Which ‘Tide to Ride?

When it comes to managing type-1 diabetes, insulin is no longer the only treatment option. Yes, insulin is necessary, but there are other injectable medications that can serve as powerful supplements to insulin. These medications can offer benefits to those trying to improve their after-meal glucose levels and/or shed unwanted pounds.

Pramlintide (brand name Symlin) is a replacement for the amylin hormone which is lacking in people with diabetes. Its job is to slow the rate of gastric emptying, blunt appetite, and inhibit the inappropriate production of glucagon by the pancreas. Liraglutide (brand name Victoza) mimics the effects of GLP-1 hormones produced by the lining of the intestines. Its job is to slow the rate of gastric emptying, blunt appetite, inhibit the inappropriate production of glucagon by the pancreas and, in those whose pancreatic beta cells are still intact, enhance pancreatic insulin secretion.

Both pramlintide and liraglutide come in pen form and are injected into the fatty layer below the skin, similar to insulin. They have been proven effective for reducing after-meal glucose peaks as well as facilitating weight loss. Both can also cause a certain degree of nausea, and may contribute to hypoglycemia unless concurrent insulin adjustments are made.

So, if your after-meal glucose levels spike excessively or you’re struggling to lose weight due to excessive hunger, which of the ‘tides (pramlintide or liraglutide) would suit you best? Obviously, this is a good discussion to have with the people who prescribe your diabetes medications, as they may have a clear preference for one or the other. Nevertheless, it’s a good idea to enter the discussion armed with a clear understanding of the benefits and drawbacks associated with each. Having used each personally and worked with hundreds of clients who have used each medication, I can offer an educated and unbiased opinion.

From my experience, pramlintide (Symlin) is the better choice when it comes to after-meal glucose control. I haven’t found anything quite as potent in this regard. Its short profile (2-3 hours) means that its actions are concentrated at the appropriate time, especially when it is taken right before meals. However, it will most likely need to be taken multiple times daily — each time a meal or snack is planned — in order to prevent a post-meal “spike” and potential over-eating. When pramlintide is taken, bolus insulin (and sometimes basal insulin) usually needs to be reduced and delayed in order to prevent hypoglycemia.

Liraglutide (Victoza), on the other hand, seems to be a more effective tool for controlling food intake and achieving weight loss. Taken once daily, its appetite-suppression effects usually last throughout the day. I have seen less intense nausea with liraglutide compared to pramlintide, and there is less of an urge to snack between meals. However, liraglutide’s effect on post-meal glucose is generally less than what we see with pramlintide. When liraglutide is taken, basal insulin (and sometimes bolus insulin) usually needs to be reduced in order to prevent hypoglycemia.

Another important consideration when choosing between the “’tides” is insurance coverage. Both medications are costly, and not all insurance plans cover both. Those that do sometimes require preauthorization by the plan’s medical department before coverage is approved. Pramlintide (Symlin) is FDA-approved for use in type-1 diabetes, while liraglutide (Victoza) is not. It can still be prescribed off-label for those with type-1, but again, not all insurance plans will cover it.

Choice is a good thing, especially when it comes to managing one’s diabetes. Whether you’re looking to choose a glucose meter, continuous glucose monitor, insulin pump, insulin type, or an adjunctive medication, it is always best to weigh your options carefully. An educated consumer makes for the best management.