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Medications

SYMLIN® (Pramlintide) is an injectable synthetic version (analog) of amylin, a hormone that is absent in people with type 1 diabetes and diminished in those with type 2 diabetes.

In a person without diabetes, a healthy pancreas releases two hormones in response to food intake-- insulin and amylin. People with type 1 diabetes, as well as many with type 2 diabetes, do not make enough insulin. In general, people who do not produce enough insulin also do not produce enough amylin at mealtimes. Because of the deficiency of both of these hormones, as soon as you eat, glucose from the food you eat enters your blood stream quicker than normal, causing your blood glucose to rise. Despite your best efforts, your blood glucose may still vary and peak too high, causing wide swings in your blood glucose control. Also, please read the related question about brittle diabetes, as there are many possible causes for being labeled as having brittle diabetes.

Dr. Steve Edelman, in the July-August 2005 issue of Diabetes Self-Management explained:

"Insulin works on the rate of glucose disappearance, allowing the cells of the body to absorb and use it. Amylin's role is to work in concert with insulin to limit the rate at which the glucose appears in the first place." He further elaborated: "Insulin has a very narrow therapeutic window. If you give too little, you have hyperglycemia, and if you give too much, you have hypoglycemia. There's not much room for error…(and) why there's the roller coaster."

How Does SYMLIN Work:

While I will provide the key points about SYMLIN, please be sure to visit the SYMLIN website for more details as well as to discuss this fully with your healthcare team.*

• Symlin is given at mealtimes, but it does not replace your daily insulin, although it may lower the amount of insulin you need, especially before meals.
• SYMLIN reduces the rise in your blood glucose after meals by doing the following:
  • It reduces the rate in which food leaves your stomach.
  • It suppresses glucagon secretion after meals, which will decrease the amount of glucose released from the liver.
  • It helps you feel more satisfied after meals, causing you to eat less, and possibly to lose weight.
  • It is always taken with insulin to help lower blood glucose levels during the 3 hours after meals.
  • Studies have shown that SYMLIN lowers A1C levels beyond what insulin alone could achieve, providing overall better diabetes control.

Who Can Use Symlin:

People with type 1 or type 2 diabetes who:

• Already use their insulin as prescribed, but still need better blood sugar control.
• Will follow their doctor's instructions exactly and will follow-up with their doctor often.
• Will test their blood glucose levels before and after every meal, and at bedtime.
• Understand how to adjust SYMLIN and insulin doses.

Who Should Not Use SYMLIN

Do NOT use SYMLIN if you:

• Have hypoglycemia unawareness (i.e. you cannot tell when your blood glucose is low)
• Have gastroparesis--- a stomach problem in which your stomach does not empty as fast as it should. For more information about gastroparesis, see the related answer at the end of this page.

Other considerations to discuss with your doctor:

• SYMLIN has not been studied in children.
• It is not known if SYMLIN can harm your unborn baby.
• It is not known if SYMLIN passes into breast milk.
• Since SYMLIN can slow down how other medications pass through your stomach, be sure to tell your doctor about ALL medications, including vitamins and herbal supplements you take, to see if you need to change the times you take certain medicines.

How Do You Take SYMLIN:

• The amount of SYMLIN depends on whether you have type 1 or type 2 diabetes. These specific dosages are provided on the SYMLIN website but should be confirmed with your healthcare team.
• Once you reach your recommended dose, you may need an adjustment in your long-acting insulin.
• Never mix SYMLIN and insulin-you must use different syringes for each of these medications, because insulin can affect SYMLIN when the two are mixed together.
• According to the patient medication guide on the SYMLIN web site, the way you inject SYMLIN is similar to the way you inject insulin--i.e. subcutaneously (under the skin), in the abdomen or upper thigh, at least 2 inches away from an insulin injection. SYMLIN should be at room temperature when injected.
• You inject it immediately before major meals and snacks. Major meals and snacks are defined as containing at least 250 calories or at least 30 grams of carbohydrates.
• Do NOT take SYMLIN if you do not plan to eat or you only eat a small meal containing fewer than 250 calories or 30 grams of carbohydrates.
• If you miss or forget a dose: wait until the next meal to take your usual dose at that meal.
• Do NOT take SYMLIN if you are sick or having a medical procedure and cannot eat your meal.
• Storage recommendations:
• • Refrigerate unopened vials. Keep opened (in use) vials either refrigerated or at room temperature (under 77 degrees F) for up to 28 days. Do not freeze vials.
  • Discard any vial that is out of date, has been frozen, has been left at above room temperature, or has been open for more than 28 days.

What Are the Side Effects of SYMLIN:

• The most important one is severe hypoglycemia, or very low blood glucose. This can occur-especially if you have type 1 diabetes-- even when SYMLIN is carefully added to your mealtime insulin therapy. This severe low blood glucose is usually seen within 3 hours after a SYMLIN injection.
• • Your doctor should advise you when starting SYMLIN to reduce your rapid-acting or short-acting insulin by 50 percent (including fixed-mix insulins such as 70/30).
  • Do not drive or operate dangerous machinery until you know how SYMLIN affects your blood glucose control. Discuss what other activities you need to avoid with your diabetes team.
  • Remember that alcohol may increase the risk of low blood glucose.
  • Always have fast-acting sugar or glucagon available to treat low blood glucose.
• Nausea is the most common side effect-more likely during the first weeks after starting SYMLIN. It usually doesn't last long, but it is very important to start SYMLIN at a low dose and increase it only as directed by your healthcare professional.
• Other side effects may include: decreased appetite, vomiting, stomach pain, tiredness, dizziness, or indigestion. Injection site reactions, including redness, minor bruising, or pain, are also possible.

Summary:

I have provided only the most important information. After you have reviewed this information, please talk to your healthcare team to see if it is right for you. While all these details may seem daunting, clinical trials have reported that many people feel better on SYMLIN and it has been speculated that it is due to the improved post meal glucose control as well as other aspects of post meal physiology that are still not clearly defined.

There have been many exciting advances in the past few years, and there are more on the horizon.

Should you decide to try SYMLIN, note that this is a prescription drug, and that you should obtain instruction and guidance from a trained healthcare professional.

You can read more details on the SYMLIN website, and you can enroll in the SYMLIN Support Program at: 1-888-SYMLIN1 (1-888-796-5461).

*Resources for this answer are from: The SYMLIN website, SYMLIN Medication Guide, Practical Diabetology, March 2006, and Diabetes Self-Management, July-August 2005.