Gucagon is a hormone produced in the pancreatic islet alpha cell. glucagon stimulates the liver to release sugar into the blood. Glucagon is normally produced as blood sugar drops in an effort to prevent hypoglycemia. In people without diabetes glucagon drops to zero when eating. However, in diabetes glucagon is increased when the person eats. The blood sugar goes up not only from the food but also from abnormal glucagon increase causing the liver to release glucose. Treatment for this abnormal glucagon is limited.
Symlin is a medication for people on insulin to take at meal time to reduce glucagon. It is only available by injection. It is effective but can be difficult to adjust to since it lowers mealtime insulin requirements. I have used Symlin when it originally came out as a vial-and-syringe treatment. I used it again when it was released in a pen device. It curbed my after-meal blood sugars and also reduced my appetite. However when it wore off in 3 hr I was hungry again. A physician suggested I try it in a pump. I absolutely loved it! I had a basal rate of Symlin as well as bolusing at meals. Blood sugars were very even and I didn't have rebound hunger. My daily insulin dropped form 28 to 24 units. When I was on a long bike ride I would suspend the Symlin so I could maintain hydration and nutrition without feeling full. The downside was keeping track of two pumps, when each one was due for a change, different alarms for batteries, low reservoir, etc. I considered using an Omnipod for the Symlin. I decided against it because the Omnipod requires 80 units minimum fill. I was using less than 20 'units' of Symlin in 3 1/2 days. I suppose I could run insulin in the 'pod and Symlin in a tubed pump but the overall hassle is huge regardless.
Byetta and Victoza are glucagon-like peptide 1 (GLP-1) replacements that increase GLP-1 by 6-10x the normal blood level. These are both approved for treating T2DM but not with insulin. They are potent in keeping glucagon low after meals. In clinical trials about 75% of patients lose weight on these products. I chose to try Victoza because it is once daily compared to Byetta twice daily.
Victoza hit hard at the beginning. On the lowest dose I felt full most of the time. It was hard for me to stay hydrated I felt so full. My mouth was dry most of the time. After a few weeks the side effects eased up dramatically. I could eat little and not be excessively hungry. Blood sugars after meals have generally been under 170. Insulin dose is around 25 units daily, down from 28-30. I've yet to take it during hot weather so I don't know how well hydrated I can stay on long bike rides.
I have prescribed Byetta and Victoza for T2DM patients on insulin and they generally work well. I've tried both in a few T1DM patients with variable effectiveness. One of the greatest difficulties is cost. Because neither product has FDA approval for use with insulin the insurance companies use this as an excuse to not pay for the product. Please keep in mind that this 'off-label' use is not forbidden; it means that there has not been sufficient data submitted to the FDA for that use to be 'indicated'.
What is next? I am hoping that Byetta or Victoza seek approval for use with insulin. I don't know if either company will go to the trouble of performing necessary studies to gain approval. It would be ideal if Symlin could be mixed with insulin but the current formulation is not stable with insulin. Maybe Amylin Pharmaceuticals will cook up an alternative recipe that is stable with insulin in a pump. There are many new GLP-1 agonists in development. Maybe one of them will start with insulin compatibility.
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