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Editor’s Note: This article is based on Ginger’s personal experience using Afrezza inhaled insulin. Please consult your healthcare team before making any changes to your diabetes care regimen. This article was not paid for by any manufacturers of inhaled insulin and is not part of any partnership with any manufacturers of inhaled insulin. Afrezza is the only insulin on the market as of April 2023.
Many people living with type 1 diabetes (T1D) are being told by their healthcare providers that inhaled insulin isn’t safe or useful. These misconceptions about inhaled insulin are a major bummer! Inhaled insulin has become a critical part of my diabetes management and I cannot imagine going back to life without it.
I’ve lived with T1D for about 25 years — and I’ve been using inhaled insulin for nearly two years. Inhaled insulin is a true gamechanger in the daily challenge of managing T1D. As Jennifer Okemah, MS, RDN, CSSD, BC-ADM, CDCES has said many times, “it should be in the toolbox” for nearly everyone with any type of diabetes.
Here’s what I wish doctors knew about using inhaled insulin in type 1 diabetes.
What is inhaled insulin?
Afrezza is an ultra-rapid-acting insulin that comes in powder form. It is administered through your mouth with a very simple inhaler. It has no taste, and you don’t feel it either. (Some people do report a slight cough during the first couple of months, but that goes away for most.)
Manufactured by MannKind, it enters your bloodstream through the cells in your lungs. Afrezza is the only inhaled insulin on the market. It was FDA-approved in 2014 and had a lot of work to do to repair the reputation of its predecessor — Exubera. (Exubera came out in 2006 and it was a massive failure for a variety of reasons.)
Afrezza is becoming increasingly popular amongst people with type 1 and type 2 diabetes for a variety of reasons. Too many people with diabetes still don’t know it exists.
Nope — inhaled insulin does not cause lung cancer.
Many people have told me, “I asked my doctor about trying inhaled insulin, but they told me it causes lung cancer, so they won’t prescribe it.”
Afrezza has been FDA-approved as safe after extensive clinical trials involving thousands of people with type 1 and type 2 diabetes.
“Lung malignancies were reported in two patients on active TI therapy with a smoking history,” explains a study. In other words: the two cases of lung cancer were in people who also had a history of smoking tobacco.
When it comes to the overall impact of Afrezza on your lung function, studies suggested there can be a 3% decrease in lung function — and that your lung function returns to normal if you stop using Afrezza.
Personally, I jog or jump rope daily for 30-45 minutes without any issues! In fact, in the last two years, my usual “easy run” has increased from 2 miles to 3 miles. My pace has increased from a 10-minute mile to a 9:30-minute mile — all while using inhaled insulin.
Some prescribers might require you to perform a lung function test prior to starting inhaled insulin and again a year later. Some prescribers won’t require this at all.
People with a variety of different lung conditions — including lung cancer — should discuss with their healthcare team if inhaled insulin is appropriate. Inhaled insulin is not recommended in people with chronic lung disease (including some types of asthma) or chronic obstructive pulmonary disease (COPD).
The dosing is very different — and it can work for T1D.
The dosing of inhaled insulin cannot be compared to dosing injected liquid insulin — it’s a completely different game of managing T1D! But that’s also why it’s so helpful for people with T1D.
Afrezza’s inhaled insulin comes in three dosing options: 4-unit, 8-units, and 12-units.
Most people assume this means 4 units like an injection of Novolog or Humalog. Which sounds downright impossible for managing T1D. It’s completely different! It also works so differently that you simply cannot accurately suggest an X = X with Afrezza to injectable insulin.
To get started, the general guidance on dosing Afrezza is the following:
- 4-unit cartridge = approximately 2-2.5 units of rapid-acting Novolog, Humalog, etc.
- 8-unit cartridge = approximately 5-8 units of rapid-acting Novolog, Humalog, etc.
- 12-unit cartridge = approximately 12 units of rapid-acting Novolog, Humalog, etc.
Personally, I think of the cartridges as small, medium, and large.
Here are a few examples of how I dose Afrezza:
- Steak & veggie salad = 4-unit cartridge
- Large honey crisp apple with cheese = 8-unit cartridge
- Cupcake with buttercream frosting = 8-unit cartridge + another 8-unit cartridge 2 hours later
Again, Afrezza is in and out of your system so quickly which gives you more flexibility when dosing — and you don’t need to count carbs so meticulously! It also means you might need a “follow-up dose” for slower digesting meals. Sometimes, I combine a little bit of Novolog with Afrezza for high-fat/high-carb meals like lasagna, pizza, or cupcakes.
I also take tiny doses of Novolog when I need only a ½ unit or 1 unit to address a stubborn high related to dawn phenomenon, etc.
It is dramatically faster (in and out) than any liquid insulin.
The action of Afrezza is what makes it so wildly different. Afrezza acts fast and is out fast. It clears your system so quickly that I spend significantly less time worrying about “insulin on board” during physical activity!
Afrezza starts working in your bloodstream within 1 minute of dosing. It can also visibly affect your blood sugar (on your CGM) within 15 minutes of dosing.
Here’s how long each dose approximately stays in your system:
- 4-unit cartridge = about 60-90 minutes
- 8-unit cartridge = up to 3 hours
- 12-unit cartridge = up to 3 hours
While MannKind states that Afrezza’s duration in your bloodstream is 2.5 to 3 hours, most users report that the impact of 4-unit cartridge is done after about 60 minutes, the impact of the 8-unit cartridge is done within 1.5 to 2 hours, and the impact of the 12-unit cartridge is done within 3 hours.
Personally, I can correct a high blood sugar of 300 mg/dL with an 8-unit cartridge of Afrezza and land safely at 100 mg/dL within 90 minutes. And then go for a dog walk! I don’t crash because Afrezza acts fast and is out fast.
This means I correct my highs faster without increasing my risk of lows. I don’t feel the need to “rage bolus” and over-correct highs! I know Afrezza will get me down quickly and safely.
It is possible to get inhaled insulin affordably — with or without insurance coverage!
People also think it’s impossible to get coverage — but there are a couple ways to get Afrezza affordably — with or without insurance coverage.
- The doctor needs to write the script and send it to UBC Pharmacy — not your local pharmacy. This is the “intake pharmacy” for all Afrezza prescriptions.
- UBC Pharmacy
- UBC then sends your order to Sterling Pharmacy, which fulfills the order and ships it to your door.
- Sterling Pharmacy
- The doctor needs to detail reasons why your current insulin method is not adequate — examples include: fear of injections, needle fatigue, scar tissue, spikes after eating, stubborn highs, etc.
- The doctor needs to follow the prior authorization steps outlined by MannKind — they will help you! Reach out to a local MannKind representative for assistance if needed.
- If you cannot get coverage, look into the Afrezza patient assistance program — it’s fantastic!
Read these tips on exactly how to get Afrezza with or without insurance coverage. MannKind has an incredibly thoughtful patient assistance program — but it all starts with a provider being willing to write a prescription.
In a nutshell, I love inhaled insulin because:
- Less worry about lows: Once you get the hang of how quickly Afrezza works, your risk of lows is significantly lower because it clears your system so quickly. If you do go low from an Afrezza dose, it doesn’t feel as draining or endless because…it clears your system so quickly! If my blood sugar is 85 mg/dL within one hour of dosing a 4-unit cartridge, I know I don’t have to worry about crashing because the biggest impact of the dose is nearly out of my system. Many people report dramatic lows when they first start using Afrezza — but that’s simply because they haven’t learned how to use it! Give the learning curve a few weeks!
- No meticulous carb-counting: Afrezza is simply more forgiving and more flexible. If you realize after an hour or two that you underdosed, you just take more as you watch the number on your CGM start trending upward. It works so quickly that you don’t get frustrated waiting for it to kick in! This rapid action means you can make mistakes without a huge commitment because it’s in and out so fast. (Inhaled insulin makes a simple dose of injected rapid-acting insulin feel like a huge commitment with bigger consequences if you take too much or too little.)
- No rage-bolusing: Correcting highs and covering meals is so much easier because it works so quickly. Quite often, I wait until I’m halfway through or done with my meal before taking a dose of Afrezza because of how quickly it starts working. Pre-bolusing is rare.
- No needles: This seems obvious, but man alive, I’m enjoying not stabbing myself all day with needles as someone who prefers multiple daily injections (MDI) over an insulin pump.
The biggest challenge with inhaled insulin…
Honestly, inhaled’s biggest challenge is that many providers still won’t prescribe it due to the many misconceptions listed above. I’m incredibly grateful for inhaled insulin and I would be downright heartbroken if I had to return to using liquid rapid-acting as my primary insulin for meals and corrections.
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