Inhaled Insulin: Meet a Type 1 Who Uses Afrezza And Keeps Her A1C Below 6.0
Judi Hoskins has lived with type 1 diabetes since the age of 5. Diagnosed in 1958, at a time when the only treatment option available was a mixture of cow and pig insulin. Back then, testing your blood sugar at home wasn’t really an option either. Today, thanks to consistent hard work along with the aid of an insulin pump, Judi, 63, has been able to maintain an A1C below 6.0 for the past 15 years.
About a year and a half ago, Judi added Afrezza’s inhaled insulin technology to her treatment method with excellent results. She recently shared her thoughts about the experience with DiabeticLifestyle.com:
DL: I can’t help from wondering what using cow and pig insulin was like compared to today’s insulin options. Can you describe what it was like?
Judi: It was all that you knew so I don’t ever remember thinking that it was terrible. It was certainly preferable to death. Before I started using early insulin I’d gone a long, long time—nearly a year—before being properly diagnosed. The doctors kept telling us that I needed vitamins, and my mother kept saying, “No! This isn’t about a lack of vitamins!” So, getting some kind of treatment was better than nothing at all.
DL: When did you begin using Afrezza and how have you fit into your diabetes management routine?
Judi: I started using it in June of 2015. I also wear an insulin pump because Afrezza alone wouldn’t meet the insulin needs of person with type 1 diabetes. Basically, I use my pump as my basal insulin, and I use Afrezza for really high-carb meals—like something with more than 50 grams of carbs. A 4-unit cartridge of Afrezza is equivalent to about 3 units of Novolog insulin—and that’s the smallest amount it comes in. So, if I needed 5 units for the dose, I'd fill in the other 2 units with the insulin in my pump. But if I only need 2 units of insulin for a meal, I’d need to use the insulin in my pump instead of my Afrezza.
Certain foods—like an apple—have too few carbs for me to use Afrezza. Because I’m a 63-year-old woman, I don’t eat large amounts of food so most of my meals don’t require using Afrezza. Dinner is the meal my carb count is most often near 50 grams so that’s when I use it the most.
DL: What are the biggest benefits of using Afrezza compared with taking a dose of rapid-acting insulin from your pump?
Judi: With Afrezza, the insulin is delivered very quickly into your system and leaves rapidly, too—usually in two hours. With rapid-acting insulin from a pump (or a syringe, or pen) it takes longer to start working and it’s in your body much longer, 4 hours or more.
I also like that I don’t have to pre-bolus with Afrezza. I eat many meals out at restaurants because I'm older and I don’t cook as much anymore. At a restaurant, I enjoy the convenience of takin my dose of Afrezza when I place my order because it’s fully working in my system by the time I start eating 15 or 20 minutes later. It’s the perfect “pre-bolus” because it works so quickly. With insulin in my pump, it takes nearly 30 minutes to start working.
Another pro is that depending on what you're eating, you might benefit from using one type of insulin over the other. For example, if I’m going to have a meal that is high in both carbs and fat—like a burger on a white bun—I’d use Afrezza two hours after eating it, instead of at the time of the meal. Because it works so quickly, it prevents my blood sugar from going much higher than 140mg/dl on my continuous glucose monitor screen. Afrezza is great for situations like that! It’s so much faster than traditional insulin.
DL: The design of the inhaler itself has come a long way since the debut of Exubera in 2006 when it was practically the length a forearm. Do you feel self-conscious about using your inhaler in public?
Judi: It does not bother me at all to use it at the table in a restaurant. My son, who also has type 1, usually leaves the table when he doses his Afrezza. No one has ever asked me about it but if they did I’d tell them to mind their own business.
DL: Some concerns have been raised about the long-term impact of using inhaled insulin since it hasn’t been around long enough for researchers to make definitive conclusions. How has Afrezza affected your lungs?
Judi: Sometimes it makes me cough a little bit, but I have found that drinking some water afterwards, stops the coughing. Since I started using Afrezza, I've had two lung functioning tests—my second test was actually stronger the first one.
(Note: According to Amy Hess-Fischl, MS, RD, LDN, BC-ADM, CDE and DiabeticLifestyle.com editorial advisory board member, some healthcare practitioners are concerned about long-term safety and liability. “Since we do not have a lot of long-term data about how it affects the lungs, many HCPs have taken a 'wait and see' approach towards Afrezza. Hess-Fischl explains adding that this has contributed to low-usage rates. “However, there are many doctors across the country who have fully embraced it, especially with individuals who have had significant resistance to taking injections for meals. For those who have concerns about lung function, studies have shown that stopping the use of Afrezza will return lungs to normal functioning. So, it’s important to test lung function annually when using inhaled insulin.")
DL: Since you’re already on an insulin pump, was it difficult to get insurance coverage for another form of insulin delivery?
Judi: I didn't have a hard time getting insurance coverage because of insulin pumping, but I did have to be pre-approved for it. My doctor is great at writing letters for pre-approval. Once I received pre-approval, it was moved to the highest-tier of my insurance plan. My monthly co-pay for Afrezza is around $140 and I'm not using it as my primary insulin. It’s definitely not cheap and since I have a Medicare Advantage Plan, none of the co-pay cards apply towards my purchases.
DL: Since you started using Afrezza, the manufacturer (MannKind) has struggled to continue producing it. Have you had trouble getting your prescription filled?
Judi: The only time I had difficulty was during the period when Sanofi ended its relationship with MannKind. Fortunately, I was able to preserve my Afrezza by using my insulin pump more frequently until I could get the prescription filled again. MannKind has been manufacturing Afrezza continuously now since May 2016.
DL: Thank you for sharing your experience, Judi!
Post script: Hess-Fischl points out that for very motivated people with type 1 or type 2 diabetes—who are also on pumps and CGMS—Afrezza could be a very useful tool for reducing post-meal blood sugar spikes. “However, the high cost of the product, combined with the difficulty of finding a healthcare provider willing to do the work necessary to obtain prior authorization, could be determining factors,” she said.