The first time I took Afrezza––an inhalable fast-acting insulin––in public, it was at Wildair, a small, hip restaurant in Manhattan. I inhaled deeply into my lungs and waited. A guy seated nearby widened his eyes and said loudly, “Are you vaping?” The question pinged through the small restaurant, but I held my breath for ten seconds per the instructions. “Is she vaping?” he exclaimed again when I didn’t answer. The friend I was dining with took over: “No, she’s not. She’s taking insulin. It’s brand new. Isn’t that cool?” The young guy wasn’t quite as interested once he learned I wasn’t vaping, but he did share his squid-ink calamari with us.
Until Afrezza came along, I injected insulin with needles: dejectable tools that I had to use, clip and dispose of daily. I don’t know why I never went on a pump, but I didn’t. (Okay, fine. I didn’t want to have something that looked like an antiquated pager attached to me 24/7.) I was twelve-years old when I was diagnosed with Type 1 diabetes. In the hospital, the nurses taught me how to inject myself using an orange. For decades thereafter I stuck myself four times a day using the citrus technique. Change doesn’t come easy to all people with diabetes and I dug in my heels doing the same thing for three decades until early 2015 when I wrote about Afrezza for Wired.
I was the first patient my doctor prescribed Afrezza to and, after passing a lung capacity test, I skipped my way over to the pharmacy practically high-fiving strangers on the street. It was one of the few times in my life that I have been excited to have diabetes. (The other time was when I crossed the finish line cycling at Tour de Cure. Everyone cheered for me!)
While insulin formulations have evolved, its delivery method is unchanged: pumps or needles. Afrezza, invented by MannKind, a Connecticut-based pharmaceutical company, is the only inhalable insulin in existence. It’s actually been on the market once before. When it was first launched, about a decade ago, the apparatus to take the insulin was so giant and ill conceived that some likened it to a bong. (The smoking theme is entirely coincidental.) The bong situation didn’t help its adoption and soon the insulin vanished. Thankfully MannKind kept at it, tinkering with the formulation and the technology. The new inhaler is small enough to fit inside a jean pocket or my curled palm.
Afrezza is dried human insulin produced in a lab from recombinant DNA*. The powder is placed into carrier particles (called Technosphere particles) that are so small that once inhaled they can reach your deep lungs, which have the surface area of about half the size of a tennis court. That’s right. A tennis court. Afrezza is absorbed into my blood stream rapidly, peaks in about 12-15 minutes and is out of my system in about 30-45 minutes. It’s so quick that I almost always start eating before I take my insulin. Instead of fast-acting, you can consider Afrezza to be ultra rapid and because of that it more closely mimics the post-meal functions of a person without diabetes.
I think of every hike I’ve ever been on, every bike ride or long, rigorous activity where my old school “fast-acting” insulin was still doing its thing in my blood stream and because of that combination of effort, food and insulin, I had to eat a snack. Eating when I don’t want to is one of the worst things about diabetes and with Afrezza I have fewer low blood sugar events. Novolog, the “fast-acting” insulin I used previously, takes two hours to completely work in my system, a huge span of time I can no longer accept.
Afrezza comes in 4- 8- or 12-unit cartridges. I use the 4-unit cartridge, which is perfect for small low-carb meals. 4-units of Afrezza works out to about 20 grams of carbohydrates in my body. Of course not all carbohydrates are the same. Throw some pancakes with syrup at me and my insulin-to-carb ratio is going to blow up.
When I first learned about Afrezza, it seemed like it was the perfect stealth solution to taking insulin, but now that I’ve been taking it for over a year, I know that’s a mistake. The Afrezza device whistles on inhale. You know when you’re camping and it’s early in the morning and there’s that first person that wakes everyone up. They unzip their tent: ZZZzzzzzzip! It’s like that. I can keep it silent on a jet plane, but anywhere else and I get looks. It’s worth it.
Where once it was universally a secret, now everyone knows that I have diabetes. Today, when I have a meal, unless it’s with someone new, I’ll bring out my inhaler, give my friends a nod, and tell them to continue their story. I take my first inhale. They stop talking. They look at me. I am now in the diabetes zoo. I hold my breath. I look at them. Then I make some Pac-Man signals with my left hand. ‘Keep talking!’ I plead with my eyes.
Sometimes this works, sometime it doesn’t. One friend suggested I ask my dining partners to count to ten for me. I liked her idea, but figured it would get old fast. I don’t do nearly as good a job of taking deep inhales and holding my breath when I take Afrezza in front of people. So I’ve learned: privacy is best—focus. The instructions say one deep inhale. I take three. I like to be sure.
Today, my average blood sugar is 134 and my A1C is well under 7.0%. In many ways I feel liberated from this disease; even if it’s solely because I am doing something new. I’ve taken Afrezza while riding Citibike. I’ve taken Afrezza while running up the subway stairs. I’ve taken Afrezza while standing in line. Where once I hid it from prying eyes, now I’m here to answer your questions. Do you inhale? Why yes, yes I do.
Things I’ve learned about Afrezza along the way:
- 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.
- On the flip side, if I am too active and don’t have enough food in my body, the Afrezza will drop my blood sugar fast.
- Occasionally it’s unavailable at the pharmacy when I need it. This means I need to be better at planning.
- 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.
- Ditto Thanksgiving dinner.
- No matter how many times friends and family have seen you do it, it’s still a surprise.
* The short explanation is that scientists use bacteria to reproduce (grow) copies of human insulin (or other proteins) in the lab.
Photo by Zack Sheppard