I saw my endo today and I was given a sample SymlinPen 60. I've blogged previously about my experiences with Symlin. So in this post I'll just talk about the pen itself.
When I got home I snapped some pictures before using it.
As you can see the pen itself is a little longer and thicker than a large ballpoint. It's an awkward fit in my shirt pocket, only about a half-inch of the clip is actually holding it in place. I'll definitely keep it in my diabetes kit.
I had planned to use the pen at lunchtime. When I opened the box and took the cap off I found...no pen needle in place. That's right, the sample cannot be used immediately. It's like a Christmas toy that has no batteries and all the stores are closed.
Luckily I had some 10-year old pen needles left from when I used an insulin pen, and once I got home I grabbed one of these. It fit perfectly.
The pen has a dial at one end that lets you choose to dispense Symlin in doses of 15, 30, 45, or 60 micrograms (mcg). For comparison, 10 units of insulin is equal to 60 mcg of Symlin. Many people with type 1 diabetes will use 45mcg or less per meal. If you have type 2 diabetes and are taking insulin then the Symlin 120 pen is probably more useful, it will deliver either 60 or 120 mcg.
To start with I attached the pen needle, dialed up a 15 mcg dose, pulled back the end to prime the pen and dispensed the dose into the air. This was to fill the needle. I repeated this several times until I saw a stream of Symlin.
Then I dialed up my regular dose of 60 mcg and was able to inject it using the wonderfully small pen needle. If you put the needle cover back on, you can replace the pen cap with the needle still in place.
There's an interesting design feature, where you can stand the pen on end. I'm not sure what the benefit of this is, or whether it's just a side-effect of having a built-in plunger. There are markings on the barrel of the plunger that help you determine whether it's pulled back far enough. This is especially useful when the cartridge is almost empty and there may not be enough Symlin left for the dose you want.
Note that once you've pulled back the plunger the only way to undo this is to dispense the dose. If you dial up too small a dose you can choose a larger number and pull the plunger further back. If you've dialed up too much, you need to just dispense the Symlin into the air.
As you push the plunger there are soft clicking noises. I didn't count these, but there seems to be one click for a 15 mcg dose and three or four (I didn't count carefully enough) for a 60 mcg dose.
Once you've started to use the pen, you can store it at room temperature up to 86 degrees F (30 degrees C). Unopened pens must be stored in a fridge.
Overall I think this is going to be a lot easier than carrying around a vial and syringe. I wish the pens themselves weren't disposable, but that seems to be the way these things are made nowadays. I think I'd give the pen design a score of 7 out of 10.
To improve the score Amylin would need to include a pen needle with their samples and reduce the size enough for this to fit in a normal shirt pocket. I think this will be a useful addition to my diabetes kit.
Update: As I've used the pen I've paid more attention to how it works.
When you press the 'plunger' to deliver there is one click for every 15 mcg. One each click 15 mcg is actually delivered, so it's a chunky delivery. Because of the pH of Symlin (4.0 which makes it acidic), that first click stings a little. After it stops clicking the plunger still has a way to go, but the last part doesn't deliver anything.
Also, when you dial up a quantity and start to pull back the plunger it clicks, again one click for every 15 mcg. If you pull slowly you can count the clicks. This is probably helpful for anyone who has vision problems. Nice design feature Amylin!
Today Amylin announced that the pen form of Symlin is available. The SymlinPen 60 can deliver 15, 30, 45, or 60 micrograms per dose, so it's clearly targeted at people with Type 1 diabetes. These doses correspond to 2.5, 5, 7.5, and 10 units on a standard insulin syringe. The SymlinPen 120 can deliver 60 or 120 micrograms per dose. The pens can be stored at room temperature up to 86 degrees F (30 degrees C) after first use.
I have a long blog post about what I've learned from using Symlin. For those of us already on Symlin this is a welcome step forward.
What I'd like to see next (anyone?) is C-peptide in pen form. I'm not holding my breath!
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 companyAmylin, 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
Symlin is intended for people with Type 1 diabetes. For Type 2 diabetes I understand that Byetta is similar in effet.
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.
If I told you I had diabetes and that I needed to inject something before meals, you might say "Oh yeah, insulin right?".
Well I'm wearing an insulin pump, so I don't actually inject insulin before meals, I use the pump to deliver it. But for about a year I've been injecting Symlin before most meals that I eat.
When I'm in the office, I just roll up my trouser leg and inject there shortly before eating.
Symlin is an artificial version of amylin, another hormone produced by the pancreas, in the beta cells. If you don't have type 1 diabetes, this hormone slows down the emptying of food from your stomach and makes you feel fuller (increasing satiety). It also seems to slow down the release of glucagon from your liver.
The net result is that my blood sugar doesn't go up as quickly as it normally would after eating. So it helps me maintain better control of my blood glucose levels.
Because it slows down food getting into your system, Symlin can cause severe lows that are difficult to treat. In my case I can also go low just from taking Symlin without mealtime insulin. This may be due to the glucagon suppression and a basal insulin level that's effectively too high when Symlin is being used.
I also had terrible nausea for the first month that I used Symlin. So bad that it made me not want to eat. But that's passed now. Even if I don't take Symlin for a few days, the nausea doesn't return.
There isn't a cure for diabetes, yet. But some of us are working to fix that.
For now, I'm trying to take diabetes365 photos at slightly later times in my diabetes day. At some stage, I'll switch to a different approach to documenting what it's like to live with diabetes 24 by 7 by 365.
I have a small scales at home that I use mostly for breakfast. Most packaged food now has nutrition labels which lets me see the carbohydrate content for a specific weight. By adding the carbs for all the foods together and using an insulin to carbohydrate ratio (I:C) I can figure out how much insulin I need to take. The I:C value is different for everyone with diabetes, it can even vary for the same person at different times of the day.
I've been using Symlin for about a year. It's a drug that's I inject shortly before meals. It slows down the release of food from my stomach and makes me feel full. Both contribute to better blood sugar control, though it can cause terrible low blood sugar reactions.
Insulin (and Symlin) are not cures for diabetes. They just allow people with diabetes to control their blood sugars.
Amylin has announced today that the FDA has approved two Symlin pen models. The pens should be available by December 2007.
The SymlinPen 60 can deliver 15, 30, 45, or 60 micrograms per dose, so it's clearly targeted at people with Type 1 diabetes. These doses correspond to 2.5, 5, 7.5, and 10 units on a standard insulin syringe. The SymlinPen 120 can deliver 60 or 120 micrograms per dose. I like it that the pens can be stored at room temperature (up to 86 degrees).
Here's a picture of the new pens, courtesy of medGadget. For me, Symlin has effectively removed the blood sugar spikes that I see after meals. Learning to use Symlin takes time. First there's the nausea. It lasted about 4 weeks for me. Then there's the struggle to figure out how much to reduce your insulin and how long to spread the bolus over to avoid the lows that can be very hard to treat.
I'm excited to learn the pen version will be out before too long. That should make it a lot easier to use.
I've been using Symlin since late 2006 to reduce the blood glucose peaks that I get after eating.
Symlin works by slowing down food processing so that your sugar levels rise more slowly after you've eaten. Typically you need to reduce your insulin dosage and, if you're using an insulin pump, take the bolus over an extended duration so that you don't have a low. It takes time to get used to Symlin and figure out how much Symlin to take and how to properly take whatever insulin you need to cover the meal.
When I started using Symlin I had a lot more lows. They were hard to fix because the Symlin slowed down the absorption of the juice or Gatorade that I took to get my blood glucose levels up.
I finally figured out this tip for fixing low blood sugars that are caused by Symlin. I chew one dex tablet at a time, holding the chewed up mess in my mouth for as long as I can. That way some of the dextrose is absorbed through my mouth What does get into my stomach is easier for my digestive system to work on. After 2-3 tablets I wait for 15 minutes and see how things are going.
This works much better than drinking a lot of juice and then having to deal with the super highs later. The juice absorption is slowed enough by the Symlin that it takes more time than usual to work.
If you're using a pump, don't forget to cancel any bolus in progress otherwise you may have a recurring low shortly after fixing the first one.
I really do like Symlin - and I've had a lot of success with using it at breakfast time.
When I last saw my endo (still waiting on the A1C from that) we talked about my trying Symlin in the evenings also. That's the time I'm most likely to eat too much.
So this evening I did use Symlin. And here I am now writing some 30 minutes after climbing up out of a low 38 mg/dL. I so hate when that happens. With the insulin on board from my square wave with dinner, I'll have to watch things for another 2 hours or so.
I think I'll have to ease into Symlin with dinner. It's going to take some getting used to.
Disclosure: I have owned shares in Amylin, makers of Symlin, in the recent past. And I'll probably buy them again at some stage in the future. So don't make any financial decisions based on what I say here.
The Diabetes Technology Blog is focused on using technology to life better with diabetes. I review: blood glucose monitors; continuous glucose monitor; blood sugar meters; diabetes software and living with diabetes.
About Me
Name: Bernard Farrell
Location: Massachusetts, United States
I was born in Ireland and now live in the US.
I have had Type 1 diabetes for over 35 years. I struggle with my blood sugar, the same as most people with diabetes.
I wear a Cozmo 1800 insulin pump and a Dexcom SEVEN CGM to track my blood glucose levels. I also take Symlin to help control my post-meal blood sugars.
I'm blessed by God, and every day brings the possibility of a cure.
Then I dialed up my regular dose of 60 mcg and was able to inject it using the wonderfully small pen needle. If you put the needle cover back on, you can replace the pen cap with the needle still in place.
The SymlinPen 60 can deliver 15, 30, 45, or 60 micrograms per dose, so it's clearly targeted at people with Type 1 diabetes. These doses correspond to 2.5, 5, 7.5, and 10 units on a standard insulin syringe. The SymlinPen 120 can deliver 60 or 120 micrograms per dose. The pens can be stored at room temperature up to 86 degrees F (30 degrees C) after first use.
