Afrezza meets low-carb high-fat, a T1D report

The recent release into the wild of the first ultra-rapid acting inhalable insulin, Afrezza, caused quite a stir in the diabetes online community. According to its package insert, once inhaled, it reaches its peak within 12-15 minutes and returns to baseline around 180 minutes. It does something special with liver signaling that moderates post-meal blood glucose (BG).

In other words, it’s way faster than the fastest insulin on the market today. In fact, its speed rivals the normal physiological speed of insulin release in a healthy non-diabetic. Equally important, it finishes more quickly and avoids hypoglycemia common to current rapid acting analog (RAA) insulin, Apidra, Humalog, and Novolog.

Early adopters report far fewer episodes of symptomatic hypoglycemia and no severe hypoglycemia. The insulin appears to act more elastic with regard to the strict insulin to carb (I:C) ratio and insulin sensitivity factor (ISF) used with RAA insulin dosing. Doses come in a 4-unit cartridge that provides equivalent insulin of one to four RAA insulin units. There’s also an 8-unit cartridge intended for when 4-8 equivalent units are needed.

Stack-of-buttery-pancakes dripping-maple-syrup fantasy

As a type I diabetic (T1D), I currently follow a low-carb high-fat, or LCHF, way of eating and target a 30-carbs/day limit. I don’t intend to abandon LCHF but would like to add a few more carbs back into my diet including beans, legumes, carrots, and sweet potatoes. I know, boring! I’d also like to celebrate once in a while and splurge on a milk shake or piece of pie without the hyperglycemia “hangover” or a tiresome ride on the blood glucose rollercoaster.

I understand Afrezza’s appeal to return to the carefree-eating days before diagnosis. It seems like a dream to restore what you once enjoyed and thought lost forever. I get the allure. That’s a tough siren call to resist. I don’t think I’ll follow that path because it’s not best for me. I will kick diabetes’ ■■■ just the same. And hopefully enjoy many more healthy years. Life is good!

I’ve been diabetic for 31 years and have now used a LCHF way of eating for three years. The entire experience has taught me that the way I ate growing up, before my diabetes diagnosis, did not support a healthy future me.

During my high school days I would drink three or four 16-ounce bottles of Coca-Cola every day. My go-to breakfast until age 30 and diabetes diagnosis was a bowl of processed sugar cereal, a banana, and milk. Ugh! Knowing what I know now about glucose metabolism, I cringe when I think about it. I regularly hammered punishing loads of fast-acting quick-to-sugar carbs to my poor metabolism.

Not carb- war II

I don’t think a high-carb processed-food diet (45-60%+ of calories as carbs) is healthy for anyone. I believe it promotes chronic inflammation and risks more serious diseases. I do not want to revert to my old carby ways, even if Afrezza can tame the blood-sugar beast.

I also believe that taking much larger total daily doses of insulin than you actually nutritionally need may itself constitute a long-term health liability. I’ve read in the medical literature that hyperinsulinemia may impair health.

The topic of low-carb versus high carb eating in diabetes fueled long and heated debates on this site and across the diabetes online community. I am not interested in that debate in this thread. Most people have made up their mind and with every meal vote their preferences.

There has already been ample writing about Afrezza and high-carb eating. This thread will tell the story of low to moderate carb intake and the effect of Afrezza. If you want to reignite the carb wars, I’m not interested. Been there, done that. Besides, asking someone to change their way of eating is akin to asking them to change their religion!

Two meals, late breakfast, early dinner

I eat two meals a day plus a snack. Breakfast is often between 10 a.m. and noon. I like to eat dinner between 5-6 p.m. The way that I currently dose is to take a carb bolus 15-45 minutes before I eat. At that time I also start an extended bolus to cover the protein and fat. I count half the protein grams and 10% of the fat grams as equivalent carb grams. I then deliver that bolus at a maximum rate of 1.2 units/hour for however long it takes, usually 2-5 hours.

I’ll use Afrezza to replace my carb bolus typically with a 4-unit cartridge as I start eating. I will still maintain my basal delivery on the pump as well as the protein/fat extended bolus. I don’t find the timing of the extended bolus as critical and it may be started from one hour before eating up until mealtime.

Here’s what I’ll track and post

  • What and when I eat, including macronutrient breakdown for meals eaten at home. For restaurant meals I may just describe the food.
  • Timing and amount of all nutritional boluses taken, including my extended pump bolus to cover protein/fat as well as the Afrezza carb dose.
  • Timing, duration, and intensity of any exercise in the four-hour post-meal period.
  • The continuous glucose monitor (CGM) line from mealtime to four hours post-meal or longer.
  • 24-hour CGM lines, if interesting.

My post and comments will not include any dramatic before and after graphs. I say this because I have been able to control my BG levels pretty well using existing technology. I use an Animas Ping insulin pump, a Dexcom G4 continuous glucose monitor, and a Roche Accu-Chek Aviva glucose meter.

Current metrics

The following CGM numbers are for the preceding month. I spent 91% of my time in range, 65-140 mg/dl. My time spent in hypoglycemia (< 65 mg/dl) is 5%. Blood glucose variability as measured by the statistical measure, standard deviation, is currently 23 mg/dl. Finally, my average BG is 94 mg/dl. One measure I hope to improve is time spent low. My goal for Afrezza will be to limit the percentage of time less than 65 mg/dl to 1%.

I also look to Afrezza to grant me more mealtime-dosing flexibility while allowing me to add some nutrient dense higher carb foods back into my diet. I am eager to quickly correct high BGs and not be forced to maintain a multi-hour hyper-vigil without over-stacking corrections. The “cherry on top” appeal for me will be the ability to safely add the occasional decadent high-carb treat back into my life.

Note: In the interest of full disclosure, I hold Mannkind (MNKD) stock (long) in my investment portfolio.

***Cross-posted at the TypeOneGrit Facebook Page***

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I left the doctor's office with my fresh supply of Afrezza samples and walked a few blocks to eat my first Afrezza-dose meal. I chose to eat a Starbuck's breakfast sandwich since I'm familiar with the dosing. This meal contains 12 grams of carbs, 12 grams of protein, and 13 grams of fat. It consists of an English muffin (I discard 3/4 of the bread), a sausage patty, a layer of scrambled egg, and melted cheddar cheese. I drank coffee with half and half.

I delivered 2.2 units over 2 hours starting at 11:45 a.m. I ate at 12:05 p.m. and inhaled a 4 unit cartridge of Afrezza (4A).

Here's my CGM line showing up to 2:20 post-Afrezza and eating:

The line started at 89 mg/dl when I ate. At 32 minutes post-prandial it started to slowly climb. It peaked at 109 mg/dl, a 20 mg/dl climb, at 1:27 after starting to eat. It now appears to be decaying at a slow rate.

I could wait four hours to post my results but I will show the entire four hour post meal period later.

First experience is very positive for me. As others have observed, I had no taste or other sensation while inhaling. No cough, either.

Much more to come...

Looks good! What would have happened to your blood sugar had you eaten that same meal and not bolused?

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Looks nice! I will be curious to see how it performs with a meal of 50-100 carbs and what kind of correction inhalations are needed in the 2-4 hours after the meal. Good luck!

To clarify, the 2.2u you delivered--- is that your pumps automatic basal rate or did you prebolus with the pump?

I would have been north of 180 and climbing at about 60-90 minutes.

Beat me to it :-)

The 2.2 unit pump-extended bolus covers my protein and fat. It is not part of my basal routine. And yes I prebolused that dose by about 20 minutes. In other words I only expected the Afrezza to cover the carbs. I'll probably try an experiment where I dose Afrezza at mealtime for the carbs and then say 30 minutes post meal for the protein/fat.

The protein/fat bolus is so dependable that I don't feel much need to use Afrezza for that. I think I'll continue with the pump. It's a big help to me when I'm wondering if I took a bolus dose or not.

Terry, I completely understand your approach, and I've been struggling with how to deal with extended boluses with Afrezza. I'd like to "dump the pump" entirely if possible, which presents a problem for slow carbs and extended boluses.

So, my variation on all this experimentation/characterization will be to carefully test and document multi-dose, spaced administration over 4 hours to see if Afrezza can be used to manage the slow carbs with a "spike" every 90-120 minutes or something.

Of course, I have much ahead to get to that point. I haven't even met with my endo yet -- TOMORROW!

What works works, my hopes will be to simplify my regimen as much as possible, so I'll be trying, initially at least, to only inhale the afrezza when I begin eating. I'll be experimenting with certain foods that cause delayed spikes for me, like chili, to see if more layers of complexity are actually necessary for me. I hope they won't be.

Thanks, Denise. I am not planning to test a 100-carb meal, but I may do 30 grams at a meal. Sorry! I don't crave or miss carbs. I know I'm in a minority here. MikeP and others online are providing many examples of high carb meals. It looks like they are successfully with their BGs.

I'm now at 3:50 post Afrezza and meal. I just fingersticked 95 and CGM shows 93. No correction needed. Pump IOB shows 0.57 units.

I am not planning to test a 100-carb meal

Never fear, folks, I will volunteer to test that meal!

Terry is really excited, but being a modest sort of person is too embarassed to show everyone what he's doing right now, he's so happy:

Another option is to use a dose of old fashioned Regular insulin, but that doesn't simplify. I've worn a pump for so long, it just feels like an extension of me. There will be many ways to use this new tool. I'm certain my way will not be the most popular!

Good luck with the endo. My endo gave me 30 sample doses of the four unit cartridges. I asked for 30 more and she gave them to me. I figure I need 5 doses per day, considering corrections. I think I'll be correcting 120s and higher!

Good luck, Sam. I can't remember the last time I was so enthusiastic about treating a fricking disease!

Sounds like I am getting 30-4u and 60-8u from what I can piece together then I have to do PFT… And hopefully that’ll e enough to have a good estimate on how many of each I’ll need per month by then

We're twins on our goals, Terry.

As far as the pump goes, I'm just a newbie tyke at 2 years in, so I'm not as habituated as you at this point. However, even more, I get allergic knots at my infusion sites that are not that big a deal, but I'd rather not have to use Hydrocortisone every 2-3 days to knock them down when I change pods.

Sam's posting about what he was given gt me curious about pricing. Found this.

Follow the link, and you see Sam got a standard "kit" which includes 30x4U, 60x8U, and 2xInhaler.

About $300 for this quantity.

Rough estimation I'll need about 2 of these a month, so about $600/mo for insulin.

That's compared to $750 for 3 vials of Humalog and $500 in pods.

If Afrezza works well for me, it will save the "Health Care System" roughly $7,800 a year to care for me, with better results and a much happier patient.

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Here's a six-hour Dex screen showing the first Afrezza dose and meal:

I ended up with about a 20 mg/dl rise topping out at 109 about 90 minutes post-meal. The line returned to the mid -80s four and one half hours after the dose/meal.

This is definitely an improvement over previous Apidra only management. I normally would rise to the high 130s after this meal. The dosing is simpler as well. I had been using an “early pre-bolus” technique using a super-bolus, a more complicated scenario.

I’m getting ready for round two and dinner!

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Very impressive!