Still in process, MD, but glad you asked as it will give me a chance to pull together and look at what I’ve learned so far.
First of all, I had a theory that I’m really not sure of, but thought was interesting. I’ve never believed that insulin per se caused weight gain, but that it happened only with some combination of insulin resistance, increasing insulin doses to cover high carb eating (both the increased insulin and the increased caloric intake) as well as overtreating lows. I was on insulin for a year with absolutely stable weight. I did nothing different the second year but I started a slow steady weight gain (10 pounds total). Hence my interest in Symlin. When I started insulin my c-peptide at 2 different labs was .70 and .38 so I’m guessing by the second year I was pretty much running on empty. Could this be when my body also stopped producing amylin?? Hmmmmm
Ok, I’m still trying different approaches but here’s what I’ve learned so far:
Contrary to what I’ve read everywhere I don’t take my Symlin immediately before eating. I take it (60mcg) 15 minutes before. The reason is that I’ve noticed right before was too soon to feel that full feeling that makes you eat less. I haven’t experienced ANY lows from this approach and so I do it all the time unless my blood sugar is low before my meal.
Everybody warns you about high risk of hypoglycemia if you dose insulin before eating, and report it is very hard to raise bg due to slowed digestion. Interestingly the Symlin literature itself warns of hypoglycemia, but gives NO instructions at all about when to take insulin! Part of the DOC’s reasoning behind dosing after eating is also to know what you eat as you have less appetite. For me, I am slowly adjusting the servings I give myself to my lowered appetite and if I leave some food it isn’t a lot as I don’t eat that much to begin with. Again, I have not experienced significant hypos…only 3 in the two weeks I’ve been doing this, all of which were alleviated by 2 glucose tablets in the usual 20 minutes. So I’m not convinced of the danger in taking insulin early - at least in my own experience.
Dosing: I’m experimenting with taking my insulin doses at a flat one hour after eating or with doing combo doses. The combo that seems to work best is 25/75 done before my meal and extended out for 4 hours. That way I don’t get a lot of insulin early before the food hits and more later when it does (Symlin definitely slows digestion). To be honest I’ve had success with both approaches, and lack of success with both. But here’s the exciting part: What I’m doing most of the time (exceptions below) is taking 50% of my regular dose!! That’s a significant reduction in insulin, so between the reduced insulin and reduced food intake I’m sure I will lose a little weight and prevent further gain. That is my main motivator, but as far as the improvement in blood sugars, I don’t yet see it. My average for the 14 days I’ve been using Symlin is 123, where my averages for 30/60/90 were 120/121/119. I feel like my “intarget” rates are about the same. But I don’t feel like I have perfected a dosing technique yet so I hope that will improve.
Problems: When I start out before a meal high or even borderline high (let’s say over 120) all bets seem to be off. Even adding corrections, increasing percentage to 60-80%, and taking my bolus sooner I seem to stay stuck. I feel I need a separate plan for those times.
When I eat a meal that I would normally combo bolus for I do very poorly. I made a recipe of artisan pizza for a potluck and there were less people there than expected so I had lots of leftovers. I used to be able to eat one good slice of this thin crust pizza with a salad, combo bolus plus .75 to 1.00 over and make out ok. I’ve eliminated the salad (because it’s too much food for my reduced appetite!) and still go high. Not sure Symlin will work at all with these meals.
All highs I experience are “late” highs due to delayed digestion: 3-5 hours later. My two hour pp’s are excellent. So this leads me to think combo boluses are the way to go. My next experiment will be with 0% now and spreading it all out, or else doing the combo at the 1 hour mark. I’ll let you know how it goes. Figuring this out is hard, but when it works it’s amazing so I’m going to keep working at it!