09 January 2007

The first day of the day before yesterday...

It would figure that on the day that I actually have to concentrate on everything else all sorts of fun things start going on in the world! That said, those fun things will get looked at when I get time. And what, pray tell, is more important than al Qaeda in Somalia finding itself being dealt with at the hands of a Specter or a large stronghold of insurgents getting themselves in the bullseye in Baghdad and Balad Ruz, Iraq or going after an Iranian bank's assets or even the latest i-Toy? Well, nothing that important to the populace at large, that is for certain.

Today I get to start on Exubera.

I have gone over this before, but the basic part of this is that 'what everybody knew' was that insulin would not get absorbed by mucus membranes or through the lung lining. I mean, that is so dead simple and easy to think of that it surely must have been checked out to an extreme by the entire medical and pharmaceutical community. Because that would only require, well... what? 1950's technology? 1930's? To do structural analysis of the actual insulin molecule you have to crystallize it, and turning that into a very fine powder is just a mechanical process which has been around for decades if not longer. Crystallizing insulin to study it and have a good way to transport it dry has likewise been around for a long time. And folks have been taking inhaled medications and such for at least a century or two, even the stuff that isn't smoke or fumes.

But, no, it takes an incredibly high tech era to do something that simple. After waiting to ensure there were supplies of it available, I got the referral for a lung capacity test, then the kit and got the 2 minute training from my specialist. Here is what the actual device looks like:
Doesn't look like very much, does it? No fancy blinking lights, no automated anything, no USB dongle... pretty humdrum to say the least.

The center part is the device closed, the right it is open and ready to inhale from. On the far left is the every two-weeks disposable puncture device/aerator that sits inside the main part of the device and your first kit has two of those as replacements along with the one already in the device.

The crystalline insulin that has been powdered comes in sturdy blister packs clearly labeled 1mg and 3mg. The device itself, as seen by the hand grip, is not over large, about the size of a one handed flashlight.

You take your dose starting at body mass, and then as you use the stuff over time you start to adjust up or down based on its effectivity with meals. This is a replacement for short-acting insulin of the humalog variety, like Lispro. Its uptake curve is a bit flattened from Lispro but it hangs in the system longer just like human insulin. Because it *is* human insulin. The air chamber needs cleaning every so often and is NOT dishwasher safe.

It is a simple system to use, actually. Ten minutes before you are to eat a meal, you lift up the clear tube until it locks in place, press the gray button to let the blister pack insert door down, insert the blister pack with the blister side down, pull the handle up, ensure the mouth piece is in the closed position, exhale as you squeeze the grip slowly closed, then press the button on the reverse side, watch the pretty white fog in the tube, turn the mouthpiece to open, slowly inhale, and then hold that breath for 5 seconds then exhale. Remove spent blister pack, release the tube, slide it down and you are done. That is your humalog insulin that you have just taken. Due to body mass and meal size you may need to take two blister packs worth.

I have had no ill reactions to it, and unlike an earlier inhaler I had for exercised induced asthma as a teen there is no grittiness to this powder, there is no taste, *nothing*. I started with one of my more minimal meals for lunch and now have a larger size meal and will do my standard 2 hour after meal test to see how it is doing. So far, so good.

The big thing to watch out for is low blood glucose level.

From what my specialist tells me this has two major advantages over injected humalog:

1) Taken right before a meal, it will prevent the liver from signaling for a glucose release to help start the digestive process. That is why you have to only take in small amounts if you have been starving for days or weeks: a sudden insurge of calories can kill you as your body removes fat and turns it into blood sugar to get the digestive processes going. Diabetics have far less to worry about on that score, and keeping glucose levels stable is the name of the game.

2) Even though it is real human insulin, it will also tend to stick around in the major arteries in the liver. This is important as it can reduce the need for basal or long-lasting insulin. There is still a need for that with this system, but reducing that is all to the good in the long run. It is no guarantee that you will need less, but a 10% decrease is not uncommon and my doctor has seen a 20% drop with one patient.

So now I get other things to do for awhile, although it doesn't take much time to ensure that things are going properly it does take some of the limited, long term attentiveness at my disposal away from looking at the world so that I am keeping tabs on my physical self. Better management of my blood glucose levels *and* eliminating four or so injections per day is a great, great boon. I expect that in the next year or so the inhaler will get smaller, the blister packs more available and longer lasting insulins also reformulated to this system.

A cure would be wonderful.

A safe, effective, pain-free management system will do until then.

And the next time someone effusively praises modern medicine and pharmaceuticals, remind them that this has been sitting on the shelves and it would never work because 'everyone knew' it wouldn't.

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