COMMENTARY

Teaching Patients How to Use Inhaled Insulin

Anne L. Peters, MD; Mark Harmel, MPH

Disclosures

January 31, 2019

Anne L. Peters, MD: Ever since I completed a research study using inhaled insulin, I found myself using it a lot more frequently. I realized that in doing this study, not only did I get used to it and how it worked in my patients, but I also developed a way to teach patients how to use it. I basically reduced the barriers to my using it, and now I use it often; therefore, I'm quite comfortable with it.

I wanted to share that experience with you and also have you learn from Mark Harmel, my diabetes educator, who is so good at teaching patients how to use it that it works quite effectively.

Inhaled insulin works as follows. You have a patient pick a dose; it comes in a cartridge of 4, 8, or 12 units. The patient takes the dose just before eating.

The insulin works very fast and it also goes away pretty quickly. It helps the patient really catch that first postprandial rise. If the patient's glucose level is high after eating, they can take another puff to bring down that blood glucose level. It doesn't cause the stacking phenomenon that you get with injected insulin.

When to Take It

Inhaled insulin is really good at the start of a meal. It's also a great correction insulin. My patients will use it after a meal—1 to 2 hours later if they have high levels—or when they're running high. For example, if a patient is on a sensor and he sees that his levels have been high all afternoon, he can take a puff of the inhaled insulin and his glucose level will come back down without going too low.

Inhaled insulin is an incredibly useful tool for my patients with diabetes. I use it in both type 1 individuals and people with type 2 diabetes who are on insulin.

The way I start patients is by having them pick one meal—usually dinner. I'm not a big believer in having a patient switch entirely to a different way [of taking insulin]. Obviously, patients stay on their basal insulin and I usually have them get used to taking it before dinner.

How Much to Take

Many patients may be nervous at first and they often don't take enough. They say, "Oh, I only need 4 units." Well, that's not true in most cases; they’ll need 8 or 12 units. I let them work up and then see the effects.

It's easy for patients who are on a continuous glucose monitor to see the effect of the inhaled insulin and see if their blood sugar is subsequently high. Those who are self-monitoring blood glucose with finger sticks can test an hour or two after a meal to see if they need a correction.

I'll start patients with taking it with one meal a day and then advance to more meals per day as they fit this into their routine. I see it as an exceedingly useful tool to add to what my patients already have for managing their diabetes. Some patients will use it often (for every meal), some patients use it for correction, and some patients use it for both.

The key to getting a patient to use inhaled insulin comfortably is in the teaching. I'm going to have Mark give you a lesson on how to teach your patients the correct way to use inhaled insulin.

Teaching Your Patients

Mark Harmel, MPH: Thank you, Anne. When I get study participants or patients in the clinic, the first thing I do is a lung test. We have to check and see if their lungs are healthy enough to use inhaled insulin.

We use this device that measures lung capacity to do the FEV1 test. There is a little cardboard tube that goes onto this device. The patient takes a deep breath and blows it out very quickly, and then we measure the reading on the front of the device. We put that into a CDC website calculator, and if their lung capacity is at 75% or more, they qualify to use inhaled insulin.

Next, you have to teach the patient how to inhale. There is this inhaler that's about the size of a whistle. You pop it open, and there are individual cartridges that you insert into the inhaler. You can see that there's a little point on the tip of one of them, and the tub that holds the powdered insulin is at the bottom. The tub goes down, you fit the point on the cartridge to the point on the inside of the inhaler, and then you snap it closed.

Once you close the inhaler, it's important to keep it level because the insulin will fall out if you tip it over. Take off the mouth guard, take a little sip of water, inhale smoothly and gently, hold it in your lungs for a few seconds, and then exhale. There's a video on the Afrezza website that worked wonders for some of my patients.

We also have to teach patients how to take care of the insulin. Inside the package, there are two folded pieces of paper. One of them has the typical drug warnings that are in many of your medications. Another paper has some nice illustrated instructions. There is also the refrigeration page. Just like your liquid insulin, you have to keep it refrigerated.

It could take a couple of days or a week before patients really get the hang of using inhaled insulin. Be conservative to start, and make sure that patients have their fast-acting glucose with them in case they use too much. They'll learn how to use it over time.

Many people find that they really like inhaled insulin as an option. Some people shift to it completely for mealtime use and others only use it occasionally. Your patients will find what's right for them.

Peters: Thank you very much for that, Mark.

If you feel comfortable with this, take the time to teach your patients, and have them watch the appropriate videos. You can teach your patients to quickly become experts in using inhaled insulin. Hopefully, it can help improve their outcomes.

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