Inspiration And Expert Advice: Expert Columns
Ask an Expert: About Inhaled Insulin
June 4, 2007
R. Keith Campbell, RPh, CDE is a Distinguished Professor of Pharmacy at Washington State University College of Pharmacy, Pullman, WA and a past recipient of the American Association of Diabetes Educators Distinguished Service Award. He talked to dLife about Exubera’s approval and the future of inhaled insulin.
dLife asks: Exubera inhaled insulin has been approved for use in type 1 (in conjunction with long-lasting insulin) and type 2 adult patients (either with or without long-lasting insulin and/or oral meds). In your opinion, who will benefit the most from Exubera’s approval?
R. Keith Campbell responds: “Patients who require insulin before meals should be candidates for pulmonary insulin. Remember the basal/bolus concept of insulin delivery. Patients need a little bit of insulin coming into their system constantly. This is called the basal insulin. Lantus (Insulin glargine) is a great basal insulin. Then patients need a bolus of insulin with or before meals to handle the food that they eat. The pulmonary insulin will be able to be used as a bolus insulin and can be inhaled rather than injected. I use an insulin pump that gives me a little bit of insulin 24 hours a day and then I bolus the amount of insulin I need to handle the carbs that I will eat at a meal. This simulates what happens in people who do not have diabetes.”
“Note also that I believe that lung function tests need to be done and pulmonary insulin should be avoided in the few people who have poor lung function. Patients will need to be trained to use pens or syringes in case they get a cold or lung infection. Finally, patients will need to self-monitor their blood glucose levels often and after they inhale the insulin and then eat.”
dLife: Can you achieve the kind of tight control that multiple daily injections or a pump allows many to achieve using inhaled insulin?
RKC: “The studies show that with frequent monitoring, patients can take enough insulin to manage their blood sugars using the pulmonary device and get good results. Remember again that a basal insulin injection will need to be taken by most patients. I have always personally wondered if the same amount of pulmonary insulin would be able to be administered in small doses to keep blood sugars normal or near normal.”
dLife: Do you think the big media buzz around the approval of Exubera inhaled insulin is a good thing for the diabetes community?
RKC: “Yes and no. I like news to the general public about diabetes that increases patient and public awareness. But we have become a headline-only news country and the details of any announcement which could really impact patients are often not read or are not readily available to patients.”
“Pulmonary insulin is possibly a big deal. It depends on each individual patient and his/her needs, insurance coverage, the price of the product, lung function tests, etc. Exubera is the first pulmonary insulin to get FDA approval. That is good and it is newsworthy. The product has been in clinical trials for many years. It is a big device and is a bit difficult to carry around. Because it only gets 10% of the insulin absorbed, it is slightly more expensive when compared to insulin shots or insulin pens. I personally think it is a big breakthrough in terms of insulin delivery and is quite safe for use in most patients needing insulin who have good lung function. Exubera can manage blood glucose levels well. But I do think that there are much better products in development stages.
dLife: Are there any side effects to Exubera that patients should be aware of?
RKC: “Anyone taking insulin needs to be aware that low blood sugars can occur so blood testing is essential – as it is with all good treatment options for diabetes patients. The studies show that many patients develop a bit of a cough with the pulmonary insulin. It took a long time to get this approved because they wanted to be almost completely sure that there would not be any long-term effects on the lungs and the ability to breath. So far, things look good there.”
dLife: What other inhaled insulin products are in the pipeline? Can you speak to any of the benefits/drawbacks these may have in comparison to Exubera?
RKC: “There are two products that I am familiar with. Mannkind’s Technosphere product is a small (size of a deck of cards), well designed, efficient product that gets up to 50% absorption of insulin whereas Exubera gets around 10%. Its main advantage is that it gets into the system and then out within 2.5 hours and people just do not get low blood sugars with it. I am really impressed with it Al Mann, who developed it, is the same man who started MiniMed insulin pumps. The other product I have heard about but have not yet seen is the one being developed by Eli Lilly and a company called Alkermes.”