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Post by stevil on Nov 12, 2023 12:09:07 GMT -5
I’ll just leave this here so it can also get ignored, again …. And then again. Probably the most succinct (and accurate) explanation on insulin resistance and disease progression that I’m aware of. youtu.be/OzZUnl3b49U?si=lPM1B94fGuGc_gvBAlso, sayhey, idk where you get your info from, but afrezza needs to be dosed HIGHER at the beginning of the meal. You don’t use 2-3x more after the meal because the “goop” that you reference messes up the receptors or signals - I honestly don’t make sense of your argument so I can’t remember how this happens. People have been under dosing afrezza, giving misleading and poorer outcomes than what’s possible. If you dose afrezza high enough at the beginning of the meal, you don’t have to do a follow up dose. It has nothing to do with the body responding differently and everything to do with meal complexity, glycemic index of food/metabolism, and the PK/PD profile of Afrezza. It’ll finish up before the job’s done. I always applaud aged for his patience. I gave up trying a long time ago since it was obvious the argument never went anywhere. Just chiming in for the sake of others. And, yes, the fear has always been IPF, not pneumothorax. Although you can have severe bronchospasm cause pneumothorax, that’s easily cured with a chest tube. IPF was the long term concern that time has effectively addressed. I believe “ELS” was a term you made up, not one aged ever wrote unless in response.
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Post by stevil on Aug 11, 2023 8:05:34 GMT -5
Ozempic, Rybelsus, and trulicity all have very good Medicare coverage. I do practice in a more affluent area and only have about 15-20% Medicaid. I don’t pay too close of attention to the MAPs… they change every year so I don’t bother myself with trying to keep up.
Most of my patients don’t pay more than $25-50 for their GLP-1s per month. There’s usually one that’s covered. I throw in Soliqua from time to time as well if there’s an issue with coverage on the other ones and they’re already on a basal. It’s extremely rare for a Medicare plan not to have very good coverage… I’m pretty sure it’s only the really crappy commercial plans that don’t cover them very well. I don’t think I ever run into the issue with my seniors unless they don’t have Medicare
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Post by stevil on Aug 10, 2023 23:42:42 GMT -5
So cool! You guys deserve it!
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Post by stevil on Aug 10, 2023 23:38:08 GMT -5
From my experience, seniors prefer once-weekly, mindless injections versus technology and “complicated” dosing adjustments. Even choosing between 1/3 colors can be overwhelming to many of them, especially when they’re faced with making that decision 3 times a day. I have put a handful of seniors on Afrezza. Every one of them decided to stop using it on their own. Every one of them chose GLP-1s
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Post by stevil on Jun 7, 2023 9:25:09 GMT -5
Mounjaro will put the GLP-1s out of business once it gets better coverage.
It’s proving to be the holy grail so far. If it doesn’t cause any long term side effects, it will have the potential to be the best selling drug of all time… until the next GIP comes out.
As a doctor, I don’t want to give my patients any unnatural chemicals. However, the thing people on this thread don’t realize is that it’s not safe/healthy to be obese, either. It’s not that I’m gunning to ram these into peoples arms. But when my patients are telling me they have tried 10 different diets and exercise every day- some I believe, others I don’t … at all. But GIP restores the body’s insulin sensitivity back to physiological levels. It basically undoes the problem caused by poor diet and lack of exercise.
Again, is this the option I personally would choose for my patients. Not a chance in hell. But do I give it to all the right patients? Without hesitation. This drug is stupid good.
I must have all the statistical outliers in my practice… my patients are only sick during the first month of loading dose. After that, they have virtually no symptoms unless we keep titrating up. Then it’s only the day of and maybe after the dose.
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Post by stevil on Apr 29, 2023 11:16:56 GMT -5
New here and trying to understand the backgrounds of posters. Curious about why 7.21 million Metformin prescriptions would be important to Sayhey? Also, is there a reasonable hope that Martine's sales of her shares (I believe to total close to $100,000,000) is to raise cash to buy Mannkind outright? Thanks all! Sayhey has views on the use of metformin More seriously I was trying to figure out how to quantify the size of the addressable Type 2 market and metformin is a good proxy. Historically once you were on metformin as a Type 2 you remained on it for ever, even when they intensified the treatment to insulin. I am not sure if that is still the case with GLP-1 though or id they discontinue metformin at that point. Typically you stay on it until your kidney function dips below a GFR around 30. Metformin has shown many significant health benefits, namely protection against certain cancers. br] Another reason to discontinue is if it makes control with insulin more difficult. Metformin can make some people have more frequent hypoglycemic episodes
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Post by stevil on Mar 16, 2023 11:27:51 GMT -5
@sayhey I’ll be honest with you. I’m not really motivated to get into arguments with you as you have shown you are set in your ways, don’t accept evidence that contradicts your narrowed and constrained focus and beliefs. It’s an exercise in futility and I don’t have the time, energy, nor determination to see it through. Here is a podcast I listened to recently, from someone who researches diabetes and is aware of the latest theories. While I don’t hold Joplin in the same esteem as you, he does mention them and gives them good remarks. I remember awhile back you stating insulin resistance wasn’t a thing and there being an issue with the junk the pancreas secretes. Both of those are… interesting… comments, neither of which make sense or have evidence to back them up. In any case, please accept my resignation on this matter. I wanted to address your question, but as I stated above, I don’t want to keep dedicating more time and energy to this. My children would like to see their father 😁. I don’t think I’ve disagreed with anything aged has said, so if you need more to chew on, your conversations with him may serve as a primer… as well as proof that you have been presented plenty of dissenting information but have apparently chosen to disregard it because you refuse to accept that you’re wrong. Here is the link to the podcast. I hope it will be of benefit to you. podcasts.apple.com/us/podcast/the-peter-attia-drive/id1400828889?i=1000586933595Stevil - we can show there is "insulin resistance" but there is a difference between insulin resistance "existing" and being the "root cause". My contention is it is a symptom. Shulman's assumption and I am Assuming yours is its the root cause. Why are we now seeing all these T2s after getting covid when we can show covid has attacked the pancreas and beta cells? You may be too young to remember but the "accepted truth" for the cause of ulcers use to be acid food. At the time this could not be questioned kind of like insulin resistance is the cause of T2s. I will probably reach out to Shulman and have him try this experiment but you can do it too. Try this as a simple experiment - have the T2 eat but stop the spike - how much afrezza do you need? Have the same person eat and spike and then try to bring down the BG - how much afrezza do you need? Its the same amount of carbohydrates so you would think you would need the same amount of afrezza not 2x or 3x. What has changed??? Why is that you need so much more? Is that insulin resistance? It seems to be but why does it change in such as short time? Doctor Shulman is assuming insulin resistance is the cause and what I am demonstrating is its a changing symptom. Then he takes the next step and attributes cancer to insulin resistance when he is really meaning out of control blood sugar. Then they ask us to take a "leap of faith" in the discussion and I will pass. I will stick with Richard Bernstein on this and say you need to keep tight glucose control. Also what happens with insulin resistance when tight glucose control is maintained in the T2? I will say at one point he does talk about beta cells not making enough insulin and reversing insulin resistance by significantly reducing calorie intake. Why are they able to do this he mentions the toxic lipid"? Then he says the problem is with the transport mechanism - I will buy this. Then they throw up their hands and say "we don't know" - great. I just got to say this guy did not impress me. I am glad you are agreeing so much with Aged. He needs some good support as he seems be losing it a bit as he does not like the fact that CMS is now paying for CGMs with "insulin treated" senior. I was not aware you had kids. Take my life advance I gave you in a previous post with the kids as they grow older in finding out what they are doing. It's all there. Just need to listen to the podcast podcasts.apple.com/us/podcast/the-peter-attia-drive/id1400828889?i=1000586933595It's a very compelling argument. He will take you step by step down the biochemical pathway, discuss NMR results, show you trial data. It all supports insulin resistance as the root cause of not only diabetes, but most metabolic disease. I'm honestly not sure why you're so fixated on Covid/viruses as the root cause of diabetes. How do you explain diabetes before covid? Why is diabetes fully correlative with the obesity epidemic? As a species, we have had viruses throughout history. Why, all of the sudden, as we have gotten fatter, are we starting to develop diabetes at a much higher rate than ever before? I'm not necessarily discounting that viruses may cause diabetes. There are probably hundreds of mechanisms. But, by far, the most predominant form is from insulin resistance. Again, I have no interest in continuing to debate you over this. Listen to the podcast. If you don't come away convinced, I don't know what to tell you. In my opinion, it's iron tight as a theory.
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Post by stevil on Mar 12, 2023 12:05:12 GMT -5
@sayhey I’ll be honest with you. I’m not really motivated to get into arguments with you as you have shown you are set in your ways, don’t accept evidence that contradicts your narrowed and constrained focus and beliefs. It’s an exercise in futility and I don’t have the time, energy, nor determination to see it through. Here is a podcast I listened to recently, from someone who researches diabetes and is aware of the latest theories. While I don’t hold Joplin in the same esteem as you, he does mention them and gives them good remarks. I remember awhile back you stating insulin resistance wasn’t a thing and there being an issue with the junk the pancreas secretes. Both of those are… interesting… comments, neither of which make sense or have evidence to back them up. In any case, please accept my resignation on this matter. I wanted to address your question, but as I stated above, I don’t want to keep dedicating more time and energy to this. My children would like to see their father 😁. I don’t think I’ve disagreed with anything aged has said, so if you need more to chew on, your conversations with him may serve as a primer… as well as proof that you have been presented plenty of dissenting information but have apparently chosen to disregard it because you refuse to accept that you’re wrong. Here is the link to the podcast. I hope it will be of benefit to you. podcasts.apple.com/us/podcast/the-peter-attia-drive/id1400828889?i=1000586933595
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Post by stevil on Mar 11, 2023 15:26:22 GMT -5
Welcome to being a doctor 😁. These are considerations I make with each patient. There are never any absolutes in medicine. It is all risk/benefit analysis. We’re playing the same waiting game with Afrezza, at least all of us but say hey. Medicine will never advance if we’re too afraid to take the first step. The only way we now know afrezza is *probably* safe is because we can look backwards and see that it is. We’ll do the same with GLP-1s. Sometimes we get it wrong. When that happens, you adjust. It’s why the first step for me when I treat diabetes is to address the underlying cause first. I stress diet and exercise changes, because THAT is the safest and best first line treatment for diabetes. Then we go from there…
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Post by stevil on Mar 9, 2023 20:09:02 GMT -5
Stevil - sorry if I hurt your feelings on points 1 2 and 3. I thought you were a young guy/gal? One thing you will learn is with age comes wisdom. I can definitely understand your new patient. First off he is a guy and he wants to totally ignore he has a health issue. I would think this is not unusual for T2s. Its a guy thing. Maybe not as much for the under 40 crowd but 50+ I would see it more the norm. I have already mentioned these T2 seminars are 70%+ women maybe closer to 80%. He can definitely contact me if you want. I can talk about my dad and how he thought having a coke at lunch gave him diabetes. I can also tell this guy how he had his first "known" heart attack at 62 and was gone by 70. Didn't hurt my feelings. BUT! I think I figured out the solution. To everyone but sayhey: (he's wrong about a lot... but also probably right about some things... proceed with caution if you choose to follow his line of thinking) To sayhey: I hope with age comes wisdom, although I hope it's just a little different than the kind you have. I hope that I choose to listen a little better before I speak, although... I think that's part of wisdom. IDK, not sure. I'm not old enough yet! Edit: Sorry, moderators. Forgot sarcasm wasn't allowed. Feel free to scrub this post if needed.
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Post by stevil on Mar 9, 2023 15:02:52 GMT -5
Stevil - my eye sight is not as great as it once was but its not too bad. When I take the Strenghtfinder evaluation and I have taken it several times my top strength is always "Command". Empathy never makes my list. However I try to listen and when I am wrong I will admit it. If I get new info and a position I have needs to change, I will change it. I think you are underestimating the influence the doctor has on the patient. Most people will do what the doctor says. Some will stop when it becomes a hassle or they see no value but many will probably keep following doctors orders - maybe more so women. When I go to T2 seminars its usually 70%+ female. We are going to differ on this statement - "The vast majority of people with (type 2) diabetes could treat their disease with diet and exercise." As we have seen with Covid there is a viral linkage to diabetes. Diet and exercise will reduce the body's insulin needs and will improve insulin uptake but what we do know from all the early insulin intervention studies is the earlier we can help take the load off the pancreas the better outcome we will have. The big problem is as a general rule and according to the SoC we don't do that today. What you may also not fully appreciate is as we get older dieting gets harder because the weight seems to stay as you continue to reduce calories. There is also the chicken and egg discussion the tech diet companies are having - did the weight come before the diabetes or did they loose post prandial control first and then the weight gain. With afrezza they have already interrupted their day to eat so all they need to do is; take sip of the water; take a puff; eat the sandwich. I am not buying Aged's using afrezza is a big ask. Then again if I am a CGM sales rep and my goal is to sell CGMs I really don't care if they use it as long as they are prescribed it and get the CGM until of course they don't improve and when they "go to the tape" the will see on the CGM it was never taken. I think what you are seeing is people not seeing benefit so they stop doing something. Immediate feedback it HUGE. With afrezza and the CGM they get immediate feedback. They can see they are in control and they can make a difference. With the basal be it daily or weekly they have no control, their post prandial numbers will still spike and they will see little benefit to the CGM #1. I'm sorry, but it's a bit amusing to me that you're a non doctor telling a doctor what MY experience is like. I can unequivocally tell you that you are absolutely 100089857% incorrect in the red statement. Patient compliance/adherence is a MAJOR issue. Again, it doesn't take a huge leap in logic to understand why. These people didn't get this disease by eating fish and salad. They're not even able to do the things THEY want to do, let alone the things I'm asking them to do. #2. What have I said or not said to lead you to that assumption? Again, it is so bizzare and fantastical that people on this board think they know more than me. I don't know everything, but I never walk up to an expert on something and immediately assume I know more than them. It's really quite fascinating. #3. Ironically, I had a patient show up today. I prescribed Afrezza for him. He was insulin naive. He literally came into the office today and told me, "I have friends who take one shot a day of insulin. Can I just do that so I don't have to check my blood sugar 3 times a day?" I kid you not. He even has a prescription for a CGM. He told me he knows himself and he's going to forget to do what he's supposed to do. If you want, I can ask him if I can give him your contact information so you can convince him to take Afrezza. I see this ALL. THE. TIME. #4. See #1.
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Post by stevil on Mar 8, 2023 23:11:12 GMT -5
@ say hey
Regarding once daily basal vs Afrezza.
My preference would be for Afrezza since it would be safer and address PPGE, but to be honest, the correct answer is “whatever the patient is willing to do”.
I think part of your problem when analyzing human behavior is you seem to have difficulty seeing life through others’ eyes. While this is an unfair generalization, there are still multitudes of truth in it. The vast majority of people with (type 2) diabetes could treat their disease with diet and exercise. It was bad habits that led them to the present day with their diagnosis. Asking someone that doesn’t have the best self control to do even more work to treat their disease is a huge ask and is not only irresponsible on my part for asking them to do that, but it also borderlines on negligence when I keep forcing a square peg into a round hole. I think this is the biggest reason for poor outcomes. Once people get on insulin, it’s not necessarily the insulin that is the issue… it’s the burden of having to deal with their disease multiple times a day. It’s not hard for you to pick up an inhaler and inhale 3-5 times a day. I get that. For a lot of people it is. Not the picking up an inhaler and breathing. The part where they have to interrupt everything they’re doing to check on their health and make a decision and act on it. I agree, it shouldn’t be hard. But I see time and time again that it is. So if I have to pick between a once weekly shot or a 3-5 times/day treatment regimen, I don’t make the decision based on what I think will give them the best potential results. I make a plan that will REALIZE the best results.
I fully agree with agedhippie on nearly anything, but especially “the more options the better”. It is my opinion that there will not be a one size fits all treatment for diabetes unless and until there is a cure.
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Post by stevil on Mar 7, 2023 23:19:23 GMT -5
@sayhey
It still would not surprise me regarding non diabetics getting small bowel obstructions. Again, delayed gastric emptying was a known mechanism. I’d be semi surprised if SBOs didn’t happen for some.
Obese people don’t often have the healthiest of diets. If you slow the transit of low fiber/highly processed food, I’d be shocked if the mud didn’t get stuck.
On that note, I’ve had a dozen or so obese patients come in with IBS just in the past couple weeks. They are already having all the symptoms listed on the side effect list of GLP-1s/GIPs. For many/most, it’s a normal day.
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Post by stevil on Mar 7, 2023 23:08:35 GMT -5
Yes, I once made the mistake of clicking the wrong dose of semaglutide in my EMR because the way it’s structured makes no sense. I accidentally started them on 1mg instead of 0.25mg a week.
They were very sick that month. After I lowered it back down to 0.5mg- no reason to titrate at 0.25mg anymore (whoops), there was no more nausea, vomiting, and diarrhea. My patient was a good sport about it and thanked me for the extra 10 pound weight loss that month.
Mostly, if you start at the correct dose and titrate slowly, most patients tolerate it without much issue. Maybe the first day they’ll be uncomfortable, but not really enough of a reason to stop treatment.
It wouldn’t be spreading like wildfire if it sucked and no one wanted it.
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Post by stevil on Mar 7, 2023 15:11:10 GMT -5
This isn't really a surprising finding... People with diabetes sometimes already have gastroparesis. It has been a well-known mechanism to further delay gastric emptying as part of what improves satiety.
From what has been shared on this thread so far, I don't think this "news" is likely to cause any considerable splashes.
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