Blogs to Boards: Question 5

This is the fifth in a series of 41 posts from both GeriPal and Pallimed to get our physician readers ready for the hospice and palliative medicine boards. Every week GeriPal and Pallimed alternates publishing a new question, as well as a discussion of possible answers to the question (click here for the full list of questions).  

Question 5

In hospice IDT, you discuss the case of a 68 year old female with ovarian cancer with abdominal pain and sudden onset nausea and vomiting. She has had no recent bowel movements and is on minimal opioids. You suggest a trial of octreotide for a likely malignant bowel obstruction and the nurses say “Doctor! You say we can use octreotide for everything! Is there anything octreotide can’t be used for in hospice?”

Which one of the following is not a potential scenario to use octreotide? Choose the best answer.

a) A 37 year old male with end stage alcoholic hepatitis who starts vomiting blood 

b) A 90 year old with a severe diarrhea with a history of a rectal tumor and radiation burns to the perineal area 

c) A 42 year old female with a tense distended abdomen leaking a small amount from a previous paracentesis site. 

d) A 27 year old male with a malignant wound with copious drainage 

e) A 31 year old female with abdominal pain from opioid-induced constipation 

Discussion:Show/hide Discussion

The correct answer is (e)

a) Octreotide is the Swiss Army Knife of palliative medications. It is a synthetic analog of
somatostatin and has many mechanisms of action: in general, it has a global effect to
decrease secretions primarily in the GI tract It can be costly as a medication alone but it
could reduce the system cost by avoiding hospitalizations. You should talk with your
local pharmacist to see about availability and cost in your local programs. It is typically
administered via intermittent subcutaneous dosing.
Study published in 2000 compared octreotide infusion with sclerotherapy and found that
octreotide to be as effective as sclerotherapy regarding hemostasis at 48 hours and on day
7 after the index bleeding episode. So for the patient looking to avoid hospitalization with
acute variceal bleed this may be a helpful (but expensive) medication.

b) While it does not work as a prophylactic treatment to prevent chemo and radiation
induced diarrhea a few studies have shown that it can treat existing diarrhea related to
these two common cancer treatments.

c) Rapidly accumulating ascites or situations where repeat paracentesis or drain may not be
readily available have been shown to be responsive to octreotide. It also has been
reported for use in pleural effusions related to cirrhosis.

d) Tumor related secretions have been show to respond to octreotide

e) Indications for octreotide include (via palliativedrugs.com) : symptoms associated with
unresectable hormone-secreting tumors, e.g. carcinoid, VIPomas, glucagonomas and
acromegaly; prevention of complications after elective pancreatic surgery; †bleeding
esophageal varices; †salivary, pancreatic and enterocutaneous fistulas; †intractable
diarrhea related to high output ileostomies, AIDS, radiotherapy, chemotherapy or bone
marrow transplant;†inoperable bowel obstruction in patients with cancer; †hypertrophic
pulmonary osteo-arthopathy;†ascites in cirrhosis and cancer; †buccal fistula; †death rattle
(noisy respiratory secretions); †bronchorrhea;†reduction of tumor-related secretions.

References:

• http://cases.pallimed.org/2008/06/am-i-really-going-to-have-to-live-like.html
• http://www.pallimed.org/2008/11/octreotide-for-radiation-induced.html
• Freitas DS, Sofia C, Pontes JM, Gregório C, Cabral JP, Andrade P, Rosa A, Camacho E,
  Ferreira M, Portela F…. (2000) Octreotide in acute bleeding esophageal varices: a
  prospective randomized study. Hepato-gastroenterology, 47(35), 1310-4. PMID:
  11100339
• Kalambokis, G. (2006-01) Octreotide in the treatment of refractory ascites of cirrhosis.
  Scandinavian Journal of Gastroenterology, 14(1), 199-121. DOI:
  10.1080/00365520510024043
• Martenson et al. The efficacy of octreotide in the therapy of acute radiation-induced
  diarrhea: a randomized controlled study. International Journal of Radiation
  OncologyBiologyPhysics, 54(1), 195-202. DOI: 10.1016/S0360-3016(02)02870-5

(For email readers – click here for the answer and discussion)