So this will be my final post in the three-part series on how to use Symlin as a Type 1 Diabetic. I really want to thank the people that have commented, offered up their own experiences, and contributed constructive criticism. I may do other posts about Symlin but they probably won't be in a guide format, at least not until 2010 when Amylin is due to release their second-generation Symlin product.
This post has been a long time coming because I have been experimenting with different ways to use Symlin and different types of boluses. Unfortunately I have also had to deal with a couple of rather difficult experiences that could have been prevented entirely had I exercised a bit more caution. I hope my experiences help you use Symlin better and help you avoid the types of situations I encountered.
So we'll begin with Advanced Techniques, including how to attack the Dawn Phenomenon, how to stop stress-induced hyperglycemia (including post-exercise highs), skipping doses, and what to do when it is time to eat but your blood glucose is heading low and you don't want to skip your Symlin dose for the meal (social situations mostly).
The Dawn Phenomenon
There appear to be two distinct causes of the DP, which can be present simultaneously or on their own. Symlin is quite effective for dealing with one of them and not very effective at all in dealing with the other. It is important to recognize what the primary cause of your particular episode of DP is in order to determine if it can be mitigated by Symlin or not. The typical "unexplainable" DP is usually caused by a release of stress hormones in the human body, which in turn signal the liver to empty its sugar stores into the bloodstream. The precise reason for this release of stress hormones is more or less unexplained at the present time, but Symlin can shut the liver's sugar dump off if you catch it in time. Unfortunately, there is virtually no way to consistently detect this problem unless you are using a CGMS or if even minor hyperglycemia tends to wake you up.
When I experience the DP due to stress hormones, the rise usually begins to materialize around 4 AM. If my CGMS alarms and I stick myself with 60mcg from the Symlin pen and a small amount of insulin (for me, .5 to 1 unit), the DP is halted, my blood glucose levels stabilize or reduce to normal, and all is good. Catching the rise later does work but not nearly as well.
The other cause of DP is eating late at night, even if you bolus correctly for the food when you eat it. This is very consistent for me and a few others I have spoken to. In this case, it isn't your liver that is dumping sugar into your blood that is causing the rise in glucose levels so Symlin just isn't very effective at dealing with the problem. If you are experiencing a combination of these two factors it may be difficult to know which is the primary cause, but if you had a substantial amount of food before bed then that is a good bet.
Very strenuous exercise generally causes the release of stress hormones that can raise blood glucose levels for a few hours following the activity. This problem is compounded by the fact that it is a good idea to eat right after your workout so your body can repair and refuel- and most of us are quite hungry then too. I like to put my protein-based meal replacement shake powder into a shaker and take it with me to my workouts so I can inject Symlin and "eat" right when my workout ends. This seems to mostly solve the problem, although sometimes I need a very small amount of insulin to stay in my target range. Again, if you have a CGMS you can sometimes see the rise due to stress hormones as it begins during the workout. If I see this I will do a small correction to prevent a more difficult situation later.
So You Forgot Your Symlin
What a sinking feeling this is for me. I've had it happen a few times and every time I just felt like skipping the meal, but I couldn't due to social obligations or the fact that I was just way too hungry and wouldn't have another opportunity to eat for hours. You're going to need more insulin than you think- obviously more than you would need without Symlin but in my experience, it is even more than you would have needed if you never used Symlin in the first place. You'll be surprised how quickly your blood glucose rises- try to bolus 15-30 minutes before you begin eating if possible.
Have you ever sat down to eat a meal at a restaurant, realized you were hypoglycemic or heading there, but still wanted to use Symlin with that meal? Depending on the contents of the meal, it can be accomplished by consuming 10-15 grams of carbohydrate over the course of ten to fifteen minutes (eat a small portion of the carbs in the meal for example), then take your Symlin and eat the rest of the food. Obviously this becomes more difficult if not impossible if the food contains no carbs and you have no glucose tabs, or if the hypoglycemia is severe. Don't try this unless you have been using Symlin for a few months at least and are very in tune with how your body responds to it and also to food.
If you have your own unique methods for using Symlin, please post them in the comments!
How to Really Screw it Up
One thing that is very tempting is to use Symlin in combination with a correction bolus to quickly solve a hyperglycemic episode. It can work to rapidly lower blood glucose and I admit to doing it when my levels are very high and I am having a difficult time getting them under control with insulin. The fact is, this technique is generally unsafe for two reasons. First of all, it can cause an extremely rapid decline in blood glucose. This is most dangerous when you already have correction insulin on board, take Symlin, and then take another corrective bolus out of frustration or miscalculation. We all know how unpredictable blood glucose changes can sometimes be, and this is especially true when we are severely out of our normal range. What can end up happening is that your blood glucose drops steeply, landing you in the normal or low-normal range while you still have a lot of mileage left from the bolus and you just injected Symlin ten or fifteen minutes prior. I won't tell you to never use Symlin to help lower very high blood glucose, because I don't believe in giving advice I wouldn't take myself, but do not take any insulin after you take the Symlin until the insulin on board is largely done doing its job.
The second problem is more mechanical in nature. How many of you wash your hands every time before you test your blood glucose? Yeah. . .neither do I. But consider this dilemma- you test after exposing your hands to something that can cause a very inaccurate high reading and decide to use a Symlin-insulin combination punch to quickly drop your levels, or, you test before a meal and get a very high reading and add a corresponding correction bolus to your pre-meal Symlin injection. But oh no, you really weren't at 344, you were really at 101 and it was just the crap on your hands that was causing the meter to spike up. So before you treat hyperglycemia this way, wash your hands and do a re-test so you don't end up sitting in your kitchen until 4 AM letting mouthfuls of orange juice steep in your mouth for 15 minutes at a time until you're back in the safe zone. Spending 90 minutes in the 40s and 50s will pretty much ruin your day and unfortunately I speak from experience. You probably see the potential for even worse disasters, like doing this while on a road trip when you've stopped for food and just got back in the car with 8 overload units of Apidra on board unbeknown to you. . .
So let's not end this on a sad note. Through my own experimenting and collecting input from a couple of you who were kind enough to message me with your own experiences, I have some good information on how to make Symlin work with a high protein/low-carb diet (or single meal if you prefer).
Protein and Symlin
Symlin officially is only for meals containing 25 or more grams of carbohydrate, but it clearly has benefits for meals that are heavy on the protein and lighter than 25 on the carbs. For one thing, the appetite suppressant properties still work and Symlin still shuts off the excess glucose that would come from your liver during the meal. Furthermore, some types of protein tend to hit your bloodstream in a fashion very similar to complex carbohydrates (or even like pizza in some cases), where others hit almost like carbs. Easily digested, "quick" proteins like whey isolate (this includes most store-bought protein powders) definitely benefit from the usual Symlin dose and will start to attack your bloodstream in about an hour. They stick around for about 2.5 to 3 hours, so the best kind of bolus for me is a 30 minute square bolus given about 30 minutes after I drink the protein shake (I only use zero carb protein powders- obviously you will need to make adjustments if yours contain sugar). You will need individual experimentation to find your "insulin to protein" ratio, but these fast-acting proteins tend to need more insulin overall than other kinds.
Have you ever eaten a hearty bacon-and-eggs breakfast, with minimal or zero carbs, and then experienced a major, extended spike hours later? This is quite common. Symlin is not as useful with this type of meal as it is with just about everything else. Egg proteins are very long-lasting, and also a very good choice a couple of times a week, especially if you are trying to gain muscle and maintain a positive nitrogen balance. I find that the Symlin does work to smooth out the eventual rise in blood glucose, but that its effects are largely gone long before the proteins in the meal are done raising your blood glucose. For me, the best sort of bolus is a dual-wave bolus taken about an hour after I finish the meal. A small portion is given up front to cover any toast or initial hit from the proteins and the rest is given over one hour. I get pretty aggressive here with the amount of insulin I use. Of course the specific amount is going to very by individual, but don't be afraid to take the gloves off.
Steak lies somewhere in the middle. It really depends on the cut of meat (filet mignon being leaner than say, a New York) and what other items you eat with it, since steak is rarely eaten alone and often with things like potatoes and cooked vegetables. Generally speaking, it takes longer to hit than whey protein, but does not have the punch of a bacon and eggs breakfast. The fattier cuts can kick up your blood glucose several hours after you eat though, so be mindful of that. It is the pizza effect to a lesser extent.
Get a watch with a stopwatch! Insulin pumps don't have a "snooze bolus" feature yet. You can't tell your pump to wait an hour and then give you the bolus you need for the meal. What works best for me for normal meals with some carbs is to hit my stopwatch when I begin eating, and then bolus for the meal at about the 50 minute mark. Using a stopwatch can also give you very excellent information about how long it takes for a certain type of food to do its damage, and how long that food stands there smacking you. Combined with a CGMS you can get this thing almost down to a science.
Well that about does it. I hope this guide has helped you in using Symlin and I welcome your comments. Take care and good luck!