Studies in Inhaled Insulin for Type 2 Diabetes

Natalie Bellini, DNP, FNP-BC: Let’s change the topic and talk a little bit about inhaled insulin in both the pediatric realm as well as [type 2 diabetes].

Diana Isaacs, PharmD, BCPS, BCACP, BC-ADM, CDCES: I’d love to.

Natalie Bellini, DNP, FNP-BC: Pediatrics is amazing. The peds studies are ongoing, and they are recruiting as we speak.

Diana Isaacs, PharmD, BCPS, BCACP, BC-ADM, CDCES: That would be great if this had approval in the pediatric population where we know that we need all the tools we can get because it’s a very challenging population in which to get to time-and-range and glucose targets. Another novel area that is starting to be studied is the combination of insulin pumps and automated insulin delivery. You might be thinking, why do you need that? You have automated insulin delivery, so isn’t that supposed to do everything? Remember the kinetics of the insulins that go into insulin pumps is not physiologic, and so what’s happening is that people are still required to bolus. Do you think people remember to bolus all of the time? No, but also timing is challenging. You need to pre-bolus, and in real life, that is hard to do all of the time. This inhaled insulin would offer an additional tool to be able to bring glucose down really, really quickly, or to be able to give at mealtimes without as much planning in terms of having to remember to pre-bolus. I am fascinated and can’t wait to see what happens with that. People are using it off-label in these types of situations, but we need the clinical data and the randomized control trial data to see how effective it really is. Where do you think this fits in with type 2 diabetes?

Natalie Bellini, DNP, FNP-BC: In type 2 diabetes, a lot of the algorithms say that you start basal insulin, then give mealtime insulin at the largest meal, in conjunction with a diet program and an exercise program and all of those other things. A lot of people in the United States eat 1 big meal a day and then 2 very small meals, or sometimes only 1 meal. We want to focus on that first meal as the biggest meal of the day with patients with type 2 diabetes. This fits beautifully within that because that way a patient can eat whenever that is, whether they have lunch 1 day and that’s their biggest meal, or dinner the next day and that’s their biggest meal, so they can use inhaled insulin. If we start to see challenges with their second biggest meal of the day, we add it to their second biggest meal. That’s how we are using it in our practice.

Diana Isaacs, PharmD, BCPS, BCACP, BC-ADM, CDCES: The guidelines recommend either starting with 4 units, generally that’s what the people injected, or 10% of the basal dose. The dose the person’s on can serve as a guide, so maybe you’d start at 4 or 8 units. One of the things I want to bring up is that it’s so common in type 2 diabetes that people are over basalized, and this is now in the guidelines, in the insulin algorithm. This is when someone’s on way too much background, long-acting insulin and clearly needs mealtime insulin coverage. There are a lot of barriers and therapeutic inertia to get there. One of the risks when this happens is that people experience hypoglycemia that goes unrecognized, such as overnight. One of the things we see is that they go to bed at 3 AM and wake up at 1 PM. You should not see a 200 [mg/dL] drop overnight, or any time of the day, without giving insulin. That’s a sign that the long-acting is too long. This offers an option to get people with type 2 diabetes onto mealtime insulin because I know sometimes that it’s intimidating when you suggest an additional injection to a person who doesn’t want to do more than 1 injection a day. This is a way to be able to do that without 4 injections. One other thing I want to bring up is that in type 2 diabetes, GLP-1 receptor agonists are very much recommended as the first injectable before insulin. We want to make sure that we’re optimizing GLP-1 receptor agonist first before adding on mealtime insulin.

Transcript edited for clarity