"By Roxanne Nelson
Another study showing an increased risk for cancer with drinking alcohol, even with just one or two drinks a day, has prompted renewed warnings on the health risks associated with alcohol consumption.
Single doses of Sandostatin® (octreotide acetate) have been shown to inhibit gallbladder contractility and decrease bile secretion in normal volunteers. In clinical trials (primarily patients with acromegaly or psoriasis), the incidence of biliary tract abnormalities was 63% (27% gallstones, 24% sludge without stones, 12% biliary duct dilatation). The incidence of stones or sludge in patients who received Sandostatin (octreotide acetate) for 12 months or longer was 52%. Less than 2% of patients treated with Sandostatin (octreotide acetate) for 1 month or less developed gallstones. The incidence of gallstones did not appear related to age, sex or dose. Like patients without gallbladder abnormalities, the majority of patients developing gallbladder abnormalities on ultrasound had gastrointestinal symptoms. The symptoms were not specific for gallbladder disease. A few patients developed acute cholecystitis, ascending cholangitis, biliary obstruction, cholestatic hepatitis, or pancreatitis during Sandostatin (octreotide acetate) therapy or following its withdrawal. One patient developed ascending cholangitis during Sandostatin (octreotide acetate) therapy and died.
Sandostatin® (octreotide acetate) alters the balance between the counter-regulatory hormones, insulin, glucagon and growth hormone, which may result in hypoglycemia or hyperglycemia. Sandostatin (octreotide acetate) also suppresses secretion of thyroid stimulating hormone, which may result in hypothyroidism. Cardiac conduction abnormalities have also occurred during treatment with Sandostatin (octreotide acetate) . However, the incidence of these adverse events during long-term therapy was determined vigorously only in acromegaly patients who, due to their underlying disease and/or the subsequent treatment they receive, are at an increased risk for the development of diabetes mellitus, hypothyroidism, and cardiovascular disease. Although the degree to which these abnormalities are related to Sandostatin (octreotide acetate) therapy is not clear, new abnormalities of glycemic control, thyroid function and ECG developed during Sandostatin (octreotide acetate) therapy as described below.
Risk of Pregnancy with Normalization of IGF-1 and GH
Although acromegaly may lead to infertility, there are reports of pregnancy in acromegalic women. In women with active acromegaly who have been unable to become pregnant, normalization of GH and IGF-1 may restore fertility. Female patients of childbearing potential should be advised to use adequate contraception during treatment with octreotide.
The hypoglycemia or hyperglycemia which occurs during Sandostatin (octreotide acetate) therapy is usually mild, but may result in overt diabetes mellitus or necessitate dose changes in insulin or other hypoglycemic agents. Hypoglycemia and hyperglycemia occurred on Sandostatin (octreotide acetate) in 3% and 16% of acromegalic patients, respectively. Severe hyperglycemia, subsequent pneumonia, and death following initiation of Sandostatin (octreotide acetate) therapy was reported in one patient with no history of hyperglycemia.
In patients with concomitant Type I diabetes mellitus, Sandostatin Injection and Sandostatin LAR® Depot (octreotide acetate for injectable suspension) are likely to affect glucose regulation, and insulin requirements may be reduced. Symptomatic hypoglycemia, which may be severe, has been reported in these patients. In non-diabetics and Type II diabetics with partially intact insulin reserves, Sandostatin (octreotide acetate) Injection or Sandostatin (octreotide acetate) LAR Depot administration may result in decreases in plasma insulin levels and hyperglycemia. It is therefore recommended that glucose tolerance and antidiabetic treatment be periodically monitored during therapy with these drugs.
In acromegalic patients, 12% developed biochemical hypothyroidism only, 8% developed goiter, and 4% required initiation of thyroid replacement therapy while receiving Sandostatin (octreotide acetate) . Baseline and periodic assessment of thyroid function (TSH, total and/or free T4) is recommended during chronic therapy.
In acromegalics, bradycardia ( < 50 bpm) developed in 25%; conduction abnormalities occurred in 10% and arrhythmias occurred in 9% of patients during Sandostatin (octreotide acetate) therapy. Other EKG changes observed included QT prolongation, axis shifts, early repolarization, low voltage, R/S transition, and early R wave progression. These ECG changes are not uncommon in acromegalic patients. Dose adjustments in drugs such as beta-blockers that have bradycardia effects may be necessary. In one acromegalic patient with severe congestive heart failure, initiation of Sandostatin (octreotide acetate) therapy resulted in worsening of CHF with improvement when drug was discontinued. Confirmation of a drug effect was obtained with a positive rechallenge.
Several cases of pancreatitis have been reported in patients receiving Sandostatin (octreotide acetate) therapy.
Sandostatin (octreotide acetate) may alter absorption of dietary fats in some patients.
In patients with severe renal failure requiring dialysis, the half-life of Sandostatin (octreotide acetate) may be increased, necessitating adjustment of the maintenance dosage.
Depressed vitamin B12 levels and abnormal Schilling's tests have been observed in some patients receiving Sandostatin (octreotide acetate) therapy, and monitoring of vitamin B12 levels is recommended during chronic Sandostatin (octreotide acetate) therapy.
Laboratory tests that may be helpful as biochemical markers in determining and following patient response depend on the specific tumor. Based on diagnosis, measurement of the following substances may be useful in monitoring the progress of therapy:
Acromegaly: Growth Hormone, IGF-I (somatomedin C) Responsiveness to Sandostatin (octreotide acetate) may be evaluated by determining growth hormone levels at 1-4 hour intervals for 8-12 hours post dose. Alternatively, a single measurement of IGF-I (somatomedin C) level may be made two weeks after drug initiation or dosage change.
Carcinoid: 5-HIAA (urinary 5-hydroxyindole acetic acid), plasma serotonin, plasma Substance P
VIPoma: VIP (plasma vasoactive intestinal peptide)
Baseline and periodic total and/or free T4 measurements should be performed during chronic therapy (see PRECAUTIONS – General).
Carcinogenesis/Mutagenesis/Impairment of Fertility
Studies in laboratory animals have demonstrated no mutagenic potential of Sandostatin (octreotide acetate) .
No carcinogenic potential was demonstrated in mice treated subcutaneously for 85-99 weeks at doses up to 2000 mcg/kg/day (8x the human exposure based on body surface area). In a 116-week subcutaneous study in rats, a 27% and 12% incidence of injection site sarcomas or squamous cell carcinomas was observed in males and females, respectively, at the highest dose level of 1250 mcg/kg/day (10x the human exposure based on body surface area) compared to an incidence of 8%-10% in the vehicle-control groups. The increased incidence of injection site tumors was most probably caused by irritation and the high sensitivity of the rat to repeated subcutaneous injections at the same site. Rotating injection sites would prevent chronic irritation in humans. There have been no reports of injection site tumors in patients treated with Sandostatin (octreotide acetate) for up to 5 years. There was also a 15% incidence of uterine adenocarcinomas in the 1250 mcg/kg/day females compared to 7% in the saline-control females and 0% in the vehicle-control females. The presence of endometritis coupled with the absence of corpora lutea, the reduction in mammary fibroadenomas, and the presence of uterine dilatation suggest that the uterine tumors were associated with estrogen dominance in the aged female rats which does not occur in humans.
Sandostatin (octreotide acetate) did not impair fertility in rats at doses up to 1000 mcg/kg/day, which represents 7x the human exposure based on body surface area.
Pregnancy Category B
There are no adequate and well-controlled studies of octreotide use in pregnant women. Reproduction studies have been performed in rats and rabbits at doses up to 16 times the highest recommended human dose based on body surface area and revealed no evidence of harm to the fetus due to octreotide. However, because animal reproduction studies are not always predictive of human response, this drug should be used during pregnancy only if clearly needed.
In postmarketing data, a limited number of exposed pregnancies have been reported in patients with acromegaly. Most women were exposed to octreotide during the first trimester of pregnancy at doses ranging from 100-300 mcg/day of Sandostatin (octreotide acetate) s.c. or 20-30 mg/month of Sandostatin (octreotide acetate) LAR, however some women elected to continue octreotide therapy throughout pregnancy. In cases with a known outcome, no congenital malformations were reported.
It is not known whether octreotide is excreted into human milk. Because many drugs are excreted in human milk, caution should be exercised when octreotide is administered to a nursing woman.
Safety and efficacy of Sandostatin (octreotide acetate) Injection in the pediatric population have not been demonstrated.
No formal controlled clinical trials have been performed to evaluate the safety and effectiveness of Sandostatin (octreotide acetate) in pediatric under age 6 years. In post-marketing report, serious adverse events, including hypoxia, necrotizing enterocolitis, and death, have been reported with Sandostatin (octreotide acetate) use in children, most notably in children under 2 years of age. The relationship of these events to octreotide has not been established as the majority of these pediatric patients had serious underlying co-morbid conditions.
The efficacy and safety of Sandostatin (octreotide acetate) using the Sandostatin (octreotide acetate) LAR Depot formulation was examined in a single randomized, double-blind, placebo-controlled, six–month pharmacokinetics study in 60 pediatric patients age 6-17 years with hypothalamic obesity resulting from cranial insult. The mean octreotide concentration after 6 doses of 40 mg Sandostatin (octreotide acetate) LAR Depot administered by IM injection every four weeks was approximately 3 ng/ml. Steady-state concentrations was achieved after 3 injections of a 40 mg dose. Mean BMI increased 0.1 kg/m² in Sandostatin (octreotide acetate) LAR Depot-treated subjects compared to 0.0 kg/m² in saline control-treated subjects. Efficacy was not demonstrated. Diarrhea occurred in 11 of 30 (37%) patients treated with Sandostatin (octreotide acetate) LAR Depot. No unexpected adverse events were observed. However, with Sandostatin (octreotide acetate) LAR Depot 40 mg once a month, the incidence of new cholelithiasis in this pediatric population (33%) was higher than that seen in other adults indications such as acromegaly (22%) or malignant carcinoid syndrome (24%), where Sandostatin (octreotide acetate) LAR Depot was 10 to 30 mg once a month.
Clinical studies of Sandostatin (octreotide acetate) did not include sufficient numbers of subjects aged 65 and over to determine whether they respond differently from younger subjects. Other reported clinical experience has not identified differences in responses between the elderly and younger patients. In general, dose selection for an elderly patient should be cautious, usually starting at the low end of the dosing range, reflecting the greater frequency of decreased hepatic, renal, or cardiac function, and of concomitant disease or other drug therapy.This monograph has been modified to include the generic and brand name in many instances.
Last reviewed on RxList: 1/26/2017
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