The treatment of carcinoid syndrome requires peripheral treatments that address its various symptoms: diuretics for heart disease, bronchodilators for wheezing, as well as targeted treatments—such as somatostatin analogues—that work at the site of carcinoid tumors to inhibit hormone secretion and relieve diarrhea and flushing1,2.
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Treatment of Carcinoid Tumors and Syndrome
A two-sided approach to the treatment of carcinoid tumors focuses first on treatment of the tumor, and second on treatment of the syndrome1. Tumor management involves surgical resection when possible and subsequent chemotherapy or interferon treatment, or hepatic embolization when hepatic metastases are prevalent. Surgical resection of local disease (and regional nodal or hepatic metastases) can result in cure or symptom relief. Radiation therapy and chemotherapy are not generally beneficial and are used primarily for symptom relief2,3,4.
According to National Comprehensive Cancer Network (NCCN) guidelines for neuroendocrine tumors, carcinoid syndrome from recurrent or unresected disease can be managed by Sandostatin® LAR Depot (octreotide acetate for injectable suspension). In addition, "rescue" injections of immediate release Sandostatin® Injection (octreotide injection) may be used to help with breakthrough carcinoid syndrome symptoms. When symptoms are well controlled, Sandostatin® LAR Depot may be resumed2,5.
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Treatment of VIPomas
Most VIPomas are malignant, but patients can live for many years with metastatic disease if the symptoms can be controlled1.
First-line therapy for VIPoma consists of replenishing fluids and electrolytes to correct the profound hypokalemia, dehydration, and metabolic acidosis—up to 5 L/day of fluid and more than 350 mEq/day of potassium. When possible, surgery is used to eliminate the tumor responsible for VIP secretions. For patients with no metastases, surgery may result in a cure. On the other hand, for patients with metastases, surgical debulking may temporarily relieve symptoms1,2.
Immediate release Sandostatin® Injection and Sandostatin® LAR Depot provide short- and long-term control of diarrhea in VIPoma/watery diarrhea syndrome for a majority of patients in whom diarrhea and hypokalemia are resistant to other modes of therapy1,2.
For patients with symptomatic metastatic disease, chemotherapy may be provided. Chemotherapy alone has been relatively ineffective, but may be more useful in combination with surgical resection1.
Since the numbers of patients with VIPomas are so small, conclusive data are not available for evaluating the efficacies of the different treatment protocols. However, all of the treatment options discussed in the following section for carcinoid tumors have been used successfully in small numbers of patients1.
Important Safety Information
Carcinoid Syndrome:
Sandostatin® LAR Depot (octreotide acetate for injectable suspension) is indicated for long-term treatment of the severe diarrhea and flushing episodes associated with metastatic carcinoid tumors and for the long-term treatment of the profuse watery diarrhea associated with VIP-secreting tumors in patients in whom initial treatment with immediate release Sandostatin® (octreotide acetate) Injection has been shown to be effective and tolerated.
Important Safety Information:
As with immediate release Sandostatin® Injection, the most frequently reported drug-related adverse events were biliary disorders (62%), gastrointestinal disorders (14% to 38%), and injection-site pain (20% to 50%). Hypoglycemia (4%), hyperglycemia (27%), sinus bradycardia (19%), conduction abnormalities (9%), and arrhythmias (3%) have been reported.
The controlled clinical trials that support the marketing clearance for Sandostatin® LAR Depot did not include determination of effect on tumor size or rate of growth. Sandostatin® LAR Depot is not indicated for tumor shrinkage.
Acromegaly
Sandostatin® LAR Depot (octreotide acetate for injectable suspension) is indicated for long-term maintenance therapy in acromegalic patients who have had an inadequate response to surgery and/or radiotherapy, or for whom surgery and/or radiotherapy is not an option. The goal of treatment in acromegaly is to reduce GH and IGF-1 levels to normal.
Important Safety Information:
As with immediate release Sandostatin® Injection, the most frequently reported drug-related adverse events were biliary disorders (52%), gastrointestinal disorders (7% to 36%), and injection-site pain (2% to 11%). Hypoglycemia (2%), hyperglycemia (15%), and hypothyroidism (2%) have been reported. While not measured in acromegalic patients receiving Sandostatin® LAR Depot, ECG changes have been reported in patients receiving immediate release Sandostatin® Injection; the degree to which these abnormalities are related to octreotide acetate is not clear, as many acromegalics have cardiovascular disease. You are encouraged to report negative side effects of prescription drugs to the FDA. Visit www.fda.gov/medwatch or call 1-800-FDA-1088.
