Octreotide

Octreotide (Sandostatin and Sandostatin LAR Depot)

OFFICE ADMINISTRATION

Indications for Prior Authorization:

• Treatment of acromegaly 
• For management of gastrointestinal neuroendocrine tumors (NETs), such as any of the following:
  • Treatment of severe diarrhea and flushing episodes associated with carcinoid tumors 
  • Prophylactic treatment to prevent carcinoid crises prior to surgery for carcinoid tumor 
  • To reverse life-threatening hypotension due to carcinoid crisis during induction of anesthesia
  • For the treatment of the profuse watery diarrhea associated with vasoactive intestinal polypeptide-secreting tumors (VIPomas)
  • Prophylactic treatment prior to surgery for functioning gastrinoma (Zollinger Ellison syndrome)
  • Prophylactic treatment prior to hepatic artery embolization for nonresectable multiple and hormone-secreting neuroendocrine tumors
• Stabilization of blood glucose levels in persons with functioning islet cell tumors (insulinomas or glucagonomas)
• To reduce the incidence and severity of the postoperative complications of high-risk pancreatic surgery
• Treatment of chemotherapy and/or radiation therapy-induced diarrhea when oral anti-diarrheal medications such as loperimide have become ineffective
• Treatment of severe secretory diarrhea associated with acquired immunodeficiency syndrome (AIDS) when anti-microbial or anti-motility agents have become ineffective
• Treatment of acute bleeding and early rebleeding of gastroesophageal varices associated with cirrhosis when used in conjunction with endoscopic band ligation or sclerotherapy or alone, if ligation/sclerotherapy is not immediately available
• Treatment of unresectable malignant thymoma that is refractory to standard chemotherapy
• To reduce output from gastrointestinal (GI) or pancreatic fistulas
• Management of persons with short bowel syndrome if daily intravenous fluid requirements are greater than 3 liters
• Management of gastrointestinal symptoms (e.g. nausea, vomiting, and pain) of inoperable bowel obstruction in persons with far advanced cancer
• Thyroid stimulating hormone (TSH) hypersecretion due to TSH secreting adenoma
• Dumping syndrome following gastric resection refractory to dietary changes and the addition of fiber

Coverage is Not Authorized For:

• Non-FDA approved indications, which are not listed above unless there is sufficient documentation of efficacy and safety in the published literature
• Sandostatin LAR is a somatostatin analogue indicated for: Treatment in patients who have responded to and tolerated Sandostatin Injection subcutaneous injection for
• Acromegaly
• Severe diarrhea/flushing episodes associated with metastatic carcinoid tumors
• Profuse watery diarrhea associated with VIP-secreting tumors

Dosing:

• Acromegaly: 50 mcg SC/IV tid (Max 1500 mcg/day) Carcinoid tumor symptoms: 100-600 mcg/day SQ/IV in 2-4 divided doses (Max 1500 mcg/day) VIPomas: 200-300 mcg SQ/IV in 2-4 divided doses Range (150-750 mcg) Western Health Advantage Pharmacy and Therapeutics Committee Approved/Revised: May 2009 Reviewed: July 2011
• Secretory diarrhea, GI or pancreatic fistulas, short bowel syndrome, gastrointestinal symptoms of inoperable bowel obstruction in persons with terminal cancer, TSH secreting adenoma, and dumping syndrome: 50-100 mcg SC/IV qd-tid (Max 1500 mcg/day)
• Sandostatin LAR
• Acromegaly: 20-40 mg IM LAR q 4 weeks (Max 40 mg q 4 weeks) Carcinoid tumor symptoms: 20-30 mg LAR IM q 4 weeks (Max 30 mg q 4 weeks) may decrease to 10 mg q 4 weeks after a period of 2 months on 20 mg q 4 weeks VIPomas: 20-30 mg LAR IM q 4 weeks (Max 30 mg q 4 weeks) may decrease to 10 mg q 4 weeks after a period of 2 months on 20 mg q 4 weeks Secretory diarrhea, GI or pancreatic fistulas, short bowel syndrome, gastrointestinal symptoms of inoperable bowel obstruction in persons with terminal cancer, TSH secreting adenoma, and dumping syndrome: Patients must be titrated to response with the short-acting product then converted to LAR