Symlin and what I know about using it
I've already written a few times about Symlin on this blog. Recently I got a long comment/question about how to use Symlin effectively. So I thought I'd share more of what I've figured out about Symlin and how I use it.Warning to reader: this is how I use Symlin and generally it works for me. But the same approach may not work for you. Please use extreme care when using Symlin, the lows can be extremely bad, and they're difficult to treat.
I use an insulin pump and that's important because I don't know how I could use Symlin if I was injecting insulin. More on that in a moment. You can find some great information about Symlin on Children with Diabetes, and there's also a discussion group for Symlin users on TuDiabetes. Finally the makers of Symlin, the company Amylin, has a Symlin website.
Symlin Facts
Symlin, or pramlintide, helps to reduce the blood sugar increase that you get after eating meals (postprandial high or postprandial excursion). It's an artificial version of the hormone amylin. Like insulin, amylin is produced by your pancreas in its beta cells. It works in three ways to reduce the amount of insulin you need to take after a meal.- It makes you feel full more quickly (increased satiety)
- It slows down how food empties from your stomach, and
- It reduces glucagon production, which slows down glucose conversion by your liver
It's recommended that you don't take Symlin unless your meal contains at least 30 grams of carbohydrates. Symlin seems to last for about 2 hours after you inject it.
Symlin dosages are in micrograms (mcg). I use an insulin syringe to inject Symlin, so I think of dosing in terms of units like insulin. It's currently only available in 5ml vials, half the size of insulin vials. The FDA approved a Symlin pen recently and these should be available in December 2007.
How I use Symlin
I now take Symlin before most of my meals.
Initially I started with a 3-unit dose, and I've gradually increased that. I had terrible nausea for about the first 4 weeks that I used Symlin. This was so bad that I didn't want to take it sometimes and couldn't always finish my meals. While that was happening I couldn't take even a reduced dose of insulin until after my meal was over since I didn't know how much insulin I'd need.
Gary Scheiner of Integrated Diabetes Services suggested working on the breakfast dose. And once that was right, trying to get the same dose to work on other meals. That was really helpful because treating a Symlin low at bedtime is too scary to think about. So I used this advice to gradually increase the amount I injected until I got to a dose that worked for me.
Now I generally take 16 units of Symlin 10-15 minutes before I eat. I'll usually inject insulin using an extended (square wave) bolus about an hour after eating to take 20% less insulin over a 90 minute period.
This is why I can't imagine injecting insulin and using Symlin. Because timing a single injection right would be too difficult for me. Maybe it's possible to take Symlin, eat a meal and 30 minutes to an hour later take a single injection with a reduced dosage.
If my carb counting is reasonable, I'll see no blood sugar rise after eating. But most days what I end up seeing is a blood glucose rise of about 50mg/dL about 2 hours after I've eaten. So my blood sugars might go from 110 to 160, and then come back down fairly quickly.
I never take Symlin if I have more than about a unit of insulin on board from a previous bolus. If I'm about to eat and my blood sugar is high, then I'll partially correct for that with a regular bolus and then use my extended bolus after eating.
For me, Symlin has also caused my blood sugar to drop even if I don't inject at all. From talking with Gary Scheiner and Amylin, this is possibly due to the slowdown of glucose production from my liver. On my Dexcom I can watch this happening and I've even verified it by taking Symlin without eating and while I was doing basal testing so there was no additional bolus insulin on board.
Overall I really like the impact Symlin has on my blood sugar control. In April 2007 my A1C was 8.4, by July it had dropped to 7.0. I attribute this to a combination of using Symlin and my Dexcom CGM. In October 2007 my A1C has drifted up to 8.0 (blast!), but I'm retaking it to see if this is simply a lab error.
With the recent interest in glycemic variability, I think Symlin is an important tool for smoothing out after meal highs. My hope is that the Symlin pen is the first step on providing different ways to take Symlin and I expect to see more Symlin users in the future.
Update: I wrote a review of the Symlin Pen in January. I like the overall design and it's much easier than carrying round a vial of Symlin and a syringe.
Note:I have purchased shares on Amylin in the past and I may do so in the future. I work not to let my investments influence what I say on this blog.
posted by Bernard @ 10:55 PM
18 Comments:
Bernard - this is a very helpful post for me as I consider adding Symlin into my routine.
I'm sure I'll have more questions for you as I digest this post a little more.
Thank you very much for sharing!
Thanks for sharing this. I too am considering Symlin, but probably wouldn't give it a try until it's available in a pen.
When I work up the nerve to do so, I may ask more questions -- you've been warned!
Thanks again.
Bernard,
Thank you so much for sharing your experiences with Symlin! I am going to give it another try! Your comments have been very helpful to me and I appreciate you taking the time to answer!
Thanks again.
Wow, those pre/post readings with symlin are impressive. Could you elaborate on what you mean about not knowing how you'd use symlin without the pump? Would you mind sharing how much your A1C improved with symlin use?
You want to really limit glycemic variability with Symlin? Try it in a pump using half your current basal rate as your Symlin dose throughout the day and then using for mealtime bolusing also. Using it in combination with a Dexcom sensor would be best to make fine adjustments in your I:C ratios, ISF and basals but it is pretty incredible if you can do it. My A1C is at its best ever at 5.6 from a 6.7 when using Symlin just as a mealtime bolus through subcutaneous injection.
Anonymous
I've wondered about adding Symlin to the pump, but I don't even know what it would mean for basal and bolus rates. I also have a challenge where just taking Symlin without any insulin reduces my blood sugar.
Are you posting more details on this anywhere, I'd love to read more.
Bernard,
I'm really glad symlin is working well for you! Symlin takes a lot of extra work! I remember really liking symlin, but I had too many problems with resistant lows, and I also have gastroparesis, so symlin and I didn't have a friendship that lasted.
Bernard, do you think your rep for symlin would want to do a chat at the DTF about this? email me gcapone1@optonline.net
Bernard, I'm no expert, but I think you have the recommendations on Byetta and Symlin reversed: Byetta is ONLY for Type I diabetics, while Symlin is primarily for Type IIs. This is according to my doctor at the Diabetes and Gladular Disease Clinic here in San Antonio, Texas. I know this because I really wanted to try Byetta and they wouldn't let me. Later, I researched the two drugs.
As for me, I am Type II, and I take 10mg of GlucotrolXL per day, as well as premeal injections of Humalog and Symlin and a bedtime injection of Lantus. Thank GOD they are all now available in pens.
By the way, glad to meet you!
Jim Holmes
San Antonio, Texas
Hi Jim
These two drugs are made by the same company (Amylin). But Symlin is definitely for people with type 1 diabetes or people with type 2 diabetes who are taking insulin. You can confirm this on the Symlin site.
Byetta is "a unique medicine that was developed to help treat people with type 2 diabetes", this is from the first paragraph on this page from the Byetta site.
You have type 2 diabetes, but you're using insulin. That's why you're on Symlin. I'm also glad for the Symlin pen, it makes taking Symlin a lot easier.
I am a Type 1 Diabetic and have been for just over 9 years. I wear a minimed paradigm pump and have no type of continuous glucose monitor. I am starting Symlin for the second time tomorrow. I had to quit before due to the nausea. It is interesting to me to see others who deal with the same stuff I do. Also it is amazing how much different we all are and yet we are all in the same boat so to speak. How has the pen worked from what you have heard? If Symlin works as well for me as it has for you... Youll hear more from me.
Mixing Symlin and Insulin would be dangerous and unpredictable because their pH is very different. They will likely be very unpredictable in 3 days or so.
I wear a minimed paradigm insulin pump and continuous blood glucose monitor. I started Symlin this last week. The first few days went great. A little nausea but not bad. I've noticed lately that I will inject my Symlin and do a bolus of insulin and my blood sugar will drop below 60. So then I have to have some glucose and then a few hours later it's high. I wonder if I should try a square bolus and see if things change. It sounds like you had the same problem. How has it worked for you?
Larry
I don't use Symlin as much these days (laziness). But when I do, I delay my meal bolus for about 30 minutes and then do a 2 hour square wave bolus with about a 30% reduction in the overall amount.
If I get it right, I basically see a small blip in my blood glucose levels about 90 minutes after eating.
As always, your results may vary. I'm glad you've got a CGM because the lows with Symlin are really scary.
Bernard
Thanks for replying. I spoke to my Doctor and she said to lower my dose and give a square wave bolus over 3 hours. I lowered my Symlin back down to 15mcg's. Seems to work great for me. I hated the lows. When they hit they hit hard. It's a scary feeling. I have to say that I'm pretty happy with the results for the most part. I also found out that not everybody takes the same doses. Like I said 14mcg's works great for me. I thought that 60mcg's was the goal. I also have to say that having the CGM is a great addition to the pump. Luckily I have insurance that covered the costs.
Thanks again for you response
Larry
Bernard... Just a little reminder, Symylin isn't used in "units", but rather by "mcg". Didn't want anyone getting confused and actually taking it in units... that wouldn't be a good thing ;-)
Thanks, Bernard. I was diagnosed with Type 1 six years ago at age 35! I have continuted to put on weight, even though I don't seem to be eating more than normal. Do you have any experience with Symlin and weight loss? Some of the gain could be attributed to aging metabolism but my dr. has told me to try Symlin. This is my third attempt - the past two times I've just forgotten to pack it with me when leaving for work, going out, etc. and eventually just given up. My A1C needs improving too...7.8 is too high! Although I just found out that my pump was malfunctioning for the past month so Medtronic sent me a new one - I'm hoping this might have been why the A1C was too high. Ugh...so much to deal with! Well, thank you for the info...your blog has been very helpful.
Sarah
I gave up using Symlin because it was too much of a challenge for me. Mostly it was dealing with the lows.
I think the weight loss is due to two things. Initially it's because of the nausea, but that's a short term thing. Later its due to the fact that you feel 'fuller' for longer (satiety) because of how Symlin acts.
In the second case I'm not sure that always works, satiety works better for some than others.
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