“Wait, you can inhale insulin?”

Yes, you can. Thanks to the novel form of insulin known as Afrezza, this is now possible. It’s the only type of insulin that you can inhale into your lungs, and it starts lowering glucose levels more quickly than other insulins that you’d inject under the skin with a needle or insulin pump.

Afrezza is a dry white powder that comes in cartridges used with an inhaler device that’s been available in the United States since 2015 and first went global in 2020. Made by California-based MannKind Corp., it was initially sold by pharmaceutical giant Sanofi before MannKind took it back the following year.

This isn’t the first inhaled insulin, but Afrezza has succeeded where an earlier version failed. Many who’ve tried Afrezza say it’s quite the effective treatment, though not necessarily a “magic bullet” that makes diabetes management perfect. Still, it has a proven clinical benefit, and an increasing number of people with diabetes (PWDs) are finding it an appealing alternative to slower-acting injected insulins.

Read on for more detail, and to hear what users with diabetes have to say about it.

Afrezza is an ultra rapid-acting insulin that you inhale rather than inject subcutaneously with a syringe or insulin pen. Instead of being a liquid formulation, it’s a dry white powder that you breathe into the lungs.

Afrezza is a mealtime (bolus) insulin, meaning you take a dose when you’re eating or drinking carbs, or as a “correction” dose to bring down high blood sugars. It begins working more quickly in your system than the injected rapid-acting mealtime insulins Humalog, Novolog, Apidra, or even Fiasp.

While Afrezza is often described as “eliminating injections,” that can be a bit misleading as it doesn’t replace long-acting basal (background) insulin that most PWDs also need every day.

No, it was never discontinued, even though that rumor is still a top Google search term for Afrezza.

This question often comes up because Sanofi initially sold and marketed Afrezza in 2015, but the pharma giant decided to drop the drug after that first year. They handed it back to the manufacturer MannKind, which has been selling and distributing this inhaled insulin ever since.

So just because you haven’t heard of it or your doctor hasn’t mentioned Afrezza before, doesn’t mean it is not available in the United States. And as of 2020, it’s also available in Brazil.

Inhaled insulin passes through the lungs and directly into the bloodstream rather than the capillary system, which allows it to start working significantly faster than injected insulin.

As Afrezza inventor Al Mann himself explained once: “We’re actually delivering insulin monomers (molecules). Nobody ever did that before. It behaves much like normal pancreatic insulin does. Normal people don’t get hypoglycemia, and people (with type 2 diabetes) taking Afrezza don’t either, even if they dose and don’t eat.”

Clinical data shows Afrezza works well, including for those with type 2 diabetes.

Afrezza is currently FDA-approved for adults 18 and older with type 1 or type 2 diabetes, but it’s not yet cleared for kids and teenagers. MannKind is conducting clinical trials for the pediatric population, and they hope to continue those through 2021 and obtain FDA permission to label Afrezza for children in 2022.

Afrezza inhaled insulin comes in tiny dosing cartridges, which are color-coded so that patients and doctors can easily recognize them:

  • 4-unit (blue) = 0.35 mg of powdered insulin inside
  • 8-unit (green) = 0.7 mg of insulin
  • 12-unit (yellow) = 1 mg of insulin

These come in thin-wrapped foil packages with three cartridges inside each blister pack. Each cartridge fits inside the little white plastic whistle-sized inhaler, dubbed the “Dreamboat.” The inhaler is disposable and meant to be replaced every 2 weeks; two extras come in each box of Afrezza cartridges.

While it’s not required, some Afrezza users report they hold their breath and count to 5 after inhaling their insulin to make sure it’s adequately absorbed.

There are various cartridge packages you can get to meet your own most common dosing needs. This includes variety packs of 4/8/12-unit cartridges as well as full boxes of a single sized cartridge type.

Dosing depends on your individual needs, of course, but each box of inhalers includes a dosing chart to help illustrate how you can combine cartridges to get the desired amount:

Importantly, Afrezza does not have a direct one-to-one ratio compared to traditional injected insulin. So if you normally take 2 units of Humalog or Novolog, that does not equate exactly to 1 unit of Afrezza.

MannKind’s data and clinical trials show that Afrezza has a roughly 1.5x conversation from injectable insulin units to Afrezza. So if you might take 5 units of injectable insulin, you’d want to plan for roughly 7.5 to 8 units of Afrezza — or an 8-unit cartridge.

It’s also important to remember how fast Afrezza works and leaves your system. It peaks at about half an hour and is generally out by an hour and a half. So it doesn’t stay in the body and continue lowering blood sugars as long as traditional insulin does.

This lack of long-tail “insulin on board” is a plus for many PWDs, because it’s easier to make choices about how to handle physical activity or snacks. But it also means that Afrezza often requires “follow-up” (correction) dosing by taking another Afrezza cartridge roughly 2 hours after eating.

This can be a bit complicated to figure out, and many physicians aren’t as knowledgeable on these dosing nuances. Many users find they need some trial and error to learn to match the color-coded cartridges with the amounts of carbs they eat, and optimize Afrezza dosing.

It’s so fast, according to Afrezza-maker MannKind, that it will appear in the bloodstream within a minute of being inhaled and you can see the first measurable effect in about 12 to 15 minutes.

As mentioned, Afrezza is out of the system within 90 minutes, compared to current fast-acting insulins that usually take at least 20 minutes to kick in, peak at 2 to 3 hours, and can stay in the system for as long as 5 hours.

Many Afrezza users — including our DiabetesMine team — have seen our CGMs showing glucose starting to drop within 15 to 20 minutes. By comparison, it can often take at least 30 minutes or more to start seeing glucose level drops when we inject or bolus through an insulin pump.

Yes, clinical data included in the FDA prescribing info show Afrezza is safe to use and doesn’t decrease lung function.

However, there are contraindications. Specifically, the FDA includes warnings that those who have chronic lung conditions, such as asthma or COPD, should not use Afrezza. It is also not recommended for smokers.

Some Afrezza users have reported a slight cough after starting on this inhaled insulin. Others also report a minimal scratchy throat at times following Afrezza use.

While that isn’t something everyone experiences, it is a more common side effect that Afrezza users saw during clinical trials. But MannKind says it’s a natural reaction to inhaling a dry powder and doesn’t indicate any safety issues or concerns.

Some PWDs have found it helpful to sip a bit of water or liquid after inhaling the insulin, and that doesn’t interfere with it working.

DiabetesMine Founder and Editor Amy Tenderich started using Afrezza just after it was launched in 2015. She shared the following about major benefits she saw:

  • I feel relieved from the constant pressure to be exact in carb counting.
  • Likewise, I’m relieved from the guessing game known as Insulin on Board (IOB) that can have unwanted impact up to several hours after taking a subcutaneous bolus dose.
  • I can eat more spontaneously (or rather achieve better glucose results with spontaneity) because Afrezza is best taken at the very moment of food consumption, or even afterward if your starting glucose is less than 120.
  • Taking less insulin through a cannula (tiny plastic tube) seems to be relieving my skin of some of its grief from overuse/ irritation/lipohypertrophy.

She also shared this: “It’s a funny little thing, this inhaler. My family giggles every time I use it, because yes, it’s reminiscent of sucking on a little cannabis pipe. Sometimes you can feel a scratchiness on your tongue as you inhale — like the powder passing over. In training, I was told you have to hold it very level, and be careful not to turn it around or even jiggle it once you’ve placed a cartridge in and pressed the top down — otherwise you run the risk of losing some of the powder. They say you should inhale normally, but I’ve found that if I don’t suck my breath in hard, some powder residue does remain in the cartridge or sprinkle out of the device right after use.”

DiabetesMine Managing Editor Mike Hoskins shared similar thoughts. He began using Afrezza for his bolus needs in 2016 and wrote, “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. I’ve also noticed that I can ‘turbocharge’ 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. reports they’ve heard numerous users describe that same ‘exercise effect’ with Afrezza.”

Hoskins also pointed out that he always checks the cloudy plastic cartridge bottom after each inhale to make sure there isn’t a lot of powder left over inside. If so, he does another inhale to get that remaining powder.

This isn’t yet possible as of 2021. For now, the only way to keep track of Afrezza doses and how much you’ve used is to manually log this.

But MannKind hopes it will be an available feature before too long. The company’s developing what is known as BluHale, a Bluetooth-enabled accessory that will attach to the inhalers and track data, and communicate that data to a companion mobile app. The hope is that this smartphone app would also allow for integration with data from other diabetes devices such as insulin pumps and CGMs.

MannKind has introduced the first version of BluHale as a training tool for healthcare professionals to help patients learn how the inhalation technique works for Afrezza. A consumer version with data tracking and sharing capabilities is in the works, likely for late 2022, once clinical trials are finished and it’s submitted to the FDA.

As always, pricing on prescription medications and insulin can be a touchy topic. It’s all too expensive, Afrezza included.

Afrezza is available on Amazon as of late 2020, though the listed prices can bring some serious sticker shock:

  • Box of 90 four-unit cartridges: $496.80 without insurance, before a 32 percent Prime discount
  • Box of 90 eight-unit cartridges: $938.70 with insurance, before a 28 percent Prime discount
  • $1,362.60 for 4- and 8-unit cartridge pack
  • $2,284 for 8- and 12-unit cartridge pack
  • $1,783 for 4-8-12 unit cartridge packs

For the underinsured or those without insurance coverage, MannKind offers a discount direct-purchase program that can bring Afrezza costs down to $99 per month for eligible people. The Afrezza Savings Program also provides a discount card that can reduce insurance copays to $15 for a month’s prescription.

MannKind says that more than 70 percent of PWDs in the United States with commercial insurance plans have access to Afrezza. That includes Medicare, which covers Afrezza. Of course, Your Insurance May Vary so you’d need to check your specific plan details on whether Afrezza is covered.

Overall, Afrezza is a great option for PWDs to consider. It removes the need to inject fast-acting insulin at mealtimes or for correction doses, and its quick action makes it a powerful tool for managing your post-meal glucose levels.

Although some may still be skeptical about the possibility of a cough or scratchy throat, Afrezza really can help many PWDs optimize their diabetes management. Because of the high price point, accessibility for many people will depend on whether their insurance covers it.

With the future development of a data-tracking accessory to allow better dose tracking and data sharing, Afrezza can become an even more beneficial tool for those with diabetes.