Updated October 29, 2007

Exenatide and Pramlintide
New Meds on the Block

by Stacy Griffin, Pharm.D., and John Borders, M.D.

Tips for use. Your response to exenatide and to all other diabetes medicines will be better if you eat well-balanced meals, watch portion sizes, and stay physically active.

You will need to continue to monitor your blood glucose levels when taking exenatide. Varying the times at which you monitor, and monitoring both before meals and after meals on some days may be useful to evaluate any changes in blood glucose control. Work with your diabetes care team to determine a monitoring schedule that is right for you.

Pramlintide
A healthy pancreas releases both insulin and amylin in response to food intake. However, people with Type 1 diabetes and many with Type 2 diabetes do not make enough insulin, with the result being that glucose from food stays in the bloodstream rather than entering muscle, fat, and other body cells. In general, people who do not produce enough insulin also do not make enough amylin at mealtimes. Without enough amylin, glucose from food enters the bloodstream more quickly than normal, causing blood glucose levels to rise.

Pramlintide, a synthetic analog of human amylin, helps to reduce the rise in blood glucose after meals in the following ways:

• It slows the speed with which food leaves the stomach.
• It suppresses the secretion of glucagon after meals, which decreases the amount of glucose released from the liver.
• It decreases appetite, so that less food is eaten. This can also lead to a small weight loss in some people.

Pramlintide is approved for use in adults with Type 1 diabetes and adults with Type 2 diabetes who have not achieved adequate blood glucose control when using intensive insulin therapy.

How to take pramlintide. Like exenatide, pramlintide must be injected, but unlike exenatide, it is not yet available in a pen device. (The SymlinPen 60 and SymlinPen 120, pen-injector devices that can delivered fixed doses of pramlintide, and are expected to be available by December 2007.) Currently, a standard, U-100 insulin syringe is used to administer pramlintide. However, pramlintide is dosed in micrograms (µg), while insulin is dosed in units. To see how micrograms correspond with units, check out the table “Pramlintide: Drawing Up the Right Dose.” Your health-care provider will tell you what size doses to take and should also demonstrate how to measure doses and inject them. Pramlintide should not be mixed with insulin or any other injectable drug in the same syringe.

Pramlintide should be injected just under the skin of the stomach area or upper thigh more than 2 inches away from insulin injections given at the same time. Pramlintide should be at room temperature when injected. A new, unused syringe and needle should be used for each pramlintide injection and then discarded in a sharps container.

Pramlintide is to be taken just before any meal that contains at least 250 calories or 30 grams of carbohydrate. Peak action is reached in approximately 20 minutes and diminishes over three hours. Unlike insulin, doses of pramlintide do not need to be adjusted for the amount of carbohydrate in meals or for physical activity. However, if you skip a meal, the dose of pramlintide should also be skipped.

Generally, pramlintide is started at very low doses, and the doses are increased gradually depending on how well it is tolerated. When you first start taking pramlintide, your physician may decrease your mealtime insulin doses to account for the effects of pramlintide and to decrease your chances of developing low blood glucose. Your physician should direct any changes to your doses of insulin and/or pramlintide as you find what works best for you.

Pramlintide vials should be stored in the refrigerator until opened. Opened vials can be refrigerated or kept at room temperature for up to 28 days. Using an insulated container that is kept cool is recommended when traveling. Do not freeze vials of pramlintide, and discard any that are accidentally frozen. Vials should be discarded 28 days after first use, even if there is some medicine left. Do not use a vial of pramlintide if it looks cloudy.

Stacy Griffin is a diabetes educator for Drs. Borders & Associates, PSC, an American Diabetes Association-recognized education service in Lexington, Kentucky, and John Borders is a practicing internist at Drs. Borders & Associates, PSC. Dr. Griffin is also a pharmacist at Central Baptist Hospital, also in Lexington, Kentucky.

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