July 15, 2006

Figured out Comments - and Comments on the Comments

Apologies to those of you who posted comments that never appeared. I didn't realize I had to approve each one. They're visible now.

A few thoughts in response to the comments.

1. Re A1c: I controlled with diet for many years before starting insulin. I did not find the A1c a good guide at all, because my diabetes was characterized by very high post-meal readings, but near normal fasting values. As a result, my A1cs were often only slightly elevated while my blood sugar, for many hours a day, was high enough to do significant damage. This, it turns out is a common pattern among women who die of heart attacks. I've got some pointers to the Rancho Bernardo study that discovered this pattern on the "What they Don't Tell You About Diabetes" site.

It's also significant that two studies of neuropathy in people with non-diabetic blood sugars found no correlation between incidence of neuropathy and A1c, but a clear relationship between 2 hour glucose tolerance test result and neuropathy. So here too, post-prandial levels are much more indicative of early damage than A1c. All this is documented at the "At what blood sugar level does organ damage occur" page on the phlaunt.com site.

Finally, just this week, Diabetes in Control reported that the ADA is now saying that an A1c of 5.8% indicates a possibility of diabetes and should be screened. My endo told me that in her experience 5.7% is almost always diabetic! But most family doctors won't even mention diabetes until you are nearing 7%!

2. Byetta: I have heard very good things about Byetta, most notably from someone with a very similar kind of diabetes to what I have who is getting excellent results. However, I have a long history of getting bad side effects, some permanent, with common drugs, so I felt it would be smart to wait until there was more data available on Byetta use, long term. Since my current regimen is working very well, there's no hurry.

3. What if Exubera turns out not to harm lungs. Is it great then? No. Not unless they can come up with a dosing mechanism that allows finer titration. As I told the Business Week editor, I often dial in my dose to 1/2 a unit. An bolus insulin delivery system that has 3 units as the smallest increment is going to be useless for anyone who is insulin sensitive. Beyond that, since 2 mg isn't the same effective dose as 2 times 1 mg, according to what I've read, even an IR type 2 is going to have trouble figuring out how to match this stuff to meals.

There's a buccal insulin in the pipeline (absorbed via the cheek membrane) that would not have the lung issues and might be more easily dosed. That could be helpful. But we'll have to see what it really does. I don't trust any of the PR you read before the drug company has to put together something that has legal standing. And even there, I've read enough Prescribing Information to see the statistical tricks they pull to make their product look more effective than it is!


Anonymous said...

The exubera doses come in both 1- and 3-unit blisters, so you can theoretically administer insulin to the nearest unit. Lung deposition is still a bit shaky however, depending, among other things, on how deeply one inhales. This non-uniformity in drug deposition and therefore drug absorption will unfortunately plaque oral/buccal delivery as well. When you spray something into your mouth, it can land on any combination of tissue types, saliva, and mucous. All of these will facilitate or hinder absorption at different rates and therefore reduce the reliability of administration. Delivery technologies are working to mitigate these issues, but it is no small hurdle.

Jenny said...

Nope. The Exubera comes in 1 and 3 MG blisters. Milligrams not Units. That's a big difference. And the 3 mg is not equivalent to 9 units, but something less.

The 1 mg blister is supposed to be equivalent to 3 units of R. Which is all the more confusing as most doctors now prescribe H which is 1/3 more powerful than R.