Editor’s note: This is not a sponsored article and is not affiliated with any particular company or product. All recommendations are based on the author’s independent research.

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Paul Madden is one of many people living with type 1 diabetes (T1D) benefiting from the use of Afrezza®, an inhalable insulin manufactured by MannKind.   

“The spontaneity of using Afrezza has been marvelous,” said Madden, who made the switch from an insulin pump to inhalable insulin and injections about 10 years ago, mainly to give his scar tissue a break. “There’s no other insulin that works as quickly. It peaks in about 35 to 45 minutes, and after 90 minutes, there’s not much kick.”  

While there isn’t a one-size-fits-all solution for diabetes management, having choices is important. Afrezza, an ultra-rapid-acting inhalable insulin, is one of them. Although it’s been available since 2015, many people remain unfamiliar with it. You may be wondering if it’s a good option for you. Here, we’ll explain its use and what research has to say.   

  

What is Afrezza?  

Afrezza is an ultra-rapid-acting inhalable insulin. It starts working in about 12 to 15 minutes and leaves the body quickly. As its name implies, it’s breathed in through the mouth to the lungs, where insulin particles are quickly absorbed.   

It’s FDA-approved for use in adults living with type 1 and type 2 diabetes (T2D).  

While it’s not a substitute for long-acting insulin, it can help decrease the number of rapid-acting injections for meals and glucose corrections. What’s more, Afrezza may help reduce hypoglycemic (low glucose) events with how quickly it peaks (in about 35-45 minutes).  

Madden, who has worked in the diabetes space as a mental health specialist for 30 years and has lived with T1D for 63 years, is happiest with his current regime. “While my A1C now ranges from 5.7 to 6.0, I want to emphasize it’s with less hypoglycemia.”   

As an educator and person with T1D, he has used various management tools as they’ve come to market. And in an age of personalized medicine, he’s found what works best for him.    

 

How does Afrezza work?  

“Afrezza works by being inhaled into the mouth. From there, the fine particles travel into the lungs, and then, directly into the bloodstream,” explained Jack Griswold, a retired mechanical engineer with a scientific background who has lived with T1D for over 60 years — and has been using Afrezza in conjunction with a manual insulin pump for almost 7 years.

Generally, people notice its effects in about 12 minutes, and it is primarily out of the system between 90 minutes to 3 hours (depending on the dose taken).  

It comes in 4, 8, and 12-unit doses. Once the cartridge is placed inside the inhaler, it’s ready to use. The inhaler is good for 15 days, but cartridges are for single use. It’s important to note that Afrezza dosing is not interchangeable with liquid, injectable insulin.    

Afrezza is well known for its properties that more closely mimic insulin’s “rapid on, rapid off” characteristics, when naturally produced in people without diabetes.  

”I joke, that Afrezza is my ‘magic fairy dust,’ said Griswold. While it’s not always perfect, it’s amazing to not linger with high glucose for hours. I can get it down quickly with Afrezza.” 

  

Is inhalable insulin safe for everyone?  

Afrezza is approved for use in adults with T1D and T2D, but exceptions exist.  

Afrezza is not recommended for those who are:  

  • Pregnant or breastfeeding  
  • Actively smoking or have recently stopped  
  • Living with or having a history of lung issues (such as asthma, COPD, or cancer)  
  • Allergic to regular human insulin  
  • Under the age of 18 (the INHALE-1 study was recently completed for ages 4-17 — stay tuned for research results)  

  

While Afrezza isn’t for everyone, it can be an important option for some. Your healthcare provider can discuss its safety and effectiveness, taking your personal risk factors and diabetes management goals into account. Together, you’ll decide what’s best for you. 

It’s important to let your provider know if you plan on becoming pregnant or are using other inhaled medications. If you’re using an insulin pump, there’s no data supporting the use of Afrezza.   

With any automated insulin delivery (AID) device, the algorithm essentially has no accountability for the amount of inhaled insulin you have on board. This has its own set of concerns. For now, this warrants a conversation with your diabetes provider so you can determine if it’s an option for you.  

  

Should I have my lung health tested while I use Afrezza?  

Yes, pulmonary function testing is recommended before starting on Afrezza.   

Your provider will order a breathing study before you start Afrezza, again in six months, then yearly. This way, they’ll understand your baseline lung health and can assess whether any changes have occurred since.   

When using inhalable insulin, people may experience throat pain, airway irritation, and coughing. For those with pre-existing lung problems, it can cause bronchospasm, a sudden lung issue.  

Alternative options include using use a 4-unit and an 8-unit cartridge instead of a single 12-unit cartridge. By dividing doses, it reduces the powder inhaled from a single dose, while having the same glucose-lowering effect. 

“The first few times I inhaled Afrezza too vigorously, and I started gagging and coughing,” shared Madden, “After talking with friends, I adjusted to a ‘slight’ inhale, which prevented coughing altogether.”   

From Griswold’s user perspective he’s found, “There are two tricks. First, I inhale slowly and don’t just puff out my chest — I use my diaphragm to go lower. And right afterward, I take a little sip of water.” 

In terms of lung health, Griswold has completed pulmonary testing every year. He explained, “My lung function has actually improved a few percentage points, so it hasn’t negatively affected me.”  

Free training sessions are offered by certified MannKind trainers who provide general support and step-by-step instructions. It’s important to note, in clinical trials, a few cases of lung cancer were identified, but data was insufficient to determine if there was a true link to inhaled insulin. Further studies are needed.  

    

What does research say about inhaled insulin?  

Grazia Allepo, MD, is a Professor of Medicine and Associate Chief for Clinical Affairs in the Division of Endocrinology, Metabolism, and Molecular Medicine at the Northwestern University Feinberg School of Medicine in Chicago, Illinois. She presented findings from the INHALE-3 research study, a 17-week, head-to-head comparison of inhaled insulin and Degludec (a long-acting, once-daily, basal insulin) versus injectable insulin therapies (automated insulin delivery (AID) systems, sensor augmented pumps, or multiple daily injections (MDI)) in adults living with T1D at the 2024 T1D Exchange Quality Improvement Learning Sessions.   

Results showed A1C improvements of greater than .5% in 21% of those on inhaled insulin. For participants with an A1C > 7% at the start of the study, 21% of those on inhaled insulin achieved an A1C goal below 7%. This was not true of any participants on traditional management modalities. Additionally, 19% of those who switched from an AID system to inhaled insulin plus Degludec saw greater than a .5% decrease in their A1C.

Not all results were positive for those on inhaled insulin: 26% had A1C increases > 5%, while only 3% of people on standard care had A1C increases. In terms of experience, half of the participants wanted to continue using inhalable insulin after the study.  

 

Key learnings Dr. Allepo shared with the audience included:  

  • Inhaled insulin may benefit those engaged in their diabetes self-management who wish to reduce hyperglycemia (high glucose) further.  
  • For those seeking an alternative to insulin pumps, inhaled insulin may be a good option.  
  • A secondary inhalation, or “booster” of Afrezza, should be taken 1 to 3 hours after meals if glucose is trending >140 mg/dL to maximize its benefits.  

  

Is Afrezza accessible?    

Yes, for the most part. Afrezza is covered by private insurers and Medicare. Plus, there is a MannKind Cares program and an Afrezza Savings Program. 

If the prescription goes through Sterling Pharmacy, a specialty mail-order pharmacy, they can also assist with obtaining coverage. When Afrezza isn’t covered, it can be costly, steering some away from its use.  

While insurance companies will require prior approval, persistence pays off, explained Madden, who appealed his insurance company’s denial of Afrezza and won. “Look, they even deny liquid insulin I’ve been on for years. I’ve gotten much better at appealing these things, and I do advocacy work to help others, too.”   

    

What is Afrezza’s potential impact on the daily burden of diabetes?  

For those who are Afrezza-curious, “Find out for yourself if it’ll work for you. In my opinion, it’s by far the quickest working treatment for high glucose that exists,” said Griswold. “I can’t get this super-fast response from any liquid insulin.” 

“Inhaled insulin starts working for me in about 15 to 20 minutes, and it’s out of my system sooner — in about 60 to 90 minutes. Plus, I have much less hypoglycemia,” said Griswold. In terms of exercise, he’s seeing benefits there, too. “There’s really no ‘insulin on board’ effect, so there’s less worry about going low during exercise.”  

As for Madden, “Afrezza has a shorter “tail” than liquid (injectable) insulin — meaning it works quicker, peaks faster, and leaves the body sooner. Because of this, I have less hypoglycemia, and T1D isn’t as physically disturbing and emotionally draining. When I do have a hypo, it doesn’t wipe me out as much,” said Madden. “I’m not working as hard as I used to with liquid insulins. The only drawback for me, and all of us, is that we still have diabetes.”