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Octreotide

      Therapeutic Reviews aim to provide essential independent information for health professionals about drugs used in palliative and hospice care. The content is also available on www.palliativedrugs.com and will feature in future editions of the Hospice and Palliative Care Formulary USA and its British and Canadian counterparts. The series editors welcome feedback on the articles ( [email protected] ).
      Class: Synthetic hormone.
      Indications: Symptoms associated with unresectable hormone-secreting tumors, e.g., carcinoid, VIPomas, glucagonomas and acromegaly; prevention of complications after elective pancreatic surgery;
      • Gurusamy K.S.
      • Koti R.
      • Fusai G.
      • Davidson B.R.
      Somatostatin analogues for pancreatic surgery.
      †bleeding esophageal varices;
      • Gøtzsche P.C.
      • Hróbjartsson A.
      Somatostatin analogues for acute bleeding oesophageal varices.
      †salivary, pancreatic and enterocutaneous fistulas;
      • Harris A.
      Octreotide in the treatment of disorders of the gastrointestinal tract.
      • Spinell C.
      • Ricci E.
      • Berti P.
      • Miccoli P.
      Postoperative salivary fistula: therapeutic action of octreotide.
      †intractable diarrhea related to high output ileostomies,
      • Dorta G.
      Role of octreotide and somatostatin in the treatment of intestinal fistulae.
      • Farthing M.J.
      Octreotide in the treatment of refractory diarrhoea and intestinal fistulae.
      AIDS, radiation therapy, chemotherapy or bone marrow transplant;
      • Harris A.
      Octreotide in the treatment of disorders of the gastrointestinal tract.
      • Rosenoff S.H.
      • Gabrail N.Y.
      • Conklin R.
      • et al.
      A multicenter, randomized trial of long-acting octreotide for the optimum prevention of chemotherapy-induced diarrhea: results of the STOP trial.
      • Crouch M.A.
      • Restino M.S.
      • Cruz J.M.
      • Perry J.J.
      • Hurd D.D.
      Octreotide acetate in refractory bone marrow transplant-associated diarrhea.
      • Benson 3rd, A.B.
      • Ajani J.A.
      • Catalano R.B.
      • et al.
      Recommended guidelines for the treatment of cancer treatment-induced diarrhea.
      • Maroun J.A.
      • Anthony L.B.
      • Blais N.
      • et al.
      Prevention and management of chemotherapy-induced diarrhea in patients with colorectal cancer: a consensus statement by the Canadian Working Group on Chemotherapy-Induced Diarrhea.
      †inoperable bowel obstruction in patients with cancer;
      • Mercadante S.
      • Casuccio A.
      • Mangione S.
      Medical treatment for inoperable malignant bowel obstruction: a qualitative systematic review.
      • Ripamonti C.
      • Mercadante S.
      How to use octreotide for malignant bowel obstruction.
      †hypertrophic pulmonary osteoarthopathy;
      • Johnson S.A.
      • Spiller P.A.
      • Faull C.M.
      Treatment of resistant pain in hypertrophic pulmonary arthropathy with subcutaneous octreotide.
      †ascites in cirrhosis and cancer;
      • Harvey M.
      • Dunlop R.
      Octreotide and the secretory effects of advanced cancer.
      • Kalambokis G.
      • Economou M.
      • Fotopoulos A.
      • et al.
      Renal effects of treatment with diuretics, octreotide or both, in non-azotemic cirrhotic patients with ascites.
      • Caims W.
      • Malone R.
      Octreotide as an agent for the relief of malignant ascites in palliative care patients.
      †buccal fistula;
      • Lam C.
      • Wong S.
      Use of somatostatin analog in the management of traumatic parotid fistula.
      †death rattle; †bronchorrhea;
      • Hudson E.
      • Lester J.F.
      • Attanoos R.L.
      • Linnane S.J.
      • Byrne A.
      Successful treatment of bronchorrhea with octreotide in a patient with adenocarcinoma of the lung.
      †reduction of tumor-related secretions.
      • Harvey M.
      • Dunlop R.
      Octreotide and the secretory effects of advanced cancer.
      Pharmacology
      Octreotide is a synthetic analog of somatostatin with a longer duration of action.
      • Lamberts S.W.
      • van der Lely A.J.
      • de Herder W.W.
      • Hofland L.J.
      Somatostatin is an inhibitory hormone found throughout the body. In the hypothalamus, it inhibits the release of growth hormone, TSH, prolactin and ACTH. It inhibits the secretion of insulin, glucagon, gastrin and other peptides of the gastro-enteropancreatic system (i.e., peptide YY, neurotensin, VIP and substance P), reducing splanchnic blood flow, portal blood flow, GI motility, gastric, pancreatic and small bowel secretion, and increasing water and electrolyte absorption.
      • Gyr K.
      • Meier R.
      Pharmacodynamic effects of sandostatin in the gastrointestinal tract.
      Somatostatin acts as an inhibitory neurotransmitter in the CNS and also inhibits cell proliferation.
      • Patel Y.C.
      Somatostatin and its receptor family.
      In Type 1 diabetes mellitus, octreotide decreases insulin requirements. However, in Type 2 diabetes, octreotide suppresses both insulin and glucagon release, leaving plasma glucose concentrations either unchanged or slightly elevated.
      • Davies R.R.
      • Turner S.J.
      • Alberti K.G.
      • Johnston D.G.
      Somatostatin analogues in diabetes mellitus.
      • Lunetta M.
      • Di Mauro M.
      • Le Moli R.
      • Nicoletti F.
      Effects of octreotide on glycaemic control, glucose disposal, hepatic glucose production and counterregulatory hormone secretion in type 1 and type 2 insulin treated diabetic patients.
      Octreotide has a direct anticancer effect on solid tumors of the GI tract and prolongs survival.
      • Deming D.A.
      • Stella A.L.
      • Holen K.D.
      • Ku G.
      • O'Reilly E.M.
      A dramatic response to long-acting octreotide in metastatic hepatocellular carcinoma.
      • Kouroumalis E.
      • Skordilis P.
      • Thermos K.
      • et al.
      Treatment of hepatocellular carcinoma with octreotide: a randomised controlled study.
      • Pandha H.
      • Waxman J.
      Octreotide in malignant intestinal obstruction.
      • Cascinu S.
      • Del Ferro E.
      • Catalano G.
      A randomised trial of octreotide vs best supportive care only in advanced gastrointestinal cancer patients refractory to chemotherapy.
      The inhibitory, antisecretory and absorptive effects of octreotide are utilized in a wide range of clinical settings:
      Hormone-secreting tumors: Octreotide improves symptoms by inhibiting hormone secretion, for example:
      • 5HT in carcinoid (improving flushing and diarrhea)
      • VIP in VIPomas (improving diarrhea)
      • glucagon in glucagonomas (improving rash and diarrhea)
      Inoperable bowel obstruction in patients with cancer: Octreotide can provide rapid relief of nausea and vomiting. The optimal dose has not been formally identified, but reports suggest <50% of patients respond to the typical starting dose of 300 microgram/24 h,
      • Shima Y.
      • Ohtsu A.
      • Shirao K.
      • Sasaki Y.
      Clinical efficacy and safety of octreotide (SMS201-995) in terminally ill Japanese cancer patients with malignant bowel obstruction.
      and 75–90% respond to 600–800 microgram/24 h.
      • Ripamonti C.
      • Mercadante S.
      How to use octreotide for malignant bowel obstruction.
      • Mystakidou K.
      • Tsilika E.
      • Kalaidopoulou O.
      • et al.
      Comparison of octreotide administration vs conservative treatment in the management of inoperable bowel obstruction in patients with far advanced cancer: a randomized, double-blind, controlled clinical trial.
      Although doses of up to 1500 microgram/24 h have been used,
      • Weber C.
      • Zulian G.B.
      Malignant irreversible intestinal obstruction: the powerful association of octreotide to corticosteroids, antiemetics, and analgesics.
      a dose of 600–800 microgram/24 h is generally sufficient to identify those likely to respond.
      • Mystakidou K.
      • Tsilika E.
      • Kalaidopoulou O.
      • et al.
      Comparison of octreotide administration vs conservative treatment in the management of inoperable bowel obstruction in patients with far advanced cancer: a randomized, double-blind, controlled clinical trial.
      • Riley J.
      • Fallon M.
      Octreotide in terminal malignant obstruction of the gastrointestinal tract.
      In comparisons with scopolamine (hyoscine) butylbromide (60–80 mg/24 h; not USA), octreotide (300–800 microgram/24 h) provides more effective and rapid relief of nausea and vomiting and reduction in NG (nasogastric) tube output. However, in those patients responding to either drug, after about 4–6 days, overall symptom relief is similar, and NG tube removal possible with both.
      • Mystakidou K.
      • Tsilika E.
      • Kalaidopoulou O.
      • et al.
      Comparison of octreotide administration vs conservative treatment in the management of inoperable bowel obstruction in patients with far advanced cancer: a randomized, double-blind, controlled clinical trial.
      (Although no head-to-head comparison has been published to date, it is likely that the same is true for glycopyrrolate (glycopyrronium).)
      Ascites: Octreotide 300 microgram SC b.i.d. can suppress diuretic-induced activation of the renin-aldosterone-angiotensin system and its addition has improved renal function and Na+ and water excretion in patients with cirrhosis and ascites receiving furosemide and spironolactone.
      • Kalambokis G.
      • Economou M.
      • Fotopoulos A.
      • et al.
      Renal effects of treatment with diuretics, octreotide or both, in non-azotemic cirrhotic patients with ascites.
      Octreotide is also reported to reduce the rate of formation of malignant ascites.
      • Harvey M.
      • Dunlop R.
      Octreotide and the secretory effects of advanced cancer.
      • Caims W.
      • Malone R.
      Octreotide as an agent for the relief of malignant ascites in palliative care patients.
      It may interfere with ascitic fluid formation through a reduction in splanchnic blood flow or as a result of a direct tumor antisecretory effect. Octreotide may also help improve the efficacy of diuretics as in cirrhosis.
      • Kalambokis G.
      • Economou M.
      • Kosta P.
      • Papadimitriou K.
      • Tsianos E.V.
      The effects of treatment with octreotide, diuretics, or both on portal hemodynamics in nonazotemic cirrhotic patients with ascites.
      Octreotide could be considered in patients with rapidly accumulating ascites requiring frequent paracentesis despite diuretic therapy. Octreotide may also help resolve chylous ascites and/or pleural effusion secondary to yellow nail syndrome,
      • Widjaja A.
      • Gratz K.F.
      • Ockenga J.
      • Wagner S.
      • Manns M.P.
      Octreotide for therapy of chylous ascites in yellow nail syndrome.
      ruptured thoracic duct,
      • Ferrandière M.
      • Hazouard E.
      • Guicheteau V.
      • et al.
      Chylous ascites following radical nephrectomy: efficacy of octreotide as treatment of ruptured thoracic duct.
      cirrhosis,
      • Zhou D.X.
      • Zhou H.B.
      • Wang Q.
      • et al.
      The effectiveness of the treatment of octreotide on chylous ascites after liver cirrhosis.
      • Pfammatter R.
      • Quattropani C.
      • Reichen J.
      • Göke B.
      • Wagner A.C.
      Treatment of hepatic hydrothorax and reduction of chest tube output with octreotide.
      • Dumortier J.
      • Leprêtre J.
      • Scalone O.
      • et al.
      Successful treatment of hepatic hydrothorax with octreotide.
      peritoneal dialysis,
      • Lee P.H.
      • Lin C.L.
      • Lai P.C.
      • Yang C.W.
      Octreotide therapy for chylous ascites in a chronic dialysis patient.
      or cancer.
      • Mincher L.
      • Evans J.
      • Jenner M.W.
      • Varney V.A.
      The successful treatment of chylous effusions in malignant disease with octreotide.
      Other antisecretory effects: Octreotide reduces salivary production and may be of use in salivary or buccal fistulas.
      • Spinell C.
      • Ricci E.
      • Berti P.
      • Miccoli P.
      Postoperative salivary fistula: therapeutic action of octreotide.
      • Lam C.
      • Wong S.
      Use of somatostatin analog in the management of traumatic parotid fistula.
      Experience of its use in death rattle is limited and recommended only in the context of a clinical trial.
      • Clark K.
      • Currow D.C.
      • Agar M.
      • Fazekas B.S.
      • Abernethy A.P.
      A pilot phase II randomized, cross-over, double-blinded, controlled efficacy study of octreotide versus hyoscine hydrobromide for control of noisy breathing at the end-of-life.
      The use of octreotide led to rapid and complete control of bronchorrhea (>1L/24 h) in a patient with diffuse adenocarcinoma of the lung.
      • Hudson E.
      • Lester J.F.
      • Attanoos R.L.
      • Linnane S.J.
      • Byrne A.
      Successful treatment of bronchorrhea with octreotide in a patient with adenocarcinoma of the lung.
      A systematic review supports the prophylactic use of octreotide with pancreatic surgery for cancer, to reduce the risk of complications, e.g., leak, fistula, but not with pancreatic surgery for other reasons.
      • Gurusamy K.S.
      • Koti R.
      • Fusai G.
      • Davidson B.R.
      Somatostatin analogues for pancreatic surgery.
      Octreotide is recommended first-line for chemotherapy or radiotherapy-induced diarrhea when severe (i.e., increase ≥7 stools/day over baseline, hospital admission and IV fluids >24 h required) and second-line for less severe diarrhea which does not respond to loperamide 16–24 mg/day.
      • Benson 3rd, A.B.
      • Ajani J.A.
      • Catalano R.B.
      • et al.
      Recommended guidelines for the treatment of cancer treatment-induced diarrhea.
      • Maroun J.A.
      • Anthony L.B.
      • Blais N.
      • et al.
      Prevention and management of chemotherapy-induced diarrhea in patients with colorectal cancer: a consensus statement by the Canadian Working Group on Chemotherapy-Induced Diarrhea.
      For those who have experienced severe chemotherapy-induced diarrhea, prophylactic depot octreotide is recommended for subsequent cycles. Octreotide also has been used for the treatment of enterovesical fistula,
      • Shinjo T.
      • Kondo Y.
      • Harada K.
      • Yamazaki J.
      • Okada M.
      Treatment of malignant enterovesical fistula with octreotide.
      and to improve mucous discharge from rectal cancers.
      • Harvey M.
      • Dunlop R.
      Octreotide and the secretory effects of advanced cancer.
      Pain: Octreotide is reported to have an analgesic effect in patients with cancer, e.g., in bone pain from metastatic carcinoid, in hypertrophic pulmonary osteoarthopathy, pain arising from GI cancer, or when given IT.
      • Johnson S.A.
      • Spiller P.A.
      • Faull C.M.
      Treatment of resistant pain in hypertrophic pulmonary arthropathy with subcutaneous octreotide.
      • Katai M.
      • Sakurai A.
      • Inaba H.
      • et al.
      Octreotide as a rapid and effective painkiller for metastatic carcinoid tumor.
      • Befon S.
      • Mystakidou K.
      • Lyra M.
      • Tubanakis N.
      • Vlahos L.
      Continuous subcutaneous octreotide in gastrointestinal cancer patients: pain control and beta-endorphin levels.
      • Penn R.D.
      • Paice J.A.
      • Kroin J.S.
      Octreotide: a potent new nonopiate analgesic for intrathecal infusion.
      However, a small RCT found octreotide to be no better than placebo.
      • De Conno F.
      • Saita L.
      • Ripamonti C.
      • Ventafridda V.
      Subcutaneous octreotide in the treatment of pain in advanced cancer patients.
      Octreotide also is reported to be of value in chronic nonmalignant pancreatic pain caused by hypertension in the scarred pancreatic ducts.
      • Donnelly P.K.
      • Hanning C.
      Somatostatin for chronic pancreatic pain.
      • Okazaki K.
      • Yamamoto Y.
      • Kagiyama S.
      • et al.
      Pressure of papillary sphincter zone and pancreatic main duct in patients with chronic pancreatitis in the early stage.
      Benefit could be secondary to its antisecretory action;
      • Lembcke B.
      • Creutzfeldt W.
      • Schleser S.
      • et al.
      Effect of the somatostatin analogue sandostatin on gastrointestinal, pancreatic and biliary function and hormone release in man.
      suppressing exocrine function by administering pancreatin supplements also reduces pain in 50–75% of patients with chronic pancreatitis.
      • Mössner J.
      • Wresky H.P.
      • Kestel W.
      • et al.
      Influence of treatment with pancreatic extracts on pancreatic enzyme secretion.
      Miscellaneous: At doses far below those necessary for an antisecretory effect (e.g., 1 microgram SC t.i.d.), octreotide protects the stomach from NSAID-related injury, probably via its ability to reduce NSAID-induced neutrophil adhesion to the microvasculature.
      • Scheiman J.M.
      • Tillner A.
      • Pohl T.
      • et al.
      Reduction of NSAID induced gastric injury and leucocyte endothelial adhesion by octreotide.
      Somatostatin receptors have been identified on leukocytes and, in rats, octreotide has been shown to suppress inflammation.
      • Karalis K.
      • Mastorakos G.
      • Chrousos G.P.
      • Tolis G.
      Somatostatin analogues suppress the inflammatory reaction in vivo.
      A recent systematic review casts doubt on the value of octreotide in the management of bleeding esophageal varices.
      • Gøtzsche P.C.
      • Hróbjartsson A.
      Somatostatin analogues for acute bleeding oesophageal varices.
      Octreotide is generally given as a SC bolus or by CSCI
      • Mercadante S.
      Tolerability of continuous subcutaneous octreotide used in combination with other drugs.
      but can be given IV when a rapid effect is required. Octreotide also has been administered IT (as an analgesic).
      • Penn R.D.
      • Paice J.A.
      • Kroin J.S.
      Octreotide: a potent new nonopiate analgesic for intrathecal infusion.
      A long-acting depot formulation is also available but evaluation has been generally limited to hormone-secreting tumors.
      • Scherübl H.
      • Wiedenmann B.
      • Riecken E.O.
      • et al.
      Treatment of the carcinoid syndrome with a depot formulation of the somatostatin analogue lanreotide.
      Benefit from depot octreotide has been reported in a RCT for the prevention of chemotherapy-related diarrhea
      • Rosenoff S.H.
      • Gabrail N.Y.
      • Conklin R.
      • et al.
      A multicenter, randomized trial of long-acting octreotide for the optimum prevention of chemotherapy-induced diarrhea: results of the STOP trial.
      and in cancer patients with bowel obstruction.
      • Massacesi C.
      • Galeazzi G.
      Sustained release octreotide may have a role in the treatment of malignant bowel obstruction.
      • Matulonis U.A.
      • Seiden M.V.
      • Roche M.
      • et al.
      Long-acting octreotide for the treatment and symptomatic relief of bowel obstruction in advanced ovarian cancer.
      Lanreotide is an alternative sandostatin analog also available in normal and depot formulations.
      Onset of action: 30 min.
      Time to peak plasma concentration: 30 min SC.
      Plasma half-life: 1.5 h SC.
      Duration of action: 8 h.

      Cautions

      Serious drug interactions: Octreotide markedly reduces plasma cyclosporine concentrations and inadequate immunosuppression may result. Increase the cyclosporine dose by 50% before starting octreotide, and monitor the plasma concentration daily to guide further adjustments.
      Insulinoma (may potentiate hypoglycemia). In Type 1 diabetes mellitus, insulin requirements may be reduced by up to 50%; monitor plasma glucose concentrations to guide any dose reduction needed with insulin or oral hypoglycemic agents. Octreotide increases the bio-availability of bromocriptine by about 40% (consider when using the combination in acromegaly).
      Cirrhosis, renal failure requiring dialysis (both lead to reduced elimination which may necessitate a dose reduction). May cause gallstones (although the manufacturer advises ultrasound examination of the gallbladder before treatment and every 6–12 months thereafter, this is generally not necessary in palliative care). Avoid abrupt withdrawal of short-acting octreotide after long-term treatment (may precipitate biliary colic caused by gallstones/biliary sludge).
      May cause bradycardia, conduction defects or arrhythmias; use with caution in at-risk patients. Monitor thyroid function during long-term treatment (may cause hypothyroidism).

      Undesirable Effects

      For full list, see manufacturer's PI.
      Bolus SC injection is painful (but less if the vial is warmed to room temperature).
      Dry mouth, flatulence (lowers esophageal sphincter tone), nausea, abdominal pain, diarrhea, steatorrhea (GI undesirable effects may be reduced by administering octreotide between meals or at bedtime), impaired glucose tolerance, hypoglycemia (shortly after starting treatment), persistent hyperglycemia (during long-term treatment), gallstones (10–20% of patients on long-term treatment), pancreatitis (associated with gallstones).

      Dose and Use

      Dose varies according to indication (Table 1). Some of the recommendations are based on experience with only a small number of patients, so the dose should always be titrated according to effect. Once improvement in the symptom is achieved, reduction to the lowest dose that maintains symptom control can be tried.
      Table 1Dose Recommendations for SC Octreotide
      IndicationStarting DoseUsual Maximum
      Hormone-secreting tumors
       acromegaly100–200 microgram t.i.d.600 microgram/24 h
      • Gyr K.
      • Meier R.
      Pharmacodynamic effects of sandostatin in the gastrointestinal tract.
       carcinoid, VIPomas, glucagonomas50 microgram once daily or b.i.d.; increased to 200 microgram t.i.d.1500 microgram/24 h; rarely 6000 microgram/24 h
      • Harris A.
      • Redfern J.
      Octreotide treatment of carcinoid syndrome: analysis of published dose-titration data.
      Intractable diarrhea (including that caused by chemotherapy and radiotherapy)300–450 microgram/24 h1500 microgram/24 h,
      • Benson 3rd, A.B.
      • Ajani J.A.
      • Catalano R.B.
      • et al.
      Recommended guidelines for the treatment of cancer treatment-induced diarrhea.
      • Maroun J.A.
      • Anthony L.B.
      • Blais N.
      • et al.
      Prevention and management of chemotherapy-induced diarrhea in patients with colorectal cancer: a consensus statement by the Canadian Working Group on Chemotherapy-Induced Diarrhea.
      • Cello J.P.
      • Grendell J.H.
      • Basuk P.
      • et al.
      Effect of octreotide on refractory AIDS-associated diarrhea. A prospective, multicenter clinical trial.
      occasionally higher
      Intestinal obstruction250–500 microgram/24 h750 microgram/24 h, occasionally higher
      Tumor-antisecretory effect50–100 microgram b.i.d.600 microgram/24 h
      • Harvey M.
      • Dunlop R.
      Octreotide and the secretory effects of advanced cancer.
      Ascites200–600 microgram/24 h600 microgram/24 h
      • Caims W.
      • Malone R.
      Octreotide as an agent for the relief of malignant ascites in palliative care patients.
      Bronchorrhea300–500 microgram/24 h
      • Hudson E.
      • Lester J.F.
      • Attanoos R.L.
      • Linnane S.J.
      • Byrne A.
      Successful treatment of bronchorrhea with octreotide in a patient with adenocarcinoma of the lung.
      Hypertrophic pulmonary osteoarthopathy100 microgram b.i.d.
      • Johnson S.A.
      • Spiller P.A.
      • Faull C.M.
      Treatment of resistant pain in hypertrophic pulmonary arthropathy with subcutaneous octreotide.
      Extrapolation from t.i.d. dosing may explain why 300–600 microgram/24 h CSCI is a common recommendation. However, because a 1000 microgram/5 mL multidose vial is available, it is simpler to dose octreotide in multiples of 250 microgram instead, e.g., 250 microgram, 500 microgram, etc.
      Octreotide can be painful if given as an SC bolus. This can be reduced if the ampule is warmed in the hand to body temperature before injection. To reduce the likelihood of inflammatory reactions at the skin injection site with CSCI, dilute to the largest volume possible (e.g. for a McKinley T-34 syringe pump, 22 mL in a 30 mL luerlock syringe given over 24 h) and consider the use of 0.9% saline.
      There are 2-drug compatibility data for octreotide in 0.9% saline with diamorphine (not USA), haloperidol, scopolamine butylbromide (not USA), scopolamine hydrobromide, midazolam, morphine sulfate, ondansetron, and oxycodone (injection not USA). Incompatibility may occur with dexamethasone or levomepromazine.
      More details and 3-drug compatibility data can be found on www.palliativedrugs.com Syringe Driver Survey Database. For compatibility data in water for injection, see Charts A4.1–A4.6 on the site.
      Depot formulation: A depot formulation of octreotide 10–30 mg, given every 4 weeks is available (Sandotatin LAR®). This has a relative bioavailability of about 60% compared to SC octreotide. Generally, the depot formulation is used only when symptoms have first been controlled with SC octreotide. Patients who have not previously received SC octreotide should have a test dose of 50–100 microgram SC and, provided there are no unacceptable undesirable effects, then switched to the depot injection. The depot formulation requires deep IM injection into the gluteal muscle; to minimize irritation, use alternate sides for subsequent injections.
      In acromegaly, stop the SC dose of octreotide when the first depot injection is given; for other neuro-endocrine tumors, continue the SC dose for a further 2 weeks.
      In a recent survey, 40% of clinicians reported the use of depot formulations in the management of cancer-related bowel obstruction.

      Palliativedrugs.com. Octreotide - What is your experience? 2010. Available from: http://www.palliativedrugs.com/download/100401_octreotide.pdf.

      There is limited published experience of their use in this setting, although benefit in a small number of patients with ovarian cancer for up to 15 months has been reported.
      • Matulonis U.A.
      • Seiden M.V.
      • Roche M.
      • et al.
      Long-acting octreotide for the treatment and symptomatic relief of bowel obstruction in advanced ovarian cancer.
      A reduction in NG tube output and symptomatic benefit is evident within 24 h.
      • Massacesi C.
      • Galeazzi G.
      Sustained release octreotide may have a role in the treatment of malignant bowel obstruction.

      Lanreotide

      Patients with acromegaly can be started directly on the depot formulation. It is given by deep SC into the gluteal region:
      • start with 90 mg every 4 weeks for the first 3 months (60 mg in moderate-severe hepatic or renal impairment
      • if necessary, increase to 120 mg every 4 weeks

      Supply

      Octreotide

      Sandostatin® (Novartis)
      Injection 50 microgram/mL, 1 mLamp=$12; 100 microgram/mL, 1 mLamp=$23; 500 microgram/mL, 1 mLamp=$111; 1 mg/5 mL multidose vial=$1,172; 5 mg/5 mL multidose vial=$4,525; for prolonged storage, keep unopened ampules and vials in a refrigerator; a multidose vial can be kept for up to 2 weeks at room temperature for day to day use.
      Octreotide (non-proprietary)
      Injection 50 microgram/mL, net price 1 mLamp=$10; 100 microgram/mL, 1 mLamp=$13; 500 microgram/mL, 1 mLamp=$82; 1 mg/5 mL multidose vial=$238; 5 mg/5 mL multidose vial=$955; for prolonged storage, keep unopened ampules and vials in a refrigerator; a multidose vial can be kept for up to 2 weeks at room temperature for day to day use.
      Sandostatin LAR® (Novartis)
      Depot injection (microsphere powder for aqueous suspension) 10 mg vial=$1,968; 20 mg vial=$2312; 30 mg vial=$3,861 (all supplied with diluent and syringe), IM injection only, every 28 days; for prolonged storage, keep in a refrigerator and protect from light; vial can be brought up to room temperature 30–60min before required but must only be reconstituted immediately before injection; see instruction booklet provided with vial for recommended reconstitution technique.

      Lanreotide

      Somatuline Autogel® (Beaufour Ipsen)
      Depot injection (prefilled syringe) 60 mg=$2,209; 90 mg=$2,873; 120 mg=$4,318; for prolonged storage, keep in a refrigerator and protect from light; the syringe should be brought up to room temperature 30min before required but should only be removed from its packaging immediately before injection.

      Abbreviations/Key

      † Off-label indication
      5HT 5-hydroxytryptamine, serotonin
      ACTH Adrenocorticotrophic hormone
      CSCI Continuous subcutaneous infusion
      GI Gastrointestinal
      IT Intrathecal
      NG Nasogastric
      RCT Randomized controlled trial
      SC Subcutaneous
      TSH Thyroid-stimulating hormone
      VIP Vasoactive intestinal peptide

      References

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