This blog post is part of the Community Viewpoint series. It talks about how the diabetes healthcare community views the inhaled insulin Afrezza. This is the product Mannkind Corporation calls “Outsulin.”
The View of “Outsulin”
Healthcare providers I know still have not heard of “Outsulin”. Outsulin is the latest marketing campaign from Mannkind Corporation. The campaign explains “Three hours after you take AFREZZA, your blood sugar returns to near pre-meal levels. That’s why you can appreciate the OUTsulin side of AFREZZA: INsulin that does its job and then leaves.” It is a good campaign for getting the word out to diabetics, but doctors and healthcare professionals are not being reached. Therefore, it is easy to see that Mannkind is sticking to their “patient first” focus.
Doctors on the Inhaled Insulin Afrezza
The Negative Views
The view doctors have on Afrezza inhaled insulin is disappointing. The endocrinologists I talk to almost all have a negative view of the product. Furthermore, the doctors have misconceptions about the product. Some are because the former Sanofi representatives who gave support to the doctors did not do a good job. Mannkind is not making enough of an effort to correct these views. As a result, this bad information continues to spread and propagate throughout the healthcare community.
An example of the healthcare community giving bad information on Afrezza came last weekend at the Minneapolis ADA Expo. A well-known local endocrine told me that “Afrezza is hard to dose” and “has uneven results”. She says she cannot calculate an exact insulin to carb ratio to tell patients how much Afrezza to take. She also says inhaled insulin has “uneven results” in regards to how blood sugars react to a dose of Afrezza. “Sometimes the same dose will cause lows, and sometimes will cause highs.”
Another endocrine insisted on knowing who prescribed Afrezza for me. She believes my doctor “broke the law” and is “irresponsible” because I have Obstructed Airway Disorder (large tonsils). In her mind, this violates the Afrezza “black box warning” of the FDA. This is, of course, incorrect. Consequently, I did not give the name of my doctor to her.
The Positive Views of “Outsulin”
On the positive side, my endocrine has taken a 180% shift from his earlier view. On every visit, he tells me that he thinks I use too much Afrezza and it causes my lows. As such, he always wants me to switch back to my pump. At my most recent visit, I asked him about restarting my pump for my basal insulin. His statement is now “why would you do that? Your numbers are perfect!” He is again testing my C-Peptide, though he has done it in the recent past. This test shows if a person is producing insulin themselves, or not.
For 53 years I have known I am a person with Type 1 Diabetes. But who am I to refuse him this test and wonderment at my 5.6 A1C?
My doctor is a believer in Afrezza. For her, the inhaled insulin Afrezza is for patients who can successfully self adjust their insulin intake. This doctor sees it work for me, and as a result, fights hard with my insurance for coverage. However, she will not prescribe it to anyone who cannot self manage their diabetes. That said, the drug is a pain in the rear for her. She has done several prior authorizations for it, for insurance. You can find the story of that adventure in this article and this article.
Pharmacist View on Inhaled Insulin
My regular pharmacist, who is the pharmacy manager, is supportive of Afrezza. He has a PharmD with a minor in diabetes education, and he sees how well I do on the drug. His assistant also is knowledgable on the inhaled insulin Afrezza. Their education on the drug comes mainly from working with me, my doctor, and my insurance. I am their only patient using Afrezza. They have learned to dispense the drug to me to avoid raising the ire of my insurance. Now that things are in place, best not to mess with them.
They do have technicians and other pharmacists who are not as experienced with dispensing the drug. For them, it is a royal pain.
Insurance gave me approval for a fixed number of units of insulin per month. However, the insurance company and pharmacy sometimes disagree on how to fill those units. I have 4 prescriptions, one for each configuration of Afrezza made in 4 unit and 8 unit cartridges. The pharmacists and insurance are now in agreement that this means 1 box of each configuration.
The less experienced pharmacists have a hard time understanding how those boxes come out to match the prior authorization. They sometimes input the wrong boxes into the system and insurance rejects the claim. That often causes delays in filling the prescriptions, and getting the needed dose cartridges. What I have learned to do is always wait until the experienced pharmacists and technicians work to fill my prescriptions.
The pharmacists expect the normal calculation of X units equals Y vials. Afrezza does not work that way. It is the same problem the doctors have.
Nurses, Diabetes Educators, and CMA’s on the Inhaled Insulin Afrezza
The most positive support I have seen for inhaled insulin comes from the medical support staff.
My diabetes educator is a PharmD and she sees my A1C numbers monthly. She is supportive, and learns all she can about Afrezza and other diabetes treatments. I have heard her speak often to other patients about the success I have with Afrezza. She is also involving me in diabetes support groups, along with my CMA wife, that they are starting together.
My wife, and her colleagues, attend diabetes education class where they often hear that Afrezza is “out of business”. They let people know that the clinics they work at has “a patient on Afrezza”. Here, again, are people who understand how effective the drug is, and they share with people they see. These are the people Mannkind needs to spend time talking to in the area I live in. Doctors here do not to speak with representatives of drug companies. The reps speak to the support staff, and the support staff brings the new drug information to the doctors.
In summary, different areas take different tactics for Mannkind to succeed with Afrezza. Sanofi is often criticized for focusing on general practitioners instead of endocrinologists. Mannkind is focusing on the endocrinologists. However, in areas such as where I live, they must use different techniques to reach the practitioners. Here, they must focus on the general practitioners and the support staff to expand the reach of the inhaled insulin Afrezza. Different areas require different focus.
I hope they learn this soon. But that is my opinion.