnerved by glimepiride. Apparently the PCP can understand the dosing. I don't have any problem with metformin, but Glimepiride I hate. It's one of those drugs that they should have gotten rid of ages ago. Not quite as bad as glyburide but getting there. Dosing is easy though! |
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Post by agedhippie on Mar 29, 2018 17:07:26 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." I am surprised that there seems to be a consensus that Afrezza takes more "work" than using conventional prandial insulins. I recall hearing from patients that one of the benefits of Afrezza was that it took much less time and effort to manage diabetes, and that they no longer had to think about it all of the time. For example, patients don't need to plan what and when they will eat and take their insulin in advance and then be sure to adhere to the plan. Instead they take Afrezza at the start of the meal. Nor do they have as many worries about severe hypos and managing "insulin on board" hours after dosing. When long term T1 PWD like Paul Sparks say that Afrezza has changed their lives, this is what I think they are referring to. You can get good results with conventional insulins, but compliance is much more difficult. Ok - I can clear this up for you. "I am surprised that there seems to be a consensus that Afrezza takes more "work" than using conventional prandial insulins."Only in so far as getting the initial titration right, and that only because it's new. Once it's set up I cannot see any difference. " For example, patients don't need to plan what and when they will eat and take their insulin in advance and then be sure to adhere to the plan."You haven't had to do that since the arrival of RAA. Nobody I know pre-boluses, you just bolus when the food arrives (it's quite entertaining watching the food arrive for a diabetic meetup - there is a sudden flurry of action and pumps bleeping). "Nor do they have as many worries about severe hypos and managing "insulin on board" hours after dosing."Most people don't worry about severe hypos, that went out when CGMs arrived. If you are hypo-unaware then the CGM is your lifeline, if you are not then you will feel the hypo and deal with it. Am I saying people don't get severe hypos on RAA? Absolutely not. You can get them on RAA or Afrezza (see the phase 3 trial data) although they are less likely on Afrezza. The thing is, a severe hypo is so unlikely in general that it's not a big consideration, although it does remain a worry. Managing insulin on board - your pump will do that, some meters will do that (especially outside the US), you can even do it yourself as it is trivial. "When long term T1 PWD like Paul Sparks say that Afrezza has changed their lives, this is what I think they are referring to."This is probably the least convincing argument for a diabetic. It is axiomatic in the diabetic community that all diabetics are different, and that what works for one may not work for another. For that reason all diabetics will be happy for Paul, but very few will regard his happiness as a reason to consider changing. |
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. All I can say is record short interest and these current prices....the gift that keeps on giving 
