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Insulin's Super Sidekick

by Gary Scheiner, MS, CDE

Strategies for success
Sidekicks often experience a “breaking-in period.” For example, it took a while for Ed McMahon to learn to wait for the punch line before laughing at Johnny Carson’s jokes on the old Tonight Show. Symlin is no different. It takes some practice and effort to get Symlin to work right — but once it does, the benefits can be significant.

Through years of personal and professional/clinical experience with Symlin, I have had the opportunity to learn what tends to work and what does not. Here are some recommendations and observations:

1. Start out using Symlin at only one meal, such as breakfast. Once the dose of Symlin and appropriate adjustments to the dose of mealtime insulin are determined, apply the same strategies to your other meals. Unlike insulin, the dose of Symlin does not vary from meal to meal; the same dose is taken regardless of what is eaten. And adjustments made to insulin’s dose size and timing should work consistently whenever Symlin is taken.

2. Take Symlin 5–10 minutes before your meal, and take your insulin 5–10 minutes after finishing your meal. This will help ensure that the Symlin is working at the right time, so that the insulin will not peak too soon and cause post-meal hypoglycemia. If you start to see a drop in your blood glucose level soon after eating followed by a significant rise a few hours later, consider switching to Regular insulin — or, if you use an insulin pump, delivering the insulin bolus over 1–2 hours. (Regular insulin starts working in 30–45 minutes, compared to 10–15 minutes for rapid-acting insulin analogs.)

3. When starting with Symlin, reduce your usual dose of mealtime insulin by about 25%. Symlin’s package insert recommends an initial 50% reduction; however, in clinical practice, most Symlin users settle on only a 10% to 20% reduction in mealtime insulin. A 25% reduction is a safe and reasonable starting point.

4. Settle on a Symlin dose before finalizing your insulin adjustments. Start with the lowest dose of Symlin (15 mcg) and increase in 15-mcg increments until an effective dose is reached. The right dose of Symlin will either cause an unusual “full” or “sour stomach” sensation 15–30 minutes after injection, or result in a reasonably constant blood glucose level for a few hours after eating. If neither of these occurs, the dose of Symlin needs to be increased. Get in the habit of checking your blood glucose level an hour after eating while adjusting your Symlin and insulin doses (or check your trends on a continuous glucose monitor).

5. The Symlin dose may need to be increased over time. After using it for several months or years, many people develop a tolerance to Symlin, and the dose may need to be increased slightly to achieve the same results as earlier.

Symlin delivery options
Symlin is most commonly given by injection pen. Symlin pens allow giving the drug in 15-, 30-, 45-, 60-, or 120-mcg doses. The low-dose (starter) pen delivers 15, 30, 45 or 60 mcg; the high-dose pen delivers 60 or 120 mcg. Because Symlin needs to be injected just below the skin, it is generally recommended that short (5- or 6-mm) needles be used.

Some people require doses higher than 120 mcg or less than 15 mcg; others need doses that are in between the preset pen increments. For these individuals, Symlin is available in vials for injection with a syringe. (One unit on an insulin syringe denotes 6 mcg of Symlin; 2.5 units would be 15 mcg, and so on.) However, the vials will be phased out by December 31, 2010.

Some people who use Symlin have opted to deliver it through an insulin pump. Limited research has been conducted on this topic, but available reports indicate that pumps can be a safe and effective method of delivering mealtime boluses of Symlin. However, some basal delivery may be necessary to prevent clogs from forming in the tube and cannula.

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