For the past six months, I've been disconnected from my insulin pump and back on multiple daily injections (MDI). Happily, I have found two insulins that are working pretty darn well together and giving me more flexibility to manage my... D-slacking, as it were.
You see, I'm the kind of guy who often misses his doses of long-acting basal insulin and finds his blood sugars running a bit higher because of miscalculated carb-counting (or failing to concentrate on the food-math at the time I'm consuming meals).
As a result, Afrezza inhaled insulin and ultra-long acting Tresiba have been great additions to my toolbox during this time off my insulin pump. I'm still using NovoLog injections for smaller meals and at certain times of the evening, when for whatever reason I've noticed that my self-discovered "Afrezza Resistance" is more pronounced.
Getting "Tresiba Ready"
You may remember that Tresiba is pretty darn new on the market, approved by the FDA in Fall 2015 and launched in early 2016. I've been using it for nearly two months now.
The big difference from the other basal insulins on the market, Lantus and Levemir, is that it has an active lifespan of up to 42 hours, meaning it can remain active for quite a bit longer than the typical 24 hours (or less) in the body. Patients are supposed to inject it once a day, and there is more flexibility on dosing timing, meaning you don't have to take it at the same time of day as you're instructed to do with other basal insulins.
I have been using the U-100 Tresiba FlexTouch pen, which is a bit thicker in form factor than other typical insulin pens.
Personally, after a handful of experiments, I've noticed that my threshold is 32-36 hours for best results with Tresiba. After that, I really need to take my next dose or I'll start seeing higher BGs. I have tested it out, and for the most part haven't seen any significant BG differences when taking my Tresiba at the 24 to 32-hour mark.
That's huge, given (as noted) that I'm the kind of guy who regularly gets distracted and forgets to take my basal dose at the prescribed time.
Based on my experience, I've found I can dose at 9pm and then skip the entire next day before dosing the following morning and still be inside that 36-hour window. So for me, even though it's labeled as a "once-a-day" insulin, Tresiba becomes an "every other day insulin" every so often.
By comparison, when I was on Lantus, I'd noticed that my blood sugars would start spiking about about 15 to 18 hours if I was taking it once a day. When I split my Lantus into two doses twice a day, roughly 12 hours apart, I'd still see my BGs rise toward the end of that period. So, yes, this Tresiba is much better and long-lasting!
When I first talked with my endo about this basal insulin, we agreed that Tresiba would be a great option in terms of making up for my "missed doses" of Lantus -- thanks to that 42-hour window of flexibility it offers. Unfortunately, my insurance company didn't immediately agree.
We appealed, citing scientific data showing the longer lifespan as well as pointing to how I'd fulfilled the "step therapy" criteria my insurer requires -- which is essentially a roadblock forcing patients to illustrate that they're failing on current therapy in order to get something new. We had to show documentation that I had previously used both Lantus and Levemir for three months without thriving, and we argued that if my insurer describes those other two insulins as "therapeutically equivalent," then there's no reason I should be forced to wait another 90 days to treat-and-fail before getting access to this medically-prescribed, and uniquely superior Tresiba.
Thankfully that won the day, and my insurance company signed off on the new prescription.
Aside from Tresiba's favorable flexibility in dosage timing, I've also been impressed by the FlexTouch pen technology that lets you dose with a simple push rather than having to hold the button down for a prolonged period to deliver all the insulin. And one of the endo-supplied sample kits I received also came with a supply of seven ultra thin pen needle caps -- nice touch!
I'm almost embarrassed to admit that I've been humming the tune from Novo's Tresiba commercial, where the token PWDs proclaim they're "Tresiba Ready!" and talk about the benefits of this basal insulin in their lives. The commercial's so annoyingly catchy that I've had no choice but to add it to my list of most memorable diabetes ads.
Yep, I'm now "Tresiba Ready!"
And I'm finding that Afrezza inhaled insulin is an outstanding complement to it.
My #RealWorldAfrezza Observations
When I first tried Afrezza, I only dipped my toes into the inhaled insulin water (see what a I did there?!). At first I wasn't impressed. But my opinion has changed since that first try in mid-2015. I've grown to like it, and have been fascinated with how it works and all the inner workings of its dosing... especially when it comes to chatting with other Afrezza folk!
I recently found myself in a meeting room with a few other Afrezza users, and noticed that I was the only one who stepped out to inhale. Despite the fact that the inhaler is small and discreet, I personally just find the dosing procedure a bit too loud and distracting when sitting in a board room or other quiet public space. Opinions may vary on that, but I would rather be step away for a quick moment to inhale to avoid drawing attention to myself.
As to my #RealWorldAfrezza results, I find that I usually start seeing it impacting my blood sugars within 20 minutes, if not a bit sooner -- which is great for quick corrections and faster acting foods. (Keep in mind, traditional insulin may not start showing a CGM effect for more than a half hour or more).
I've also noticed that I can "turbo-charge" the action by adding exercise to the mix. Similar to injectable insulin, if I inhale just prior to starting a moderate walk or bike ride, or during that exercise, the Afrezza kicks in much faster. I've heard others describe this same experience, and MannKind Corp tells me they've heard numerous users describe that same "exercise effect" with Afrezza.
Yet that hasn't led to low blood sugars. In fact, I've had fewer hypos over the course of these past six months using this inhaled insulin.
Fewer Hypos? You bet. I would say without a doubt, that Afrezza (along with Tresiba) has slashed my hypoglycemia rate, and although I still experience them at times thanks to my own mismanagement, this is a huge selling point, IMHO. (Note that FDA restricted MannKind from adding 'less hypoglycemia' to its product labeling, even though
I'm now using Afrezza mostly during the day and am going back to NovoLog in the evening hours, in large part due to what I refer to as my "Afrezza Resistance."
There are just times when it doesn't work as effectively for me. Sometimes, not at all. It can be very frustrating, especially since sometimes Afrezza works so magically but at other times it doesn't seem to work at all (almost like when my insulin is water.) No, it's not a basal issue and isn't specific to carbs on board -- I have trial-tested and eliminated those factors, by bumping up my basal and not eating at specific times.
Generally, I notice that my Afrezza needs are higher than they were in the early months of using it, and sometimes the 4-unit (blue) cartridge doesn't seem to work as well as it did previously, so I've bumped up to the 8-unit (green) variety more often.
(Note to MannKind: the blue and green cartridges are very difficult to tell apart, especially in dark places and for those of us who are even partially color-blind -- can you make them more distinct please?!)
I have yet to try out the 12-unit (yellow) cartridges that MannKind Corp is now selling, but that's about to change as I have a pending Rx to obtain a box of those soon. I'm also happy that my co-pay isn't be more than $30, thanks to the Afrezza savings card that makes this much more affordable than what I'd normally be paying for this highest tier medication.
I remain quite concerned about the survival prospects of manufacturer MannKind Corp, but that's a concern for another day...
In the meantime, I'm inhaling like a champ and enjoying the experience for as long as I can.
Continuing the Insulin Pump Vacation
Using these new insulins hasn't completely cured my D-slacking -- nor would I expect it to. These aren't magic bullets, and it takes effort and a willingness from the PWD to use them effectively for best control. Remember, I've been living with insulin-dependent diabetes for most of my life (over 30 years) and honestly, burnout may be the hardest part.
I'm well aware that over the past few months, I haven't been carb counting or dosing as well as I should. But after my latest endo visit that happened to fall on World Diabetes Day, Nov. 14, I am working to get my act together. I have been using the mySugr mobile app to track my D-Data, and I've found this is one of the best to keep track of my different insulins (Afrezza included!) along with all my meal and other information.
A number of months ago, someone in the D-Community wondered if I still considered my current Pump Hiatus to be a short-term plan, or if it had manifested into a permanent choice. I've always maintained that at some point TBD, I'll return to my insulin pump.
Now, I'm not so sure.
Personally, I have lost faith in Medtronic as a company. Their insulin pump specifically still stands strong in my eyes, but I don't like their business practices or what they seem to stand for. I will not be returning to MedT as a customer, at least not for the foreseeable future. That leaves me mulling over which other insulin pump might work for me, and whether I even want to jump back on that boat or stay on MDI -- which may be better referred to as "MDD" (Multiple Daily Doses) these days using Afrezza.
Whatever I decide, I'm lucky to have choice.
For now, my #PumpHiatus continues. The task at hand for now is motivating myself to do better, and right now I'm confident that I can improve my overall blood sugar management without pumping as long as I have both Afrezza and Tresiba in my toolbox.
We'll see what the future holds, as to the rest.
Long live choice, when it comes to deciding what works best for our own diabetes health!