Inhaled Insulin

Inhaled Insulin Brand Names- Afrezza | Exubera

What is Inhaled Insulin

Inhaled Insulin is a dry powder formulation of rapid-acting recombinant human insulin that is administered via oral inhalation.

Following pulmonary absorption into systemic circulation, metabolism and elimination are comparable to regular human insulin.

Inhaled insulin is rapid in onset and is used as prandial insulin. In 24-week studies of patients with inadequately controlled type 1 diabetes mellitus (DM), inhaled insulin has been compared to injectable insulin aspart. At Week 24, treatment with basal insulin and mealtime inhaled insulin provided a mean reduction in A1C that met the prespecified non-inferiority margin of 0.4%. Inhaled insulin provided less A1C reduction than insulin aspart, and the difference was statistically significant.

More subjects in the insulin aspart group achieved the A1C target of 7% or less compared to the inhaled insulin group (27.1% vs. 13.8%, respectively).

Inhaled insulin has been studied in patients with inadequately controlled Type 2 DM despite taking therapeutically maximized metformin monotherapy or 2 or more oral antidiabetic drugs (OADs).

At Week 24, treatment with inhaled insulin plus OADs provided a mean reduction in A1C that was statistically significantly greater compared to the inhaled placebo plus OADs group (-0.82% vs. -0.42%, respectively).

In the treatment of type 1 DM, insulin therapy may be initiated with a basal-bolus regimen and then further individualized to achieve treatment goals.

In the treatment of type 2 DM, insulin is generally reserved for patients who continue to have an A1C above target despite dual/triple therapy with metformin and other antidiabetic agents.

In patients who need the greater glucose-lowering effect of an injectable medication, GLP-1 receptor agonists (GLP-1 RA) are the preferred choice to insulin.

Evidence from trials comparing GLP-1 RAs and insulin (basal, premixed, or basal-bolus) shows similar or even better efficacy in A1C reduction; GLP-1 RAs have a lower risk of hypoglycemia and are associated with reductions in body weight compared to weight gain with insulin.

In patients who cannot tolerate a GLP-1 RA, or who fail to meet glycemic targets with dual/triple therapy, insulin therapy with basal insulin should be initiated and titrated to target.

If A1C remains above target, prandial insulin, such as inhaled insulin should be added. Consider an initial injectable combination (i.e., GLP-1 RA plus basal insulin or prandial/basal insulin) if A1C is greater than 10% and 2% above target.

Consider the early introduction of insulin if there is evidence of ongoing catabolism, if symptoms of hyperglycemia are present, or when A1C levels (greater than 10%) or blood glucose levels (300 mg/dL or more) are very high.

In patients who are starting on insulin therapy and are taking a thiazolidinedione or sulfonylurea, discontinue or reduce the dose of the oral medication

Indications

• type 1 diabetes mellitus
• type 2 diabetes mellitus

Equivalent Dose Chart – Subcutaneous Prandial Insulin vs. Afrezza brand Inhaled Insulin 

• Subcutaneous prandial insulin up to 4 units = Afrezza 4 units (one 4-unit cartridge)
• Subcutaneous prandial insulin 5 to 8 units = Afrezza 8 units (one 8-unit cartridge)
• Subcutaneous prandial insulin 9 to 12 units = Afrezza 12 units (one 12-unit cartridge)
• Subcutaneous prandial insulin 13 to 16 units = Afrezza 16 units (one 4-unit cartridge and one 12-unit cartridge)
• Subcutaneous prandial insulin 17 to 20 units = Afrezza 20 units (one 8-unit cartridge and one 12-unit cartridge)
• Subcutaneous prandial insulin 21 to 24 units = Afrezza 24 units (two 12-unit cartridges)

Side Effects

1. anaphylactoid reactions
2. antibody formation
3. blurred vision
4. bronchospasm
5. confusion
6. contact dermatitis
7. cough
8. diaphoresis
9. diarrhea
10. fatigue
11. headache
12. hyperinsulinemia
13. hypertension
14. hypoglycemia
15. hypokalemia
16. hypothermia
17. infection
18. insulin resistance
19. irritability
20. nausea
21. new primary malignancy
22. pallor
23. palpitations
24. peripheral edema
25. pruritus
26. sinus tachycardia
27. Somogyi effect
28. throat irritation
29. tremor
30. urticaria
31. vomiting
32. weight gain
33. wheezing
34. yawning

Monitoring Parameters

• blood glucose
• glycosylated hemoglobin A1c (HbA1c)
• pulmonary function tests (PFTs)

Contraindications

• acute bronchospasm
• asthma
• breast-feeding
• children
• chronic obstructive pulmonary disease (COPD)
• coma
• diabetic ketoacidosis
• diarrhea
• fever
• geriatric
• hepatic disease
• hyperosmolar hyperglycemic state (HHS)
• hypoglycemia
• hypokalemia
• infants
• infection
• lung cancer
• neonates
• new primary malignancy
• pregnancy
• pulmonary disease
• renal failure
• renal impairment
• surgery
• thyroid disease
• tobacco smoking
• trauma
• vomiting

Interactions

• Acebutolol
• Acetaminophen; Aspirin, ASA; Caffeine
• Acetaminophen; Caffeine; Magnesium Salicylate; Phenyltoloxamine
• Acetaminophen; Caffeine; Phenyltoloxamine; Salicylamide
• Acetaminophen; Chlorpheniramine; Dextromethorphan; Phenylephrine
• Acetaminophen; Chlorpheniramine; Dextromethorphan; Pseudoephedrine
• Acetaminophen; Chlorpheniramine; Phenylephrine; Phenyltoloxamine
• Acetaminophen; Dextromethorphan; Guaifenesin; Phenylephrine
• Acetaminophen; Dextromethorphan; Phenylephrine
• Acetaminophen; Dextromethorphan; Pseudoephedrine
• Acetaminophen; Dichloralphenazone; Isometheptene
• Acetaminophen; Guaifenesin; Phenylephrine
• Acetaminophen; Propoxyphene
• Acetaminophen; Pseudoephedrine
• Acetazolamide
• Acrivastine; Pseudoephedrine
• Aliskiren; Amlodipine; Hydrochlorothiazide, HCTZ
• Aliskiren; Hydrochlorothiazide, HCTZ
• Aliskiren; Valsartan
• Alogliptin; Metformin
• Alogliptin; Pioglitazone
• Amiloride; Hydrochlorothiazide, HCTZ
• Aminosalicylate sodium, Aminosalicylic acid
• Amlodipine; Benazepril
• Amlodipine; Hydrochlorothiazide, HCTZ; Olmesartan
• Amlodipine; Hydrochlorothiazide, HCTZ; Valsartan
• Amlodipine; Olmesartan
• Amlodipine; Telmisartan
• Amlodipine; Valsartan
• Amoxicillin; Clarithromycin; Lansoprazole
• Amoxicillin; Clarithromycin; Omeprazole
• Amphetamine
• Amphetamine; Dextroamphetamine
• Amprenavir
• Androgens
• Angiotensin II receptor antagonists
• Angiotensin-converting enzyme inhibitors
• Aripiprazole
• Articaine; Epinephrine
• Asenapine
• Aspirin, ASA
• Aspirin, ASA; Butalbital; Caffeine
• Aspirin, ASA; Butalbital; Caffeine; Codeine
• Aspirin, ASA; Caffeine; Dihydrocodeine
• Aspirin, ASA; Caffeine; Orphenadrine
• Aspirin, ASA; Carisoprodol
• Aspirin, ASA; Carisoprodol; Codeine
• Aspirin, ASA; Citric Acid; Sodium Bicarbonate
• Aspirin, ASA; Dipyridamole
• Aspirin, ASA; Omeprazole
• Aspirin, ASA; Oxycodone
• Aspirin, ASA; Pravastatin
• Atazanavir
• Atazanavir; Cobicistat
• Atenolol
• Atenolol; Chlorthalidone
• Atropine; Benzoic Acid; Hyoscyamine; Methenamine; Methylene Blue; Phenyl Salicylate
• atypical antipsychotic
• Azelastine; Fluticasone
• Azilsartan
• Azilsartan; Chlorthalidone
• Beclomethasone
• Benazepril
• Benazepril; Hydrochlorothiazide, HCTZ
• Bendroflumethiazide; Nadolol
• Benzoic Acid; Hyoscyamine; Methenamine; Methylene Blue; Phenyl Salicylate
• Benzphetamine
• Beta-blockers
• Betamethasone
• Betaxolol
• Bexarotene
• Bismuth Subsalicylate
• Bismuth Subsalicylate; Metronidazole; Tetracycline
• Bisoprolol
• Bisoprolol; Hydrochlorothiazide, HCTZ
• Bortezomib
• Brexpiprazole
• Brimonidine; Timolol
• Brompheniramine; Carbetapentane; Phenylephrine
• Brompheniramine; Dextromethorphan; Phenylephrine
• Brompheniramine; Hydrocodone; Pseudoephedrine
• Brompheniramine; Pseudoephedrine
• Budesonide
• Budesonide; Formoterol
• Bumetanide
• Canagliflozin; Metformin
• Candesartan
• Candesartan; Hydrochlorothiazide, HCTZ
• Captopril
• Captopril; Hydrochlorothiazide, HCTZ
• Carbetapentane; Chlorpheniramine; Phenylephrine
• Carbetapentane; Diphenhydramine; Phenylephrine
• Carbetapentane; Guaifenesin; Phenylephrine
• Carbetapentane; Phenylephrine
• Carbetapentane; Phenylephrine; Pyrilamine
• Carbetapentane; Pseudoephedrine
• Carbinoxamine; Dextromethorphan; Pseudoephedrine
• Carbinoxamine; Hydrocodone; Phenylephrine
• Carbinoxamine; Hydrocodone; Pseudoephedrine
• Carbinoxamine; Phenylephrine
• Carbinoxamine; Pseudoephedrine
• Carbonic anhydrase inhibitors
• Cariprazine
• Carteolol
• Carvedilol
• Cetirizine; Pseudoephedrine
• Chlophedianol; Dexchlorpheniramine; Pseudoephedrine
• Chlophedianol; Guaifenesin; Phenylephrine
• Chloroquine
• Chlorothiazide
• Chlorpheniramine; Dextromethorphan; Phenylephrine
• Chlorpheniramine; Dihydrocodeine; Phenylephrine
• Chlorpheniramine; Dihydrocodeine; Pseudoephedrine
• Chlorpheniramine; Guaifenesin; Hydrocodone; Pseudoephedrine
• Chlorpheniramine; Hydrocodone; Phenylephrine
• Chlorpheniramine; Hydrocodone; Pseudoephedrine
• Chlorpheniramine; Phenylephrine
• Chlorpheniramine; Pseudoephedrine
• Chlorpromazine
• Chlorthalidone
• Chlorthalidone; Clonidine
• Choline Salicylate; Magnesium Salicylate
• Chromium
• Ciclesonide
• Cisapride
• Clarithromycin
• Clonidine
• Clozapine
• Codeine; Phenylephrine; Promethazine
• Codeine; Promethazine
• Colesevelam
• Conjugated Estrogens
• Conjugated Estrogens; Bazedoxifene
• Conjugated Estrogens; Medroxyprogesterone
• Corticosteroids
• Cortisone
• Cyclosporine
• Daclatasvir
• Danazol
• Dapagliflozin; Metformin
• Darunavir
• Darunavir; Cobicistat
• Darunavir; Cobicistat; Emtricitabine; Tenofovir alafenamide
• Dasabuvir; Ombitasvir; Paritaprevir; Ritonavir
• Dasabuvir; Ombitasvir; Paritaprevir; Ritonavir
• Deflazacort
• Desloratadine; Pseudoephedrine
• Dexamethasone
• Dexchlorpheniramine; Dextromethorphan; Pseudoephedrine
• Dexmethylphenidate
• Dextroamphetamine
• Dextromethorphan; Diphenhydramine; Phenylephrine
• Dextromethorphan; Guaifenesin; Phenylephrine
• Dextromethorphan; Guaifenesin; Pseudoephedrine
• Dextromethorphan; Promethazine
• Diazoxide
• Dienogest; Estradiol valerate
• Diethylpropion
• Diethylstilbestrol, DES
• Dihydrocodeine; Guaifenesin; Pseudoephedrine
• Diphenhydramine; Hydrocodone; Phenylephrine
• Diphenhydramine; Phenylephrine
• Disopyramide
• Dobutamine
• Dopamine
• Dorzolamide; Timolol
• Drospirenone
• Drospirenone; Estradiol
• Drospirenone; Ethinyl Estradiol
• Drospirenone; Ethinyl Estradiol; Levomefolate
• Edetate Calcium Disodium, Calcium EDTA
• Edetate Disodium, Disodium EDTA
• Elagolix; Estradiol; Norethindrone acetate
• Elbasvir; Grazoprevir
• Empagliflozin; Linagliptin; Metformin
• Empagliflozin; Metformin
• Enalapril, Enalaprilat
• Enalapril; Felodipine
• Enalapril; Hydrochlorothiazide, HCTZ
• Ephedrine
• Epinephrine
• Eprosartan
• Eprosartan; Hydrochlorothiazide, HCTZ
• Ertugliflozin; Metformin
• Erythromycin; Sulfisoxazole
• Esmolol
• Esterified Estrogens
• Esterified Estrogens; Methyltestosterone
• Estradiol
• Estradiol Cypionate; Medroxyprogesterone
• Estradiol; Levonorgestrel
• Estradiol; Norethindrone
• Estradiol; Norgestimate
• Estradiol; Progesterone
• Estramustine
• Estrogens
• Estropipate
• Ethanol
• Ethinyl Estradiol
• Ethinyl Estradiol; Desogestrel
• Ethinyl Estradiol; Ethynodiol Diacetate
• Ethinyl Estradiol; Etonogestrel
• Ethinyl Estradiol; Levonorgestrel
• Ethinyl Estradiol; Levonorgestrel; Ferrous bisglycinate
• Ethinyl Estradiol; Levonorgestrel; Folic Acid; Levomefolate
• Ethinyl Estradiol; Norelgestromin
• Ethinyl Estradiol; Norethindrone
• Ethinyl Estradiol; Norethindrone Acetate
• Ethinyl Estradiol; Norethindrone Acetate; Ferrous fumarate
• Ethinyl Estradiol; Norethindrone; Ferrous fumarate
• Ethinyl Estradiol; Norgestimate
• Ethinyl Estradiol; Norgestrel
• Ethotoin
• Etonogestrel
• Exenatide
• Fenofibrate
• Fenofibric Acid
• Fexofenadine; Pseudoephedrine
• Fibric acid derivatives
• Fludrocortisone
• Flunisolide
• Fluoxetine
• Fluoxetine; Olanzapine
• Fluoxymesterone
• Fluphenazine
• Fluticasone
• Fluticasone; Salmeterol
• Fluticasone; Umeclidinium; Vilanterol
• Fluticasone; Vilanterol
• Formoterol; Mometasone
• Fosamprenavir
• Fosinopril
• Fosinopril; Hydrochlorothiazide, HCTZ
• Fosphenytoin
• Furosemide
• Garlic, Allium sativum
• Gemfibrozil
• Glecaprevir; Pibrentasvir
• Glimepiride; Pioglitazone
• Glimepiride; Rosiglitazone
• Glipizide; Metformin
• Glucagon
• Glyburide; Metformin
• Green Tea
• Guaifenesin; Hydrocodone; Pseudoephedrine
• Guaifenesin; Phenylephrine
• Guaifenesin; Pseudoephedrine
• Hydralazine; Hydrochlorothiazide, HCTZ
• Hydrochlorothiazide, HCTZ
• Hydrochlorothiazide, HCTZ; Irbesartan
• Hydrochlorothiazide, HCTZ; Lisinopril
• Hydrochlorothiazide, HCTZ; Losartan
• Hydrochlorothiazide, HCTZ; Methyldopa
• Hydrochlorothiazide, HCTZ; Metoprolol
• Hydrochlorothiazide, HCTZ; Moexipril
• Hydrochlorothiazide, HCTZ; Olmesartan
• Hydrochlorothiazide, HCTZ; Propranolol
• Hydrochlorothiazide, HCTZ; Quinapril
• Hydrochlorothiazide, HCTZ; Spironolactone
• Hydrochlorothiazide, HCTZ; Telmisartan
• Hydrochlorothiazide, HCTZ; Triamterene
• Hydrochlorothiazide, HCTZ; Valsartan
• Hydrocodone; Phenylephrine
• Hydrocodone; Potassium Guaiacolsulfonate; Pseudoephedrine
• Hydrocodone; Pseudoephedrine
• Hydrocortisone
• Hydroxychloroquine
• Hydroxyprogesterone
• Hyoscyamine; Methenamine; Methylene Blue; Phenyl Salicylate; Sodium Biphosphate
• Ibuprofen; Pseudoephedrine
• Iloperidone
• Indapamide
• Indinavir
• Insulin Degludec; Liraglutide
• Insulin Glargine; Lixisenatide
• Irbesartan
• Isocarboxazid
• Isoproterenol
• Labetalol
• Lanreotide
• Ledipasvir; Sofosbuvir
• Leuprolide; Norethindrone
• Levobetaxolol
• Levobunolol
• Levonorgestrel
• Levothyroxine
• Levothyroxine; Liothyronine (Porcine)
• Levothyroxine; Liothyronine (Synthetic)
• Linagliptin; Metformin
• Linezolid
• Liothyronine
• Liraglutide
• Lisdexamfetamine
• Lisinopril
• Lithium
• Lixisenatide
• Lomefloxacin
• Lopinavir; Ritonavir
• Loratadine; Pseudoephedrine
• Lorcaserin
• Losartan
• Lovastatin; Niacin
• Lumateperone
• Lurasidone
• Macimorelin
• Magnesium Salicylate
• Mecasermin rinfabate
• Mecasermin, Recombinant, rh-IGF-1
• Medroxyprogesterone
• Meperidine; Promethazine
• Mepivacaine; Levonordefrin
• Mesoridazine
• Mestranol; Norethindrone
• Metformin
• Metformin; Pioglitazone
• Metformin; Repaglinide
• Metformin; Rosiglitazone
• Metformin; Saxagliptin
• Metformin; Sitagliptin
• Methamphetamine
• Methazolamide
• Methohexital
• Methyclothiazide
• Methylphenidate
• Methylprednisolone
• Methyltestosterone
• Metoclopramide
• Metolazone
• Metoprolol
• Metreleptin
• Metyrapone
• Midodrine
• Moexipril
• Mometasone
• Monoamine oxidase inhibitors
• Nadolol
• Nandrolone Decanoate
• Naproxen; Pseudoephedrine
• Nebivolol
• Nebivolol; Valsartan
• Nelfinavir
• Niacin, Niacinamide
• Niacin; Simvastatin
• Nicotine
• Norepinephrine
• Norethindrone
• Norgestrel
• Octreotide
• Olanzapine
• Olmesartan
• Ombitasvir; Paritaprevir; Ritonavir
• Orlistat
• Oxandrolone
• Oxymetholone
• Paliperidone
• Pasireotide
• Pegvisomant
• Pemoline
• Penbutolol
• Pentamidine
• Pentoxifylline
• Perindopril
• Perindopril; Amlodipine
• Perphenazine
• Perphenazine; Amitriptyline
• Phendimetrazine
• Phenelzine
• Phenothiazines
• Phentermine
• Phentermine; Topiramate
• Phenylephrine
• Phenylephrine; Promethazine
• Phenytoin
• Pindolol
• Pioglitazone
• Pramlintide
• Prasterone, Dehydroepiandrosterone, DHEA (Dietary Supplements)
• Prasterone, Dehydroepiandrosterone, DHEA (FDA-approved)
• Prednisolone
• Prednisone
• Prilocaine; Epinephrine
• Prochlorperazine
• Progesterone
• Progestins
• Promethazine
• Propoxyphene
• Propranolol
• Protease inhibitors
• Pseudoephedrine
• Pyrimethamine; Sulfadoxine
• Quetiapine
• Quinapril
• Quinolones
• Racepinephrine
• Ramipril
• Reserpine
• Risperidone
• Ritodrine
• Ritonavir
• Rosiglitazone
• Sacubitril; Valsartan
• Salicylates
• Salsalate
• Saquinavir
• Segesterone Acetate; Ethinyl Estradiol
• Sodium Polystyrene Sulfonate
• Sofosbuvir
• Sofosbuvir; Velpatasvir
• Sofosbuvir; Velpatasvir; Voxilaprevir
• Somatropin, rh-GH
• Sotalol
• Sparfloxacin
• Sulfadiazine
• Sulfamethoxazole; Trimethoprim, SMX-TMP, Cotrimoxazole
• Sulfasalazine
• Sulfinpyrazone
• Sulfisoxazole
• Sulfonamides
• Sympathomimetics
• Tacrolimus
• Tegaserod
• Telmisartan
• Testolactone
• Testosterone
• Thiazide diuretics
• Thiethylperazine
• Thioridazine
• Thyroid hormones
• Timolol
• Tipranavir
• tobacco
• Torsemide
• Trandolapril
• Trandolapril; Verapamil
• Tranylcypromine
• Triamcinolone
• Triamterene
• Trifluoperazine
• Valsartan
• Ziprasidone