Octreotide Injection Research Articles

9337 Postprandial And “Fasting” Hypoglycemia In A Patient With A History Of Gastric Bypass Surgery And Carcinoid Syndrome

Abstract Disclosure: S. Ntelis: None. M. Pennant: None. Background: Hypoglycemia is an increasingly recognized complication of bariatric surgery that can occur years after the procedure. Episodes most commonly occur 1-3 hours after meals. Fasting hypoglycemia is not typical and raises concerns for other etiologies, including adrenal insufficiency and other causes of endogenous hyperinsulinism. Clinical Case: A 51-year-old woman with a history of carcinoid tumor of unknown origin with liver metastases, treated with monthly octreotide injections, and history of Roux-en-Y gastric bypass presented with multiple episodes of symptomatic hypoglycemia up to 24 mg/dl. Symptoms included tremor and diaphoresis and improved with juice. Morning cortisol was 22.7 mcg/dL (n > 19.4 mc/dL), ruling out adrenal insufficiency. A continuous glucose monitor (CGM) was placed, and she was advised to have frequent low-carbohydrate meals mixed with healthy fats and protein. She was also advised to add cornstarch to meals, until mixed-meal testing could be performed. She was hospitalized for a seizure provoked by hypoglycemia after a heavy high-carbohydrate meal, and treatment with acarbose 25 mg three times daily was started. Mixed-meal testing was consistent with post-prandial hyper-insulinemic hypoglycemia, with elevated insulin (58 mcIU/ml, n: 2.6-24.9 mcIU/ml) and c-peptide (11.2 ng/ml, n: 1.1-4.4 ng/ml) levels during an episode of symptomatic hypoglycemia (glucose 22 mg/dL) 2.5 hours after the patient’s meal. CGM showed hypoglycemia mostly occurring after meals and some episodes of hypoglycemia early in the morning, that occurred after late-night snacks. Clinical picture and laboratory testing were suggestive of post-bariatric surgery hypoglycemia. Poor hepatic glycogen reserve, secondary to the liver metastases, was considered a contributing factor. Interestingly, although hypoglycemia was mediated by hyperinsulinemia, treatment with a somatostatin analogue provided no benefit. The frequency of hypoglycemia decreased with adherence to a low-carbohydrate diet, and episodes mostly occurred when acarbose use was delayed. Octreotide was transitioned to lantreotide. Due to persistence of early-morning low glucose values on follow-up, further work-up was pursued to rule out etiologies of fasting hypoglycemia. Glucose values remained >70 mg/dl during 72 hours of fasting. IGF-I (115 ng/ml, n: 53-287 ng/ml) and IGF-II (608 ng/ml, n: 267-616 ng/ml) levels were normal, and insulin antibodies were undetectable. Post-bariatric surgery hypoglycemia was confirmed and acarbose dose was increased to 50 mg three times daily. Conclusion: Postprandial hypoglycemia is a late complication of bariatric surgery. Early-morning hypoglycemia can also be seen after bariatric surgery in patients who have late-night meals and snacks. Presentation: 6/1/2024

6774 Recurrent Hypoglycemia In Malignant Insulinoma With Multiple Liver Metastases Successfully Managed With Octreotide

Abstract Disclosure: K. Kim: None. S. Mascarell: None. Introduction: Insulinoma is a rare functional pancreatic neuroendocrine tumor (pNET) with the incidence of 1-4/million person-years. Malignant insulinomas with locoregional invasion or metastases consist 10% among insulinomas. While the treatment of a single insulinoma is surgical resection, treatment of malignant insulinoma requires a comprehensive approach. Due to the low prevalence of the disease, data on therapeutic modalities of malignant insulinomas are limited. We hereby present a case of malignant insulinoma in which recurrent hypoglycemia was successfully managed with octreotide. Case: A 36 year old female diagnosed with grade III well differentiated pNET with multiple metastases to the liver and abdominal lymph nodes 1 year ago was admitted for recurrent hypoglycemic episodes. She reported progressively worsening hypoglycemia for the past 1 month. She was eating every 2 hours including her sleeping hours to prevent hypoglycemia. Due to recurrent hypoglycemia she required hospitalization with IV dextrose. After 13 hours of fasting in the ICU, hypoglycemia due to insulin hypersecretion was confirmed with blood glucose 51 mg/dL and elevated serum insulin 51.11 uIU/mL (1.9-23uIU/mL). She underwent the short octreotide test which showed suppressed insulin (5.25 uIU/mL) 6 hours after receiving 100 mcg of octreotide. She was started on octreotide 50 mcg every 12 hours and monitored for further hypoglycemic episodes. She tolerated octreotide without any side effects including hypoglycemia. She was discharged home with a continuous glucose monitor (CGM) and transitioned to intramuscular lanreotide 20mg injections every 4 weeks as an outpatient. No further hypoglycemic episodes occurred. Discussion: Few cases report treatment of hypoglycemia in malignant insulinoma with octreotide. Octreotide has the dual effect of suppressing insulin secretion and tumor growth on insulinomas that express SSTR2 receptors. However, because somatostatin agonists also inhibit the secretion of glucagon, in insulinomas without SSTR2 expression, octreotide can aggravate hypoglycemia. This was especially a concern for our patient with a large tumor burden. Thus the short octreotide test was conducted. We suggest that the octreotide test of 100 mcg SQ octreotide injection followed by hourly measurements of glucose and insulin levels is a useful and convenient test to predict efficacy while monitoring for octreotide induced hypoglycemia. Finally the use of CGM in the outpatient setting enabled successful transition to octreotide LAR which improved the patient’s quality of life greatly by enabling once a month injections. Presentation: 6/3/2024

Clinical Profile and Efficacy of Long-Acting Octreotide in Hyperinsulinemic Hypoglycaemia.

Hyperinsulinemic hypoglycaemia (HH) is characterised by unregulated insulin secretion, leading to persistent non-ketotic hypoglycaemia with a lack of alternate fuel that induces a severe risk for brain damage and neurodevelopmental abnormalities. Octreotide, a somatostatin analogue, has been effectively administered as subcutaneous injections or depot preparations in diazoxide-unresponsive HH. Children and infants with HH receiving short-acting octreotide injections were included. Anthropometric values, hypoglycaemic episodes, HbA1C, and side effects were noted from the records and were followed up for 12 months. Informed written consent was obtained from the parents before administration of a single dose of LAR (long-acting octreotide). Based on home-based glucose monitoring (HBGM), the dosage of LAR was modified, and short-acting octreotide was eventually withdrawn. The patients shared the injection's cost for cost-effectiveness. HH affects the quality of life (QoL) if not diagnosed and controlled adequately. A QoL questionnaire was given before starting LAR and after 6 months of receiving LAR, and the changes were noted accordingly. Twenty-two patients were diagnosed with HH, of which 11 infants and children were included in the study. Mutations were identified in 7 (63.63%) children. Daily octreotide could be tapered and stopped with the addition of sirolimus in one patient with an increasing dose of LAR to maintain euglycaemia. The hypoglycaemic episodes decreased with increasing dose of LAR with a decrease in the severity. Eight (72.7%) patients showed an improved lifestyle on LAR quantified through a QoL questionnaire. LAR was found effective in reducing hypoglycaemic episodes with no adverse effects. The patient's parent's satisfaction was higher. Given its high cost, this trial achieved cost-effectiveness by sharing a single sitting of LAR injection.

Role of Octreotide and Instillation of Povidone-Iodine in the Treatment of Lymphorrhea in Renal Transplantation: A Comparative Study

Background: Lymphorrhea is a minor complication after kidney transplantation but may develop into a lymphocele and prolong hospital stay. Treatment is conservative based on percutaneous drainage until lymphatic leakage cessation. It has been reported that povidone iodine instillation and octreotide has beneficial effects to treat lymphorrhea after renal transplantation. Aims and Objectives: The aim of this study was to compare the povidone iodine instillation and octreotide treatment in lymphorrea after kidney transplantation. To evaluate the efficacy of povidone iodine and octreotide injection in comparison to control group for the treatment of lymphorrhea in renal transplant patient. Materials and Methods: It was comparative analytical study included 60 recipients of both cadaveric and live kidney allografts with posttransplant lymphorrhea including 20 treated with instillation of betadine solution, 20 with octreotide (0.1 mg three times a day subcutaneously), and 20 was control group (no betadine and octreotide was used). We reviewed the daily amount of fluid collection, duration of lymphorrhea, complications, lymphocele formation, rejection episodes, graft outcomes, and hospital stay. Results: The average duration of lymphorrhea was (8.85 ± 0.88) and (11.6 ± 0.94) and (16.15 ± 0.81) days for the betadine groups, the octreotide groups and control groups respectively. (P < 0.05). No lymphoceles occurred among the betadine group, while three lymphoceles were found among patients treated with octreotide and five lymphocele were found among control groups. No differences were observed for wound infection, graft dysfunction episodes or renal function and death between the groups. No octreotide and povidone related adverse events were noted. Conclusion: The mean length of lymphorrhea was lower with povidone iodine instillation as compared to octreotide treatment. There was a shorter hospital stay and minor patient discomfort in betadine groups. In conclusion, lymphatic leakage after kidney transplantation may be successfully managed by betadine instillation as compared to octreotide and control groups.

Standard of Care Versus Octreotide in Angiodysplasia-Related Bleeding (the OCEAN Study): A Multicenter Randomized Controlled Trial

Background and aimsGastrointestinal angiodysplasias are vascular anomalies that may result in transfusion-dependent anemia despite endoscopic therapy. An individual patient data meta-analysis of cohort studies suggests that octreotide decreases rebleeding rates, but component studies possessed a high risk of bias. We aimed to investigate the efficacy of octreotide in reducing the transfusion requirements of patients with angiodysplasia-related anemia in a clinical trial setting. MethodsThe study was designed as a multicenter, open-label, randomized controlled trial. Patients with angiodysplasia bleeding were required to have had at least four red blood cell (RBC) units and/or parental iron infusions in the year preceding randomization. Patients were allocated (1:1) to 40mg octreotide long-acting release intramuscular every 28 days or standard of care, including endoscopic therapy. The treatment duration was one year. The primary outcome was the mean difference in the number of transfusion units (RBC + parental iron) between the octreotide and standard of care groups. Patients who received at least one octreotide injection or followed standard of care for at least one month were included in the intention-to-treat analyses. Analyses of covariance were used to adjust for baseline transfusion requirements and incomplete follow-up. ResultsWe enrolled 62 patients (mean age 72 years, 32 males) from 17 Dutch hospitals in the octreotide (n=31) and standard of care (n=31) groups. Patients required a mean number of 20.3 (SD 15.6) transfusion units and 2.4 (SD 2.0) endoscopic procedures in the year before enrolment. The total number of transfusions was lower with octreotide (11.0; 95% CI, 5.5–16.5) compared to standard of care (21.2; 95% CI, 15.7–26.7). Octreotide reduced the mean number of transfusion units by 10.2 (95% CI, 2.4–18.1; P = .012). Octreotide reduced the annual volume of endoscopic procedures by 0.9 (95% CI, 0.3–1.5). ConclusionOctreotide effectively reduces transfusion requirements and the need for endoscopic therapy in patients with angiodysplasia-related anemia. ClinicalTrials.gov, NCT02384122.

SAT139 Non-insulinoma Pancreatogenous Hypoglycemia Syndrome In A Patient With 1p36 Deletion Syndrome

Abstract Disclosure: E.D. Auckley: None. M.A. Arosemena: None. L. Philipson: None. Background: 1p36 deletion syndrome comprises a phenotypic presentation that includes central nervous system, cardiac, and craniofacial anomalies. There has been no report of associated hypoglycemia with this syndrome. Nesidioblastosis, also known as non-insulinoma pancreatogenous hypoglycemia syndrome (NIPHS), is understood as a rare condition defined by diffuse pancreatic hypertrophy with subsequent hyperinsulinemic hypoglycemia. Diagnosis requires serologic workup consistent with endogenous hyperinsulinemic hypoglycemia, intraarterial calcium stimulation positive for inappropriately elevated insulin secretion, and imaging studies without identified masses. Clinical Case: A 21-year-old female with 1p36 deletion syndrome (seizure disorder, cerebral palsy, vision loss and heart failure) was admitted to the hospital due to persistent falls. On admission vital signs were within normal limits, and physical exam revealed a thin non-verbal patient without significant other findings. During hospitalization and prolonged fasting periods of approximately 14-18 hours related to poor appetite she developed several episodes of hypoglycemia with serum glucose as low as 57 mg/dl. As patient was non-verbal at baseline, symptoms of hypoglycemia such as sweating, lightheadedness or shakiness were not confirmed. Even when she started to eat, hypoglycemic events continued to occur. Dextrose containing fluids (Dextrose 5% and later 10%) were added to try to maintain blood sugars within the normal range. Nevertheless, she continued to develop hypoglycemia. Endocrinology service was consulted and recommended to obtain a critical sample. A critical sample revealed serum glucose of 59 mg/dl, insulin level of 20.6 mcU/mL, proinsulin of 33 pmol/L, and beta-hydroxybutyrate of <0.10 mmol/L. Insulin antibodies was negative. Adrenal insufficiency was unlikely due to a normal 9 am cortisol level of 13.7 ug/dl. Due to the presence of hyperinsulinemic hypoglycemia further workup was conducted. A CT of the abdomen with a pancreatic protocol and 68Ga-DOTATATE PET/CT scan was negative for a pancreatic mass. Endoscopic ultrasound did not reveal a clear pancreatic mass either. This was followed by a calcium stimulation test which showed a two-fold increase in insulin levels in all 3 catheterized pancreatic territories. In the absence of a discrete mass, non-surgical management was recommended. For hypoglycemia management patient was started on octreotide injections with resolution of hypoglycemia. Prior to discharge she was switched to lanreotide and was discharged to continue monthly lanreotide injections. Conclusion: To our knowledge, this is the first case reported of NIPHS in a patient with a mutation in 1p36 deletion. Hyperinsulinism in the setting of diabetes has been reported in this syndrome1 but to our knowledge no cases of hypoglycemia with NIPHS have been reported. Presentation: Saturday, June 17, 2023

FRI356 SIADH In Acromegaly And Cerebrovascular Accident

Abstract Disclosure: S. Siddiqui: None. I.A. Guatemala Funes: None. G. Simranpreet: None. T. Zahedi: None. F. Zhang: None. Introduction: Acromegaly is characterized by excess growth hormone secretion with distinctive features of acral overgrowth, soft tissue swelling, arthralgia, jaw prognostication, hyperglycemia, hyperhidrosis, and frontal bone bossing. Hypotonic hyponatremia may occur in patients with syndrome of inappropriate antidiuretic hormone secretion (SIADH), hypothyroidism, hypocortisolism, polydipsia, medications, heart failure, liver disease, or renal dysfunction. We reported a rare case of a patient with acromegaly treated with octreotide (somatostatin analogue) who was admitted for cerebrovascular accident and developed hyponatremia due to SIADH. Case Report: Patient is an 81 year old female with typical clinical features of acromegaly who presented with expressive aphasia and left sided facial droop. MRI and CT head revealed a 26 x 14 x 29 mm densely calcified/ossified extra-axial mass in the posterior fossa, displacing the brainstem and small vessel ischemia. Patient was treated with monthly intramuscular injection of octreotide for more than 20 years before she was switched to oral octreotide formula two weeks ago. Patient had nausea, vomiting, and altered mental status. Labs showed hyponatremia with serum Na 118 mmol/L, low serum osmolality 247 mOsm/kg, high urine osmolality 437 mOsm/kg, and urine Na 104 mmol/L. Serum Na further dropped to 115 mmol/L after IV normal saline which may be related to the desalination phenomenon of SIADH. Tolvaptan and hypertonic saline were initiated followed by treatment with salt tablets and furosemide. After several days, her serum Na level slowly trending up back to normal 135 mmol/L and patient recovered with no focal neurological deficits. Discussion: Treatment for acromegaly involves multiple approaches, such as somatostatin receptor ligands, GH antagonism, surgery, radiotherapy, and dopamine receptor agonists. Life-treating endocrine disorder may result from pituitary infarction or hemorrhage in patient with acromegaly. Although gastrointestinal sodium loss may precipitate hyponatremia in our patient, her elevated urine sodium and urine osmolality were consistent with SIADH. Clinicians should be cautious of the sudden onset of hyponatremia due to SIADH in acromegaly patients and prompt treatment is warranted. Presentation: Friday, June 16, 2023

SAT158 Hypoglycemia After Bariatric Surgery Caused By Insulinoma

Abstract Disclosure: A. Yaseen: None. H. Lam: None. Introduction: Post bariatric surgery hypoglycemia occurs at least 6 to 12 months after bariatric surgery, presents as postprandial neuroglycopenia with documented blood glucose <54 mg/dl occurring 1 to 3 hours after meals, resolving with carbohydrate intake, and normal fasting glucose. Fasting hypoglycemia or hypoglycemia > 4 hours after caloric intake is not typical of post-bariatric hypoglycemia and should raise concern for other etiologies, specifically insulinoma. Clinical Case: A 62 year old female who had Roux-en-Y gastric bypass (RYGB) surgery 18 years ago presented with confusion and a blood glucose level of 35 mg/dl.She had been having episodic hypoglycemia fasting and nonfasting for 4 years prior to presentation. Initial workup revealed serum insulin 10 uIU/ml, C-peptide 2.3 ng/ml, and serum glucose of 19 mg/dl. A dextrose 20% in water intravenous infusion was started in addition to octreotide injections, acarbose, and diazoxide. Prednisone was added later and acarbose discontinued. Magnetic resonance imaging of the abdomen and magnetic resonance cholangiopancreatography showed a 1.8 x 1.3 cm enhancing lesion within the pancreatic tail. Selective arteriography and intra-arterial calcium stimulation with hepatic venous sampling revealed significant elevation of insulin after calcium gluconate injection into the accessory pancreatic tail artery arising from the superior mesenteric artery which supplies the hypervascular pancreatic tail mass. Patient had an exploratory laparotomy and splenic preserving distal pancreatectomy. Surgical pathology revealed a 2.1 cm grade 1, well-differentiated neuroendocrine tumor that was limited to the pancreas. Hypoglycemia resolved after surgery and she was discharged on glargine insulin and metformin. 1 month after surgery, C-peptide was 0.3 ng/ml, serum glucose was 101 mg/dl and HbA1c was 6.5%. Discussion and Conclusion: The incidence of hypoglycemia after RYGB is uncertain but has been reported to be 0.1 to 0.4% of cases. Only 9 cases of insulinoma in patients with a history of gastric surgery have been reported, 7 of 9 (78%) being female with an average age of 56 years old. Symptoms included fasting and postprandial hypoglycemia occurring 6 months to 20 years after bariatric surgery. CT, MRI, and endoscopic ultrasound have been found to have excellent sensitivity for preoperative localization of insulinoma. Selective arteriography and intra-arterial calcium stimulation with hepatic venous sampling is recommended when non-invasive imaging modalities fail to localize the tumor. Surgical resection remains the mainstay for cure. Dietary modification and pharmacological therapy with diazoxide or somatostatin analogues are used in poor surgical candidates. Insulinoma after RYGB is rare, but needs to be considered in patients with hypoglycemia occurring in the fasting state, as this is atypical for post-bariatric hypoglycemia Presentation: Saturday, June 17, 2023

S3020 Octreotide Injection for Management of Small Bowel Bleeding From a Vascular Mass in a Blood Transfusion Dependent Patient

S3020 Octreotide Injection for Management of Small Bowel Bleeding From a Vascular Mass in a Blood Transfusion Dependent Patient

Primary weight loss failure after Roux-en-Y gastric bypass is characterized by impaired gut-hormone mediated regulation of food intake

Background/ObjectivesAfter Roux-en-Y gastric bypass (RYGB) a subset of patients never obtain excess BMI loss (EBMIL) > 50% and are categorized as having primary weight loss (WL) failure. We hypothesized that postprandial concentrations of glucagon-like peptide 1 (GLP-1) and peptide YY (PYY) would be lower in patients with primary WL failure compared with patients with successfully maintained WL. Furthermore, that inhibition of gut hormone secretions would increase ad libitum food intake less in patients with primary WL failure.Subjects/MethodsTwenty women with primary WL failure (LowEBMIL < 50%) were individually matched to twenty women with successful WL (HighEBMIL > 60%) on age, preoperative BMI and time from RYGB. On separate days performed in a random order, patient-blinded subcutaneous injections of octreotide or saline (placebo) were followed by a fixed breakfast and an ad libitum lunch with blood sampling for appetite regulating hormones and Visual-Analogue-Scale (VAS)-scoring of hunger/satiety. Furthermore, participants underwent gene variant analysis for GLP-1, PYY and their receptors, indirect calorimetry, dual-energy X-ray absorptiometry (DXA)-scans, 4-days at-home food registration and 14-days step counting.ResultsOn placebo days, postprandial GLP-1, PYY and cholecystokinin (CCK) concentrations were similar between groups after breakfast. Fasting ghrelin was lower in LowEBMIL, but the postprandial suppression was similar. LowEBMIL had lower satiety VAS-scores and less suppression of hunger VAS-scores. Gene variants did not differ between groups. Octreotide diminished GLP-1, PYY, CCK and ghrelin concentrations in both groups. Octreotide did not affect ad libitum food intake in LowEBMIL (−1% [−13, 12], mean [95%CI]), while food intake increased in HighEBMIL (+23% [2,44]).ConclusionsPrimary WL failure after RYGB was not characterized by impaired secretions of appetite regulating gut hormones. Interestingly, inhibition of gut hormone secretions with octreotide only increased food intake in patients with successful WL post-RYGB. Thus, an impaired central anorectic response to gut hormones may contribute to primary WL failure after RYGB.

Ectopic Cyclic Cushing's syndrome, A Diagnostic Challenge: A Case Report

Introduction: Cyclic Cushing's syndrome is a not widely known pathology with low incidence; however, an increase in the number of cases has been observed in recent years. The intermittent clinical symptoms and discordant laboratory results make it a complicated diagnosis; therefore, close follow-up is crucial. We describe a case of ectopic cyclic Cushing's syndrome in a woman in her seventies who presented weight gain, proximal myopathy, moderate hypokalemia and uncontrolled hypertension; in the first evaluation hypercortisolism was found, however, 2 months later cortisol presented normal levels. Subsequently, a close follow-up was carried out and the study protocol was continued once the presence of 3 peaks and 2 valleys was demonstrated, obtaining compatible values for ectopic ACTH-dependent cyclic Cushing's syndrome. In thoracoabdominal MRI a spiculated lesion was found in the left basal lung field surrounding 25% of the aorta. Due to the location of the lesion, the patient refused surgical treatment, being currently under adequate control with the use of ketoconazole and octreotide injections. Conclusions: The possibility of cyclic Cushing's syndrome diagnosis should be kept in mind in those patients with symptoms suggestive of Cushing's syndrome that remit sporadically and whose laboratory studies show intermittent results of hypercortisolism and normocortisolism, since early identification allows opportune treatment and therefore better prognosis.

Non-islet cell tumour hypoglycaemia: A rare cause of persistent hypoglycaemia.

Non-islet cell tumour hypoglycaemia (NICTH) is a rare cause of hypoglycaemia. There is no single pathogenic mechanism that can explain all cases of NITCH. With this case, we wish to highlight the complexity in diagnosis and management of this condition.

Efficacy of octreotide to reduce lymphorrhea and prevent lymphocele after pelvic lymph node excision in gynecological malignancies.

To study the efficacy of octreotide to reduce lymphorrhea and prevent lymphocele after pelvic lymph node excision in gynecological malignancies. Patients with more than 200 mL of lymph drained per day until postoperative day 3 after pelvic lymph node excision were enrolled. Of the 75 patients, 36 were managed by conservative methods without the injection of octreotide, and the other 39 patients were treated with the injection of octreotide. The treated group was injected with 0.1 mg octreotide q8h for 5 days, starting on postoperative day 3. The drainage tube was removed when the amount of drained lymph decreased to 100 mL per day. The age, BMI, operation time, removed lymph nodes, amount of lymph, duration of drain placement, proportion of patients with lymphocele and complications between these two group were compared. The total and mean daily amount of lymph produced per patient was significantly lower in the octreotide-treated group than in the untreated group. The duration of drain placement was shorter in the octreotide group than in the untreated group. The proportion of patients with lymphocele in the treatment group was lower than that in the untreated group. The injection of octreotide is effective to reduce lymphorrhea and prevent lymphocele after pelvic lymph node excision in gynecological malignancies.

Outcomes of Management of Pituitary Adenoma by Use of Octreotide Injections Preoperatively

Objective: This study explored the effects of octreotide injections in patients with pituitary adenoma pre-operatively.&#x0D; Material and Methods: A quasi-observational study was conducted on 12 patients in the Neurosurgery department of the Punjab Institute of Neurosciences (PINS) with a diagnosis of pituitary adenoma. To determine the size of the tumor, we did an MRI brain with pituitary protocol and after octreotide medication. The mode of diagnosis was clinical status, MRI brain, and biopsy of the tumor. We gave 14 short-acting octreotide injections to all patients before surgery and monitored their clinical and serum IGF levels. After the completion of 14 injections of octreotide, we planned surgery for the complete excision of the tumor. We performed IGF level 2 weeks after surgery. Then, we gave long-acting octreotide injections to all patients after every 28 days.&#x0D; Results: The mean age was 43 years. 67% of patients were male and 33% of patients were female. 92% of patients presented with decreased vision. 17% of patients presented to us with complete loss of vision. In 17% of patients, the vision of the patients improved. Serum IGF levels significantly decreased after short-acting octreotide, surgical excision, and long-acting octreotide therapy.&#x0D; Conclusion: With the use of octreotide therapy clinical status and outcomes of management of pituitary adenoma improve.

Successful Treatment of Congenital Hyperinsulinism Due to KJNJ11 Gene Mutation with Long-Acting Release Octreotide: A Case Report from the Arab Region

AbstractCongenital hyperinsulinism is a rare hereditary condition that is caused by various gene mutations related to the function of the pancreatic β-cells. It is characterized by dysregulation of insulin secretion leading to profound and recurrent hypoglycemia. Its clinical presentation, histology, response to treatment, and underlying genetic defects are variable making it a heterogeneous condition. Pancreatectomy is indicated in diazoxide un-responsive cases. However, surgical treatment is associated with the possibility of persistent hypoglycemia and iatrogenic diabetes. We report a 3 months old girl who presented with hyperinsulinemic hypoglycemia. She was born to consanguineous parents and had a history of four neonatal deaths in siblings. Whole exome sequencing detected a KCNJ11 variant c.350_352del p.(Phe117del) in a homozygous state. Pancreatic scan (positron emission tomography/computed tomography) showed a diffusely increased radioisotope uptake in the head and tail of the pancreas. She was resistant to diazoxide and nifedipine and was shifted to octreotide treatment through multiple daily subcutaneous injections initially. Treatment was changed to monthly depot injection of octreotide that resulted in euglycemia. She kept a normal rate of growth, insulin-like growth factor-1, and liver function. This case is an example of an alternative effective medical therapy that avoids major surgical intervention and prevents long-term complication of recurrent hypoglycemia and iatrogenic diabetes resulting after surgery.

Outcomes of Acromegaly Patients Treated with Sandostatin LAR after Surgical Excision of Pituitary Adenoma

Objectives: An observational study to evaluate the outcomes of Acromegaly patients treated in the department of Neurosurgery III, Punjab Institute of Neurosciences (PINS), Lahore, Pakistan. Materials and Methods: This study was the analysis of a case series of 20 patients (mean age: 30 years) of both genders with acromegaly due to macroadenoma who had endonasal excision and postoperative treatment with Sandostatin LAR. Results: This study consisted of a total of 20 patients out of which 11 (55%) were male and 9 (45%) were female. All 20 Patients (100%) had a headache as their main symptom and 13 patients (65%) had visual field deterioration. 19 patients (95%) had complete resection of the tumor whereas 1 (5%) had a subtotal resection. After surgery and treatment growth hormone levels improved in 19 patients (95%) and remained elevated in 1 patient (5%), IGF-1 (Insulin-like growth factor – 1) levels improved in all 20 (100%) patients. Following consecutive octreotide injections vision of 11 patients (84%) out of 13 improved and in 2 (16%) patients, it remained the same as of Preoperative status whereas Headache improved in all 20 (100%) of the patients. None of the patients had any complications related to the procedure or the injection of octreotide LAR. Conclusion: Acromegaly due to macroadenoma responds well to treatment with octreotide LAR after endonasal resection in terms of hormonal levels and symptoms of the patients. It is a safe treatment with very less side effects and complications.

Octreotide may improve pharyngocutaneous fistula healing through downregulation of cystatins: A pilot study.

Pharyngocutaneous fistula (PCF) and salivary leaks are well known complications of head and neck surgery. The medical management of PCF has included the use of octreotide without a well-defined understanding of its therapeutic mechanism. We hypothesized that octreotide induces alterations in the saliva proteome and that these alterations may provide insight into the mechanism of action underlying improved PCF healing. We undertook an exploratory pilot study in healthy controls that involved collecting saliva before and after a subcutaneous injection of octreotide and performing proteomic analysis to determine the effects of octreotide. Four healthy adult participants provided saliva samples before and after subcutaneous injection of octreotide. A mass-spectrometry based workflow optimized for the quantitative proteomic analysis of biofluids was then employed to analyze changes in salivary protein abundance after octreotide administration. There were 3076 human, 332 Streptococcus mitis, 102 G. haemolyans, and 42 Granulicatella adiacens protein groups quantified in saliva samples. A paired statistical analysis was performed using the generalized linear model (glm) function in edgeR. There were and ~300 proteins that had a p< .05 between the pre- and post-octreotide groups ~50 proteins with an FDR-corrected p< .05 between pre- and post-groups. These results were visualized using a volcano plot after filtering on proteins quantified by 2 more or unique precursors. Both human and bacterial proteins were among the proteins altered by octreotide treatment. Notably, four isoforms of the human cystatins, belonging to a family of cysteine proteases, that had significantly lower abundance after treatment. This pilot study demonstrated octreotide-induced downregulation of cystatins. By downregulation of cystatins in the saliva, there is decreased inhibition of cysteine proteases such as Cathepsin S. This results in increased cysteine protease activity that has been linked to enhanced angiogenic response, cell proliferation and migration that have resulted in improved wound healing. These insights provide first steps at furthering our understanding of octreotide's effects on saliva and reports of improved PCF healing.

PSUN369 Glucagonoma-Associated Dilated Cardiomyopathy in a Young Female: A Case Report

Abstract Background Dilated cardiomyopathy has been reported in patients with glucagonoma. Since glucagon increases myocardial cAMP levels independent of beta adrenoreceptor blockade, thereby increasing heart rate and cardiac output, chronic excessive glucagon stimulation of the heart may lead to cardiomyopathy (Chang-Chretien, 2004). Clinical Case A 26 year old female presented with a 2-year history of palpable epigastric mass, vomiting and weight loss. Abdominal CT showed a heterogeneously enhancing, lobulated pancreatic head-body mass measuring 6.7×6.1×9.9 cm and a hypo-enhancing nodule in hepatic segment IVb, worrisome for metastasis. Endoscopy-guided FNAB of the pancreatic mass revealed a well-differentiated pNET, Grade 3. Chromogranin and synaptophysin stains were positive, Ki-67 index was 33.6%. She was lost to follow-up. After 4 months, she was admitted due to 1 week history of increased vomiting episodes up to 10x daily and abdominal discomfort with 2 day history of incomprehensible speech and right-sided weakness. On examination, she was weak-looking, tachycardic (114 bpm), underweight (BMI 17.45 kg/m2) and with palpable, hard, non-tender epigastric mass measuring 10×7 cm. She also had hyperpigmented patches on both legs initially manifesting as intermittent oozing excoriations over the past 2 years. Cranial MRI revealed subacute CVD infarct. Anticoagulation was given. On the second day, she started having diarrheal episodes. Supportive management was given. Serum glucagon was markedly elevated (&amp;gt;25,000 pg/mL, normal &amp;lt;80). Serum PP (6562 pg/mL, normal &amp;lt;228) and gastrin (621 pg/mL, normal 13-115) were elevated. Serum VIP (&amp;lt;50 pg/mL, normal &amp;lt;75) was normal. Further investigations showed prediabetes (FBS 112 mg/dL, HbA1c 5.7%) and normocytic, normochromic anemia. Screening for MEN1 was unremarkable. On the third day, she had progression of slurred speech and right-sided weakness. Cranial MRI revealed acute lacunar infarcts. As part of hypercoagulability workup, 2D-Echocardiogram showed depressed ejection fraction (20.9%), dilated LV with normal relative wall thickness, and global hypokinesia of the LV wall, confirming dilated cardiomyopathy. Carotid and Venous Duplex scans were normal. Anti-heart failure regimen was initiated. Due to her current neurologic, cardiac and metabolic conditions, she cannot proceed with surgery and chemotherapy. She was given octreotide injection 30 mg every 4 weeks for 3 doses. Post-treatment, repeat abdominal CT and 2D-Echocardiogram showed no significant change. In the meantime, she had improved appetite and no recurrence of vomiting nor diarrhea. She denies palpitations and can better tolerate walking and climbing stairs. Conclusion We reported a rare case of glucagonoma in a young female with documented constellation of symptoms and complications associated with the syndrome, prominently including dilated cardiomyopathy. It is therefore recommended that cardiovascular evaluation should be initiated at the time of glucagonoma diagnosis for timely and appropriate management. Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.

S3514 A Case of Symptomatic Ileal Non-Secretory Neuroendocrine Tumor Successfully Treated With Octreotide

Introduction: Neuroendocrine tumor incidence is steadily increasing, likely from detection due to better imaging, routine colonoscopies, and endoscopies. Most NETs, 55%, are found in the GI tract and only 0.1-1% found on routine colonoscopy. About 40% of NETs are hormone producing leading to the clinical diagnosis of carcinoid syndrome. One of the most common symptoms of carcinoid syndrome is diarrhea occuring in 80% percent of cases, however diarrhea can be present in non-secretory NETs. Here we report a case of GNET presenting as diarrhea that responded to octreotide injections despite having normal 5-HIAA and chromogranin A levels. Case Description/Methods: Our patient is an 80 year old female with past medical history of hypertension, renal stones, and IBS with baseline diarrhea of about 2-4 pasty stools a day. In November she developed two days of severe diarrhea with 10 watery stools a day and multiple episodes of incontinence which prompted patient to go to the ED. The inpatient workup was negative for acute causes, CT showed diverticulosis, and stools returned to baseline. The patient was discharged with outpatient GI follow up. At home the severe diarrhea retuned so outpatient GI planned for colonoscopy. Results of the procedure included a 2cm submucosal non-obstructing mass in the terminal ileum. Pathology showed a G1 well differentiated neuroendocrine tumor. Patient was referred to oncology and workup revealed no metastasis on PET/CT and negative 5-HIAA and chromogranin A levels. During initial oncology visit patient was started on octreotide injections which greatly improved the diarrhea. Even with negative carcinoid workup the decision was made to continue octreotide injections and not to pursue surgical options. (Figure) Discussion: The terminal ileum is the most common GI location for NETs. Terminal ileum intubation on coloscopy is attempted 30-80% and greatly aids in diagnosis, as with our patient. Once diagnosed, there is limited guidance on treatment of diarrhea in patients with NETs and negative carcinoid workup. There are no abstracts or research on treatment of diarrhea with negative carcinoid syndrome. One treatment for carcinoid syndrome is somatostatin analogues but no guidelines with non-carcinoid NETs and therapeutic value in octreotide. However, with our patient, treatment with monthly octreotide injections resolved their symptoms. Our case emphasizes importance of ileal intubation in coloscopy and that somatostatin analogue treatment should be considered in non carcinoid NETs.Figure 1.: Small bowel (terminal ileum): well-differentiated neuroendocrine tumor (G1).

Response of Patients with Acromegaly to Long-acting Octreotide with regard to Regression of Pituitary Adenoma, Growth Hormone and Insulin-like Growth Factor-1

Introduction: Acromegaly is a rare endocrine disease; its treatment is surgical (Hypophysectomy). However, somatostatin analogs represent another modality of therapy in addition to deep X-ray therapy as a third, option. The aim of the study is to find out the response of patients with acromegaly to octreotide as reflected on regression of adenoma size, insulin-like growth factor (IGF), and growth hormone (GH) by studying the medical records of many patients with acromegaly. Method: A total of 80 patients with acromegaly are enrolled in the study from July/2019 to April/2020. Their age range (20–72 years). They are 47 men and 33 women. Their selection was based on their visits to NDC on the basis of prescheduled appointments to be given their monthly injections of long-acting octreotide (LAR) and to be examined clinically plus conducting various types of hormonal studies and biochemical workups to assess their response to treatment on the following parameters: Adenoma size, IGF-1 and GH and its correlation with octreotide dose. Results: It is a cross-sectional comparative clinical trial study of 80 patients with acromegaly. Mean of age was 46.7 ± 12.4 years’, and their age range (20–72 year) minimum and maximum-year-old. Mean duration of taking drug was 8 ± 6.7 years. The mean of total LRA injection was (1073.6 ± 666.2 mg). 58.75% of patients were male while 41.25% were female. 46.25% of patients do not have transsphenoidal direct surgery, but 46.25% undergo one surgery, 7.5% undergo two transsphenoidal hypophysectomies. 87.5% of patients have no gamma knife while 12.5% have gamma knife radiosurgery. Conclusion: Acromegaly is a multi systemic disease that should be diagnosed and treated as early as possible to prevent complications and improve mortality rates.