LifeAfterDx--Diabetes Uncensored

A internet journal from one of the first T1 Diabetics to use continuous glucose monitoring. Copyright 2005, 2006, 2007, 2008, 2009, 2010, 2011, 2012, 2013, 2014, 2015, 2016

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Location: New Mexico, United States

Hi! I’m William “Lee” Dubois (called either Wil or Lee, depending what part of the internet you’re on). I’m a diabetes columnist and the author of four books about diabetes that have collectively won 16 national and international book awards. (Hey, if you can’t brag about yourself on your own blog, where can you??) I have the great good fortune to pen the edgy Dear Abby-style advice column every Saturday at Diabetes Mine; write the Diabetes Simplified column for dLife; and am one of the ShareCare diabetes experts. My work also appears in Diabetic Living and Diabetes Self-Management magazines. In addition to writing, I’ve spent the last half-dozen years running the diabetes education program for a rural non-profit clinic in the mountains of New Mexico. Don’t worry, I’ll get some rest after the cure. LifeAfterDx is my personal home base, where I get to say what and how I feel about diabetes and… you know… life, free from the red pens of editors (all of whom I adore, of course!).

Sunday, July 09, 2006

Will huffing and puffing blow the house down?

I had seen pictures of it, of course. We all have. But now I held one in my very own hands. Was this the future of insulin delivery? Or the biggest flop since the Edsel? It is not as big in person as it looks in the pictures on the web and in the trade journals. Not until you expand it, at least. Then it looks more like a police baton than an insulin delivery device. And, as been pointed out by others, a bit more "bong" like than I'd personally care to be seen puffing in public.

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....


Anonymous Dan said...

You've got another fan.
I can't wait to read more.
I decided to shell out for Minimed's CGMS after reading your
earlier posts.

9:14 PM  
Blogger Sandra Miller said...

I've been skeptical about Exhubera from the get go. How can you really control the dosing? (I've had trouble getting all of the medication with an inhaler prescribed for a respiratory infection). Can it possibly match the precision of an insulin pump?

And the dosage is based on weight! I'm with you, man. That just sounds messed up.

But still, it'll be very interesting to read of your experience with this.

Have I mentioned how good it is to "hear" your voice again? So glad you're back.

9:54 PM  
Blogger Scott K. Johnson said...

Hey Wil!

Great post! Very entertaining to read (as usual!).

It really doesn't sound practical to me. Even for those that are scared to death of needles, there are some pretty big obstacles to get over.

And yes, as Sandra said - great to hear your voice again!

11:27 AM  
Anonymous Anonymous said...

Hi Wil, thanks for your blog. I too am wearing the Guardian (since Jan 2006) and if it hadn't been for you I never would have figured the thing out. I'm glad you're back at it. You are very entertaining and it's nice to hear from someone who understands what I'm experiencing. Keep it up. I'm having my dad read your blog so I can rig him up on my Guardian while I upgrade to the paradigm 522. I've even suggested that Medtronic's 24 hr helpline staff read your blog so they too can understand how their product works. I think they should put you on retainer. (If they haven't already) If you put your blog on paper and bind the edges, you could sell it as a 1st hand guide for the Guardian user. (Guardian for dummies??)

10:33 PM  
Anonymous Anonymous said...

Soooooooooooo good to have you back. (I have to figure out how to log in under my name.)


8:31 PM  
Anonymous Janet Ruhl said...

Glad to see someone else who gets why this inhaler is innately dangerous!

Did you see where Pfizer is going to put $50 million a MONTH into pushing it directly to needlephobes?

I was the "sample patient" interviewed by Business Week about Exubera but could NOT get the journalist to understand or quote me on why the dosing method was so worthless for anyone looking to get blood sugar control.

9:13 AM  
Anonymous JasonJayhawk said...

A pharmacist friend of mine in Arizona has also reported that endocrinologists are rare -- in fact, the hospital she works at does not even have an endocrinologist.

She said that the reps came to talk about Exhubra to their group, and they brought Boston Market items to their free lunch. The rep could not answer questions, always stating, "I don't know" when asked -- so perhaps this is either a new, inexperienced rep, or reps were told to say this in answering any questions.

Anyhow, the device will be $10 charged directly to patients, rather than handing them out for free -- because patients would tend to "lose" the devices if they did not get charged this fee.

None of the pharmacists were impressed with it at their hospital. The lack of precise dosing (or requiring more puffs) as well as the jokes about males actually carrying these around in public, as well as the fear that needlephobes would also be lancetphobes and would not test glucose.

Good to see you blogging again... I haven't been here in months, and was shocked to see new content.

5:18 AM  
Anonymous Anonymous said...

I was part of an Exhubra trial for three years, and I loved it. Control was awesome and absorption issues became a thing of the past. I have been a type one diabetic for 34 years, and absorption is a big deal for me.

It is now three years since the trial and I have not had any lung issues.

I don't understand all the fuss about the size of the inhaler. You pull it out, you fill it, inhale, and put it away. You don't have to wear it on a chain around you neck. And, you can't tell me a syringe in the hand or a pump on a belt doesn't get some weird looks when they're brought out in public.

I loved using inhalable insulin and I will be among the first to cross the border from Canada to pick some up in New York State. I can't wait.

I think all this negative press is just blah, blah, blah. Let's hear from some people who have actually used the stuff for more than a week.

6:47 AM  
Anonymous Anonymous said...

It's my first time on this site. What an interesting experience. I am considering a position as a Diabetes Educator to promote Exhubera (or Exhubra?). I wanted some insight from the actual users. I don't like to represent and or sell a product that I don't believe in.
Please enter your experience with this Insulin Inhaler. I want to know more about it from the users so I can compare with the info provided by the company.
Thank you!

1:43 PM  

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