We recently looked at two ways to deliver (in this case, inject) insulin: insulin syringes and insulin pens. While most people with type 1 diabetes are familiar with at least one of these methods, it’s natural to be curious about other options, especially if it means giving yourself fewer injections. Here’s where inhaled insulin and insulin pumps come in. Let’s take a look at both of these delivery methods.
In 2006, the first inhaled insulin was approved by the U.S. Food and Drug Administration (FDA) called Exubera. Jointly developed by Aventis and Pfizer, Exubera was found to be effective in lowering A1C in both type 1 and type 2 diabetes compared with a mix of regular and NPH insulins. For those with type 1 diabetes, Exubera was intended to replace injections of short- or fast-acting insulin (longer-acting insulin injections were still needed). Hailed as a medical breakthrough with predictions of more than $1 billion in sales, many hopes were place on this new insulin to replace the need for insulin injections.
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Despite the all the hype and promise, Exubera underwent its demise in 2007 for several reasons. From a health perspective, the insulin decreased lung function, affecting absorption and raising the risk of hypoglycemia or hyperglycemia; it was not appropriate for those who smoked or who had poorly controlled asthma or chronic obstructive lung disease (COPD); and it increased the risk of respiratory infection, coughing, shortness of breath and sore throat. Other drawbacks included a high price, challenges with dosing, and a large, bulky device that was inconvenient and indiscreet to use.
In 2014, Afrezza, the second inhaled insulin to be made available, was approved by the FDA for adults with type 1 and type 2 diabetes. Distributed by MannKind, Afrezza is a dry form of a fast-acting insulin. It’s delivered with a small, whistle-shaped device (much more portable than Exubera), and it starts to work within 12 minutes of inhalation. Once Afrezza is inhaled, it passes into the lungs and then into the bloodstream to lower blood glucose. It lasts anywhere from 1.5 to 4 hours, depending on the dose.
Afrezza comes in three strengths in the form of cartridges:
• 4 units
• 8 units
• 12 units
If your prescribed dose of mealtime insulin is more than 12 units, you need to use more than one cartridge. You can likely see that one of the challenges with using Afrezza is with the dosing: if you only need, say, two units of mealtime insulin, Afrezza won’t work for you. Likewise, if you are fine-tuning your mealtime insulin dose to match your carbohydrate intake and your calculations indicate that you need an odd number of units, Afrezza won’t help you be that precise with your dosing.
Afrezza isn’t intended for use by people who:
• Currently smoke or have recently stopped smoking (within 6 months)
• Have COPD
• Have asthma
• Are under the age of 18
It may not be appropriate to use if you have or have had lung cancer, or liver or kidney problems, as well.
Side effects of Afrezza include:
• Hypoglycemia (low blood sugar)
• Decrease in lung function (your doctor should check your lung function before starting and periodically thereafter)
• Possible risk of lung cancer
• DKA (diabetic ketoacidosis)
• Low potassium
• Allergic reaction
• Heart failure if also taking a diabetes pill called a thiazolidinedione (TZD)
Talk with your doctor if you’re interested in taking Afrezza. You’ll also need to check with your health plan about coverage. (According to the website GoodRx.com, a pack of 180 cartridges of 4 and 8 units costs approximately $972 to $1,050, and that’s with a coupon.)
Finally, if you have type 1 diabetes, remember that you will still need to inject your longer-acting (basal) insulin with a syringe or a pen, so injections aren’t completely eliminated from your insulin routine.
According to a study published in the journal Diabetes Care in 2018, 400,000 people with type 1 diabetes in the U.S. use an insulin pump, and 30% to 40% of those with type 1 use a pump and a continuous glucose monitor.
Insulin pumps are small, computerized devices that deliver insulin through a small cannula (tube) that’s inserted just below the skin. The pump delivers fast-acting insulin 24 hours a day, called the “basal rate,” mimicking how the pancreas works. You only use fast-acting insulin in the pump — no long-acting insulin is used. You can set up basal rates in your pump with the guidance from your doctor or diabetes educator; you may have multiple basal rates throughout the day and night. When it’s time to eat a meal or a snack, you program the amount of insulin, called a “bolus,” that covers the amount of carbohydrate you’ll be eating and also takes into account your blood glucose level at that time.
The pump is about the size of a deck of cards and is worn on the outside of the body. The insulin is delivered through a catheter that’s connected to a thin cannula. Many people wear their pump on the waistband of their pants or skirt or in a pocket; others wear their pump on an armband or even in their bra. One pump company, Insulet, makes a tubeless pump: this includes attaching a “pod” to the body that stores a three-day supply of insulin and contains a built-in cannula. The pod communicates wirelessly with a device called the Personal Diabetes Manager to program and deliver the insulin.
As with any type of insulin delivery device, there are pros and cons to pump therapy. First, the pros:
• More flexibility with your lifestyle, including food choices, timing of meals and level of physical activity
• More precise insulin delivery
• Improved blood glucose and A1C levels
• Less hypoglycemia
• Fewer blood glucose fluctuations
• Lower incidence of the dawn phenomenon
• Only one type of insulin that you have to use
Now, the cons:
• More time and effort upfront, learning how to use and troubleshoot the pump compared with learning how to give injections
• Risk of a skin infection at the insulin infusion set (catheter) site
• Higher risk of DKA compared with insulin injections
• More frequent blood sugar checks (unless you’re using CGM)
• Keeping a backup supply of insulin and syringes or pens in case of a clogged catheter or pump failure
The following insulin pumps are available in the U.S.:
• Insulet Corp. OmniPod
• Insulin Corp. OmniPod Dash
• Medtronic Diabetes MiniMed 630G System
• Medtronic Diabetes MinMed 670G System
• Tandem Diabetes Care t:slim X2 Pump
• Sooil Development Dana Diabecare IIS
Some insulin pumps are integrated with a CGM (continuous glucose monitor), as well. If you’re serious about becoming a “pumper,” talk with your doctor or diabetes educator about your options and spend some time exploring the pump companies’ websites, as well as type 1 communities — it always helps to learn what others think about a particular pump. Don’t forget to explore coverage from your health plan, too. Health plans generally don’t cover a new pump more often than every four years, so choose wisely. The good news is that pump companies have a return policy; if you’re unhappy with the pump, you will likely be able to return it within 30 days of the shipping date.
While insulin pumps continue to grow in popularity and use, they’re not necessarily right for everyone. A lot goes in to learning how to use the pump, and being a pump wearer involves time and commitment. How do you know if a pump is right for you? Ask yourself the following questions:
• Are you willing to check your blood sugar levels at least four (likely more) times a day?
• Are you willing to share your glucose data to help your diabetes team determine and adjust your basal rates and bolus doses?
• Are you willing to count carbohydrates and keep track of your carb and food intake?
• Are you willing to commit to the time it takes to get properly trained on use of the pump?
• Do you have a diabetes team who will teach you how to use the pump and give you ongoing, proper guidance?
• Are you willing to keep regular appointments with your diabetes team?
• Are you willing to wear or carry a piece of hardware with you at all times, including when you’re sleeping?
• Are you willing to have a backup plan in case of pump failure?
Obviously, deciding to use a pump requires a lot of thought, homework and discussion with your health-care team — and possibly others who are using a pump. Keep in mind that if you decide to use a pump but decide you want to take a “pump vacation” down the road, that’s fine — you can transition back to injections and then restart the pump at another time. In other words, the decision to use a pump is not a permanent one.