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Health: Inhaled insulin is back, but at what price?

Phil Mohler, M.D.
MOHLER’S MEDICATION MAXIMS

Remember Exubera, the first inhaled insulin that made a brief appearance a few years ago? It was the cock and fire device that resembled a Red Ryder BB gun. Exubera sales never got off the ground and Pfizer lost $2.8 billion before abandoning their innovative product. Exubera was not a user-friendly drug, as doses were in milligrams rather than units of insulin.

Now Afrezza!

Afrezza is a rapid acting insulin delivered by a dry powder inhaler. It comes in four unit and eight unit cartridges. Afrezza’s onset of action is 12 to 15 minutes with peak activity in about 60 minutes. Its duration is a little shorter than other rapid acting insulins.



Adverse effects of Afrezza

Afrezza has reported decreases in lung function as did Exubera. The average loss of volume is about three tablespoons over two years. Cough occurs in 29 percent of users. Afrezza is not recommended for diabetics who have asthma, COPD or those who smoke.



The Rules

Afrezza cartridges should be kept refrigerated. A sealed blister card is good for 10 days at room temperature. Patients are encouraged not to open the cartridges and not to swallow them. (Yes, the package insert really says that.) Afrezza should be at room temperature for 10 minutes before using.

Administration

Inhale Afrezza immediately before meals. It has no propellant; it is administered with a quick inhalation from the whistle-sized device.

Place in therapy

This is a mealtime insulin for patients who don’t like injections.

Cost

$226 for #90 4 unit cartridges (360 units) (63 cents per unit)

$280 for #30 4 unit cartridges and #60 8 unit cartridges (600 units) (46 cents per unit)

$200 for a 10mL vial of injectable rapid acting insulin (1000 units) (20 cents per unit)

My Take:

Is it worth two to three times as much to avoid mealtime needle sticks? One of the drivers of high cost medications (particularly oncology and diabetes drugs) is our unquenchable thirst for new drugs with very modest to almost no benefits.

In an editorial published February 2015, in The Journal of Clinical Oncology, Dr. Leonard Saltz from Memorial Sloan Kettering Cancer Center commented, “There is virtually no level above which we have been willing as a society to say, no, it does not make sense to spend that much money for that little benefit, and therefore we won’t do it. Drugs, and cancer drugs in particular, are unlike virtually all other goods and services because they are above discussion of, and indeed even consideration of, cost.”

Thank you to Steve Nolan, PharmD, for creating the nuts and bolts of this review. The skeptical commentary is all mine.

Free Press health columnist Dr. Mohler has practiced family medicine in Grand Junction for 39 years. He has a particular interest in pharmaceutical education. Phil works part-time for Rocky Mountain Health Plans. Email him at nancyandphilmohler@gmail.com.


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