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Lanreotide – it’s calling the shots!

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Somatuline_image_2

A standard Lanreotide syringe

When I was discharged from hospital following major surgery in Nov 2010, I knew I would shortly be commencing long-term monthly ‘somatostatin analogue’ treatment and had assumed Octreotide (Sandostatin LAR) would be the drug of choice. However, my Oncologist prescribed Lanreotide (known in the UK as Somatuline Autogel and elsewhere as Somatuline Depot).  Technically this is a hormone therapy (it’s not chemo).

Somatostatin Analogues (Octreotide/Lanreotide) are mainstay treatments for many Neuroendocrine Cancer patients and their introduction is a very significant factor in the improvement of both prognostic outcomes and quality of life.  Both drugs are designed to control Carcinoid Syndrome (but can be used selectively in other NET syndromes) and both have anti-tumour effects.  Check out my Lanreotide vs Octreotide comparison blog.

1d723232d70759d9c8fbe23a6f25a811Although I didn’t relish the thought of any injection in the ‘rear end’ every 28 days for the rest of my life, I admit to being slightly relieved with his choice.  I had been reading about patient experiences with the alternative, mainly the needle length and the occasional problems mixing the drug prior to injection.  Although Lanreotide has a similar gauge (thickness), the needle is a good bit shorter and is deep subcutaneous rather than Octreotide LAR’s intramuscular (IM) route. No mixing is required as Lanreotide comes prefilled.

If you’re interested in the science, please be aware that a somatostatin analogue is a synthetic (manufactured) version of a naturally occurring hormone which inhibits the peptides and amines that can be dangerously hypersecreted by certain neuroendocrine tumours.  If you are after a more technical explanation of this process, you should check out my blog Neuroendocrine Tumours – not an exact Science – inside you will also find a link to a fantastic paper by Dr Eugene Woltering, one of the world’s top NET Cancer experts.

Following an Octreotide Scan, various areas lit up confirming the output from previous CT scans.  It also confirmed new ‘hotspots’ for further investigation.  This specialist scan confirmed I probably had working receptors to receive something known as a Somatostatin Analogue to help with combatting the effects of Carcinoid Syndrome (please note that not having working receptors does not mean there is no benefit of receiving somatostatin analogues). I was therefore prescribed daily Octreotide (self-injecting) whilst I was waiting for my first major ‘debulking’ surgery, This treatment did eventually lessen the main effect of the carcinoid syndrome, facial flushing.  It wasn’t until after my first surgery that the facial flushing was dramatically reduced.  I commenced Lanreotide on 9 Dec 2010 and I haven’t had a facial flush since. It’s worth adding that my Chromogranin A (CgA) blood test (correlated to tumour mass) did not return to normal until after a liver resection 3 months later.  My 5HIAA urine test results (mainly correlated to serotonin levels) returned to normal prior to liver surgery in Apr 2011 indicating the Lanreotide was doing its job! Somatostatin Analogue side effects are to be expected and most people seem to have different and/or greater or lesser effects than others. The daily Octreotide did not bother me too much other than some discolouring of the stomach at the injection sites (i.e. black and blue!) ….I’m more observant nowadays, so it’s possible I may not have recorded this experience properly.

If you read the UK patient leaflet which comes with each injection, you can see a list of potential side effects as long as your arm.  Neuroendocrine Cancer comes with many signs, syndromes, symptoms and suspicions, so I always advise caution and some analysis when assigning reasons for problems encountered.  For North America, the equivalent medicine leaflet can be found here (Somatuline Depot). I don’t know precisely why (……. I do have my suspicions), but I’m always very sceptical about the criteria used to compile the list of side effects for any medicine. In my own mind, I’m fairly certain that people have existing symptoms or new symptoms as a result of coincidental treatment that are erroneously labelled under drugs during trials.

side view of Lanreotide

side view of Lanreotide

You can also self-inject Lanreotide (upper thigh area) but I’m not ready for that yet!  Close family members can be trained to inject but again, I’m not ready for that and neither is Chris!

I think the injection site is very important and getting this wrong will worsen the side effects. The site should be the superior external quadrant but not of the whole ‘butt’, it means of the left or right buttock that is being used on an alternative basis.  If nurses think the whole ‘butt’, they might be tempted to stick it quite close to the ‘intergluteal cleft’ – not advisable!  Although the patient leaflets are very clear on how to administer the drug, once the location is established, I always discuss the following with the Nurse before I receive the ‘dart’:

1.  The injection should have been removed from the fridge at least 30 minutes before treatment.

2.  Don’t pinch the skin, stretch it.

3.  Put the needle in fast at 90 degrees, inject the drug slow – 20 seconds is recommended. As the drug is viscous, in any case, there is normally some resistance to a fast release.

4. Do not rub the area after as this action can interfere with the formulation of the drug.

My experience with side effects.  People have different experiences with side effects and just because a particular side effect is mentioned, does not mean to say that everyone will be troubled – many patients experience little or none.  For me, over 6 years, I think I can attribute the following to Lanreotide:

  • itching but only on the legs below the knees centred on the ankles – and nearly always the right leg.  Occasionally, the injection site will itch but only for a day or two.  I have a tub of emollient cream (almond oil) on standby which seems to calm it down.  Note …… a little bit of me thinks there could be a connection with vitamin/mineral deficiency and perhaps a coincidental occurrence and this problem seems much less of an issue 6 years later.
  • minor pain at the injection site but this only lasts for an hour or two and I believe this to be associated with the administration of the injection, i.e. if the injection is done properly, I don’t really have this problem except for a second or two as it enters.  Once, I had pain for 10 days.  In my own experience, the best and least painful injections are those done by trained personnel who are confident.
  • small lumps form at the injection site which is alternating superior external quadrant of the each buttock. You may occasionally hear these being called ‘granulomas‘. I find that they are more conspicuous if the injection is done slightly too high which was my initial experience and they took months to fade.  I opted to stand up for the first two injections and I attribute this decision for a slightly too high injection site.  I now lie down which is actually recommended for the smaller and thinner patient. Although the lumps have reduced in size, I have not seen a new lump for some time indicating location might have been the cause.
  • fatigue normally within 24-48 hours of the injection but this is not consistent. Not even sure it can be classed as proper fatigue but it’s a ‘you need to sit down and fall asleep‘ feeling! When this occurs, it normally only lasts for 1 day before the normal energy levels return.  Again, like the itching, this appears to be less of an issue today.
  • malabsorption. although the side effects of gastro-intestinal (GI) surgery and gallbladder removal can cause malabsorption issues leading to steatorrhea (basically the inability to digest fat properly); somatostatin analogues can cause or exacerbate existing steatorrhea, as they inhibit the production of digestive/pancreatic enzymes which aid fat digestion.  Most months, I notice a marked but short-term increase in this problem normally within 48-72 hours of the injection.

Watch a useful injection demonstration video here

A few years ago, there was some ‘talk’ that somatostatin analogues were also able to stunt or reverse the growth of certain neuroendocrine tumours.  Has this been the case for me?  Possibly.  I’ve had regular CT scans every 3-6 months and since two bouts of major surgery in 2010/2011, I’ve also had 3 x Octreoscans over the same period.  I did once spend a day analysing 4 years of scan results looking for variations in size and concluded that there was a stable trend and potentially a fading of one or two of my largest liver tumours. I was reminded these two types of scans were not really precise enough to detect small millimetre increases or decreases and as there were other factors at play, there was little commitment to make this declaration.  However, I did note in the summary of the CLARINET study, Lanreotide was associated with prolonged progression-free survival among patients with advanced, grade 1 or 2 (Ki-67 <10%) enteropancreatic, somatostatin receptor–positive neuroendocrine tumours with prior stable disease, irrespective of the hepatic tumour volume.  In terms of its anti-proliferative effects, an interim report from the CLARINET extension study suggested longer-term Lanreotide treatment is well tolerated with ‘anti-tumour’ effects in patients with progressive disease.  The final CLARINET open label extension study report additionally provided evidence for long-term PFS benefits of Lanreotide Autogel 120 mg in patients with indolent pancreatic and intestinal NETs.

There’s currently a trial ongoing in relation to Lanreotide and Lung NETs – read by clicking here.

I have my ups and downs and I do feel quite well most of the time.  Most people tell me I look quite well too – lucky they can’t see my insides!  Over the last 6 years, I’ve made some fairly significant adjustments to cope with my condition and maintain a reasonable quality of life – my monthly injection of Lanreotide is no doubt playing a big part.

Finally, please spend 5 minutes watching this fascinating video from Ipsen.  It explains in easy terms how Lanreotide works.  It also has a useful summary of the side effects at the end.  Click here to watch the video.

Here’s to another 6 years of Lanreotide!

Thanks for listening

Ronny

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8 Comments

  1. renee renninger says:

    I was diagnosed with Neuroendocrine cancer in June of 2014 & had sugery July of 2014. They were not able to remove all cancer so I did 6 weeks of radiation therapy & now am on Lanreotide monthly

    Liked by 1 person

  2. I love the you are posting about your journey. I am doing the same, it’s very therapeutic and helps me deal sometimes. I’ve only just discovered your blog, but I’m definitely following you now! Feel free to follow me if you want:

    http://www.YourWorthyOpponent.WordPress.com

    Liked by 1 person

  3. Anna Oliver says:

    Great blog as Always Ronny, thanks. Also very pleased to read this today as I had been trying to find out if lanreotide was prescribed for NETs on nhs.
    I was wondering, did your oncologist explain why he chose lanreotide over sandostatin for you?
    Thanks again

    Liked by 1 person

    • ronnyallan says:

      Not really but I’m glad he did when I look at the issues Octreotide users can sometimes have (mixing etc). Plus in hindsight, the evidence of its antitumour effects.

      Like

  4. zebrakat says:

    I’m amazed you have had the injection for 5 years and I’m learned about this year. ☺

    Liked by 1 person

  5. edebock says:

    My NET cancer was diagnosed Sept. 2013 and I have not had surgery either. My primary tumour is in my colon with three secondary tumours on my liver and one on a lymph node. Beginning Sept. 2014, I had 4 treatments of Lutetium 177 (PRRT) over a 7.5 month period. The primary tumour has shrunk significantly and the largest liver tumour is also noticeably smaller. The other growths have not changed and there are no new ones. As a result, I am now receiving Lutetium every 6 months. I have also had 30 Sandostatin LAR injections on a 28 day schedule. They are given by a trained nurse who is provided by the drug company. Self administration is not encouraged because of the very precise mixing requirements. I have had absolutely no side effects from the Sandostatin other than constipation which may or may not be related since I’m also taking a blood pressure medication and calcium. Either one or both of those could be responsible for that. The viscosity of the medication has occasionally been an issue as the needle can plug up requiring more than one poke. That rarely happens though and only once did I require more than 2. I felt a bit like a pincushion that day when I ended up being poked twice on each side! It has been worth even that discomfort though as I no longer experience any of my previous symptoms which included stomach pain, diarrhea, occasional racing heart and flushing. I am thrilled to say that, at this point, my quality of life is hardly affected at all by the fact that I have NETS. I count each day a blessing as I know there’s no guarantee that this will last.

    Liked by 1 person

  6. Emma says:

    Ronny, Have been following your progress for a year now since my own diagnosis in October, 2014. I have had no surgery even though I’m stage IV NETS with main in ilieum, gone to liver, breast and one lymph node. Monthly injections of Octreotide, stable, no further cancer progression. Changed lifestyle completely, take herbs, homeopathic preps, etc. Wonder how long I can continue like this without surgery. Am waiting for and opting for PRRT treatments to be FDA approved here in the states. Any ideas or comments on this?

    Liked by 1 person

    • ronnyallan says:

      I think Doctors have so many variables and factors to consider. One is grade. Most NETs are Grade 1 (low), I. E. They are slow growing. Now…. as you have liver and other mets, presumably your primary could be considered malignant withvariable potential to spread regardless of the grade. Personally I would say you should be a candidate for surgery. Back to the doctor’s variables and factors. I suspect that occasionally doctors will take the patients condition into account, such as comorbidities, condition to withstand the surgery (perhaps bringing age into the equation). Has your doctor said why no surgery? Is he a NET specialist?

      Like

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