Thank you for an outstanding article on Afrezza. I have followed (NASDAQ:MNKD) for nearly six years. Iwrote a long thesis on MNKD last year, outlining reasons that other excellent SA writers (Marcelo Zinn's MCA) have mentioned. Further, I called Mannkind and I talked to CFO, Matt Peffer lastyear. I was impressed with what I heard, which confirmed my story. Please excuse my writing onthe first paper that I wrote for my grammar in that paper was subpar. I am not the type of person who would take the refuge under the umbrella that English was not my primary language. On the contrary, I've been working on my writing skills and I hope that it would improve ... so that I could express my thoughts to the retail investors more coherently.
Per your research, I noticed that you mentioned the scientific term "oxidative stress" quite a bitand I was wondering ... would you elucidate the concept in laymen terms to educate me, as wellas, some of the readers?
I am not going to paint a rose picture, as you could also see in my linkedin profile ... I always stick to the fact. I am a non-licensed Medical Doctor, a researcher, and what's not. I worked as aresident physician. Nowadays, I became a full writer and an investor for family reasons ... the reason that I would not have change one bit ... for my family/frinends have alway been my toppriority.
What I saw with my very own eyes was that the hundreds of patients that I treated, many of whomhave diabetes, are being treated by primary care docs (family physicians and internists) ratherthan the endocrinologists. Therefore, the key to getting Afrezza prescribed should be focusing onPCPs rather than endocrinologists as you seemed to state in your article per se.
I realized that many people who donot prescribe a single pill of medicine tend to "look down"on resident physicians ... full degree honored doctors, who completed at least 8 years ofvigorous/intense medical education/clinical training. The one who made it to medical school, asyou are quite familiar with, are the elite in your class. They are the cream of the crops in theirundergraduate/graduate classes ... in my opinion that I could speak for myself and not all ... notbecause they are any smarter than anyone else .... rather because they worked excruciatinglyhard and made many sacrifices (while their friends have weekends to enjoy) ... all for the bestinterest of the patients rather than for monetary gains. They would make much more deneiro working as fund managers or bankers. In addition, graduating from medical school takes evenmore pain and sacrifices than getting into the school itself. Since I had my master degree beside the MD, I had more shares of schooling/training ... a total of more than 10 years of bloody/sweats while having no supports or resources. I noticed that when I had a break from medical school or from work or like now ... I tend to double my portfolio in very short time, which is the equivalent to as if I would work for years as a resident physician.
Previously as a resident, I was hungry ... both for foodsand sleep .... and hungry for knowledge, for the opportunity to learn, to restore health to my patients, and the opportunity to seek the truth (not seeking alpha ... ast least not until now), ... I noticed that resident physicians outnumbered thefaculty physicians in all the hospitals that I worked at. As a result, when there's a new drugs ornew treatments, resident physicians are those who have to master the new drugs/devices on top of the conventional treatments modalities. The attending physicians had their shares of sacrifices already so they delegate all the hard works to residents, thus that even increases our roles whether a new drug would get prescribed. I myself am too stubborn to say no to any patients due to my personality so I had my fair shares of learning new procedures/drugs.
In stark contrast to your thesis, in reality resident physicians (MDs/DOs) do not go to internetforums as you mentioned for we have to work the 80 hours work week (until recent years before the changes in ACGME rule, we used to work more than 80hrs). Further, I rarely heard of attending physicians scouring internet forums for learning new treatments either. Lunch time isusually when we would go to conferences to listen to the experts guest speakers (MD/DO or PharmD themselves or other experts) either delivering their presentations or demonstrating theworking of various devices. It is true that when we were students, we would check SDN.net ... butI rarely heard residents or our attending docs scouring SDN or other forums on a consistent basisfor the fact as I mentioned ... we don't have the time. I have read comments from many anonymous alias (md in high paying specialities ... and what's not ... who spoke through the cloak of anonimity on SA. Nevertheless, I questioned whether that they have prescribed any medicine at all or whether they understand medicine in general). If I have not prescribe any medicine ... butrather my clinical skills are limited to the readings of papers, not talking to the physiciansthemselves, and imagine what they would do, then I would have come to similar conclusion as youhave.
While doctors, regardless if one has 10 years of experience or not, relies on evidence basedmedical guidelines. We'd go to UpToDate and/or reliable databses to check changes in thecurrently medical treatments protocols, and we would present to our colleagues sometime during confences ... like those M&Ms (Morbidity and Mortality sessions). After our initial reading of UTD and the guidelines, we would go to the appropriate sources on the articles for the studies asevidence to back up our practice pattern. If you are too familiar with UTD, I would recommendUTD for those who have not used it yet. It is a useful/powerful database for those who could readthe medical jargons ... which I despise. Nevertheless, UTD also have the abbreviated articleswritten in common language based on grades level so that most people could comprehend.
As for the other premise in your paper, though I might be wrong, I questioned the validity, as wellas, the practicality of using glucose excursions as an indicator for monitoring the status of diabetes mellitus. Forgive me Professor that I might missed what you've stated about "glucoseexcursion".... Would you break down the basic mechanisms why "glucose excursions" would bebetter predictor of diabetic complications like neuropathy, nephropathy, and etc.
In my opinion based on my actual care of the diabetic patients, I belived that it isimpractical/inconvenience for us MDs/DOs to employ glucose excursions in assessing/monitoring our patients' diabetes. Doing so ... would counter the "convenience factor"that I mentioned in my article regarding Afrezza. We physicians are heavily influenced by the "conveneice" factor for we have to cover tremendous number of patients. Conversely, I stronglybelieved that the standard of using hemoglobin A1c is still the best indicator for monitoringglucose .... not only for the fact that it's evidence based medical guidelines practice ... but also forreasons that lie in the fundamental principles of biochemistry itself ....
I am still long MNKD to-this-day. Nevertheless, I read one of the commenters, who pointed out afact that I overlooked in my research. In specific, I did not emphasize how Afrezza would affectthe pulmonary profile ... because I was too narrow focused on the fact that anti-asthmatic agents(delivered through the pulmonary system or lungs) like albuterol/ipratropium are widely prescribedand they indeed proved themselves as safe. The comment posted by the excellent SA writerprompted me to re-examine my thesis. When I am wrong about my thesis, I would admit it for nobody would be accurate all the time. As the seasoned investors know quite well, you could outperform the market given that you are right more than you are wrong. I am now cognizantof the fact that I was biased toward Afrezza ... Afrezza is still insulin and that it does not havesimilar biochemical properties with Albuterol, hence it does not confer the similar safety inpulmonary profile as albuterol does. By virtue of being an insulin, Afrezza is a growth agent. Itworks by helping the cells to express more receptors that translocate themselves to the cellularsurfaces pull in glucose inside the cell for metabolism/growth. Now, I might be wrong but thedelivery of a trophic or growth agent to lungs ... raise a red flag in my mind. Excessive growthcould lead to hyperplasia ... I would need to do further research on the cross-reactivity of IGFR vsInsulin Receptors, ... the binding of insulin and IGFs. I would have to examine their 3-Dstructures, dynamic, kinetics ... and what's not.
Despite what I would find, I would not short MNKD even if my long thesis might change for factthat I highly respect CEO Alfred Mann and CFO Matt Peffer. They are great human beings, who have done the good deeds for mankind (no pun intended) for me or anyone that I know of.
Once again, thank you for your excellent article, and I would appreciate if you would shed somelights for me and the readers with the regards to the aforementioned questions that I posted.
Hung V Tran, MD, MS
Disclosure: I am long MNKD.