Pramlintide: Where Does It Fit into Diabetes Care?

Recently, I was attending a luncheon, hosted by a medical science liaison. In the meeting, faculty member and student pharmacists were being educated about the recent updates in the American Diabetes Association 2015 guidelines. The medical science liaison provided an overview of the algorithm from this organization, in comparison with that of the American Association of Clinical Endocrinologists. 

While I was attending this luncheon, I took some time to reflect on the algorithms from these two organizations and think about how I apply these recommendations in clinical practice. That’s when it hit me — neither algorithm includes pramlintide, also known as Symlin. So, I had to wonder — in what situation do we still use this particular and unique medication for the management of diabetes?

In my short career of 8 years, I have only initiated pramlintide in one individual.

During my residency, my preceptor and I agreed to initiate this synthetic amylin analog in an individual with type 2 diabetes who was injecting a bolus and basal insulin regimen and had fluctuating postprandial glucose levels. The patient did not have adequate glycemic control, was overweight and complained about always feeling hungry.

We were able to get the VA Medical Center to approve this non-formulary medication, and we initiated the patient on pramlintide. I recall the extensive counseling on the product because at the time, it was available only as vials and required specific education on the dosing. Pramlintide is now available in prefilled devices, but I wanted to take some time and reflect on this medication.

Pathophysiology

Amylin is a natural hormone that is co-secreted with insulin. Among patients with diabetes, there can be absolute or impaired secretion of amylin from the pancreatic beta-cells. Amylin is effective for reducing postprandial glucose levels, as it can decrease glucagon secretion following a meal, slow gastric emptying and increase satiety. 

Evidence

Pramlintide can lower peak postprandial glucose levels with an average HbA1c reduction of 0.2% to 0.4% in patients with type 1 diabetes and 0.4% to 0.6% in patients with type 2 diabetes. Patients may lose 1.1 lb to 2.2 lb with this medication.

Advantages

Pramlintide is approved for patients with type 1 and type 2 diabetes. The dose is different between these patients. For type 1 diabetes, 15 mcg is the initial dose and can be titrated to 30 mcg or 60 mcg prior to each meal. For type 2 diabetes, the initial dose is 60 mcg, which can be titrated to 120 mcg prior to each meal. 

Disadvantages

Hypoglycemia will occur, as mealtime insulin must be used concomitantly with pramlintide. To prevent or lower the risk for hypoglycemia, the dose of mealtime insulin is reduced by 50%. Pramlintide is not indicated for patients using only basal insulin.

Caution should also be used if pramlintide is being considered for a patient with frequent hypoglycemic episodes or hypoglycemic unawareness.