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Question: When should primary care providers consider prescribing pramlintide (Symlin, Amylin) to their patients with diabetes?
Answer: The neurohormone amylin was long overlooked, yet much has been learned about it in the past few decades. It has several mechanisms of action, but in effect, it helps fine-tune the actions of insulin by inhibiting glucagon secretion, delaying gastric emptying, and acting as a satiety agent.1 Therefore, amylin replacement might improve glycemic control in some people with diabetes.2
The new compound pramlintide is the first, and currently the only, drug available in the amylin analog family. It was approved by the Food and Drug Administration earlier this year for use in patients with either type 1 or type 2 diabetes who are treated with insulin (DOC News, May 2005).
Amylin and its analog, pramlintide, blunt the effects of glucose that are primarily responsible for increased hepatic glucose output (HGO), which has a strong influence on fasting hyperglycemia. Both compounds also reduce the rate at which glucose is absorbed from the gastrointestinal tract.
The compounds cause early satiety via their effects on the central nervous system. This may be the reason that patients with type 1 or type 2 diabetes often experience improved glycemic control and weight loss when treated with pramlintide.
The real question is, who is likely to benefit? Without the luxury of definitive comparative trials, we are left with extrapolation from other trials and our own clinical judgment. Type 1 patients who are not quite to goal despite alterations in their insulin regimens may benefit, as may those who are overweight and/or require high insulin doses. In both cases, clinicians should use great caution in patients with a significant history of hypoglycemia.
Similarly, type 2 candidates are patients who have not reached goal with insulin therapy, those who require high insulin doses, or those who are overweight. While severe hypoglycemia is less likely in these patients, it should always be considered.
Finally, patients with postprandial hyperglycemia or erratic gastrointestinal uptake of calories are likely to benefit.
In trials that evaluated patient observations, pramlintide was very well accepted, and patients' perception was that the agent improved their glucose control.3
DOSE
Pramlintide has few side effects but can cause hypoglycemia in some instances; therefore, insulin doses need to be adjusted and the patient should monitor blood glucose vigilantly during the titration period. The most common side effect of pramlintide is nausea, which is usually transient, and most patients can continue therapy.3
Type 2 diabetes patients typically should be started on 60 µg just before meals. Concurrently, clinicians should reduce the dose of rapid acting or 70/30 premix insulin by 50% and titrate accordingly. The dose can be increased up to 120 µg.
Patients with type 1 diabetes should be started on 15 µg just before each major meal (250 calories or 30 g carbohydrate) with the same change in insulin as described for type 2 patients. If titration is required, the steps are to 30 µg, then 45 µg, and then 60 µg.
Should we be starting patients on pramlintide when they start insulin?
Evaluation of normal endocrine and biochemical functioning would lead us to
say "yes." Lack of clinical experience, however, should lead us to
the conclusion that we are not sure. 
Footnotes
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For more details on the manufacturer's recommendations for using pramlintide, visit the Symlin Web site at www.symlin.com.
References
2. Baker DE: Pramlintide: Improves glycemic control and reduces postprandial glucagon in patients with type 1 and 2 diabetes mellitus. Advances in Pharmacy 1:130–140, 2003.
3. Schmitz O, Brock B, Rungby J: Amylin agonists: A novel approach in
the treatment of diabetes. Diabetes 53 (Suppl. 3):S233
–S238, 2004.
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| DOC News | Diabetes | Diabetes Care | Clinical Diabetes | Diabetes Spectrum |
