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Symlin
Aka: Symlin, Pramlintide, Amylinomimetic, Amylin Analogue
- Indications
- Type I and II Diabetes Mellitus
- Adjunct to Insulin therapy
- Third-line measure due to Hypoglycemia risk and cost
- Contraindications
- Gastroparesis
- 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
- 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
- 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
- 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%)
- Occurs 3 hours after Insulin and Pramlintide dose
- FDA Black box warning (decrease Insulin dose before starting)
- Advantages
- Lowers weight 3 lb or 1.4 kg (Placebo: 0.6 kg gained)
- Disadvantages
- Nausea
- Severe Hypoglycemia (FDA black box warning)
- No good longterm outcome data (other agents with better longterm efficacy are preferred)
- Expensive (>$1000)
- Efficacy
- Drops A1C 0.5 to 0.6% (contrast with Placebo: 0.25% )
- References
- Jones (2007) Am Fam Physician 75:1831-5 [PubMed]
- Kruger (2004) Drugs 64: 1419-32 [PubMed]
- Kleppinger (2003) Ann Pharmacother 37:1082-9 [PubMed]
- Ryan (2005) Clin Ther 27:1500-12 [PubMed]
- Steinberg (2019) Am Fam Physician 99(4): 237-43 [PubMed]