What is the recommended dose of Afrezza (insulin human) for an adult with type 1 or 2 diabetes?

Afrezza Dosing Guidelines

Standard Dosing for Prandial Coverage

Afrezza is dosed in pre-filled cartridges of 4,8, or 12 units, administered via oral inhalation immediately before meals to provide rapid-acting prandial insulin coverage. 1

Initial Dose Selection

• For patients with type 1 diabetes: Start with 4 units inhaled at the beginning of each meal, then titrate based on postprandial glucose response 1
• For patients with type 2 diabetes: Begin with 4 units at the start of the largest meal, then expand to other meals as needed 1
• The dose must be rounded to the nearest available cartridge strength (4,8, or 12 units) 2

Dose Titration Algorithm

• Increase by one cartridge strength (4→8→12 units) if 2-hour postprandial glucose consistently exceeds 180 mg/dL 2
• Decrease by one cartridge strength if hypoglycemia occurs within 3 hours of dosing 3, 4
• Adjust every 3-7 days based on postprandial glucose patterns 2

Dose Conversion from Subcutaneous Insulin

When switching from subcutaneous rapid-acting insulin to Afrezza, expect to use approximately twice the total daily dose due to differences in bioavailability and absorption. 5

• If currently using 24 units/day of subcutaneous rapid-acting insulin, anticipate needing approximately 50-55 units/day of Afrezza divided among meals 5
• Round each meal dose up to the nearest cartridge for high-dose conversion (AH) or down for low-dose conversion (AL) 2
• The higher dose strategy (rounding up) produces better postprandial control with peak glucose of 195 mg/dL versus 208 mg/dL with lower dosing 2

Critical Pharmacokinetic Considerations

• Afrezza peaks at 40-60 minutes and has a duration of only 2-3 hours, significantly shorter than subcutaneous rapid-acting analogs 4
• This ultra-rapid action reduces early postprandial glucose excursions by 30 minutes but may require additional coverage beyond 2 hours 2
• Must be administered immediately before eating, not after meals 1

Mandatory Basal Insulin Requirement

Afrezza provides only prandial coverage and must always be combined with long-acting basal insulin in type 1 diabetes. 1

• Continue basal insulin (glargine, degludec, detemir) at approximately 40-50% of total daily insulin needs 5
• Do not use Afrezza as a substitute for basal insulin therapy 1

Absolute Contraindications

• Active smokers or those who quit within the past 6 months - causes acute bronchospasm 1, 3
• Chronic lung disease including asthma or COPD - risk of severe bronchospasm 1, 3, 4
• Diabetic ketoacidosis - not appropriate for acute metabolic emergencies 1

Mandatory Monitoring Requirements

• Baseline spirometry (FEV1) before initiating therapy 3
• Repeat pulmonary function testing at 6 months 3
• Annual spirometry thereafter for all patients on Afrezza 3

Common Adverse Effects

• Cough occurs in 24-33% of patients, typically dry and occurring within 10 minutes of inhalation 3, 4
• Cough usually subsides after several weeks of continued use 3
• Hypoglycemia risk is lower than subcutaneous rapid-acting insulin, particularly late postprandial hypoglycemia 3, 4
• Weight gain is less than with subcutaneous insulin 3, 4

Clinical Efficacy Data

• HbA1c reduction with Afrezza is 0.21-0.4% compared to 0.4% with subcutaneous insulin aspart 3, 4
• When compared to placebo, Afrezza reduces HbA1c by 0.8% versus 0.4% with placebo 4
• In combination with degludec over 30 weeks, 42% of patients achieved HbA1c <7.0% 5
• Time in range 70-180 mg/dL was maintained at 54% over 30 weeks of use 5

Ideal Candidate Profile

• Patients with frequent late postprandial hypoglycemia on subcutaneous rapid-acting insulin 4
• Those with needle phobia or skin reactions to subcutaneous insulin 4
• Patients seeking improved early postprandial glucose control during automated insulin delivery systems 2
• Adults with normal pulmonary function who are non-smokers 1, 3