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Symlin Makes You Smile - 9 hours, 9 months and the "Post-Sex Buzz"

 Previously on test drive: In people without diabetes, the same beta cells that make insulin also produce amylin, the hormone on which Symlin is patterned.. However, people with type 1 don't make either amylin or insulin because their beta cells have been destroyed. Amylin is usually released in conjunction with insulin - especially after eating - because it helps the body maintain flatter blood-sugar profiles. It does this in three ways: by slowing gastric emptying (allowing sugar to enter the bloodstream more slowly), making people feel full more quickly so they eat less, and inhibiting post-meal secretion of glucagon, a hormone that makes the liver release extra sugar into the bloodstream.


What takes 75 seconds* to administer, may initially cause nausea, must be refrigerated, and may or may not tingle your senses with a "post-sex buzz?" Old Symlin.

What takes 30 seconds* to administer, may initially cause nausea, needs no refrigeration, and may or may not tingle your senses with a "post-sex buzz?" Symlin in a SymlinPen.

*Note: these times were obtained from a quasi-scientific, one mouse study, in which I played the principal investigator, the mouse, the funding agency and the review panel.

The last test drive I wrote on Symlin was a year ago in diaTribe issue #2, when we had just started diaTribe - now that seems like the old days! I think it's excellent that six issues later, we're revisiting the same topic and seeing marked improvements in the technology. The SymlinPen 60 and SymplinPen 120! Although I wasn't part of the clinical trial that led to its approval, I was still able to lay my hands on one of the first pens in circulation, and I couldn't resist testing it out once, pregnant and all - Symlin is still not approved for use during pregnancy, and nobody is willing to test its efficacy and safety in this population given the potential liability. In my opinion, however, the reduction in post-meal blood glucose that Symlin had previously helped me achieve would be helpful in maintaining the tight glycemic control that any obstetrician will tell you is key to a worry-free (um, more like worry-minimized) delivery.

So what’s different about the pen versus drawing Symlin out with a syringe? Well, really, the true value of the pen lies in its convenience. Using the pen is simple - it involves replacing the needle, selecting from one of four doses on the SymlinPen 60 (two doses on the SymlinPen 120 – geared towards a type 2 population) using the easy-to-turn knob on the pen until the required dose appears in the very readable dose window – 15, 30, 45, or 60 micrograms are the FDA approved doses on the SymlinPen 60. To inject the dose, all I do is press firmly down on the plunger (knob doubles as a plunger) until I hear a click and that’s about it. Then back into my bag it goes – no strange looks from worried mothers, no averted gazes from curious diners, it just sort of “fits” better into the daily routine. (Our medical advisors made me write this sentence: “Remember this is just based on having tried it one or two times since I’m pregnant and technically should absolutely not be using it.”)

So last year, when I went off Symlin during pregnancy, my A1c jumped from a little over 6 percent to over 6.5 percent, while my doctors recommend being in the 5.0 percent - 5.5 percent range. I worked really hard, but honestly, I couldn’t come close to getting it down to that level. 5.0! Someday?! Really, that seems like a dream, though with the SymlinPen, once I can use it everyday, I can start thinking big again! In the meantime, you can imagine how dejected I am now, again being off Symlin, and finding out that my A1c is again moving from the low 6 percent level toward 7 percent!! I have found that pregnancy does the weirdest things to blood glucose – I can check in the middle of the night, see 90 mg/dL (5.0 mmol/l) on my SEVEN CGM, and think all is fine and then hear beeping a couple of hours later, and see a 155 mg/dL (8.6 mmol/l) – and I didn’t even do anything!! Talk about crazily changing basal rates Batman! It's actually fairly depressing, and I am looking forward to going back on Symlin particularly in conjunction with my continuous monitor - I just know my post-prandial and overall glycemic control will improve substantially with the SymlinPen, and the ability to set the alarms – talk about great tools! Maybe the elusive five point five isn’t such an impossible dream…

Unfortunately, however, no doctor would go on record to prescribe off-label use of Symlin even though the drug doesn't cross the placenta - from what I understand - and the dangers associated with maternal hyperglycemia during gestation have been well documented. Some doctors did say off the record - in fact, all with whom I spoke - that if one of their relatives were considering Symlin in pregnancy, they would tell them to go for it, without a doubt. "But don't quote me, the FDA wouldn't like that..."

Had I not already taken Symlin and benefited from the drug, I might be looking too simplistically about this given that it can be a complicated drug to take. When I started out, it took me more than a few tries, and a few highs in order to figure out how to get the right balance between my insulin and Symlin; but then I figured out the insulin part (as I wrote last year, when going on Symlin, you actually reduce your insulin dose – the trick is everyone reduces it differently), and I became better about remembering to dose my insulin about 15-20 minutes before a meal - as my doctor encourages - and things became much easier. Now when I hearken to the days when my pre-meal to-do list was often longer than the menu, I give myself a personal high-five. Of course, the pen has only shaved about 45 seconds off the clock per dose, but that adds up when you are covering 3-4 meals a day, plus snacks.

I was just calculating before I started writing this Test Drive that before the pen came out, I used to spend almost 23 hours every year taking my Symlin injection. From getting the vial from the fridge (I later found that once opened, vials could be kept out of the fridge up to a month but I hadn’t realized that!), finding a new syringe (I needed a new syringe practically every time I took Symlin because the top of the Symlin vial was so tough it cleaned the coating off of the syringe and really hurt if used multiple times), drawing up the dose, flicking for air bubbles time and again, up until the actual injection – that probably took about 75 seconds with average concentration. With my new SymlinPen 60, the process of fishing the device from my hopelessly disarrayed purse, dialing in the dose and injecting takes about 30 seconds maximum. And actually, when I'm being timed, I can go even faster!

Now here's the really excellent part: saving 45 seconds of pre-meal injections over a year of three-meal days adds up to saving almost 14 hours in one year. Not bad while also reining in post-prandial glucose levels. I think Amylin, the company that makes Symlin, should look into an ad campaign for the SymlinPen with slogans like, "this device will save you 14 hours of Symlin dosing time per year AND improve your glycemic variability - check THAT out," or even, "Symlin makes you smile." Hee hee, just kidding - actually, not really! I just don't think the buzz part is really well documented but at least a third of the people I know on Symlin (admittedly not a huge group - though it should be) do experience this "side benefit" - it's just a feel-good drug.

All the benefits, even besides the buzz, that I have received from Symlin are well worth the initial nausea - true the nausea is temporary for most people, but temporary can mean up to 10 weeks which doesn't quite seem so transient in the middle of week one. For anybody who decided to wait for the pen before making a decision to start, I believe the opportunity is right, given the advantages: reduction in A1c from improved post-prandials, reduced glycemic variability leading to feeling better overall, some association with weight loss, and possibly the infamous "buzz." Reimbursement for the product has also been very good (and there is no difference in price from vial to pen – a very novel idea) and with a continuous glucose monitor, if you can possibly lay your hands on one, I think learning how to use Symlin will be much easier.

Now, one possible limitation of the pen is that the smallest dose is only 15 micrograms, whereas a syringe and vial can deliver an even smaller 5 microgram dose. The 15 microgram dose is right for me - if you start on the drug and see that that is too big a dose to start, you may want to use a vial and syringe for a smaller dose while you are ramping up – then switch to SymlinPen! As always, consult your healthcare team.

I think it is worth your while to read up a bit more on Symlin (www.symlin.com) and talk to your healthcare team about whether the drug might help you. In addition to A1c benefit, overall, many patients have found themselves just in the “euglycemia” more often – i.e., more often in their target zone, say 80-140 mg/dL (4.2 mmol/L to 7.4 mmol/L). This is another hot topic in and of itself – you might ask your doctor how he or she feels about glycemic variability, while you are at it. Although there aren’t yet long-term studies on this topic, we hope some will be planned – from a patient perspective, we think the less glycemic variability the better – and we hope someone would help the FDA wake up to this as well (for them, they still look at most studies in terms of the traditional gold standard, A1c). Evidence is the best medicine – may we come up with some soon! In the meantime, you might ask your doctor if Symlin is worth a try - and do your own experiments reducing glycemic variability!

Fine print: Symlin is currently to be used in patients who take mealtime insulin and is not approved for use in pregnancy or in children under 16 years of age. diaTribe does not encourage off-label use of any medications. Always talk to your healthcare team before making changes to any aspect of your diabetes therapy.