From the Guidelines
The primary treatment for insulinoma is surgical removal of the tumor, with medical management focusing on controlling hypoglycemia through diet and medications such as diazoxide prior to surgery. Surgery is curative in about 90% of cases, with complete enucleation of the tumor or partial pancreatectomy being the preferred approaches depending on tumor location and size 1. Prior to surgery, medical management focuses on controlling hypoglycemia through frequent small meals, complex carbohydrates, and medications such as diazoxide (starting at 50-100mg three times daily, titrated up to 300-600mg daily) to inhibit insulin release 1.
Key Considerations
- Octreotide should be used with caution in patients with insulinoma because it can also suppress counterregulatory hormones, such as growth hormone, glucagon, and catecholamines, and can precipitously worsen hypoglycemia 1.
- Everolimus (10mg daily) or sunitinib (37.5mg daily) may be considered for patients with unresectable or metastatic insulinomas, or those awaiting surgery 1.
- Streptozocin-based chemotherapy regimens are options for malignant insulinomas.
- Continuous glucose monitoring and education about hypoglycemia symptoms and management are essential components of care.
Treatment Goals
- The goal of treatment is to maintain normal blood glucose levels and prevent neuroglycopenic symptoms, as chronic hypoglycemia from excess insulin secretion can lead to neurological damage and is potentially life-threatening.
- Surgical resection is the optimal treatment for locoregional pancreatic endocrine tumors, and should be performed by an experienced surgeon 1.
From the FDA Drug Label
Diazoxide Oral Suspension is indicated for the management of hypoglycemia due to hyperinsulinism associated with the following conditions: Adults: Inoperable islet cell adenoma or carcinoma, or extrapancreatic malignancy. Diazoxide Oral Suspension may be used preoperatively as a temporary measure, and postoperatively, if hypoglycemia persists.
The treatment for a patient with insulinoma may include diazoxide as it is indicated for the management of hypoglycemia due to hyperinsulinism associated with inoperable islet cell adenoma or carcinoma 2.
- Key points:
- Diazoxide may be used preoperatively as a temporary measure.
- Diazoxide may be used postoperatively if hypoglycemia persists.
- The treatment should be considered after a diagnosis of hypoglycemia due to one of the above conditions has been definitely established.
- Treatment with diazoxide should be considered when other specific medical therapy or surgical management either has been unsuccessful or is not feasible.
From the Research
Treatment Options for Insulinoma
The treatment for a patient with insulinoma can vary depending on the severity and type of the tumor.
- Surgery is considered the ideal treatment for insulinoma, with curative surgical excision being the treatment of choice for single solitary insulinomas 3, 4.
- For patients with unresectable metastatic disease, systemic therapy may be required to prevent severe preoperative hypoglycemia 5, 6.
- Medications such as diazoxide and somatostatin analogues (e.g. octreotide and lanreotide) can be used to control hypoglycemia in patients with insulinoma 5, 6, 3.
- In cases of malignant insulinoma, debulking procedures, somatostatin receptor ligands, peptide receptor radionuclide therapy, everolimus, sunitinib, and cytotoxic chemotherapy can be valuable options 6, 3.
- Supportive measures, such as frequent oral carbohydrate and continuous i.v. dextrose, can also be used to manage hypoglycemia in patients with insulinoma 6.
Surgical Management
- The surgical management of insulinoma involves the diagnosis, localization of the tumor, and treatment 4.
- Depending on the location of the insulinoma, surgical options can include enucleation, partial or distal pancreatectomy, or pancreaticoduodenectomy 4.
- Over 90% of insulinomas are benign and single, and can be cured by simple excision 4.
Medical Management
- Medical management of insulinoma can include the use of medications such as diazoxide and somatostatin analogues to control hypoglycemia 5, 6, 3.
- Novel agents such as mammalian target of rapamycin (mTOR) inhibitors and radiolabelled peptides may be effective in managing hypoglycemia in patients with unresectable malignant insulinoma 6.
- Glucagon-like peptide 1 receptor positron emission tomography/computed tomography or positron emission tomography/magnetic resonance imaging can be used to localize the insulinoma and guide treatment 3.