One More Afreeza Trial Run: Time to Dump the Pump?

Thought I'd add more to the conversation detailing my experience. First a little background:

Me - I'm a 38 year old male, been Type 1 for 25 years, and been using a pump for 8 years.

Diabetes Control - Since starting the pump I've had extremely tight control, usually with an A1c between 5.5 - 5.7. Over the last two years I've increasingly had issues with absorption of my insulin. I don't blame the insulin or the pump, it is a problem at the insertion sight. Increasingly I'll be high, bolus, and nothing will happen. When high, I don't eat until my sugar drops. While my last A1C was 6.0, this came at the expense of essentially giving up eating breakfast, and dealing with the above issues. I change my insertion sites on average every day to day and a half. There's nothing more frustrating than having hyper events that refuse to go away after multiple boluses, and the waiting between each bolus to see if they work.

I recently had a mechanical issue with my pump and had to go back to shots for 5 days. In many ways it was fantastic. I could take a corrective bolus, and it ALWAYS worked! This was a refreshing alternative to the absorption issues I've been dealing with from the pump, and made me strongly consider a pump alternative. Now, suddenly, Afreeza is available.

Motivations to Try Afreeza - They are threefold:

1. An alternative means of delivery that will hopefully alleviate pump related absorption issues.

2. Reduction of hypo events

3. Reduction of hyper events

The Test - I picked up a 10 day free sample today from my endo's office. I am going to fully disconnect from the pump, relying on a twice daily shot of lantus for my basals. This will be interesting as my pump basal rates vary significantly throughout the day. I'm also curious to see what happens with minor corrections. I will bolus if my bg gets to 120 or 130. The Afreeza units I have are all 4 unit cartridges, so I'm not sure how that will play out.

I start tonight at dinner and will post updates as the day goes along. Thanks to mikep, dave, and all the rest for starting these threads and sharing so much useful information.

Went out for dinner tonight (in-laws in town) which made tonights dinner an inexact science. I estimated 60 carbs on the plate. Following BG's from the Dexcom 4 (with the updated 505 software):

Time - BG

7:57 - 109. Started eating
8:03 - 112. Took 8 units of Afreeza
8:15 - 119. This was the highest my BG's got, Then began to drop slightly.
8:50 - 90. Arrow on Dexcom switches from flat to dropping.
9:10 - 79. Starting to make me nervous as it continues to drop.
9:17 - 74. Flatlined here and didn't go lower.
9:37 - 76.
9:46 - 81.

10:04 - 86.

Pretty awesome. It was a gamble going out, and I tried to order pretty conservatively as far as carbs. My previous I/C ratio was 11, so when eating 60 carbs would've taken 5.5 units of insulin on the pump. Also, historically when guesstimating a dinner carb count lows and highs are pretty common. Couldn't be happier with these numbers.

I do expect some highs tonight due to switching my basal from the pump to lantus. My lantus will be taken in two doses, one in the morning and one 12 hours later in the evening (12 units each time.) Since I've only taken one dose, I expect some overnight highs.

I'll let the chart speak for itself.

This morning started with excitement but has quickly turned the other direction. My bf's remained steady and flat all night, floating around the 90-110 mark. This surprised me since I only had one of my two daily lantus doses injected. When I woke up I took my morning lantus dose, then ate a bagel and yogurt. Bagels are my weekend guilty pleasure, but have always posed problems of quick massive spikes. The lenders bagel has 51 carbs. Because I only had the option of 4 or 8 units of Afreeza, which on my old bolus schedule would equate to 40 or 80 carbs respectively, I decided to add the yogurt to up my carb intake to 66 carbs, putting me more in the middle ground. It did not go well.

Time - BG

830 - 106. Began eating
837 - Took 8 units of Afreeza

837 - 109

912 - 167

945 - 207

1006 - 230

1012 - 241

1012 - 4 unit correction bolus

Somethings obviously not working right. I don't know if the lantus hasn't taken affect yet which is aggravating the situation. There was also an issue I had with the lantus pen syringe this morning. It's a type I've never used before with the enclosed needle. I wasn't sure if I got all the lantus I needed, but regardless that shouldn't be the root cause of the above spike. All of my carb counts were read directly from labels, so not much room for error. I'm going to take a 4 unit correction and see what happens. Disappointing, but speed bumps were to be expected.

Would you have eaten a bagel and yogurt before with pump and been able to cover it better? I could never eat something like that without the same results you had today…

Yes. Would’ve had a spike, but it would come back down.

I seem to have flatlined around 260. Been there for the last 20 minutes

What you describe is exactly the kind of trial I’d like to see, as I have a 12-year-old daughter who might consider a Levemir or Lantus plus Afrezza regimen ( once Afrezza gets pediatric approval) in place of her current pump with Apidra regimen. Please keep us posted.

It's definitely been a rough morning and I'm not sure why.

1012 - Correction Bolus 4 units
1022 - 261
1032 - 261
1039 - 262
1052 - 258
1115 - 247
1115 - 4 unit correction
1130 - 240
1158 - 213. Finally down arrow
1201 - 204
1204 - 194
1215 - 184
1220 - 185
1225 - 183
1229 - 180
1234 - 181
1240 - 4 unit correction
1240 - 182
1250 - 178
1255 - 170
100 - 150
109 - 137
114 - 128
130 - 120

I had to take an additional 12 units over what I expected. That may be in part due to moving from my pump basal to lantus, but not all of it. I'm also wondering if I somehow messed something up mechanically.

A couple of key learning points are starting to become clear:

Correction Ratio - My old Humolog and Apidra correction ratios were 1 to 30. The Afreeza is working very specifically at 1 to 15.

Start and End Times - The Afreeza is consistently beginning to lower blood sugars within 10 minutes, and stops lowering my bg 50 minutes to an hour after inhalation.

These two observations may change, but they've held true with my various corrections.

Note the plateaus an hour after each bolus

50-IMG_5024.JPG (703 KB)

Thanks so much for joining the Guinea Pig population. This is what we PWD really need: Real world use/trials, and figuring out how to fine tune this stuff.

Clearly Afrezza is radically different than current insulins in several very important ways. I love that we (TuD) are doing Yeoman's work developing useful, practical protocols for using the drug most effectively in actual life.

There is always the tension between optimizing use -- which is always more complex -- and ensuring safety for the general patient population. I share that concern.

However, that should not stand in the way of responsible people, eager and willing to learn and put in the effort, gaining better control and richer lives by benefiting from the learned experience of others.

Thanks for contributing to "the project" :-)