Concomitant sulfonylurea and/or basal insulin may need to be reduced based on the patient’s glucose levels.
Nausea is another common adverse event; therefore, pramlintide could be initiated with the largest meal and slowly titrated over days in dose or number of injections.
Pramlintide can be injected in the abdomen or thigh and with an administration technique similar to insulin therapy. Prefilled devices can be kept in the refrigerator prior to use, but can be at room temperature prior to the injection.
Patients should be encouraged to eat at least 250 calories or 30 grams of carbohydrates with each meal when injecting pramlintide. Similar to bolus insulin, a patient can skip the pramlintide dose if the meal is skipped.
A patient should not inject a cloudy pramlintide solution; it should be a clear solution. Pramlintide should not be used in patients with gastroparesis.
Overall, pramlintide should be used in a motivated individual who is willing to inject multiple times per day, as well as monitor glucose level before and after meals.
After reflecting on the current medication, I asked myself, “Why have I not recommended this medication since I was a resident?”
At my practice site, we have samples of pramlintide. However, we are a rural-health family medicine office with 80% of the patient population having Medicare or Medicaid. I believe that I have not recommended pramlintide for any of these patients for two main reasons.
First, pramlintide would require the patient to potentially inject three additional shots. If a patient is currently doing four or five injections with a basal-bolus regimen, then I am increasing the number of injections per day, which may not be agreeable to the patient. Second, it may be difficult for the patient to afford this medication.
I am interested in what other people are doing in clinical practice with pramlintide (or Symlin), as it still seems to be a viable option for those patients on a basal-bolus regimen with the erratic postprandial concentrations and who are in need of weight loss.