1.Pramlintide
| Pramlintide |
| Availability Solution for injection: 0.6 mg/ml in 5-ml vials; 1.5-ml disposable multidose pen-injector containing 1,000 mcg/ml;2.7-ml disposable multidose 120 peninjector containing 1,000 mcg/ml |
| Indications and dosages ➣ Type 1 diabetes mellitus as adjunct treatment in patients who take insulin with meals but haven’t obtained desired glycemic control despite optimal insulin therapy Adults: Initially, 15 mcg subcutaneous injection immediately before major meals; after 3 days, increase in 15-mcg increments to maintenance dosage of 30 or 60 mcg as tolerated. Decrease preprandial rapid- or short-acting insulin dosages (including fixed-mix insulins) by 50%. ➣ Type 2 diabetes mellitus as adjunct treatment in patients who take insulin with meals but haven’t obtained desired glycemic control despite optimal insulin therapy, with or without concurrent sulfonylurea, metformin, or both Adults: Initially, 60 mcg subcutaneous injection immediately before major meals; after 3 to 7 days, increase to 120 mcg as tolerated. Decrease preprandial rapid- or short-acting insulin dosages (including fixed-mix insulins) by 50%. |
Mechanism of Action
Slows the rate at which food is released from stomach to small intestine, thus reducing initial postprandial rise in serum glucose level. Pramlintide also suppresses glucagon secretion and promotes satiety, thus furthering weight loss, which also lowers serum glucose level. Pramlintide is a synthetic analogue of amylin, a naturally occurring neuroendocrine hormone secreted with insulin by pancreatic beta cells. In diabetes, secretion of insulin and amylin is reduced or absent.
Pharmacokinetics
- Half-Life: 48 min
- Bioavailability: 30-40%
- Metabolism: kidneys
- Excretion: Primarily urine
- Duration: 3 hr
- Protein binding: 60%
Administration
- Administer immediately before major meals (at least 250 kcal or 30 g carbohydrates).
- Give pramlintide and insulin as separate injections.
- Inject pramlintide and insulin more than 2′′ apart
Contraindications
- Hypersensitivity to drug or its components
- Confirmed gastroparesis
- Hypoglycemia unawareness
Precautions:
- Patients with poor compliance to insulin therapy or hemoglobin A1c levels above 9%
- Patients with recurrent or severe hypoglycemia who’ve required treatment during past 6 months
- Concurrent insulin therapy for type 1 diabetes
- Concurrent use of drugs that stimulate GI motility
- Elderly patients
- Pregnant or breastfeeding patients
- Children (safety and efficacy not established)
Adverse reactions
- CNS: headache, dizziness, fatigue
- EENT: pharyngitis
- GI: nausea, vomiting, abdominal pain, anorexia
- Metabolic: severe hypoglycemia
- Musculoskeletal: arthralgia
- Respiratory: cough
- Other: allergic reaction
Patient monitoring
- Monitor premeal and postmeal blood glucose levels closely; watch for hypoglycemia.
Patient teaching
- Instruct patient to take drug immediately before major meals.
- Teach patient how to self-administer injection; describe proper storage, handling, and disposal of drug and supplies.
- Instruct patient to inject pramlintide and insulin separately, more than 2′′ apart. Caution patient not to mix them together.
- Teach patient to recognize and immediately report hypoglycemia symptoms; tell him these may occur within 3 hours after pramlintide injection.
- As appropriate, review all other significant and life-threatening adverse reactions and interactions, especially those related to the drugs mentioned above.
Nursing Considerations
- Because of the risks involved with pramlintide therapy, insulin-using patients with type 1 or 2 diabetes must have failed to achieve adequate glycemic control despite individualized insulin management and must be receiving ongoing care with guidance of insulin prescriber and a diabetes educator before pramlintide is prescribed.
- Expect that certain patients won’t be prescribed pramlintide because its risks may outweigh its benefits. These include patients with poor compliance with current insulin regimen, poor compliance with monitoring blood glucose level, a glycosylated hemoglobin greater than 9%, recurrent severe hypoglycemia that required assistance during past 6 months, hypoglycemia unawareness, gastroparesis, concurrent therapy with drugs that stimulate GI motility, and pediatric patients.
- Before pramlintide therapy starts, make sure patient’s pre-meal insulin dosage has been reduced by 50%.
- Give drug immediately before main meals.
- Monitor patient’s pre- and post-meal blood glucose levels regularly to determine effectiveness of pramlintide and insulin therapy and to detect hypoglycemia.
- For 3 hours after each dose of pramlintide, monitor patient closely for hypoglycemia, which may be severe, especially in patients with type 1 diabetes. Effects may include hunger, headache, sweating, tremor, irritability, and trouble concentrating. They may occur with a rapid decrease in blood glucose level regardless of glucose values.
- Although pramlintide doesn’t cause hypoglycemia, it’s use with insulin increases the risk of insulin-induced severe hypoglycemia, which can result in loss of consciousness, coma, or seizures. If hypoglycemia occurs, provide supportive care, including glucagon if prescribed, and notify prescriber. Expect insulin dosage accompanying pramlintide to be reduced.
- Keep in mind that early warning symptoms of hypoglycemia may be different or less severe if patient has had diabetes for a long time; has diabetic nerve disease; takes a beta blocker, clonidine, guanethidine, or reserpine; or is under intensified diabetes control.
- Closely monitor patients taking oral antidiabetics, ACE inhibitors, disopyramide, fibrates, fluoxetine, MAO inhibitors, pentoxifylline, propoxyphene, salicylates,or sulfonamide antibiotics because of an increased risk of hypoglycemia.
- Expect pramlintide to be stopped if patient develops recurrent hypoglycemia that requires medical assistance, develops persistent nausea, or becomes noncompliant with therapy or follow-up visits.
REFERENCES
- Robert Kizior, Keith Hodgson, Saunders Nursing Drug handbook,1st edition 2024, Elsevier Publications. ISBN-9780443116070
- McGraw Hill- Drug Handbook, Seventh Edition, 2013, McGraw Hill Education Publications,9780071799430.
- April Hazard, Cynthia Sanoski, Davi’s Drug Guide for Nurses -Sixteenth Edition 2019, FA Davis Company Publications,9780803669451.
- Jones and Bartlet, Pharmacology for Nurses, Second Edition, 2020, Jones and Bartlet Learning Publications, ISBN 9781284141986.
- Nursebro.com, Search – Nursebro
Stories are the threads that bind us; through them, we understand each other, grow, and heal.
JOHN NOORD
Connect with “Nurses Lab Editorial Team”
I hope you found this information helpful. Do you have any questions or comments? Kindly write in comments section. Subscribe the Blog with your email so you can stay updated on upcoming events and the latest articles.
