Afrezza: Tips from Users on Titration (Dosage and Timing)

Get Support from other Afrezza Users

If you are just starting to use Afrezza, you can post questions (such as titration or any other related issues) to the Afrezza User Facebook Group.  People there are very helpful and responsive. Fudiabetes.org is a new forum run by a group of Afrezza-friendly people.  Quite a few active Afrezza users post on that forum.  Twitter is another platform where active Afrezza users post their results and share their experience quite frequently.

Afrezza: Timing is Everything

I have previously mentioned the importance of dosage timing when taking Afrezza, but have not gone into much detail. So I thought it would be worthwhile talking about what I have learned so far about timing.

As a general rule, I dose about 10 minutes after I start eating, which is before my glucose levels start to rise from the meal. As I mention in the video, the best time to dose seems to depend on the fat content of the meal. And for some high fat meals, a follow up dose of Afrezza is neccesary.

I have found the same rule also applies if a follow-up dose is required. It is important to have the follow-up dose before the levels begin to rise out of range. If I had a CGM with alerts, I would use this to notify me as soon as it levels began to increase. That way I wouldn’t miss the optimum time for the follow-up.

It is worth remembering that much, much more Afrezza is needed to correct high glucose levels than to cover meals. As the video details, if I wait too long to dose, the dose required may be four times higher!

– Matt

Editor’s Note on timing of Afrezza doses:

Matt’s observation and comment in his video and article regarding the timing and dosage of follow-up doses also support Al Mann’s statements below. [In his video, Matt gave an example where he was having a five-course Japanese banquet, he took a green dose (8-Unit) Afrezza every forty-five minutes or so and his BG level remained perfect throughout the dinner. And the same approach worked for him at a dinner party, where he even drank sugary cocktails].

Al made his following comment in this interview: An Exclusive Interview with Al Mann, Founder and CEO, Mannkind Corp.

“SF: Was that when you changed to the new device?

AM: No, I think that a problem during the trials was that some patients took their dose of Afrezza even before starting to eat. The trial protocols called for Afrezza to be dosed “at the beginning of the meal,” but sometimes it was taken even before. We need to do additional trials to gain more experience with optimized dosing times.

Actual ingestion of food in most meals in the United States except in restaurants takes only about 30 minutes, so I believe that the first Afrezza dose really ought to be taken ten or fifteen minutes after starting to eat.

For a longer meal, which is not very common, a second dose might be taken fifty or sixty minutes after starting to eat.

For a long feast that lasts for an hour and a half or more, I suggest a third dose be taken at maybe one and a half hours after start.

Interestingly I believe the size of all those doses should probably be the same for most patients.

Unfortunately the trial protocols called for dosing at the beginning of the meal so we will need to do more trials to be able to gain FDA label approval of optimized dosing.

Here is an Afrezza user’s comment regarding this after a few days’ experiments:

“I read Matt’s piece on “Timing is Everything” and decided to give it a try. The basic idea is instead of taking Afrezza at the beginning of the meal you’ll get better results by waiting 10 minutes into your meal. OK I’ll bite….how can I go wrong on a trial.

For my test I picked a Taco Bell Taco Salad. Taco Salad has 74 carbs with the shell. Gusty move you say. Pre meal my BG was 89….took my basic 8 units….one hour later my BG was 92. Amazing.

Morning FBG is 88.  No more testing on the dosing times. It is now standard procedure that I dose 10 minutes after my meal begins.

This mornings FBG was 89.  OK I’m convinced on the dosing 10 minutes after starting a meal. It appears to be the ticket.”

Here is another Afrezza user’s comment regarding timing of Afrezza dosing:

“Today’s results— 84 before lunch, ate a salad, vegetables, and a Hawaiian chicken sandwich on a ciabatta bun (only ate half the bun because last time I ate a whole one I shot up pretty high).

8u at 30 minutes this time (delayed longer than usual because a lot of fat in the salad toppings and dressing).

84 at start, 92 at 1 hour. 107 at two hours.”

Here is another comment from the same Afrezza user regarding timing :

“I have a very nice wrist watch… It has a dive timer on it, which just means the circular ring surrounding the bezel can twist to different numbers from 0-60. When I bolus, with novolog, I set it to zero when I bolus– then I eat when it gets to 20. When I bolus With afrezza, I eat at zero and pretty much do the opposite. The watch timer has been part of my program all along…. I literally don’t feel comfortable eating, at all, without this watch on because it has just become a fundamental part of the process to me… I’m a little quirky about it but it works for me.”

Dosing Aggressively

Here is a comment from Jeremy H. Pettus, MD, regarding dosage:

Based on clinical experience, 4 unites of Afrezza is roughly equivalent to 2.5 units of SC insulin.  [slide 77 of the presentation].

Here is a comment from an Afrezza user regarding dosage:

From my experience (and that of some of my colleagues), they have about half the potency of injected insulin, so they can be treated as 2, 4 and 6 units.

Here is a comment from an Afrezza user regarding dosage:

I just ordered more Afrezza and am pretty much ready to ditch the 4’s altogether. They do very little for me. On the other hand I love the new 12’s! Perfect for corrections or large carb meals. I noticed it’s just not the same taking two separate cartridges than one of the same equal dose. It’s weird but taking one 8 then an immediate 4 does not do the same as one 12.

Since they now have the 60 count each of 4,8,12 I just got that since one NDC costs less.

One thing for me I noticed is if I take it before my blood sugar starts rising I can take much less. If I wait, it takes much more to counteract so 12 works better. I spike very easily though with food so I need more than most people I think. Afrezza is a godsend for me. You just have to experiment with how it works for YOU. I would have quit long ago if I only did 4’s like most do. But having a 300 bs, which is rare now thankfully, and being able to inhale a 12 and have it come down in 20-30 min is unbelievable. UNBELIEVABLE

CGM Helps in Dialing In and Gettiong Optimal Control

I have found the same rule also applies if a follow-up dose is required. It is important to have the follow-up dose before the levels begin to rise out of range. If I had a CGM with alerts, I would use this to notify me as soon as it levels began to increase. That way I wouldn’t miss the optimum time for the follow-up.

– Matt

Afrezza Units & Insulin:Carb Ratios

This video explains why insulin:carb ratios don’t work with Afrezza, no matter how hard you try.

Afrezza works so differently to previous insulins, and yet there is nothing on the box explaining how or why. It works so differently that for a while I wondered if I had a bad batch.

This video explains why the labelling on the box is unhelpful and confusing. The units just can’t be compared, and it takes a while to work out that Afrezza has two independent effects.

The first phase begins immediately but it doesn’t lower blood glucose, instead it temporarily stops it rising. This effect seems to be responsible for all the weird and wonderful properties of Afrezza, the first phase does not happen with previous insulins.

The second phase, however, works like a small dose of injectable insulin. It lowers blood glucose, and takes longer to start working. This is the only phase of Humalog or Apidra.  [Note that Dr. Steven V. Edelman pointed out in this video that dose for dose, 4-units of Afrezza is probably more like 2.5 units of RAA.]

Previous treatments work by flooding the body with an unnaturally high level of insulin for hours, in order to slowly lower high blood glucose levels. Afrezza stops blood glucose rising in the first place using the natural first phase signal instead. This means that much lower, natural levels of insulin can now occur for the first time in T1 diabetics.

– Matt

 Use Follow-Up Dose(s)

Adjusting Basal Dosage or Timing (or if necessary, Switching Basal )

Allow Time to Dial-In

Dial In Basal First

Here is an Afrezza user’s comment:

“Afrezza is not instead of basal. In fact, you have to be really stable with your basal in order to use Afrezza effectively. I have a pump for my basal, so I use Afrezza only for meals. With insulin from my pump or shots, if I eat carbs, they raise my blood sugar much faster than insulin can bring it down. Because Afrezza works immediately, I don’t have to worry about those highs. Tonight, I had pasta with vegetables and cheese, I had ice cream and I took 8 units of Afrezza, and my blood sugar was 145 two hours after dinner. If I’d used my pump for that meal, my blood sugar would have been in the 200s for a long time. In fact, I would not have eaten that meal if I had to use insulin from my pump or shots.”

Exercise Makes Afrezza More Effective

Here is an Afrezza user’s comment:

It works better (faster, stronger) when I take it and then walk or move around. If I sit on the couch it can be sluggish.

Mixing Afrezza and RAA may help in some circumstances

Here is an Afrezza user’s comment:

If I’m eating a long, slow meal or I’m at a barbecue or a party with endless snacks, then I find using a combination of Novolog and Afrezza works better.

Use Afrezza as a supplement to Oral Pills and Basal for Type 2s just for Correction worth consideration

Dr. Steven V. Edelman pointed out in this video that use Afrezza as a supplement to oral pills and/or basal for Type 2s just for corrections is worth consideration.

How to get rid of Dry Cough:

Here is an Afrezza user’s comment on this:

“The suggestion of drinking water sometimes before and sometimes after inhalation has worked wonders for me. My cough is essentially gone after inhaling Afrezza. I use it for all meal and correction boluses now and have zero constrictive cough.”

Here is another Afrezza user’s comment on this:

“[T]he recommendation to drink water before and after inhaling it… has actually been very helpful to me..”

For further discuss on this topic, see this article: Tips on Dry Cough.

Replacing Inhaler and Clear out Residue

Here is an Afrezza user’s question regarding replacement of inhaler: “How often do you replace the “whistle” dispenser? It looks like the recommended is 15 days. What about refrigeration? I ask because sometimes these restrictions are overkill.”

Here is an Afrezza user’s comment regarding this:  “that’s a good question… And kind of a poor concept on their part, because a “month supply” box of afrezza is never going to last exactly 30 days…. And there’s only two inhalers, so it’s never going to work out just right.

I’ve used the inhalers way, way past the 15 daysThey do get a lot of powder residue inside them over time, which can be cleaned up quite a bit just by tapping the inhaler mouthpiece on a hard surface… After you’ve used it a few days you’ll see that doing so knocks loose some powder that’s stuck inside.

From a practical standpoint id recommend just replacing your inhaler when your box is about half empty… And keep a used one as a spare in case you lose or break one.

There’s no good reason I’ve found to replace them every 15 days, I use them well past that.”

Positioning of Inhaler

Placement of CGM and Carrying Afrezza

Titration Package Saves on Co-pay and Reduces Prescription Confusion

Taking Afrezza when having a Cold

Additonal Tips

How To Use Afrezza Inhaled Insulin – This Is How I Do Diabetes – Tips & Tricks

Daniele Hargenrader / published on Jan 29, 2017

Afrezza Users talk about “Journey so far” on #Afrezza: Afrezza Users talk about “Journey so far” on #Afrezza

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