Practice Pearl 2: Choosing 1 Agent Over Another in the Management of NETs
The panel of experts discuss how they choose 1 somatostatin analogue over another and the factors to consider in the management of NETs.
Daneng Li, MD: Moving to you, Megan, we have talked a lot, and you have shared with us the efficacy data. Cecilia has helped provide potentially some of the safety data. At the end of the day, what factors might you consider when you are choosing 1 of these agents over the other?
Megan May, PharmD, BCOP: We have already talked about the dosing, and that would be 1 consideration I would have—determining if they need that immediate release up front while you are transitioning to the long acting, or if you need it for breakthrough also.
Another thing to consider is how you mix these medications and administer them, considering the pharmacy preference, the nursing side preference, and then also patient preference. The lanreotide is a prefilled syringe, and so there is less preparation time from a pharmacy standpoint. It also has a low injection volume that is given into the subcutaneous tissue. The breakthrough is also something we are going to consider when deciding what regimens to use. Even though patients are on long-acting SSAs [somatostatin analogues], about 40% can still have breakthrough symptoms. That would also require us to use the immediate-release octreotide.
Daneng Li, MD: I definitely agree that these are all things to consider and certainly important. For our pharmacy colleagues, is there a general preference? Megan, maybe you can comment based on your institution, and we can certainly comment from our institution [City of Hope]. Do pharmacists like 1 preparation or another?
Megan May, PharmD, BCOP: Yeah. Where I practice [Baptist Health Lexington], the lanreotide is easier for us to get out the door to the nurses vs the octreotide long-acting. It does take longer to reconstitute for them, to put it into the syringe and get it out.
Daneng Li, MD: How do you guys have that conversation with providers in terms of making that decision? Most organizations are trying to make this decision between these 2 long-acting somatostatin analogues. I’m curious as to how, at your institution, you potentially make that decision.
Megan May, PharmD, BCOP: We also do have a formulary for the outpatient, so these were all conversations we had with the providers up front when we were trying to decide what we were going to carry here—if we were going to have both in stock all the time or have a preferred and then order the other 1 if a doctor requested it for a patient and had a reason why. For us, the conversation starts right away. We do not wait until we already have an order to have that conversation with our providers.
Daneng Li, MD: That’s great, and we are very similar in everything. We have dual communication from providers with pharmacy and everything in terms of trying to optimize both these agents. One of the other things is some patients might already be coming in with 1 or the other if they’re coming to our center. Usually, because of patient preference, we are not going to necessarily force someone to switch if they’re already on 1 agent vs the other. For a lot of us who treat patients with this condition, it’s becoming more common that we are very comfortable with the efficacy of both these agents moving forward.