II. Indications
- Type I and II Diabetes Mellitus
- Adjunct to Insulin therapy
- Third-line measure due to Hypoglycemia risk and cost
III. Contraindications
IV. Mechanism
- Pramlintide is a synthetic analogue of human Amylin
- Amylin is secreted with Insulin from Pancreas
- Amylin lowers post-prandial Blood Sugars
- Delays gastric emptying
- Inhibits glucago release
V. Dosing
- Protocol
- Reduce short and mixed-acting Insulin dose by 50%
- Use 100 unit 0.3 ml syringe
- Take with at least 250 calories (>30 g Carbohydrate)
-
Type I Diabetes Mellitus
- Start: 15 mcg (2.5 U) SQ tid immediately before meals
- Titrated in 15 mcg increments q3-7 days
- Target: 30-60 mcg (5-10 units) SQ tid before meals
- Discontinue if significant Nausea
-
Type II Diabetes Mellitus
- Start: 60 mcg (10 U) SQ tid immediately before meals
- Target: 60-120 mcg (10-20 units) SQ tid before meals
- Discontinue if significant Nausea
VI. Precautions
- Switch to new pen device which replaces the vials and prevents dosing errors
- Warning: Pen concentration is different than vial concentration
- Dosing errors are common with the vials
- Dosing is typically listed in mcg, but is drawn up in Insulin syringes marked with units
- A patient who mistakes their 30 mcg dose for 30 units is accidentally taking 180 mcg
VII. Adverse effects
-
Nausea (28%) or Vomiting (8%): Especically Type I DM (related to Delayed Gastric Emptying)
- Contraindicated in Gastroparesis
- Headache (13%)
- Anorexia (9%)
- Abdominal Pain (8%)
- Severe Hypoglycemia (4.7%)
VIII. Advantages
- Lowers weight 3 lb or 1.4 kg (Placebo: 0.6 kg gained)
IX. Disadvantages
- Nausea
- Severe Hypoglycemia (FDA black box warning)
- No good longterm outcome data (other agents with better longterm efficacy are preferred)
- Expensive (>$1000)
X. Efficacy
- Drops A1C 0.5 to 0.6% (contrast with Placebo: 0.25% )