II. Indications

  1. Type I and II Diabetes Mellitus
    1. Adjunct to Insulin therapy
    2. Third-line measure due to Hypoglycemia risk and cost

III. Contraindications

IV. Mechanism

  1. Pramlintide is a synthetic analogue of human Amylin
  2. Amylin is secreted with Insulin from Pancreas
  3. Amylin lowers post-prandial Blood Sugars
    1. Delays gastric emptying
    2. Inhibits glucago release

V. Dosing

  1. Protocol
    1. Reduce short and mixed-acting Insulin dose by 50%
    2. Use 100 unit 0.3 ml syringe
    3. Take with at least 250 calories (>30 g Carbohydrate)
  2. Type I Diabetes Mellitus
    1. Start: 15 mcg (2.5 U) SQ tid immediately before meals
    2. Titrated in 15 mcg increments q3-7 days
    3. Target: 30-60 mcg (5-10 units) SQ tid before meals
    4. Discontinue if significant Nausea
  3. Type II Diabetes Mellitus
    1. Start: 60 mcg (10 U) SQ tid immediately before meals
    2. Target: 60-120 mcg (10-20 units) SQ tid before meals
    3. Discontinue if significant Nausea

VI. Precautions

  1. Switch to new pen device which replaces the vials and prevents dosing errors
    1. Warning: Pen concentration is different than vial concentration
  2. Dosing errors are common with the vials
    1. Dosing is typically listed in mcg, but is drawn up in Insulin syringes marked with units
    2. A patient who mistakes their 30 mcg dose for 30 units is accidentally taking 180 mcg

VII. Adverse effects

  1. Nausea (28%) or Vomiting (8%): Especically Type I DM (related to Delayed Gastric Emptying)
    1. Contraindicated in Gastroparesis
  2. Headache (13%)
  3. Anorexia (9%)
  4. Abdominal Pain (8%)
  5. Severe Hypoglycemia (4.7%)
    1. Occurs 3 hours after Insulin and Pramlintide dose
    2. FDA Black box warning (decrease Insulin dose before starting)

VIII. Advantages

  1. Lowers weight 3 lb or 1.4 kg (Placebo: 0.6 kg gained)

IX. Disadvantages

  1. Nausea
  2. Severe Hypoglycemia (FDA black box warning)
  3. No good longterm outcome data (other agents with better longterm efficacy are preferred)
  4. Expensive (>$1000)

X. Efficacy

  1. Drops A1C 0.5 to 0.6% (contrast with Placebo: 0.25% )

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Related Studies

Cost: Medications

symlin (on 1/1/2017 at Medicaid.Gov Survey of pharmacy drug pricing)
SYMLINPEN 120 PEN INJECTOR $172.13 per ml
SYMLINPEN 60 PEN INJECTOR $261.39 per ml

Ontology: Pramlintide (C0537551)

Definition (NCI) A peptide analogue of human amylin with 3 proline substitutions at positions 25, 28 and 29, with antihyperglycemic activity. By mimicking amylin, pramlintide slows gastric emptying, inhibits digestive secretions (gastric acid, pancreatic enzymes, and bile), reduces glucagon secretion, and increases satiety; all of these actions are mediated mostly by glucose-sensitive areas in the brain stem. The overall result is a decrease in blood glucose levels. The use of pramlintide may cause an increased risk of insulin-induced hypoglycemia.
Concepts Pharmacologic Substance (T121) , Hormone (T125) , Amino Acid, Peptide, or Protein (T116)
MSH C105254
SnomedCT 416392006, 416425000
English pramlintide, PRAMLINTIDE, Pramlintide, pramlintide [Chemical/Ingredient], Triproamylin, Pramlintide (product), Pramlintide (substance)
Spanish pramlintida (producto), pramlintida (sustancia), pramlintida

Ontology: Symlin (C1174780)

Concepts Amino Acid, Peptide, or Protein (T116) , Pharmacologic Substance (T121) , Hormone (T125)
MSH C105254
English Symlin, Amylin Pharmaceuticals brand of pramlintide acetate