October 2, 2024 • 43 mins
In this delightfully candid podcast, a motley crew of diabetes experts engaged in a spirited discussion about the wonders and woes of inhaled insulin. With a delightful blend of wit and wisdom, they explored the rapid-fire effects of this ultra-fast insulin, likening it to a plane landing (or crashing, depending on who you ask). From hijacking insulin pens to feeling like a drug dealer, these "Diabetes Nerds" left no stone unturned in their quest to demystify this innovative treatment option. Amidst the banter, they offered sage advice on navigating the insurance labyrinth and striking the perfect balance between micromanagement and 'set it and forget it' diabetes care. A must-listen for anyone seeking a refreshingly humorous take on the ever-evolving world of diabetes management.
You can find more Inhaled Insulin content from Ginger Vieira on her YouTube channel @DiabetesNerd and her articles on Inhaled Insulin at https://beyondtype1.org/inhaled-insulin/
For one-on-one education on the use of inhaled insulin from qualified CDCESs, contact Integrated Diabetes Services.
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
(00:33):
Welcome to Think Like a Pancreas, the podcast.
I'm Jenny Smith and I have the privilege of stepping in as your host so that Gary can sitalongside our guest, Ginger Vieira, to discuss their experiences with inhaled insulin.
It's been around for a while, but we're gonna really get into some good details about useand everything today.
(00:56):
You may know Ginger from her content on social media channels, many of them, where shediscusses her life.
with diabetes and all the ups, downs, tips, tricks, and things that she's developed alongthe way to make it less cumbersome and more just doable.
Most notable is her newer Diabetes Nerd channel on YouTube.
(01:17):
And she also recently released a new book, The Exercise with Type 1 on Amazon.
She's got many others that are available and just wonderful resources.
but you may also know her because together we wrote the book, Type 1 Diabetes inPregnancy.
So thank you very much for joining us, Ginger.
(01:38):
We're super excited to talk to you.
Yeah.
good to see both of your faces.
Absolutely.
And Gary, I'm kind of settling in.
kind of have my big old armchair here as the host a couple of times now for the Think Likea Pancreas, the podcast.
So I don't know.
I might need to watch out.
I like this hosting thing.
(01:58):
Yeah, I think the 2 of you are ganging up on me all
Look at, his arms are already crossed.
He's already mad.
So, you know, over the past couple of weeks, our Integrated Diabetes team has sort ofwatched and heard we sort of, you know, chit chat back and forth.
We text each other just as a clinical team and as friends with diabetes.
(02:21):
So Gary has been trialing use of Afrezza, an inhaled insulin, and we've kind of watchedyour ups and downs and, you know, kind of some of your highs and or maybe sort of they're
your
lowlights on social media about using it, right?
We also will have a really awesome blog that you wrote about your experience specifically,pros, cons, of insights into using on our Integrated Diabetes website.
(02:51):
So I think I'd like to kind of get an idea of what is inhaled insulin?
Tell me.
Inform me like I am new to using it, please.
I mean, the exact name of the product is Technosphere.
Technosphere is this dry powdered form of insulin that sits in a little cartridge.
(03:15):
It looks a lot like, I think of the houses from Monopoly, those little green houses thatyou step on and they hurt like anything.
That is, yeah, there's a cartridge example.
That little white part of it is where the insulin is
And the cartridge is loaded into something that looks like a whistle.
(03:36):
You just drop it in, close it up, and inhale the stuff.
Instead of giving the insulin below the skin, the insulin absorbs through the lining ofthe lungs.
It actually absorbs through the alveoli of the lungs directly into the pulmonarycirculation.
(03:57):
So it gets into the bloodstream really quick.
and starts working pretty fast.
Within a few minutes, it starts working.
So it's definitely really, when we talk about rapid, so many people complain about ourrapid insulin being called rapid, but not really being rapid, right?
We still need that pre -bolus time, so to speak.
(04:18):
But what it sounds like you're saying is that it really is truly rapid comparatively.
rapid, ultra, ultra rapid.
Come on, Gary, admit it.
with that rapid, uber rapid, what did you guys find with how quickly it starts to work foryou?
I mean, within 15 minutes, I see it turning my CGM around.
(04:40):
And they say, you know, it's active in your system within 2 and a half minutes, and thenyou can see a noticeable change in direction of your blood sugar within 15.
And I experienced that.
And I have to remind myself of that sometimes too, when I'm correcting like a frustratinghigh because I underdosed or, you know, I eat Chinese food and I'm going through the roof
(05:01):
or something and I just underdosed.
And I have to remind myself like, no, just...
Wait a minute, and then sure enough, you know, it's like.
Is yours similar, Gary?
I remember reading some of the things that you were texting as you were using it, but doyou find similar?
yeah, it's 2 to 3 times faster.
It starts 2 to 3 times faster.
It peaks 2 to 3 times earlier and it clears 2 to 3 times faster.
(05:25):
So yeah, is very uber- ultra- rapid, whatever you want to call it.
And I mean, that has clear advantages.
Having the insulin work that quickly.
you're not as likely to see the big spikes in the blood sugar after meals.
And that plagues almost everybody with diabetes because like you point out, the rapidacting insulins that we're used to using are not rapid at all.
(05:53):
They're, they're, they're rapider than regular insulin that we had decades ago, but theydon't come close to matching the insulin our bodies produce, which works in seconds.
So the insulin we give below the skin in
many cases, it just doesn't work quickly enough and doesn't clear quickly enough to workeffectively for us.
(06:15):
That's actually, was.
as like, sorry I was just gonna say, explain it as it's in fast, but it's also out fast,which has advantages and disadvantages.
actually what I was gonna ask is that finish, right?
I've heard a couple of people that I get to work with who've commented that when they'veused it, the end effect of it, it's almost like landing a plane correctly.
(06:38):
Like it's got a finish and you know when it's done, especially if you know that your basalbehind everything is the right dose to begin with.
You can almost watch the end effect of Afrezza compared to the sort of the
the little drip effect that you get with rapid acting insulin not quite seeing 100 % thestop line.
(06:59):
Is that right?
What I mean, what I love about it is, you know, once you learn how to use it, and I willsay it takes a few months to really learn the basics of using it.
And then from there, there's, we'll get into this later, but lots of experimenting of, Icombine it with Novalog for some meals too.
But it's like, let's say I took my dose at 1:00 and I ate at 1:00, or I was correcting ahigh at 1:00.
(07:24):
Either way, I took that small dose at 1:00.
If I'm 90mg/dL at 2:00,
I don't worry about going low because I know that that smaller dose of Afrezza has alreadycleared my system.
If anything, if I ate a meal and now that system, that's cleared my system, that firstdose, if anything, I'm thinking, all right, if I'm about to walk my dogs, I'm not gonna
(07:49):
take another dose yet, but I'm gonna watch and see if I start going back up.
Cause I might need what's called a follow -up dose because the food is still digesting.
the first dose cleared my system.
So the 4s the little blue ones, last about, they say 90 minutes, but most people would sayit's more like 60.
And then the greens, which are 8 units, and this is not comparable to 8 units of Novalog.
(08:13):
I'm sure Gary, and I won't get into that later, the dosing, but I think of them as small,medium, and large.
So the 8 is like medium.
That's more like I think of it as being in my system, definitely for an hour and a half interms of being aware of insulin on board.
And then the 12s, I hadn't even used until recently.
I got some from a friend who didn't need them.
(08:34):
And I was like, whoa, these are awesome.
And that definitely is like 2 hours and is helpful for certain types of meals.
Hmm.
Was that, did you try a couple of different doses too, Gary?
I can't remember.
Yeah, you know, I started out only using the 2 and a half, I shouldn't say the 4s, the 4sact like about 2 and a half.
(08:57):
The 8s act like 5, the 12s act like 7 and a half.
So each, you can dose in roughly 2 and a half unit increments.
But I would argue with that eventually.
At first it seems like that, but for me 2 and a half units of Novolog can drop my bloodsugar 150 - 200 points.
(09:17):
Like I would never, if my blood sugar was 250mg/dL for example, I would take 1 unit ofNovolog.
But if my blood sugar is 250mg/dL and I want to correct it with Afrezza, I can take a 4and I don't crash.
Yeah, I had some of my most severe low blood sugars in a long time that way, taking the 2and the small cartridge and the same way, know, 2 and a half units can drop me 150 to 200
(09:44):
points also.
And I did.
It wasn't as if it came down to a hundred and stop.
It kept going and ended up with some nasty lows that way.
some scary, I had a severe low, not like losing consciousness, but I was like, my gosh.
And when I first used it, when you're first using it, I've heard this from a lot ofpeople, you're really sensitive in that first month.
(10:11):
And then definitely by the second and third month, that hypersensitivity calms down andit's much more manageable.
Like I can take a 4
for what's a very low carb meal, let's say it was some chicken and broccoli, and I mightneed another 4 an hour later.
So it's like that hypersensitivity I experienced at first, and I was actually, I learnedthis from somebody else in Afrezza group on Facebook, I was dividing the cartridges in
(10:40):
half to make twos, and that was really helpful at first, and then I found I just didn'tneed to do that at a certain point.
And then I use Novolog if I need a smidge of insulin and yeah.
I've talked to people who have been using Afrezza for an extended period of time and somehave reported just what you're saying that it has sort of a forgiving effect after a while
(11:05):
and doesn't produce the dramatic drops that know that full dose normally would.
But other people say that didn't happen to them ever.
And personally, you know, I don't want to go through 3 months of dealing with that inhopes that somehow the insulin is going to start
thinking and adjusting on my behalf and turn into smart insulin.
(11:31):
low I had is I had also Novalog on board.
So did you have basal insulin from your pump on board?
That is what I think contributes to the worst lows on Afrezza is when you have these typesof insulin stacked.
And it doesn't matter that your basal insulin was for background needs.
It was still rapid acting insulin on top of ultra rapid acting insulin.
(11:54):
Yeah, but my basal insulin is titrated.
It keeps me steady when I'm not eating and not bolusing.
So it shouldn't be contributing.
think there's still something to be said for the combination of Afrezza with long actingversus the combination of Afrezza.
And I know a lot of pump users who use Afrezza to correct their highs and they love it.
(12:17):
But it, yeah.
it would come down, but I'd have to be up around 250mg/dL or higher before I could trustthe small cartridge.
But I did like you.
Gary?
Was it 2 weeks?
Yeah, I did 2 weeks of pure nothing but Afrezza for my bolus dosing.
And then I've continued to use it on occasion, just in certain situations.
(12:42):
So, Jenny, you were describing the plane landing.
I like that analogy.
You know, for a plane to land successfully, it's got to come down, you know, certain paceand level off.
You don't want the runway going, you don't want it taxiing too long because it'll go offthe runway.
Correct.
And you don't want it dropping out of the sky because it'll crash.
(13:02):
It's got to be just the right length of time that it's gliding down.
And I found in a lot of cases, the traditional rapid insulin has just worked far too longwith exercise of especially it's frustrating to try to work out after meals and between
meals when you've still got bolus insulin acting and you have to just.
(13:26):
eat all this carb to try to keep yourself from dropping too low.
Afrezza was great for that because it would clear.
Usually within 90 minutes, I didn't have to worry about it causing me a drop during myworkouts.
But sometimes the other problem is that it works too fast.
That plane does fall out of the sky sometimes when you're using Afrezza.
(13:49):
Where the insulin just plops, does its thing and it's gone.
The problem is that's not how
most food works.
Very rarely do find food that's finished digesting in 60 to 90 minutes.
The average food takes about 3 hours and that's average.
Most American diet food takes even longer than that.
(14:12):
and I think that's, no, it's okay.
I was just gonna say, I think that's where it takes some experience, right?
You used it for a set amount of time.
I think, you you've used and used new things and tried kind of everything, you're your ownguinea pig, Gary, for as long as I've known you, right?
You like to try it, figure it out, put something out there from a pro -con kind of listand give it to the general population who really needs to know more.
(14:39):
So your use was really, I want to get some information out there and to take away from itmaybe some experiences that prove when and why you want to use it, even if you're not
gonna use it on a day -to -day basis where, Ginger, you kind of do the same thing and youkind of try a lot of different things too.
(15:00):
on also, I'm on 2 meds for type 2 diabetes that I really love.
But we won't even get into that rabbit hole.
about a diabetes science experiment, perhaps.
It would make a good book.
That book needs to be updated.
That's not even available anymore because it's so outdated.
It's 20 years old.
(15:20):
I need to rewrite it basically.
Theresa is helping me actually.
I was gonna say, cause you your experiences that have led to your decision to use and whatsounds like ongoing use, you've used it for a much longer time.
if this medication was taken from me.
Heartbroken if Afrezza was taken from me.
(15:41):
I don't want to be on a pump, right?
Well, so let's start with that fact, right?
Is that I do not want to be on a pump and I will not go back on a pump until they changethis whole infusion site entire thing.
Just thinking about having an infusion site in my skin again makes me like, I don't knowwhat kind of, how do you describe it?
I curl up in a ball.
(16:01):
Yeah.
when you were, I think it was Omnipod and we were chatting, we were working together andyou texted me like, I'm pulling this thing off.
I'm going back to injections.
I cannot do this anymore.
And I was like, that's okay.
We'll just go back to MDI.
That's totally, I mean, everybody's got their thing, but what was your grand pull totrying Afrezza finally?
(16:23):
Cause it's been out for a while.
So.
Yeah, yeah.
So Jenny's referring to, she was my pregnancy coach for my first pregnancy.
And I tried Omnipod because you're supposed to want to be on a pump, right?
For pregnancy, it's supposed to be easier, but I couldn't take it.
So anyway, I got a little bit of Afrezza from a friend at a diabetes camp I was speakingat.
(16:44):
I tried it.
I went really low.
was like, this stuff's crazy.
Ditched it.
And a year later, I was writing lots of articles about inhaled insulin for a website.
and the articles were sponsored by Mannkind.
And so I was listening to like six different people tell me about how much they loveAfrezza.
(17:04):
And I was like, all right, I gotta try this again.
And I started using it and I approached it as an experiment.
I didn't use any Novolog for a month and figured out just what, you know, what can I doand not do with Afrezza.
And it takes a long time to really figure it out, but you have to go into it with such anopen mind because it's so different than rapid acting injectable insulin.
(17:31):
And I would challenge you, Gary.
I would love to see if you lowered your basal rates a little bit and tried Afrezza again.
I know you had them titrated and I know you know what the heck you're doing, but I wouldlove to see if maybe they need to come down when you're on Afrezza because it's just so
fast that I would be curious a friend told me that when you start when you start Afrezzayou might need a boost a little boost in your long acting because you don't have all this
(18:03):
Novolog hanging out
around.
Huh.
about how often you take Novolog it's like practically always present in your system.
So I did increase my Lantus dose by like 10 or 20 % at first and it's since kind ofsettled.
Yeah.
Well and I wonder the difference you know Gary you using it with a pump with rapid insulineven that you're getting a little hint of drawn out effect so I wonder if some of your
(18:36):
experiences were also very different to Ginger's mainly because she's using a true basalinjected insulin versus a pumped drip drip of a rapid insulin to mimic basal right?
I tried it both ways.
The first week I was taking Degladec, which is Tresiba as my basal insulin.
(18:59):
And it was not good.
I I have a significant peak and valley in my basal needs, so my sugars were constantlyrising or falling depending on the type of day.
So I went on the pump with the auto adjustment features off, just my
basal rates that I know from testing keep me steady.
(19:21):
And the whole point is that the basal insulin should not be influencing the glucose level.
It should just be holding it steady.
Even if I, if I had artificially raise or lower my basal insulin to compensate for theaphresia being too great or not working enough at different times of day, that means that
(19:42):
now the basal is not keeping me steady in a fasting state.
So
Yep.
basal insulin, you basically, once you have it fine -tuned, you can write it off as anissue.
It's no longer a factor that's affecting your glucose levels.
It's just the bolus insulin that's doing that.
And that's why I just could not get the correction dose to work right.
(20:06):
I couldn't fine -tune it.
But Ginger, tried also what you tried also, which was splitting the cartridge into a halfdose.
Yeah.
Yeah, it does.
It feels so shady.
picture of that and put it in the blog post that's going to be on our website.
But yeah, you got to literally it's like you tapping it out.
(20:28):
You're taking a credit card, splitting it into different doses.
I did use my HSA card, so I feel like it was at least healthcare related to do that.
And then, know, scraped it about half the dose back in.
Yeah, you know, it worked like half.
I don't know how sanitary that really is or anything, it did the job.
(20:48):
It was tedious.
I did that for a few months and then I just stopped and started using Novolog when Ineeded tiny dose.
on Afrezza while they'll take like an hour and just take a whole bunch of their smallcartridges and make up a whole bunch of half those cartridges, which are like a 1 and a
quarter unit instead of 2 and a half of actual insulin.
(21:10):
guy who eats only meat.
He's a intense carnivore and he uses Afrezza and he spends a lot of time, you know, makinghis micro doses.
Yeah.
And I've asked the CEO why they don't make a smaller 1 for type ones.
he said that it doesn't seem like enough people would need it, which I would argue with.
And then he said that also it just costs so much money to demonstrate to the FDA why theyneed yet another dose.
(21:37):
Yeah, the manufacturing process is expensive.
It's a lot of equipment and they would really add to the cost of the product.
Well, and since you guys both seem to have found some experiences where they'rebeneficial, mean, Ginger, you said even that you're using it in combination with Novolog
(21:59):
as a rapid insulin.
And Gary, you've found some circumstances that really are a definite pro to using itcompared to pumping the insulin.
So what are, I guess, what are some of those circumstances that you're using just theAfrezza?
or the combination or what meals.
Sure.
(22:20):
So to give you a little example, so right now I take 10 units of long acting Lantus.
I love Lantus.
I've tried the newer ones.
I just hate them.
I'm so old school.
I am like 90 years old at heart.
Jenny knows this.
Yeah, I'm okay with it.
I don't watch Matlock, but yeah.
So I...
(22:41):
She Wrote, you watched that.
did watch it a lot back in the day, yes.
You know, in my youth, when I was a teenager, I was only about 50 years old at heart, soanyway.
So, I need a teeny smidge of Novalog around 8:00 in the morning because I don't eatbreakfast, I practice intermittent fasting, and so my liver is like, here's some sugar,
(23:05):
right?
I used to need more insulin, a little bolus for dawn phenomenon, but I take metformin nowbefore bed.
and that has totally calmed down my glucose production in the morning, which has been sohelpful.
So that's the first dose of insulin I take most days is that little, I use a syringe, Ihijack, I don't know if we can share this, but whatever.
(23:29):
I have a YouTube video on this actually.
I hijack my pen and I'm not even taking a half unit.
I'm taking like sometimes, like an amount I can barely see because it sometimes overlapswith when I'm about to go for a jog.
of assuming it's like a quarter unit -ish.
Maybe, yeah.
barely see it.
So I'm sticking the syringe into my pan like it's a vial of insulin.
(23:51):
And I was doing that front of a type 1 the other day at dinner and she was just like, Icannot get over this.
Yeah, yeah, yeah.
Yeah, so Afrezza cannot do that for me, right?
And that's to prevent the high.
If I miss that dose and I did already go up to 200, then I could use a 4, but not if I'mabout to go run 3 miles.
(24:12):
So it depends on some other variables.
So the first meal I usually eat every day, I use a combo of Novalog and Afrezza.
I eat a giant honey crisp apple with freshly ground peanut butter.
I'm kind of addicted to it.
like, I can't wait to eat it today.
It's going to be so good.
And I like to take 1 unit of Novalog with it.
(24:34):
And then I'll take a 12, now that I have the 12s, I used to need two 8s of Afrezza.
And what I like about adding the Novalog is,
that when the two 8s or the 12 runs out, my blood sugar is gonna rise really quickly.
And that's the hardest thing about Afrezza is that when it clears your system and thefood's still digesting, it shoots up.
(24:58):
And if you don't have a CGM to say like, hey, you just crossed your threshold, then you'renot gonna know.
But it is so fast that you also don't have to freak out.
Like I have another friend who uses Afrezza and she's like, I don't even worry about highsanymore because Afrezza turns around so fast.
I'm like, all right, I'd still prefer to prevent the highs, right?
(25:19):
But she's right.
you can fix that high so quickly.
On a graph, looks like, and you know, if it was novalog, it'd be like, gradually comingdown.
so slow.
So you're kind of hitting almost your peanut butter effect with the Novalog on the backend where it would be creating the creep.
And I think, Gary, that was a kind of a con to you, right?
(25:44):
You saw the quick impact of the Afrezza, but without taking as you were cutting yourdoses, right?
To take just a little bit of a smidge more.
This is where discussion is really beneficial because you found a system, Ginger, withNovalog that kind of hits the creep later.
by dosing it in a timely manner where you've tested and done some experimentation.
(26:07):
And you found the rise that you were annoyed with, Gary.
I know.
Yeah, well, I learned something just listening to you, about combining traditional insulinwith Afrezza at a meal.
Because one thing I really didn't like was having to think more about covering my mealsand having to dose at the meal and then to see what's going on an hour or 2 later and dose
(26:33):
again.
I just didn't want to have to be thinking about it between meals.
I want to be living my life.
But the idea of doing a little bit of bolus insulin, I think using a pump for the basaland using a pump to give a little bit of bolus is easy enough to do.
And then, know, do the, the Afrezza The situations that I still find useful and I stilluse Afrezza for.
(27:01):
One, like you said, is when you have a really high blood sugar and, you know, short ofdoing the rage bolusing, you can use Afrezza to bring it down.
really fast.
Usually within 90 minutes the glucose will be leveling off and back close to where youwant it.
So that's one.
Another is before a workout.
(27:22):
If you're having a meal and then you're going to go exercise soon afterwards and you don'twant all that insulin in your system during the workout, you use the Afrezza.
It's going to clear quickly so you won't have all the insulin overlapping then and makingyou drop.
And that did work nicely.
And then the third is certain breakfast.
(27:45):
I find in the morning my food digests really fast and I often eat cereal in the morning.
Depends what kind of cereal.
If I have Cheerios, it's not too bad.
I don't spike that high, but almost any other cereal and I spike super high.
So doing the aphrasa with those kinds of breakfasts, it keeps things relatively flat.
(28:06):
You might get a slight rise.
would be the like, it is like finally the way a type 1 could manage cereal.
You know what I mean?
It's like, cause it's just so, yeah.
Yeah.
index food, it's really well built for.
I don't think it's well built for slower digesting foods though.
On its own, it's exhausting to use just Afrezza.
(28:29):
Because even an apple and peanut butter, is not like, it's not like eating pizza, right?
Yes, the peanut butter is pure fat, but it's not like eating pizza where it's digestingfor 8 hours.
So even those basic meals, even a salad with a lot of protein and fat, I might, if I knowI'm not about to go for a dog walk or exercise in the next 2 hours.
(28:54):
I might take a unit of Novolog if it seems a little easier based on how much, know, ifit's a rich restaurant salad, for example, or I might do a combo.
Even the salmon Caesar salad is a common thing I would order in a restaurant and I mighttake a 4 and 1 unit of Novolog so that I just don't have to worry about that big spike.
(29:15):
Yeah.
Or like really indulgent foods, like cupcakes, pizza.
I want a good amount of Novolog on board.
so that I'm not relying as much on Afrezza.
And I use the Afrezza to keep pounding it down and keep it down, but I don't have to takeas much.
Do you remember when the Medtronic 670 launched?
(29:35):
That was the first real sort of hybrid closed loop system.
It did what it said, you know, it did keep people's blood sugars in range more often.
But why did that system sort of flop?
What was it about it that turned people off?
For me it just was an insulin pump.
(29:57):
I mean, yeah, mean, overall, the 670, for me specifically, was the sensor that was neveraccurate.
And so that created a problem with what it was doing as an algorithmic system in terms ofturning basal off and adjusting.
And it didn't work fast enough.
(30:18):
It never worked fast enough.
Hmm.
the sensor wasn't trustworthy.
People had to be more, at least as many finger sticks as they used to do, right?
There were alarms and alerts going off constantly.
It would drop out of automated mode all the time.
It was disturbing people's lives.
It was getting in the way of their daily quality of life just to be able to use thissystem.
(30:42):
So yeah, you can get better control, but if it's detracting from your quality of life, itmay not be worth it.
So I think this is something that we teach our patients here.
Well, I'm just saying that there's some things about it that it makes diabetes managementmore complicated.
(31:02):
argue there's, I think you could take that, tackle that from both sides.
If you're used to the pump doing all this stuff for you, right?
And that's amazing.
If I could tolerate a pump, I get it why people love it so much.
I just, I hate them with a passion and I hate the split second of it not doing its thingand ending up in ketosis land.
(31:25):
DKA is what normal people call it.
But.
The, for me, once you get a hang of this, it's such a, to me it feels like such a lowcommitment because it's out of my system so quickly that it's like, all right, I'm gonna
take a 4 and see if that's enough.
And like, nope, wasn't quite enough.
(31:46):
just, I'm getting up towards my little threshold there.
I'm gonna take a little more and it's like, eh, take it, on you go.
When you take a dose of Novolog, it's like, you better really meant that.
Like you better be committed to that dose because now for the next 4 hours, that's in yoursystem and you can't undo it.
It's like a hammer versus this feels like a little blanket.
Like, I'm gonna put another blanket.
(32:07):
here honestly of the 2 things that you guys are kind of debating so to speak, right?
Because on MDI as you're doing, right?
With Afrezza, Ginger, you were also, you've also long -term been in the mindset ofmicromanagement too.
And I say that as a positive, right?
(32:28):
That's not a con.
It is the way that you've chosen to manage.
I remember pregnancy.
I mean, some of those days in third trimester, it was 16 little micro injections a day toget your blood sugar where you wanted it to go, right?
So you've got this willingness piece.
But to your point, Gary, you want almost like a set it and forget it to a degree.
(32:52):
You're willing to work, but you also want what you're using to work with you so you haveless...
that you have to truly consciously think of.
And so what I can kind of see is maybe extended use of using it would be, because I knowyou're using an automated system, Gary, you could potentially navigate with the kind of
(33:18):
system you use by adjusting targets, navigating when you enter your food.
So you could get the benefit of the automation to back up.
what the initial amount of Afrezza isn't providing long -term for you.
You could use, you know, temporary overrides.
You could tell your system to do something for you into the future ahead so that you getthat oomph that you want and it's said it and done now so you don't have to think about
(33:49):
it.
Whereas,
With most meals, can just bolus with my system the way I normally do and it works fine.
It's, you know, breakfast where it's a challenge.
So I find the aphresia more effective than, I think it's about striking a balance.
It's a balance between the amount of work you're willing to put in and how intensely youwant to manage your diabetes.
(34:13):
and what stresses you out?
you know, you're managing your diabetes intensely.
It's not like it's, you know, but I think there's, it's personalities and what is morestressful to you?
Having an insulin pump attached to my body is so much more stressful to me than beinglike, I need another follow -up dose.
Right?
And also, you know, I would have guessed that Gary is...
(34:37):
OCD and micromanager, but maybe not.
Maybe he's really relaxed.
And so I'm definitely more type A personality where I was like, man, I am not gonna letthat machine make these decisions for me.
And I'm not convinced that AID is the end all be all because I know too many people whoare frustrated with their systems all the time.
So they're not perfect either, right?
(34:59):
We gloss it over, but they're...
They're amazing, but they're not perfect.
You still have to intervene and deal with annoying stuff all the time.
that the AID systems, honestly, it's when you enter into using, if that's your choice, itis like a marriage.
expect to give and take, you expect to understand and learn what are your system'sabilities and what will it not do if you don't work with it and give it the right
(35:31):
information, right?
You can't expect.
any of the AID systems, whether you're doing an FDA approved 1 or 1 of the do it yourselfsystems, it will not 100 % do for you unless you've got something fancier.
They can.
the other day.
They were up in the middle of the night and they weren't coming to me for help, but I workwith them on social media diabetes content and we posted about it.
(35:58):
They're up in the middle of the night because her AID system was not communicating gooddata and her blood sugar said it was 500 and 200 and it was like, it was just a mess,
right?
So none of it is perfect.
And I think it always comes down to like choosing which battles feel less
obnoxious to you.
Right, which also comes down to
(36:19):
a lot of put a lot of doctors who make the decision for their patients.
Instead of teaching them about the pros and cons and letting the patient make thedecision.
We're making the decision for them.
Yes.
So many people have come to me and said, I wanted to try it.
My doctor said, no, it's not for type 1.
And so I have a YouTube video that's all about getting inhaled insulin because if youdon't follow the steps right in the process of how the prescription is written and then
(36:48):
the appeal, it will get rejected.
I actually, I switched insurance companies and I had to, I got rejected automaticallybecause my doctor did the thing wrong.
They didn't care that he tried to fix it.
They said it was too late.
The appeal was done and he just didn't understand what he was doing.
But I figured out the name of the CEO at my insurance company.
(37:11):
found his...
I live in Vermont, it's a small place.
I found his name, his address.
I contacted him directly.
I figured out the email system.
I guessed his email address and I...
I contacted him, I wrote him a letter and said I have taken 52 ,000 injections.
Imagine if there was something that could reduce this for the next 25 years of my lifewith type 1.
(37:35):
And wait, there is, but your company rejected it because of a paperwork mistake.
Please.
Yeah.
that's 1 of the drawbacks is almost everyone has to get pre -authorization for this.
And I listed in the blog post, and this is on our Thinking Like a Pancreas blog, you go tointegrateddiabetes .com, it's on our website.
(37:59):
But I listed what I felt were the strengths, the benefits, and then some of the challengesassociated with using this.
Anybody who wants to can can learn about it and then decide is it worth my trying and isit worth using on a full time basis?
Not at all or something in between.
Maybe I want to use it in conjunction with MDI or with a pump or with an AID system.
(38:25):
And if it's going to be used with an AID system, you gotta get some expert training sothat the AID system doesn't foul things up.
Be careful.
Yeah.
to understand.
That's I was actually going to ask is if there's, you know, if you guys had advice to giveprospective users, people who have heard of it or maybe considering it or have a friend
(38:49):
who's gotten is like, Hey, you want to take a puff?
You got some ginger, right?
I mean, what would be, you know, if you had, you know, an idea of what advice you'd giveto somebody, what
I mean, I give advice to people on this all the time.
(39:09):
Yeah, right, of course.
if you just for the people maybe listening to this, what would your, like in a nutshell,what would be your advice to people who are considering?
go into it with a very open mind and also only use Afrezza for meals and corrections forat least 2 weeks just so that you're not creating a dangerous mess of overlapping it with
(39:32):
meal boluses from Novolog And then if you're on a pump that's, as Gary already said,definitely talk to your healthcare team because you...
You don't want that AID system correcting when you're also trying to correct and etcetera.
I know people who do it well.
John Sjolund I don't know how to say his last name, he created one of the smart pens,Timesulin He uses it and he's a big fan of it.
(40:01):
That would be my 2 cents is go into it like an experiment for the first month.
It's gonna take time.
I'd recommend dipping your toe in the water before diving in completely.
I think it's worth trying, but do it on a very limited basis.
Like maybe just use it to fix your highs or just use it for breakfast or pick a meal or asnack and master it in that situation and then spread it out and use it in other
(40:30):
situations.
But I think it's also important to work with a healthcare team that understands it.
that has used it, has experience with it, so they don't just say, nah, it's not for you.
yeah.
I mean, had no healthcare team supporting me.
I had a few people that I'd interviewed.
But I think it does make a difference if you're on a pump and you have other, if you're ona long -acting insulin, I think it's a much simpler experiment than if you're adding it to
(40:57):
a pump.
to a pump and then.
through Zoom, phone, email, anywhere in the world so people can reach out to us if theyneed help.
Right, I know most of us on our Integrated team have definitely given a try to Afrezza andor have it in our back pocket, so to speak, for use in those circumstances.
As you defined, you're not using it every single time or every meal, Gary, but you'vefound your circumstances.
(41:22):
And my kind of 2 cents in that would really be start with your known meals.
Ginger, your apple and peanut butter.
has I don't know how long been in your intake.
You have eaten your apple.
You have been eating that a very, very long time.
And so you had it figured out with your rapid insulin.
(41:44):
And so it was kind of a little easier for you to roll into using the Afrezza to say, okay,yeah.
I also changed what kind of apples I eat.
The apples I keep choosing bigger ones that are even sweeter.
So I've gone from, you know, like a basic normal sized apple now to like the highlygenetically modified honeycrisp that are half the size of my head.
(42:06):
there was, I did have to do some learning, but yeah.
was a known meal.
that is kind of my point is choose your known meals kind of along the same lines as yousaid, Gary, you know, don't go out for the meal.
That's the craziest something you've never eaten.
And I'm going to throw Afrezza in here.
That's not the greatest time to start it.
(42:27):
It would be do it with your typical lunch meal, see how it goes, and then do someexperimentation around that.
And, you know, as always, if you need some
help with it.
Obviously the Integrated Diabetes team is certainly here to help.
Ginger has some wonderful online resources as well and information and blogging and everynot not so much blogging anymore.
(42:52):
I think mostly just hosting.
Okay, fantastic.
Well, it's been really a great I think a great conversation about Afrezza because it'sbrought a lot of perspective from 2 people who have
different use to begin with, to kind of bring some ideas around how to make your best useof it.
(43:14):
So thank you guys for joining.
Yeah, absolutely.
Absolutely.
So Think Like a Pancreas, the podcast.
Thanks, Ginger, again, for joining us.
Gary, thanks for handing over hosting to me.
I like that I'll let you be host as much as you like.
It's nice being, yeah, I can just chill.
(43:36):
This is good.
natural host.
Well, you guys are awesome and thanks again for being here.
If you need anything, obviously just find us at integrateddiabetes .com.
Have a great day.
Welcome to Think Like a Pancreas, the podcast.
I'm Jenny Smith and I have the privilege of stepping in as your host so that Gary can sitalongside our guest, Ginger Vieira, to discuss their experiences with inhaled insulin.
It's been around for a while, but we're gonna really get into some good details about useand everything today.
(00:56):
You may know Ginger from her content on social media channels, many of them, where shediscusses her life.
with diabetes and all the ups, downs, tips, tricks, and things that she's developed alongthe way to make it less cumbersome and more just doable.
Most notable is her newer Diabetes Nerd channel on YouTube.
(01:17):
And she also recently released a new book, The Exercise with Type 1 on Amazon.
She's got many others that are available and just wonderful resources.
but you may also know her because together we wrote the book, Type 1 Diabetes inPregnancy.
So thank you very much for joining us, Ginger.
(01:38):
We're super excited to talk to you.
Yeah.
good to see both of your faces.
Absolutely.
And Gary, I'm kind of settling in.
kind of have my big old armchair here as the host a couple of times now for the Think Likea Pancreas, the podcast.
So I don't know.
I might need to watch out.
I like this hosting thing.
(01:58):
Yeah, I think the 2 of you are ganging up on me all
Look at, his arms are already crossed.
He's already mad.
So, you know, over the past couple of weeks, our Integrated Diabetes team has sort ofwatched and heard we sort of, you know, chit chat back and forth.
We text each other just as a clinical team and as friends with diabetes.
(02:21):
So Gary has been trialing use of Afrezza, an inhaled insulin, and we've kind of watchedyour ups and downs and, you know, kind of some of your highs and or maybe sort of they're
your
lowlights on social media about using it, right?
We also will have a really awesome blog that you wrote about your experience specifically,pros, cons, of insights into using on our Integrated Diabetes website.
(02:51):
So I think I'd like to kind of get an idea of what is inhaled insulin?
Tell me.
Inform me like I am new to using it, please.
I mean, the exact name of the product is Technosphere.
Technosphere is this dry powdered form of insulin that sits in a little cartridge.
(03:15):
It looks a lot like, I think of the houses from Monopoly, those little green houses thatyou step on and they hurt like anything.
That is, yeah, there's a cartridge example.
That little white part of it is where the insulin is
And the cartridge is loaded into something that looks like a whistle.
(03:36):
You just drop it in, close it up, and inhale the stuff.
Instead of giving the insulin below the skin, the insulin absorbs through the lining ofthe lungs.
It actually absorbs through the alveoli of the lungs directly into the pulmonarycirculation.
(03:57):
So it gets into the bloodstream really quick.
and starts working pretty fast.
Within a few minutes, it starts working.
So it's definitely really, when we talk about rapid, so many people complain about ourrapid insulin being called rapid, but not really being rapid, right?
We still need that pre -bolus time, so to speak.
(04:18):
But what it sounds like you're saying is that it really is truly rapid comparatively.
rapid, ultra, ultra rapid.
Come on, Gary, admit it.
with that rapid, uber rapid, what did you guys find with how quickly it starts to work foryou?
I mean, within 15 minutes, I see it turning my CGM around.
(04:40):
And they say, you know, it's active in your system within 2 and a half minutes, and thenyou can see a noticeable change in direction of your blood sugar within 15.
And I experienced that.
And I have to remind myself of that sometimes too, when I'm correcting like a frustratinghigh because I underdosed or, you know, I eat Chinese food and I'm going through the roof
(05:01):
or something and I just underdosed.
And I have to remind myself like, no, just...
Wait a minute, and then sure enough, you know, it's like.
Is yours similar, Gary?
I remember reading some of the things that you were texting as you were using it, but doyou find similar?
yeah, it's 2 to 3 times faster.
It starts 2 to 3 times faster.
It peaks 2 to 3 times earlier and it clears 2 to 3 times faster.
(05:25):
So yeah, is very uber- ultra- rapid, whatever you want to call it.
And I mean, that has clear advantages.
Having the insulin work that quickly.
you're not as likely to see the big spikes in the blood sugar after meals.
And that plagues almost everybody with diabetes because like you point out, the rapidacting insulins that we're used to using are not rapid at all.
(05:53):
They're, they're, they're rapider than regular insulin that we had decades ago, but theydon't come close to matching the insulin our bodies produce, which works in seconds.
So the insulin we give below the skin in
many cases, it just doesn't work quickly enough and doesn't clear quickly enough to workeffectively for us.
(06:15):
That's actually, was.
as like, sorry I was just gonna say, explain it as it's in fast, but it's also out fast,which has advantages and disadvantages.
actually what I was gonna ask is that finish, right?
I've heard a couple of people that I get to work with who've commented that when they'veused it, the end effect of it, it's almost like landing a plane correctly.
(06:38):
Like it's got a finish and you know when it's done, especially if you know that your basalbehind everything is the right dose to begin with.
You can almost watch the end effect of Afrezza compared to the sort of the
the little drip effect that you get with rapid acting insulin not quite seeing 100 % thestop line.
(06:59):
Is that right?
What I mean, what I love about it is, you know, once you learn how to use it, and I willsay it takes a few months to really learn the basics of using it.
And then from there, there's, we'll get into this later, but lots of experimenting of, Icombine it with Novalog for some meals too.
But it's like, let's say I took my dose at 1:00 and I ate at 1:00, or I was correcting ahigh at 1:00.
(07:24):
Either way, I took that small dose at 1:00.
If I'm 90mg/dL at 2:00,
I don't worry about going low because I know that that smaller dose of Afrezza has alreadycleared my system.
If anything, if I ate a meal and now that system, that's cleared my system, that firstdose, if anything, I'm thinking, all right, if I'm about to walk my dogs, I'm not gonna
(07:49):
take another dose yet, but I'm gonna watch and see if I start going back up.
Cause I might need what's called a follow -up dose because the food is still digesting.
the first dose cleared my system.
So the 4s the little blue ones, last about, they say 90 minutes, but most people would sayit's more like 60.
And then the greens, which are 8 units, and this is not comparable to 8 units of Novalog.
(08:13):
I'm sure Gary, and I won't get into that later, the dosing, but I think of them as small,medium, and large.
So the 8 is like medium.
That's more like I think of it as being in my system, definitely for an hour and a half interms of being aware of insulin on board.
And then the 12s, I hadn't even used until recently.
I got some from a friend who didn't need them.
(08:34):
And I was like, whoa, these are awesome.
And that definitely is like 2 hours and is helpful for certain types of meals.
Hmm.
Was that, did you try a couple of different doses too, Gary?
I can't remember.
Yeah, you know, I started out only using the 2 and a half, I shouldn't say the 4s, the 4sact like about 2 and a half.
(08:57):
The 8s act like 5, the 12s act like 7 and a half.
So each, you can dose in roughly 2 and a half unit increments.
But I would argue with that eventually.
At first it seems like that, but for me 2 and a half units of Novolog can drop my bloodsugar 150 - 200 points.
(09:17):
Like I would never, if my blood sugar was 250mg/dL for example, I would take 1 unit ofNovolog.
But if my blood sugar is 250mg/dL and I want to correct it with Afrezza, I can take a 4and I don't crash.
Yeah, I had some of my most severe low blood sugars in a long time that way, taking the 2and the small cartridge and the same way, know, 2 and a half units can drop me 150 to 200
(09:44):
points also.
And I did.
It wasn't as if it came down to a hundred and stop.
It kept going and ended up with some nasty lows that way.
some scary, I had a severe low, not like losing consciousness, but I was like, my gosh.
And when I first used it, when you're first using it, I've heard this from a lot ofpeople, you're really sensitive in that first month.
(10:11):
And then definitely by the second and third month, that hypersensitivity calms down andit's much more manageable.
Like I can take a 4
for what's a very low carb meal, let's say it was some chicken and broccoli, and I mightneed another 4 an hour later.
So it's like that hypersensitivity I experienced at first, and I was actually, I learnedthis from somebody else in Afrezza group on Facebook, I was dividing the cartridges in
(10:40):
half to make twos, and that was really helpful at first, and then I found I just didn'tneed to do that at a certain point.
And then I use Novolog if I need a smidge of insulin and yeah.
I've talked to people who have been using Afrezza for an extended period of time and somehave reported just what you're saying that it has sort of a forgiving effect after a while
(11:05):
and doesn't produce the dramatic drops that know that full dose normally would.
But other people say that didn't happen to them ever.
And personally, you know, I don't want to go through 3 months of dealing with that inhopes that somehow the insulin is going to start
thinking and adjusting on my behalf and turn into smart insulin.
(11:31):
low I had is I had also Novalog on board.
So did you have basal insulin from your pump on board?
That is what I think contributes to the worst lows on Afrezza is when you have these typesof insulin stacked.
And it doesn't matter that your basal insulin was for background needs.
It was still rapid acting insulin on top of ultra rapid acting insulin.
(11:54):
Yeah, but my basal insulin is titrated.
It keeps me steady when I'm not eating and not bolusing.
So it shouldn't be contributing.
think there's still something to be said for the combination of Afrezza with long actingversus the combination of Afrezza.
And I know a lot of pump users who use Afrezza to correct their highs and they love it.
(12:17):
But it, yeah.
it would come down, but I'd have to be up around 250mg/dL or higher before I could trustthe small cartridge.
But I did like you.
Gary?
Was it 2 weeks?
Yeah, I did 2 weeks of pure nothing but Afrezza for my bolus dosing.
And then I've continued to use it on occasion, just in certain situations.
(12:42):
So, Jenny, you were describing the plane landing.
I like that analogy.
You know, for a plane to land successfully, it's got to come down, you know, certain paceand level off.
You don't want the runway going, you don't want it taxiing too long because it'll go offthe runway.
Correct.
And you don't want it dropping out of the sky because it'll crash.
(13:02):
It's got to be just the right length of time that it's gliding down.
And I found in a lot of cases, the traditional rapid insulin has just worked far too longwith exercise of especially it's frustrating to try to work out after meals and between
meals when you've still got bolus insulin acting and you have to just.
(13:26):
eat all this carb to try to keep yourself from dropping too low.
Afrezza was great for that because it would clear.
Usually within 90 minutes, I didn't have to worry about it causing me a drop during myworkouts.
But sometimes the other problem is that it works too fast.
That plane does fall out of the sky sometimes when you're using Afrezza.
(13:49):
Where the insulin just plops, does its thing and it's gone.
The problem is that's not how
most food works.
Very rarely do find food that's finished digesting in 60 to 90 minutes.
The average food takes about 3 hours and that's average.
Most American diet food takes even longer than that.
(14:12):
and I think that's, no, it's okay.
I was just gonna say, I think that's where it takes some experience, right?
You used it for a set amount of time.
I think, you you've used and used new things and tried kind of everything, you're your ownguinea pig, Gary, for as long as I've known you, right?
You like to try it, figure it out, put something out there from a pro -con kind of listand give it to the general population who really needs to know more.
(14:39):
So your use was really, I want to get some information out there and to take away from itmaybe some experiences that prove when and why you want to use it, even if you're not
gonna use it on a day -to -day basis where, Ginger, you kind of do the same thing and youkind of try a lot of different things too.
(15:00):
on also, I'm on 2 meds for type 2 diabetes that I really love.
But we won't even get into that rabbit hole.
about a diabetes science experiment, perhaps.
It would make a good book.
That book needs to be updated.
That's not even available anymore because it's so outdated.
It's 20 years old.
(15:20):
I need to rewrite it basically.
Theresa is helping me actually.
I was gonna say, cause you your experiences that have led to your decision to use and whatsounds like ongoing use, you've used it for a much longer time.
if this medication was taken from me.
Heartbroken if Afrezza was taken from me.
(15:41):
I don't want to be on a pump, right?
Well, so let's start with that fact, right?
Is that I do not want to be on a pump and I will not go back on a pump until they changethis whole infusion site entire thing.
Just thinking about having an infusion site in my skin again makes me like, I don't knowwhat kind of, how do you describe it?
I curl up in a ball.
(16:01):
Yeah.
when you were, I think it was Omnipod and we were chatting, we were working together andyou texted me like, I'm pulling this thing off.
I'm going back to injections.
I cannot do this anymore.
And I was like, that's okay.
We'll just go back to MDI.
That's totally, I mean, everybody's got their thing, but what was your grand pull totrying Afrezza finally?
(16:23):
Cause it's been out for a while.
So.
Yeah, yeah.
So Jenny's referring to, she was my pregnancy coach for my first pregnancy.
And I tried Omnipod because you're supposed to want to be on a pump, right?
For pregnancy, it's supposed to be easier, but I couldn't take it.
So anyway, I got a little bit of Afrezza from a friend at a diabetes camp I was speakingat.
(16:44):
I tried it.
I went really low.
was like, this stuff's crazy.
Ditched it.
And a year later, I was writing lots of articles about inhaled insulin for a website.
and the articles were sponsored by Mannkind.
And so I was listening to like six different people tell me about how much they loveAfrezza.
(17:04):
And I was like, all right, I gotta try this again.
And I started using it and I approached it as an experiment.
I didn't use any Novolog for a month and figured out just what, you know, what can I doand not do with Afrezza.
And it takes a long time to really figure it out, but you have to go into it with such anopen mind because it's so different than rapid acting injectable insulin.
(17:31):
And I would challenge you, Gary.
I would love to see if you lowered your basal rates a little bit and tried Afrezza again.
I know you had them titrated and I know you know what the heck you're doing, but I wouldlove to see if maybe they need to come down when you're on Afrezza because it's just so
fast that I would be curious a friend told me that when you start when you start Afrezzayou might need a boost a little boost in your long acting because you don't have all this
(18:03):
Novolog hanging out
around.
Huh.
about how often you take Novolog it's like practically always present in your system.
So I did increase my Lantus dose by like 10 or 20 % at first and it's since kind ofsettled.
Yeah.
Well and I wonder the difference you know Gary you using it with a pump with rapid insulineven that you're getting a little hint of drawn out effect so I wonder if some of your
(18:36):
experiences were also very different to Ginger's mainly because she's using a true basalinjected insulin versus a pumped drip drip of a rapid insulin to mimic basal right?
I tried it both ways.
The first week I was taking Degladec, which is Tresiba as my basal insulin.
(18:59):
And it was not good.
I I have a significant peak and valley in my basal needs, so my sugars were constantlyrising or falling depending on the type of day.
So I went on the pump with the auto adjustment features off, just my
basal rates that I know from testing keep me steady.
(19:21):
And the whole point is that the basal insulin should not be influencing the glucose level.
It should just be holding it steady.
Even if I, if I had artificially raise or lower my basal insulin to compensate for theaphresia being too great or not working enough at different times of day, that means that
(19:42):
now the basal is not keeping me steady in a fasting state.
So
Yep.
basal insulin, you basically, once you have it fine -tuned, you can write it off as anissue.
It's no longer a factor that's affecting your glucose levels.
It's just the bolus insulin that's doing that.
And that's why I just could not get the correction dose to work right.
(20:06):
I couldn't fine -tune it.
But Ginger, tried also what you tried also, which was splitting the cartridge into a halfdose.
Yeah.
Yeah, it does.
It feels so shady.
picture of that and put it in the blog post that's going to be on our website.
But yeah, you got to literally it's like you tapping it out.
(20:28):
You're taking a credit card, splitting it into different doses.
I did use my HSA card, so I feel like it was at least healthcare related to do that.
And then, know, scraped it about half the dose back in.
Yeah, you know, it worked like half.
I don't know how sanitary that really is or anything, it did the job.
(20:48):
It was tedious.
I did that for a few months and then I just stopped and started using Novolog when Ineeded tiny dose.
on Afrezza while they'll take like an hour and just take a whole bunch of their smallcartridges and make up a whole bunch of half those cartridges, which are like a 1 and a
quarter unit instead of 2 and a half of actual insulin.
(21:10):
guy who eats only meat.
He's a intense carnivore and he uses Afrezza and he spends a lot of time, you know, makinghis micro doses.
Yeah.
And I've asked the CEO why they don't make a smaller 1 for type ones.
he said that it doesn't seem like enough people would need it, which I would argue with.
And then he said that also it just costs so much money to demonstrate to the FDA why theyneed yet another dose.
(21:37):
Yeah, the manufacturing process is expensive.
It's a lot of equipment and they would really add to the cost of the product.
Well, and since you guys both seem to have found some experiences where they'rebeneficial, mean, Ginger, you said even that you're using it in combination with Novolog
(21:59):
as a rapid insulin.
And Gary, you've found some circumstances that really are a definite pro to using itcompared to pumping the insulin.
So what are, I guess, what are some of those circumstances that you're using just theAfrezza?
or the combination or what meals.
Sure.
(22:20):
So to give you a little example, so right now I take 10 units of long acting Lantus.
I love Lantus.
I've tried the newer ones.
I just hate them.
I'm so old school.
I am like 90 years old at heart.
Jenny knows this.
Yeah, I'm okay with it.
I don't watch Matlock, but yeah.
So I...
(22:41):
She Wrote, you watched that.
did watch it a lot back in the day, yes.
You know, in my youth, when I was a teenager, I was only about 50 years old at heart, soanyway.
So, I need a teeny smidge of Novalog around 8:00 in the morning because I don't eatbreakfast, I practice intermittent fasting, and so my liver is like, here's some sugar,
(23:05):
right?
I used to need more insulin, a little bolus for dawn phenomenon, but I take metformin nowbefore bed.
and that has totally calmed down my glucose production in the morning, which has been sohelpful.
So that's the first dose of insulin I take most days is that little, I use a syringe, Ihijack, I don't know if we can share this, but whatever.
(23:29):
I have a YouTube video on this actually.
I hijack my pen and I'm not even taking a half unit.
I'm taking like sometimes, like an amount I can barely see because it sometimes overlapswith when I'm about to go for a jog.
of assuming it's like a quarter unit -ish.
Maybe, yeah.
barely see it.
So I'm sticking the syringe into my pan like it's a vial of insulin.
(23:51):
And I was doing that front of a type 1 the other day at dinner and she was just like, Icannot get over this.
Yeah, yeah, yeah.
Yeah, so Afrezza cannot do that for me, right?
And that's to prevent the high.
If I miss that dose and I did already go up to 200, then I could use a 4, but not if I'mabout to go run 3 miles.
(24:12):
So it depends on some other variables.
So the first meal I usually eat every day, I use a combo of Novalog and Afrezza.
I eat a giant honey crisp apple with freshly ground peanut butter.
I'm kind of addicted to it.
like, I can't wait to eat it today.
It's going to be so good.
And I like to take 1 unit of Novalog with it.
(24:34):
And then I'll take a 12, now that I have the 12s, I used to need two 8s of Afrezza.
And what I like about adding the Novalog is,
that when the two 8s or the 12 runs out, my blood sugar is gonna rise really quickly.
And that's the hardest thing about Afrezza is that when it clears your system and thefood's still digesting, it shoots up.
(24:58):
And if you don't have a CGM to say like, hey, you just crossed your threshold, then you'renot gonna know.
But it is so fast that you also don't have to freak out.
Like I have another friend who uses Afrezza and she's like, I don't even worry about highsanymore because Afrezza turns around so fast.
I'm like, all right, I'd still prefer to prevent the highs, right?
(25:19):
But she's right.
you can fix that high so quickly.
On a graph, looks like, and you know, if it was novalog, it'd be like, gradually comingdown.
so slow.
So you're kind of hitting almost your peanut butter effect with the Novalog on the backend where it would be creating the creep.
And I think, Gary, that was a kind of a con to you, right?
(25:44):
You saw the quick impact of the Afrezza, but without taking as you were cutting yourdoses, right?
To take just a little bit of a smidge more.
This is where discussion is really beneficial because you found a system, Ginger, withNovalog that kind of hits the creep later.
by dosing it in a timely manner where you've tested and done some experimentation.
(26:07):
And you found the rise that you were annoyed with, Gary.
I know.
Yeah, well, I learned something just listening to you, about combining traditional insulinwith Afrezza at a meal.
Because one thing I really didn't like was having to think more about covering my mealsand having to dose at the meal and then to see what's going on an hour or 2 later and dose
(26:33):
again.
I just didn't want to have to be thinking about it between meals.
I want to be living my life.
But the idea of doing a little bit of bolus insulin, I think using a pump for the basaland using a pump to give a little bit of bolus is easy enough to do.
And then, know, do the, the Afrezza The situations that I still find useful and I stilluse Afrezza for.
(27:01):
One, like you said, is when you have a really high blood sugar and, you know, short ofdoing the rage bolusing, you can use Afrezza to bring it down.
really fast.
Usually within 90 minutes the glucose will be leveling off and back close to where youwant it.
So that's one.
Another is before a workout.
(27:22):
If you're having a meal and then you're going to go exercise soon afterwards and you don'twant all that insulin in your system during the workout, you use the Afrezza.
It's going to clear quickly so you won't have all the insulin overlapping then and makingyou drop.
And that did work nicely.
And then the third is certain breakfast.
(27:45):
I find in the morning my food digests really fast and I often eat cereal in the morning.
Depends what kind of cereal.
If I have Cheerios, it's not too bad.
I don't spike that high, but almost any other cereal and I spike super high.
So doing the aphrasa with those kinds of breakfasts, it keeps things relatively flat.
(28:06):
You might get a slight rise.
would be the like, it is like finally the way a type 1 could manage cereal.
You know what I mean?
It's like, cause it's just so, yeah.
Yeah.
index food, it's really well built for.
I don't think it's well built for slower digesting foods though.
On its own, it's exhausting to use just Afrezza.
(28:29):
Because even an apple and peanut butter, is not like, it's not like eating pizza, right?
Yes, the peanut butter is pure fat, but it's not like eating pizza where it's digestingfor 8 hours.
So even those basic meals, even a salad with a lot of protein and fat, I might, if I knowI'm not about to go for a dog walk or exercise in the next 2 hours.
(28:54):
I might take a unit of Novolog if it seems a little easier based on how much, know, ifit's a rich restaurant salad, for example, or I might do a combo.
Even the salmon Caesar salad is a common thing I would order in a restaurant and I mighttake a 4 and 1 unit of Novolog so that I just don't have to worry about that big spike.
(29:15):
Yeah.
Or like really indulgent foods, like cupcakes, pizza.
I want a good amount of Novolog on board.
so that I'm not relying as much on Afrezza.
And I use the Afrezza to keep pounding it down and keep it down, but I don't have to takeas much.
Do you remember when the Medtronic 670 launched?
(29:35):
That was the first real sort of hybrid closed loop system.
It did what it said, you know, it did keep people's blood sugars in range more often.
But why did that system sort of flop?
What was it about it that turned people off?
For me it just was an insulin pump.
(29:57):
I mean, yeah, mean, overall, the 670, for me specifically, was the sensor that was neveraccurate.
And so that created a problem with what it was doing as an algorithmic system in terms ofturning basal off and adjusting.
And it didn't work fast enough.
(30:18):
It never worked fast enough.
Hmm.
the sensor wasn't trustworthy.
People had to be more, at least as many finger sticks as they used to do, right?
There were alarms and alerts going off constantly.
It would drop out of automated mode all the time.
It was disturbing people's lives.
It was getting in the way of their daily quality of life just to be able to use thissystem.
(30:42):
So yeah, you can get better control, but if it's detracting from your quality of life, itmay not be worth it.
So I think this is something that we teach our patients here.
Well, I'm just saying that there's some things about it that it makes diabetes managementmore complicated.
(31:02):
argue there's, I think you could take that, tackle that from both sides.
If you're used to the pump doing all this stuff for you, right?
And that's amazing.
If I could tolerate a pump, I get it why people love it so much.
I just, I hate them with a passion and I hate the split second of it not doing its thingand ending up in ketosis land.
(31:25):
DKA is what normal people call it.
But.
The, for me, once you get a hang of this, it's such a, to me it feels like such a lowcommitment because it's out of my system so quickly that it's like, all right, I'm gonna
take a 4 and see if that's enough.
And like, nope, wasn't quite enough.
(31:46):
just, I'm getting up towards my little threshold there.
I'm gonna take a little more and it's like, eh, take it, on you go.
When you take a dose of Novolog, it's like, you better really meant that.
Like you better be committed to that dose because now for the next 4 hours, that's in yoursystem and you can't undo it.
It's like a hammer versus this feels like a little blanket.
Like, I'm gonna put another blanket.
(32:07):
here honestly of the 2 things that you guys are kind of debating so to speak, right?
Because on MDI as you're doing, right?
With Afrezza, Ginger, you were also, you've also long -term been in the mindset ofmicromanagement too.
And I say that as a positive, right?
(32:28):
That's not a con.
It is the way that you've chosen to manage.
I remember pregnancy.
I mean, some of those days in third trimester, it was 16 little micro injections a day toget your blood sugar where you wanted it to go, right?
So you've got this willingness piece.
But to your point, Gary, you want almost like a set it and forget it to a degree.
(32:52):
You're willing to work, but you also want what you're using to work with you so you haveless...
that you have to truly consciously think of.
And so what I can kind of see is maybe extended use of using it would be, because I knowyou're using an automated system, Gary, you could potentially navigate with the kind of
(33:18):
system you use by adjusting targets, navigating when you enter your food.
So you could get the benefit of the automation to back up.
what the initial amount of Afrezza isn't providing long -term for you.
You could use, you know, temporary overrides.
You could tell your system to do something for you into the future ahead so that you getthat oomph that you want and it's said it and done now so you don't have to think about
(33:49):
it.
Whereas,
With most meals, can just bolus with my system the way I normally do and it works fine.
It's, you know, breakfast where it's a challenge.
So I find the aphresia more effective than, I think it's about striking a balance.
It's a balance between the amount of work you're willing to put in and how intensely youwant to manage your diabetes.
(34:13):
and what stresses you out?
you know, you're managing your diabetes intensely.
It's not like it's, you know, but I think there's, it's personalities and what is morestressful to you?
Having an insulin pump attached to my body is so much more stressful to me than beinglike, I need another follow -up dose.
Right?
And also, you know, I would have guessed that Gary is...
(34:37):
OCD and micromanager, but maybe not.
Maybe he's really relaxed.
And so I'm definitely more type A personality where I was like, man, I am not gonna letthat machine make these decisions for me.
And I'm not convinced that AID is the end all be all because I know too many people whoare frustrated with their systems all the time.
So they're not perfect either, right?
(34:59):
We gloss it over, but they're...
They're amazing, but they're not perfect.
You still have to intervene and deal with annoying stuff all the time.
that the AID systems, honestly, it's when you enter into using, if that's your choice, itis like a marriage.
expect to give and take, you expect to understand and learn what are your system'sabilities and what will it not do if you don't work with it and give it the right
(35:31):
information, right?
You can't expect.
any of the AID systems, whether you're doing an FDA approved 1 or 1 of the do it yourselfsystems, it will not 100 % do for you unless you've got something fancier.
They can.
the other day.
They were up in the middle of the night and they weren't coming to me for help, but I workwith them on social media diabetes content and we posted about it.
(35:58):
They're up in the middle of the night because her AID system was not communicating gooddata and her blood sugar said it was 500 and 200 and it was like, it was just a mess,
right?
So none of it is perfect.
And I think it always comes down to like choosing which battles feel less
obnoxious to you.
Right, which also comes down to
(36:19):
a lot of put a lot of doctors who make the decision for their patients.
Instead of teaching them about the pros and cons and letting the patient make thedecision.
We're making the decision for them.
Yes.
So many people have come to me and said, I wanted to try it.
My doctor said, no, it's not for type 1.
And so I have a YouTube video that's all about getting inhaled insulin because if youdon't follow the steps right in the process of how the prescription is written and then
(36:48):
the appeal, it will get rejected.
I actually, I switched insurance companies and I had to, I got rejected automaticallybecause my doctor did the thing wrong.
They didn't care that he tried to fix it.
They said it was too late.
The appeal was done and he just didn't understand what he was doing.
But I figured out the name of the CEO at my insurance company.
(37:11):
found his...
I live in Vermont, it's a small place.
I found his name, his address.
I contacted him directly.
I figured out the email system.
I guessed his email address and I...
I contacted him, I wrote him a letter and said I have taken 52 ,000 injections.
Imagine if there was something that could reduce this for the next 25 years of my lifewith type 1.
(37:35):
And wait, there is, but your company rejected it because of a paperwork mistake.
Please.
Yeah.
that's 1 of the drawbacks is almost everyone has to get pre -authorization for this.
And I listed in the blog post, and this is on our Thinking Like a Pancreas blog, you go tointegrateddiabetes .com, it's on our website.
(37:59):
But I listed what I felt were the strengths, the benefits, and then some of the challengesassociated with using this.
Anybody who wants to can can learn about it and then decide is it worth my trying and isit worth using on a full time basis?
Not at all or something in between.
Maybe I want to use it in conjunction with MDI or with a pump or with an AID system.
(38:25):
And if it's going to be used with an AID system, you gotta get some expert training sothat the AID system doesn't foul things up.
Be careful.
Yeah.
to understand.
That's I was actually going to ask is if there's, you know, if you guys had advice to giveprospective users, people who have heard of it or maybe considering it or have a friend
(38:49):
who's gotten is like, Hey, you want to take a puff?
You got some ginger, right?
I mean, what would be, you know, if you had, you know, an idea of what advice you'd giveto somebody, what
I mean, I give advice to people on this all the time.
(39:09):
Yeah, right, of course.
if you just for the people maybe listening to this, what would your, like in a nutshell,what would be your advice to people who are considering?
go into it with a very open mind and also only use Afrezza for meals and corrections forat least 2 weeks just so that you're not creating a dangerous mess of overlapping it with
(39:32):
meal boluses from Novolog And then if you're on a pump that's, as Gary already said,definitely talk to your healthcare team because you...
You don't want that AID system correcting when you're also trying to correct and etcetera.
I know people who do it well.
John Sjolund I don't know how to say his last name, he created one of the smart pens,Timesulin He uses it and he's a big fan of it.
(40:01):
That would be my 2 cents is go into it like an experiment for the first month.
It's gonna take time.
I'd recommend dipping your toe in the water before diving in completely.
I think it's worth trying, but do it on a very limited basis.
Like maybe just use it to fix your highs or just use it for breakfast or pick a meal or asnack and master it in that situation and then spread it out and use it in other
(40:30):
situations.
But I think it's also important to work with a healthcare team that understands it.
that has used it, has experience with it, so they don't just say, nah, it's not for you.
yeah.
I mean, had no healthcare team supporting me.
I had a few people that I'd interviewed.
But I think it does make a difference if you're on a pump and you have other, if you're ona long -acting insulin, I think it's a much simpler experiment than if you're adding it to
(40:57):
a pump.
to a pump and then.
through Zoom, phone, email, anywhere in the world so people can reach out to us if theyneed help.
Right, I know most of us on our Integrated team have definitely given a try to Afrezza andor have it in our back pocket, so to speak, for use in those circumstances.
As you defined, you're not using it every single time or every meal, Gary, but you'vefound your circumstances.
(41:22):
And my kind of 2 cents in that would really be start with your known meals.
Ginger, your apple and peanut butter.
has I don't know how long been in your intake.
You have eaten your apple.
You have been eating that a very, very long time.
And so you had it figured out with your rapid insulin.
(41:44):
And so it was kind of a little easier for you to roll into using the Afrezza to say, okay,yeah.
I also changed what kind of apples I eat.
The apples I keep choosing bigger ones that are even sweeter.
So I've gone from, you know, like a basic normal sized apple now to like the highlygenetically modified honeycrisp that are half the size of my head.
(42:06):
there was, I did have to do some learning, but yeah.
was a known meal.
that is kind of my point is choose your known meals kind of along the same lines as yousaid, Gary, you know, don't go out for the meal.
That's the craziest something you've never eaten.
And I'm going to throw Afrezza in here.
That's not the greatest time to start it.
(42:27):
It would be do it with your typical lunch meal, see how it goes, and then do someexperimentation around that.
And, you know, as always, if you need some
help with it.
Obviously the Integrated Diabetes team is certainly here to help.
Ginger has some wonderful online resources as well and information and blogging and everynot not so much blogging anymore.
(42:52):
I think mostly just hosting.
Okay, fantastic.
Well, it's been really a great I think a great conversation about Afrezza because it'sbrought a lot of perspective from 2 people who have
different use to begin with, to kind of bring some ideas around how to make your best useof it.
(43:14):
So thank you guys for joining.
Yeah, absolutely.
Absolutely.
So Think Like a Pancreas, the podcast.
Thanks, Ginger, again, for joining us.
Gary, thanks for handing over hosting to me.
I like that I'll let you be host as much as you like.
It's nice being, yeah, I can just chill.
(43:36):
This is good.
natural host.
Well, you guys are awesome and thanks again for being here.
If you need anything, obviously just find us at integrateddiabetes .com.
Have a great day.
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