Dosing and uses of Sandostatin, Sandostatin LAR (octreotide)
Adult dosage forms and strengths
injectable solution
- 0.05mg/mL
- 0.1mg/mL
- 0.2mg/mL
- 0.5mg/mL
- 1mg/mL
depot injection
- 10mg/kit
- 20mg/kit
- 30mg/kit
Acromegaly
Solution: 50 mcg SC q8hr initially; titrate up to 500 mcg SC q8hr if necessary; after successful treatment with solution for 2 weeks, initiate treatment with suspension (depot injection)
Suspension (depot injection): 20 mg IM (gluteal) every 4 weeks for 3 months; titrate up or down to 10-30 mg IM every 4 weeks, depending on response; not to exceed 40 mg, as follows
Symptoms controlled: If GH < 1 ng/mL and IGF-1 normal, decrease dose to 10 mg IM every 4 weeks; if GH < 2.5 ng/mL and IGF-1 normal, maintain dose at 20 mg IM every 4 weeks
Symptoms uncontrolled: If GH > 2.5 ng/mL or IGF-I elevated, increase dose to 30 mg IM every 4 weeks; if symptoms persist, increase to 40 mg Im
Dosing Considerations
- Monitor IGF-1 levels every 2 weeks to guide titration; goal: GH levels <5 ng/mL or IGF-1 levels <1.9 units/mL (men) and <2.2 units/mL (women)
- Monitor IGF-1 or GH levels every 6 months
- Withdraw drug yearly for 4 weeks (solution) or 8 weeks (suspension) from patients who have undergone irradiation to assess
Carcinoid Tumor
Solution: 100-600 mcg/day SC divided q6-12hr; may titrate to 1500 mcg/day; after successful treatment with solution for 2 weeks, initiate treatment with suspension (depot injection)
Suspension (depot injection): 20 mg IM every 4 weeks if regular injection well tolerated
VIPoma
Solution: 200-300 mcg/day SC divided q6-12hr; after successful treatment with solution for 2 weeks, initiate treatment with suspension (depot injection)
Suspension (depot injection): 20 mg IM (gluteal) every 4 weeks for 2 months; continue solution for first 2 weeks; titrate suspension up or down to 10-30 mg IM every 4 weeks
Esophageal Variceal Bleeding (Off-label)
Solution: 50 mcg IV bolus, then 25-50 mcg/hr for 1-5 days
GI or Pancreatic Fistula (Off-label)
Solution: 50-200 mcg SC q8hr for 2-12 days
AIDS-Related Diarrhea (Off-label)
Solution: 100-500 mcg SC q8hr
Ileostomy-Related Diarrhea (Off-label)
Solution: 25 mcg/hr IV or 50 mcg SC q12hr
Chemotherapy-Related Diarrhea (Off-label)
Low-grade or uncomplicated: Solution: 100-150 mcg SC q8hr for 1-30 days
Complicated: Solution: 100-150 mcg SC q8hr or 25-50 mcg/hr IV; may increase to 500 mcg q8hr until controlled
Severe: Solution: 100-150 mcg SC q8hr; may increase to 500-1500 mcg SC/IV q8hr
Dumping Syndrome (Off-label)
Solution: 50-150 mcg/day IV; may adjust to 25-600 mcg/day dose range
Suspension (depot injection): 10-20 mcg/month Im
Chylothorax (Off-label)
Solution: 50-100 mcg SC q8hr
Neuroendocrine Tumors (Orphan)
Orphan indication sponsor
- Novartis Pharmaceuticals Corporation, One Health Plaza, East Hanover, NJ 07936-1080
Dosing Modifications
Hepatic impairment: Cirrhosis, 10 mg IM every 4 weeks initially, then titrate to effect
Renal impairment: Without dialysis, dose adjustment not necessary; with dialysis, 10 mg IM every 4 weeks initially, then titrate to effect
Pediatric dosage forms and strengths
injectable solution
- 0.05mg/mL
- 0.1mg/mL
- 0.2mg/mL
- 0.5mg/mL
- 1mg/mL
depot injection
- 10mg/kit
- 20mg/kit
- 30mg/kit
Safety and efficacy not established
GI Bleeding (Off-label)
1 mcg/kg bolus, then 1 mcg/kg/hr infusion; taper by 50% when no active bleeding for 24 hours
Diarrhea (Off-label)
1-10 mcg/kg/day IV/SC
Chylothorax (Off-label)
0.3-4 mcg/kg/hr SC/IV, depending on nature of chylothorax
Hyperinsulinemia/Hypoglycemia of Infancy (Off-label)
2-10 mcg/kg/day SC/IV divided q12hr; increase on basis of response
Sulfonylurea Overdose (Off-label)
1 mcg/kg SC/IV q12hr OR 25 mcg once; monitor blood glucose concentrations
Geriatric dosage forms and strengths
Acromegaly
Solution: 50 mcg SC q8-12hr initially; titrate up to 500 mcg SC q8hr if necessary; after successful treatment with solution for 2 weeks, initiate treatment with suspension (depot injection)
Suspension (depot injection): 20 mg IM (gluteal) every 4 weeks for 3 months; titrate up or down to 10-30 mg IM every 4 weeks, depending on response; not to exceed 40 mg
Dosing Considerations
Dose adjustment may be necessary; clearance may decrease by 26% and half-life by 46%
Monitor IGF-1 levels every 2 weeks to guide titration; goal: GH levels <5 ng/mL or IGF-1 levels <1.9 units/mL (men) and <2.2 units/mL (women)
Monitor IGF-1 or GH levels every 6 months
Withdraw drug yearly for 4 weeks (solution) or 8 weeks (suspension) from patients who have undergone irradiation to assess
Carcinoid Tumor
Solution: 100-600 mcg/day SC divided q6-12hr; may titrate to 1500 mcg/day; after successful treatment with solution for 2 weeks, initiate treatment with suspension (depot injection)
Suspension (depot injection): 20 mg IM every 4 weeks if regular injection well tolerated
VIPoma
Solution: 200-300 mcg/day SC divided q6-12hr; after successful treatment with solution for 2 weeks, initiate treatment with suspension (depot injection)
Suspension (depot injection): 20 mg IM (gluteal) every 4 weeks for 2 months; continue solution for first 2 weeks; titrate suspension up or down to 10-30 mg IM every 4 weeks
Esophageal Variceal Bleeding (Off-label)
Solution: 50 mcg IV bolus, then 25-50 mcg/hr for 1-5 days
Sandostatin, Sandostatin LAR (octreotide) adverse (side) effects
>10%
Gallbladder problems (>60%): Decreased gallbladder contractility, gallstones, cholecystitis, cholestatic hepatitis
Dysglycemia (25%)
Hypothyroidism (25%)
Bradycardia (25%)
1-10%
ECG changes (10%)
Arrhythmia (9%)
Pancreatitis
Upper respiratory tract infection
Fatigue
Headache
Malaise
Rash
Diarrhea
Nausea
Vomiting
Pain at injection site
Joint pain
Blurred vision
Postmarketing Reports
Pediatric Patients
- No formal controlled clinical trials have been performed to evaluate the safety and effectiveness of octreotide depot injection in children younger than 6 years
- Serious adverse events, including hypoxia, necrotizing enterocolitis, and death, have been reported in children (mostly in those younger than 2 years)
- The relation of these events to octreotide has not been established, because the majority of these pediatric patients had serious underlying comorbid conditions
Warnings
Contraindications
Hypersensitivity
Cautions
Hepatic or renal impairment may necessitate dosing adjustments
May alter fat absorption in some patients (monitor for pancreatitis)
May decrease vitamin B12 levels (monitor)
Monitor for hypothyroidism (octreotide suppresses secretion of TSH)
Use caution when giving drug to patients with cardiovascular disease
May enhance toxicity of QTc-prolonging agents
Do not use depot formulation in patients with sulfonylurea-induced hypoglycemia
Dosage adjustments may be necessary in the elderly
Females of childbearing age should use adequate contraception because the treatment may restore fertility
Pregnancy and lactation
Pregnancy category: B
Lactation: Whether octreotide crosses into breast milk is not known; avoid giving to lactating women
Pregnancy categories
A: Generally acceptable. Controlled studies in pregnant women show no evidence of fetal risk.
B: May be acceptable. Either animal studies show no risk but human studies not available or animal studies showed minor risks and human studies done and showed no risk.
C: Use with caution if benefits outweigh risks. Animal studies show risk and human studies not available or neither animal nor human studies done.
D: Use in LIFE-THREATENING emergencies when no safer drug available. Positive evidence of human fetal risk.
X: Do not use in pregnancy. Risks involved outweigh potential benefits. Safer alternatives exist.
NA: Information not available.
Pharmacology of Sandostatin, Sandostatin LAR (octreotide)
Mechanism of action
Somatostatin analog; decreases GH secretion, secretion of gastrin, VIP, glucagon, secretin, serotonin release and pancreatic polypeptide; in acromegaly, octreotide decreases growth hormone and IGF-1 secretion; suppresses LH response to GnRH secretion and decreases splanchnic blood flow
Absorption
Absorption rapid and complete (SC)
Bioavailability: SC, 100%; IM, 60%
Peak plasma time: IV, immediately after injection; SC, 15-30 min; PO, 90-120 min; IM, 60 min
Distribution
Protein bound: 65% binds to lipoprotein
Vd: 13.6 L
Metabolism
Metabolized by liver
Elimination
Half-life: 1.7 hr
Total body clearance: 10 L/hr
Excretion: Urine (32%)
Administration
IV Incompatibilities
Fat emulsion 10%
IV Preparation
Common diluent: 50-100 μg/50 mL Ns
Common diluent for continuous IV infusion: 1200 μg/250 mL Ns
Minimum volume: 50 mL Ns
IV/IM Administration
Im
- Administer suspension (depot injection) immediately after reconstitution; inject into gluteal muscle, avoiding deltoid
IV
- IV administration may be IVP, IVPB, or continuous infusion
- Regular injection only: IVP should be administered undiluted over 3 minutes
- IVPB: Administer over 15-30 minutes
- Continuous infusion: 25-50 μg/hr for treatment of esophageal variceal bleeding
- Do not use if solution contains particles or is discolored
Storage
Refrigerate solution
Ampule may be stored at room temp for up to 14 days when protected from light
