Will huffing and puffing blow the house down?
I'm at a swank dinner in Albuquerque hosted by the good folks at Pfizer. I'm actually in a room full of Pharmacists due to a series of bizarre email and miscommunication problems. That's OK. I like Pharmacists just fine. But I was the only Diabetes Educator there. Oops! I let the cat out of the bag about my new job, didn't I? Well, more on that later. It probably deserves a post of its own.
We are about two weeks before the roll out of Exhubera, the first FDA approved inhaled insulin and Pfizer is both trying to drum up excitement and get the Docs, Pharmacists, and Educators up to speed on how to prescribe, dose, train, and all of that kind of stuff.
Actually, if the inhaler had been a snake it would have bit me. I was sitting at the table, yakking with some of the other attendees, and eyeing a real life inhaler that was sitting on the projector table in the center of the room.
As I reach for my ice tea goblet my hand hesitates. Right there. Two inches from my tea, is an actual Exhubera inhaler sitting innocently on the table in front of me. I could have snitched it and put it in my pocket. It would have made a fine trophy. I tried to wrangle one later, with no luck. They are under lock and key until the official release date. I wanted to put it on my desk with my Byetta Pen, OptiClik, and Novo Training pens. Well, I'll have one in a few weeks....
I play with it for about ten minutes before mastering all of its buttons. It is clever and well engineered but there is no shortage of ways the user can get confused. You slip your finger into a ring at the bottom and pull the handle out of the mixing chamber with a satisfying shuuuunk! A little pouch full of dry human insulin the size of a Pepcid AC slides into the drawer. You pull open the handle, reveling a syringe-like air plunger. Snap the handle closed to pressurize the unit. Squeeze the trigger, and you are supposed to see the insulin powder fly into the clear chamber. Of course the training packets are empty. Couldn't they have filled them with some sort of inert powder for visual effect? We are forced to use our imaginations. The patient would then swivel the mouth guard around, make a seal with their lips around it and inhale deeply.....wait five seconds....and then you'd think your done, huh? Wrong!
Depending on your weight, you may need to do this three more times for a single meal dose. Hmmmmm.....I'm not thinking most of us are going to be too enthusiastic about this....
The device is less than discrete. And you have to load, cock, twist, and suck on it four times? Oh yeah. And the waiter better not be slow. You got 10 minutes to start eating. Fast on-set. On the back end the tail stretches out. Hypo territory is at the four hour mark.
One thing that troubles me is that the insulin delivery is based on the patient’s weight, not the amount of carbs in the meal. Whatthefuck? How is that supposed to work? The 200 pound guy who is eating barbeque ribs, potato salad, apple sauce with cinnamon sugar, and pecan pie with vanilla ice cream is supposed to take the same amount of insulin as the 200 pound guy eating a chef’s salad? Printcrafter's stock tip of the week: sell Pfizer.
I salute them for trying something new, but I don't see this working out. It also looks like they are pricing themselves quite a bit higher than liquid insulin. I don't see insurance companies forking out for inhaled insulin when liquid is cheaper. Insurance doesn't care if some folks are scared of needles. Other than innovative delivery, it does not seem to have any medical benefit over traditional insulin. In fact, the long range effect of the powder in the lungs is an open question that has many folks worried.
BTW, it is honest-to-God real human insulin, not an analog. They spin the insulin into tiny drops that dry to between 3 and 5 microns. That is really, really, really, really, really small. Why human insulin, when that product has otherwise nearly disappeared from the market? I asked. The answer: they started working on this before analog insulin came along. Wow. Lots of time. Lots of dollars. Did they back the right horse? I suspect insurance will make or break this product.
That said, I love having another arrow in my quiver. My local Pfizer rep is coming by the clinic later this week. Once the insulin is available I'd like to offer it as an option to my patients who can either afford it or can qualify for assistance. Me? I'm willing to take a huff (or three), pop a couple of cherry slices and see what happens. After all, I still have the Girl to watch out after me. It will be interesting to compare the curve of inhaled insulin to that of pumped....
To my surprise, as things kick off, the clinical presenter is a friend of mine. She's the CDE who "fired" me, saying every time I visited her she learned something from me; instead of the other way around. As she starts talking the salads arrive. Looks good, but I leave mine untouched, as I'm taking notes. No one else seems to share my priorities. Next comes gumbo. We're at a Big Easy themed seafood place, which, I'm told, is based out of Chicago. Go figure. Big Easy seafood from Chicago in Albuquerque. Makes some sort of cosmic-global-economy sense, I suppose. I let the soup sit as well. I like free food as much as the next diabetic, but I'm an information junkie. This is interesting stuff. The wait-staff begins to collect the salad and soup bowls. I set my pen down long enough to grab a fork to threaten the girl's hand. Take the soup bowl, but don't touch my salad. Then the entree comes. 16 ounce rib eye. Oh my God. So tender you could cut it with a fork. I abandon my note taking and rely on my memory. I'm not letting this puppy get cold. I could also have chosen from crawfish, mahi-mahi, or chicken breast. This is followed up with key-lime pie. There was a good crowd, it must have cost a fortune. Earlier there were three kinds of appetizers. Turns out they also held sessions for Docs, and later will be holding one for my crowd. I wonder to myself if the menu is the same for all three groups, or is there stratification? Did the Docs get champagne? Will the Educators only get chicken and crawfish?
Most of the attendees leave as soon as their stomachs are full and the presentation is over.
Some even before the pie! Not me. That's why God created insulin pumps, right?
I close out the party, with just me, the CDE and the two guys from Pfizer.
As the CDE and I are chatting the rep says, "I take it you two know each other?" Yes, I tell the rep, in fact she fired me once. The rep now looks pained and doesn't know how to proceed. We both laugh. We talk about the good and bad points we can see with this new therapy. Then the conversation drifts to the new oral meds, Byetta, and continuous glucose monitoring. I have my Girl with me. My CDE friend has been wearing a Dex Com. We compare notes. We talk about the politics of insurance, the spread of diabetes. The UN resolution. And then it is 10 o’clock at night. She needs to get home to her kids. I’ve got a two hour drive home to Debbie and Rio. I try one last time on the way out to score an inhaler. No luck. The only way would be to conk the guy on the head with a coffee cup and steal the whole batch. I think about it for a second or two and it isn’t worth it. Oh well. Soon.
A stop at Starbucks for a iced latte. Some caffeine to get me home, but not enough to keep me up until dawn; and then it is off into the night, lightning dancing across the horizon.
A fun night. The smell of distant rain on the desert air. New info. Some hands on with the latest thing. Chatting with peers. Free steak. It doesn’t get much better than this.
And, no. This is not the new toy. But that is a story for another day....