Management of malignant bowel obstruction with Lanreotide for a community palliative care patient

Dr Kate Markham, Dr Shan Shan Vijeratnam and Dr Pia Amsler, Isabel Hospice, Welwyn Garden City, UK, explain the background to their longer article published in the November/December edition of the European Journal of Palliative Care.

Dr Kate Markham

Dr Kate Markham

We are doctors from Isabel Hospice, providing specialist palliative care in the community in southern England. We see many patients with malignant bowel obstruction and would like to present two case reports outlining the potential for treatment with three to four weekly depot injections of Lanreotide. This method of slow-release injections could be used for patients who are mobile, in order to allow freedom from having one or more syringe drivers, and potentially higher quality of life.

Malignant bowel obstruction is a common distressing complication in patients with advanced abdominal or pelvic carcinoma.(1) In most patients with advanced disease, surgical options such as a colostomy or venting gastrostomy may not be feasible due to peritoneal carcinomatosis, ascites, multiple co-morbidities and poor performance status.(2) This can pose a challenge in such cases with advanced disease to healthcare professionals. The medical management of bowel obstruction is complex. There is limited data to support Lanreotide, a long-acting somatostatin analogue, in this situation.(3) In our two case reports, we found that Lanreotide can significantly improve the symptoms and quality of life of the patients who were both ambulatory with an undetermined prognosis despite advanced intra-abdominal disease. We believe that Lanreotide can be an effective treatment in the community in this particular group of patients.

We would advise consideration of the use of somatostatin analogues for patients in the community with malignant bowel obstruction if other medical treatments fail. We recommend that a trial of Octreotide be given via a syringe driver for one week in order to assess whether a patient would respond to somatostatin analogues. Once proven to be effective, the drug can be switched to the longer-acting Lanreotide, which can then be administered every three to four weeks via depot injection (slow release muscular injection), depending on the clinical picture.

However, the expense of somatostatin analogues remains an issue. An injection of Octreotide acetate of 200microgram/ml costs GB£70 (79 Euros). A depot injection of Lanreotide 30mg costs around GB£320 (359 Euros), 60mg costs around £550 (618 Euros) and 90mg costs over £730 (820 Euros).(4) Depending on the Octreotide dose required, a single monthly Lanreotide injection can therefore be more cost-effective, both in terms of nursing time to attend to the syringe driver daily and for the medication itself.

We believe that Lanreotide can be an effective treatment in the community in this particular group of patients. Once-monthly injections of Lanreotide can offer patients more freedom with their activities of daily living, and improve quality of life, without having to use syringe drivers at all times. Wider use of such treatment may reduce the need for admission to hospice or hospitals for symptom management and should be tailored to patients’ individual needs and wishes.

Lanreotide has proven to be a viable alternative to Octreotide in both our patients. Although expensive, the use of Lanreotide should be considered in ambulatory patients with advanced disease who are not expected to die within a few weeks.

References

  1. Mercadante S. Assessment and management of mechanical bowel obstruction. In: Portenoy RK, Bruera E, eds, Topics in Palliative Care. Vol 1. New York, NY, Oxford University Press; 1997: 113-130
  2. NHS palliative care guidelines, 2015. Accessed March 2016
  3. Marini P, Blumbery J, Landau Q, et al. Symptomatic treatment with lanreotide microparticles in inoperable bowel obstruction due to peritoneal carcinomatosis, a randomized, double-blind, placebo-controlled phase 3 study. J Clin Oncology 2012: 30; 4337-4343.
  4. Twycross R, Wilcock A, Howard P. Palliative Care Formulary. 5th ed. Nottingham: Palliativedrugs.com Ltd, 2014.

4_cover_2-jpgRead the full article in the European Journal of Palliative Care
This post relates to a longer article, Managing malignant bowel obstruction with lanreotide by K Markham, S Shan Vijeratnam and P Amsler, published in the November/December 2016 edition of the European Journal of Palliative Care (vol. 23.6). If you have a web-based subscription to the journal you’ll be able to download this issue, plus all articles in the journal archive. You can also browse the archive and download articles by taking a 10-minute or 30-minute subscription. Members of the EAPC receive discounted subscription rates to the journal – click here to subscribe online.

Read more posts relating to articles published in the European Journal of Palliative Care on the EAPC Blog

ejpclinkedinEJPC Palliative Care Development Award 2017 – nominations form now online.

Do you know someone who has made a major contribution to palliative care policy development? Why not nominate them for the EJPC Palliative Care Policy Development Award? Click here to nominate. Launched by the European Journal of Palliative Care in collaboration with the European Association for Palliative Care, the award is aimed at professionals working in palliative care worldwide who have made a substantial contribution to policy development through research, clinical practice or as policy activists. The 2017 Award will be presented at the 15th World Congress of the EAPC in Madrid, Spain (18–20 May 2017). Deadline for applications: 31 March 2017.

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