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Patient Information
I request that an Afrezza Trainer contact me to schedule product training to learn how to take and use Afrezza.


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To be completed by Healthcare Provider (HCP)

I certify that this therapy is medically necessary and that this information is accurate to the best of my knowledge. I authorize MannKind Corporation and any wholly
owned subsidiary, subcontractor, assignee, or affiliate entities (collectively, “MannKind”) that operate its patient support hub, as well as its patient onboarding or
training of its products, including Afrezza and FEV1, to use and disclose the patient information herein contained to the patient’s insurers and pharmacies, to patient
training providers, and to obtain information, including protected health information (as defined in 45 CFR § 160.103), from the patient, or from the patient’s insurer
or pharmacy, to facilitate dispensing as well as the patient’s enrollment and participation in services offered by MannKind in a manner consistent with the HIPAA
minimum necessary standard. I authorize MannKind to contact the patient to report insurance coverage information, to inform the patient about the financial
assistance programs offered by MannKind, and to obtain any patient consent(s) that may be necessary to support the patient’s treatment with MannKind as
prescribed by me.

WARNING: RISK OF ACUTE BRONCHOSPASM IN PATIENTS WITH CHRONIC LUNG DISEASE. Acute bronchospasm has been observed in patients with asthma and COPD
using AFREZZA. AFREZZA is contraindicated in patients with chronic lung disease such as asthma or COPD. Before initiating AFREZZA, perform a detailed medical
history, physical examination, and spirometry (FEV1) to identify potential lung disease in all patients.

Please see Brief Summary of Prescribing Information for AFREZZA, including BOXED WARNING accompanying this form. FULL Prescribing Information including
MEDICATION GUIDE and INSTRUCTIONS FOR USE (IFU) can be found on www.afrezzahcp.com.

Training Requested:








Step 1


Step 1

Take Prescribed Afrezza Dose






Fillable Table


BREAKFAST LUNCH DINNER SNACK
Units Units Units Units







Step 1


Step 2

Check Blood Glucose






Fill in the Blanks



hours after the start of the meal, check your blood glucose* to see how Afrezza is working for you







Fill in the Blanks


Target After-Meal Blood Glucose

to

mg/dl


*American Diabetes Association suggests 1-2 hours after the start of the meal.1





Step 1


Step 3

Give a Correction Dose, if Needed






Fillable Table


AFTER-MEAL BLOOD GLUCOSE CORRECTION DOSE
Blood glucose greater than mg/dL Take units
Blood glucose greater than mg/dL Take units







Step 1


Step 4

Adjust Dose, if Needed






Fillable Bullet Points


If you require treatment for low blood glucose OR correction doses for high blood glucose for or more days, consult your HCP to consider adjusting your prescribed Afrezza dose
Continue adjusting dose until your after-meal blood glucose is consistently within your target



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Read more

What is AFREZZA?

Read more

Important Safety Information

What is the most important information I should know about AFREZZA? AFREZZA can cause serious side effects, including:

Sudden lung problems (bronchospasms). In a study, some AFREZZA-treated patients with asthma, whose asthma medication was temporarily withheld, experienced sudden lung problems. Do not use AFREZZA if you have long-term (chronic) lung problems such as asthma or chronic obstructive pulmonary disease (COPD). Before starting AFREZZA, your healthcare provider will give you a breathing test to check how your lungs are working.

 

Important Safety Information(cont’d)

Who should not use Afrezza®?

Do not use Afrezza® if you:

  • Have chronic lung problems such as asthma or COPD.
  • Are allergic to regular human insulin or any of the ingredients in Afrezza®.
  • Are having an episode of low blood sugar (hypoglycemia).

What should I tell my healthcare provider before using Afrezza®?

Before using Afrezza®, tell your healthcare provider about all your medical conditions, including if you:

  • Have lung problems such as asthma or COPD
  • Have or have had lung cancer
  • Are using any inhaled medications
  • Smoke or have recently stopped smoking
  • Have kidney or liver problems
  • Are pregnant, planning to become pregnant, or are breastfeeding. Afrezza® may harm your unborn or breastfeeding baby.

Tell your healthcare provider about all the medicines you take, including prescription and over-the-counter medicines, vitamins or herbal supplements.

Before you start using Afrezza®, talk to your healthcare provider about low blood sugar and how to manage it.

What should I avoid while using Afrezza®?

While using Afrezza® do not:

  • Drive or operate heavy machinery, until you know how Afrezza® affects you.
  • Drink alcohol or use over-the-counter medicines that contain alcohol.
  • Smoke.

What are the possible side effects of Afrezza®?

Afrezza® may cause serious side effects that can lead to death, including:

See “What is the most important information I should know about Afrezza®?”

  • Low blood sugar (hypoglycemia). Signs and symptoms that may indicate low blood sugar include:
    • Dizziness or light-headedness, sweating, confusion, headache, blurred vision, slurred speech, shakiness, fast heartbeat, anxiety, irritability or mood change, hunger.
  • Decreased lung function. Your healthcare provider should check how your lungs are working before you start using AFREZZA, 6 months after you start using it, and yearly after that.
  • Lung cancer. In studies of Afrezza® in people with diabetes, lung cancer occurred in a few more people who were taking Afrezza® than in people who were taking other diabetes medications. There were too few cases to know if lung cancer was related to Afrezza®. If you have lung cancer, you and your healthcare provider should decide if you should use Afrezza®.
  • Diabetic ketoacidosis. Talk to your healthcare provider if you have an illness. Your Afrezza® dose or how often you check your blood sugar may need to be changed.
  • Severe allergic reaction (whole body reaction). Get medical help right away if you have any of these signs or symptoms of a severe allergic reaction:
    • A rash over your whole body, trouble breathing, a fast heartbeat, or sweating.
  • Low potassium in your blood (hypokalemia).
  • Heart failure. Taking certain diabetes pills called thiazolidinediones or “TZDs” with Afrezza® may cause heart failure in some people. This can happen even if you have never had heart failure or heart problems before. If you already have heart failure it may get worse while you take TZDs with Afrezza®. Your healthcare provider should monitor you closely while you are taking TZDs with Afrezza®. Tell your healthcare provider if you have any new or worse symptoms of heart failure including:
    • Shortness of breath, swelling of your ankles or feet, sudden weight gain.

Treatment with TZDs and Afrezza® may need to be changed or stopped by your healthcare provider if you have new or worse heart failure.

Get emergency medical help if you have:

• Trouble breathing, shortness of breath, fast heartbeat, swelling of your face, tongue, or throat, sweating, extreme drowsiness, dizziness, confusion.

The most common side effects of Afrezza® include:

  • Low blood sugar (hypoglycemia), cough, sore throat

These are not all the possible side effects of Afrezza®. Call your doctor for medical advice about side effects.
You are encouraged to report negative side effects of prescription drugs to the FDA. Visit www.fda.gov/medwatch, or call 1-800-FDA-1088 (1-800-332-1088).

Please See Full Prescribing Information, including BOXED WARNING, Medication Guide and Instructions for Use for AFREZZA.


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