The diabetes community is abuzz about inhaled insulin. On June 27, the U.S. Food and Drug Administration (FDA) approved a new product, called Afrezza, that has been years in the making. Many people with diabetes are quick to say: “Insulin that doesn’t need to be injected? No more needles? Sign me up!”
First, the basics. Afrezza is a rapid-acting insulin you take before each meal, or soon after you start to eat. It comes in a small inhaler, and each cartridge contains a single dose. Anyone who relies on insulin—that is, all people with type 1 diabetes and a growing number of those with type 2—can use Afrezza.
Because it’s inhaled, Afrezza is absorbed by your body more quickly and in a different way than injected insulin. It peaks about 12 to 15 minutes after you inhale it, much faster than either human regular or rapid-acting insulin analogues do. So inhaled insulin makes bolusing much easier; you can use it as you begin to eat, eliminating much of the guesswork as to exactly when your meal will be ready and you can begin to eat.
If your meal is delayed or you anticipate more carbohydrate than you actually eat, your blood glucose can crash. But Afrezza is broken down by the body more quickly than injected insulin. So not only does inhaled insulin help manage the rise in blood glucose from food, but it also lessens your risk for post-meal hypoglycemia, or very low blood glucose. On those occasions when you have a very prolonged meal—think Thanksgiving!—you may end up needing to take another dose. But that’s better than having taken too much.
When I testified at the FDA committee hearing on Afrezza, back in April, I spoke about this tension in diabetes management: preventing complications from hyperglycemia (high blood glucose) while also avoiding unacceptable levels of hypoglycemia. The complications of diabetes, such as heart disease, kidney disease and amputations, are very serious. But constant lows come with very real risks as well, including poor quality of life, hospitalizations and even death. Afrezza is an effective choice for managing post-meal blood glucose while also minimizing those debilitating lows.
Living with diabetes requires so much diligence, especially for people who use insulin. With every meal and snack, with every bout of exercise, with countless other everyday activities, they must stop to check their blood glucose and wonder, “How is what I am about to do going to change that number?” This internal conversation happens several times a day, for a lifetime.
Then there are the social influences. People with diabetes have every right to manage their health in public, such as pricking their fingers to test or giving themselves insulin before enjoying a meal. But in reality, people are not always kind to those with diabetes, whether out of fear or ignorance or squeamishness. That social pressure often gets in the way of proper diabetes care. If you don’t feel comfortable giving yourself a shot in front of others, say at a restaurant, you may just skip it. And that’s the last thing we want to see happen.
But a quick puff on an inhaler instead? Suddenly, taking mealtime insulin is much less obtrusive, for you and the people around you.
Until there is a cure, we need more options for managing diabetes. Very rapidly absorbed inhaled insulin would help overcome many of the limitations of the currently available forms. Diabetes care is highly personalized, and the best treatment plan is not only the one that gets good medical results—a healthy A1C, for example—but also the one that the patient can stick to. People with diabetes also deserve to be confident in knowing the precise amount of insulin they’re getting with each treatment, and that there will be predictable results (understanding that diabetes can always throw you a curve ball!).
When a person who relies on insulin to live gets to choose which method best suits his or her goals and lifestyle, that’s empowering. And that sets the scene for living well with diabetes.
Some caveats: Afrezza does not replace long-acting (basal) insulin for those who need it. And if you have asthma or chronic obstructive pulmonary disease (COPD), this would not be the drug for you. Same goes if you smoke (please think about quitting!).
If you have diabetes, talk with your diabetes care team about whether inhaled insulin would be a good fit for your lifestyle—as you would with any new element of your diabetes management plan.
We don’t know exactly when Afrezza will hit the market, or how much it will cost, although its manufacturer, MannKind Corporation, predicts the price will be comparable to that of today’s insulin pens. The FDA has asked for more studies and trials to look at long-term cancer, heart and infection risks, as well as to determine the safety for use in children.
But for many affected by diabetes, it will be an exciting day, and very understandably so.
Robert E. Ratner, MD, FACP, FACE
Chief Scientific & Medical Officer
American Diabetes Association