In this section, you will find information about:
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 present. Surgical resection of local disease (and regional nodal or hepatic metastases) can result in cure or symptom relief2.
According to the National Comprehensive Cancer Network (NCCN) guidelines for neuroendocrine tumors, octreotide is an appropriate treatment for the severe diarrhea and flushing associated with carcinoid syndrome. In addition, "rescue" injections of immediate-release octreotide may be used to help with breakthrough carcinoid syndrome symptoms. When symptoms are well controlled, long-acting release (LAR) octreotide may be resumed2.
Octreotide may alter absorption of dietary fats. Monitoring of vitamin B12 levels is recommended during therapy with Sandostatin® LAR Depot. Patients on total parenteral nutrition (TPN) and octreotide should have periodic monitoring of zinc levels.
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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 symptoms1,3.
Immediate-release Sandostatin® Injection and Sandostatin® LAR Depot provide short- and long-term control of profuse watery diarrhea in VIPoma/watery diarrhea syndrome for a majority of patients in whom severe diarrhea and hypokalemia are resistant to other modes of therapy1,3.
Warnings and Precautions:
Thyroid Function: Hypothyroidism may occur. Baseline and periodic assessment of thyroid function (TSH, total and/or free T4) is recommended.
Cardiac Function: Bradycardia, arrhythmia, conduction abnormalities, and other EKG changes may occur.
The relationship of these events to octreotide acetate is not established because many of these patients have underlying cardiac disease. Use with caution in at-risk patients.
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 protocols1.
INDICATIONS AND USAGE
Sandostatin® LAR Depot (octreotide acetate for injectable suspension) is indicated for patients in whom initial treatment with immediate release Sandostatin® (octreotide acetate) Injection has been shown to be effective and tolerated for:
- Long-term maintenance therapy in acromegalic patients who have had 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).
- Long-term treatment of the severe diarrhea and flushing episodes associated with metastatic carcinoid tumors.
- Long-term treatment of the profuse watery diarrhea associated with VIP-secreting tumors.
In patients with carcinoid syndrome and VIPomas, the effect of Sandostatin Injection and Sandostatin LAR Depot on tumor size, rate of growth and development of metastases has not been determined.
IMPORTANT SAFETY INFORMATION
Warnings and Precautions:
- Gallbladder abnormalities may occur: Patients should be monitored periodically.
- Glucose Metabolism: Hypoglycemia or hyperglycemia may occur. Blood glucose levels should be monitored when Sandostatin LAR Depot treatment is initiated or when the dose is altered. Antidiabetic treatment should be adjusted accordingly.
- Thyroid Function: Hypothyroidism may occur. Baseline and periodic assessment of thyroid function (TSH, total and/or free T4) is recommended.
- Cardiac Function: Bradycardia, arrhythmia, conduction abnormalities, and other EKG changes may occur. The relationship of these events to octreotide acetate is not established because many of these patients have underlying cardiac disease. Use with caution in at-risk patients.
- Nutrition: Octreotide may alter absorption of dietary fats. Monitoring of vitamin B12 levels is recommended during therapy with Sandostatin LAR Depot. Patients on total parenteral nutrition (TPN) and octreotide should have periodic monitoring of zinc levels.
Drug Interactions: The following drugs require monitoring and possible dose adjustment when used with Sandostatin LAR Depot: cyclosporine, insulin, oral hypoglycemic agents, beta-blockers, bromocriptine. Octreotide has been associated with alterations in nutrient absorption, so it may have an effect on absorption of orally administered drugs. Drugs mainly metabolized by CYP3A4 and which have a low therapeutic index should be used with caution.
Adverse Reactions: The most common adverse reactions occurring in patients receiving Sandostatin LAR Depot are:
- Acromegaly: biliary abnormalities (52%), diarrhea (36-48%), cholelithiasis (13-38%), abdominal pain or discomfort (11-29%), flatulence (26%), influenza-like symptoms (20%), constipation (19%), headache (15%), anemia (15%), hyperglycemia (15%), injection site pain (2-14%), hypertension (13%), dizziness (12%), fatigue (11%), nausea (10%), vomiting (7%), hypothyroidism (2%), hypoglycemia (2%), and goiter (2%).
- Carcinoid Tumors and VIPomas: biliary abnormalities (62%), injection site pain (20-50%), nausea (24-41%), abdominal pain (10-35%), fatigue (8-32%), headache (16-30%), hyperglycemia (27%), back pain (8-27%), constipation or vomiting (15-21%), dizziness (18-20%), sinus bradycardia (19%), pruritus (18%), URTI (10-18%), myalgia (4-18%), flatulence (9-16%), arthropathy (8-15%), rash (15%), generalized pain (4-15%), sinusitis (5-12%), conduction abnormalities (9%), hypoglycemia (4%), and arrhythmia (3%).
