Octreotide Palliative Care Continuing Care Guideline

Specialist Details Patient Identifier

Name: Name: Date of Birth: Location: NHS No: Address: Tel:

Introduction Octreotide is an analogue of natural hypothalamic release-inhibiting hormone, somatostatin. Its use in palliative medicine is frequently beyond licence and indications include: 1. Malignant bowel obstruction 2. Severe discharge from rectal carcinoma 3. Intractable non-infective diarrhea 4. High output GI fistula 5. Malignant ascites Octreotide should only be initiated and prescribed for adult patients by a Palliative Medicine Specialist. This guideline is therefore only valid for these patients.

Dosage & Octreotide is administered as a continuous subcutaneous infusion (CSCI) using sodium Administration chloride 0.9% as the diluent. Dose range varies according to indication and clinical response. Usual dose range is 300 – 1200micrograms daily, although higher doses are occasionally used. Once improved symptom control is achieved, the dose may be reduced.

Compatibility in Octreotide appears to be compatible with morphine, diamorphine, oxycodone, haloperidol and Syringe Pumps hyoscine butylbromide (depending on drug concentrations). Precipitation may occur with cyclizine. If 2 or more drugs are to be mixed in the same syringe, please seek Specialist Palliative Care advice via Farleigh Hospice (01245 455478)

Available Available as octreotide injection: Preparations 1. 1mL solution for injection: 50 micrograms/mL, 100 micrograms/mL, 500 micrograms/mL 2. 5mL solution for injection: 200 micrograms/mL The depot preparation must not be used in a CSCI Note: octreotide should be stored between 2 – 8 0C

Adverse effects,  GI side effects: anorexia, nausea, vomiting, cramping abdominal pain, abdominal precautions & bloating, flatulence, loose stools & diarrhea are common. Steatorrhoea due to inhibition contraindications of pancreatic enzyme secretion may be overcome by using pancreatic enzyme supplements.  Pruritus, rash, alopecia are common  Gallstone formation: octreotide may reduce gallbladder motility and may lead to gallstone formation in long-term recipients  Cholelithiasis-induced pancreatitis has been reported with long term treatment. Very rarely, acute pancreatitis has been reported within the first hours/days of treatment  Altered glucose regulation: possible inhibitory effects on secretion of insulin and glucagon have been reported (both hyper and hypoglycaemia) in diabetic patients. Monitoring of blood glucose may be appropriate  Bradycardia: possible sinus bradycardia in patients with cardiac disorders. Concomitant administration of bradycardia-inducing drugs (e.g. beta blockers) may have an additive effect Common Drug  Drugs mainly metabolized by CYP3A4 which have a low therapeutic index (e.g. Interactions carbamazepine, digoxin, warfarin); caution should be exercised during co- administration  Dopaminergics: increases plasma concentration of bromocriptine  Ciclosporin: reduces plasma concentrations OctreotideContinuingCareGUI201608V1.0FINAL Page 1 of 5

 Cimetidine: delays intestinal absorption A Palliative Medicine Specialist is herein defined as a Specialist Palliative Medicine Physician or a Specialist Palliative Care Non-Medical Prescriber under supplementary prescribing agreement (template)

Palliative  Assess appropriateness of octreotide use, considering any contraindications Medicine  Initiate and titrate the dosage regimen for octreotide, assessing response and adverse Specialist effects Responsibilities  Ensure that at least 14 days’ supply is issued originally to ensure continuity of supply in the community  To provide an on-going prescription when requested by the district nursing team when the patient has less than 5 days’ supply remaining  Strength of vial or ampoule must be stated on the prescription  Ensure that the prescription details and continuing care guideline are sent to the patient’s nominated community pharmacy  Review the patient’s response and continuing appropriateness of octreotide at agreed specified intervals, sending a written summary to the GP following a review. This may be facilitated by the Community Specialist Palliative Care CNS team  Provide patient/family/carer with relevant information on use, side effects and need for monitoring  Provide GP,district nurses, community pharmacist (as nominated by the patient) with: - A copy of continuing care guideline - Detailed patient (discharge) summary - GP/pharmacist letter as appropriate (template attached)  Notify and liaise with the district nursing team  Provide the GP/DN team with any advice or information as required  Stop treatment when no longer considered appropriate

Pharmacist Farleigh Hospice currently receive a pharmacy service on their In-Patient Unit from Day Lewis responsibilities Pharmacy

 Ensure that at least 14 days’ supply is issued originally to ensure continuity of supply in the community if patient is discharged from Farleigh Hospice In-Patient Unit  Notify the patient’s nominated community pharmacy  Liaise and provide advice to the patient’s nominated community pharmacy e.g. regarding on-going supply

GP  Support monitoring of the patient’s glucose in liaison with the District Nursing team and responsibilities Community Specialist Palliative Care Team  Continue to review the patient from a GP perspective to monitor control of symptoms  Refer to specialist if symptoms fail to respond to treatment  Liaise with community and specialist nurses  Identify adverse drug reaction and report to the Palliative Medicine Specialist and the CHM/MHRA

DN  Support monitoring of the patient’s glucose in liaison with the GP and Community responsibilities Specialist Palliative Care Team  Support the use of octreotide in a continuous subcutaneous syringe pump (CSCI) including the daily renewal of the pump  Liaise with GP and community specialist palliative care team  Refer to specialist if symptoms fail to respond to treatment

Communication For any queries relating to this patient’s treatment with octreotide, please contact the specialist named at the top of this document

Acknowledgements Interface Pharmacist Network Specialist Medicines (www.ipnsm.hscni.net)

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Appendix 1 - GP Template letter Farleigh Hospice Private and Confidential North Court Road Chelmsford Essex CM1 7FH Tel No: 01245 457300 Fax: 01245 457314

Dear

DOB: NHS Number: The above named patient has been an inpatient and is due for discharge on date:………. See attached discharge summary. They have been started on…………………… by our team. Prescribing responsibility is to remain with the palliative care team for this only. Please can you ensure that this is added to the patient record as outlined in the “Guideline on the recording of non GP prescribed medications on GP clinical systems” http://midessexccg.nhs.uk/your-health-services/medicines-optimisation/general-prescribing- guidance/1558-guidance-on-recording-non-gp-medications-in-clinical-systems-feb-2015/file

All other regular medications will need prescribing by yourself. They have been discharged with ……days of medication.

Yours sincerely

Private and Confidential c.c.

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Appendix 2 – Community Pharmacy Template Letter Farleigh Hospice North Court Road Private and Confidential Chelmsford Essex CM1 7FH Community pharmacist Tel No: 01245 457300 Address Fax: 01245 457314

Dear ……….(community pharmacist)

DOB: NHS Number: The above named patient has been an inpatient and is due for discharge on date: They have identified you as their regular pharmacist. Please inform us if this is not the case. See attached the discharge summary for the above named patient. Note the following changes to their regular prescription:

They have been discharged with ……days of medication. Medication will run out on……..

Yours sincerely

Private and Confidential c.c.

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Title Octreotide continuing care guidelines Document OctreotideContinuingCareGUI201608V1.0FINAL reference Author Dr Eva Lew, Lead Consultant in Palliative Medicine Natalie Leong, Senior Pharmacist, MECCG Approved by APC Date approved September 2016 Next review date September 2018

Previous version Key Changes - New guidance

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