Frequently Asked Questions - Nutritional Concerns

They are both pancreatic extracts of animal active origin, made by different manufacturers, and are roughly equal in effectiveness.  They come in several strengths and each include lipase, amylase and protease (enzymes that break down fats, carbohydrates and protein). They help the digestion (and thereby) of fats, carbohydrates  and protein. They help people with conditions in which they have a deficiency of pancreatic secretions of these digestive enzymes, including: partial pancreatectomy surgery, post gastrectomy bypass surgery, chronic pancreatitis, cystic fibrosis, short bowel syndrome, various diarrheal diseases with rapid intestinal transit (carcinoid syndrome) and suppression of pancreatic function which often occurs as a side effect of Sandostatin treatment.

Low doses of niacin (25 mg twice a day after meals) should not cause flushing, is sufficient, and is easily metabolized.  However, if you are hypersensitive, you can take ½ (81 mg) of a pediatric aspirin just before each niacin dose to prevent flushing or else do use niacinamide.  The mechanism of niacin flush is quite different from, and unrelated to, that of carcinoid syndrome.

Other than a well-rounded diet supplemented by the standard one-a-day vitamin, there is no recognized specific dietary treatment for metastatic carcinoid in the liver if liver failure or carcinoid syndrome are not present.  If a significant degree of liver function impairment is present, a diet used for any cause of liver failure (high carbohydrate, low protein and fat) is indicated along with standard vitamins and extra fat-soluble vitamins (A, D and E).  if carcinoid syndrome is present, low dose supplements of niacin and a high protein diet are advised.

All alcohol should be avoided because of its ability to trigger carcinoid crisis.

Pancreatic enzyme replacement varies from 1-3 Viokase tablets with each meal and at bedtime, or 1-2 Creon or Pancrease capsules taken with each meal and at bedtime.

Food tolerances are highly individual and not necessarily related to carcinoid.

The nutritional deficiency disease pellagra results from niacin deficiency.  Diarrhea is one symptom of pellagra.  All carcinoid syndrome patients have subnormal blood levels of tryptophan, an evidence of its depletion by being diverted to make large amounts of serotonin.  Hence niacin deficiency can occur.  Taking niacin in low doses prevents this; high doses are not necessary and can cause flushing.   Tryptophan is obtained only via ingested food, particularly meat.

The only reason for carcinoid patients to eat a low fat diet would be to reduce steatorrhea (fat-containing diarrhea) if they have malabsorption due to short bowel syndrome or as a side effect of Sandostatin.  If fat malabsorption is present or even suggested, then I treat with pancreatic enzymes.  I encourage a high protein diet and that includes lean meat (beef, pork and lamb all have lean parts that would fall into this category).  Tryptophan normally is the only raw material from which protein and niacin are formed and only a little goes to make serotonin, but in an active carcinoid making lots of serotonin, tryptophan is diverted to this use and protein and niacin synthesis suffer.

I do endorse a multiple vitamin supplement and all patients with carcinoid syndrome should take low doses of niacin to prevent subclinical pellagra.

Niacin synthesis is deficient in carcinoid syndrome because of metabolic diversion of its precursor, tryptophan, to form serotonin.  In some untreated individuals this can even lead to pellagra.  Hence the recommendation for niacin supplementation.  Niacin supplementation (in the nicotinic acid form) of up to 10 times the RDA (recommended dietary allowances which range from 15-20 mg/day to prevent pellagra), i.e., up to 200 mg per day, does usually not cause flushing or other side effects.  Megadoses of nicotinic acid (100 mg - 3 g), which are sometimes given to people with hypercholesterolemia, on the other hand, have well-documented side effects of flushing, hyperuricemia, abnormalities in liver function, and occasionally hyperglycemia.  Not a very good idea for carcinoids.  The purpose for supplementation in carcinoids is to prevent pellagra not hypercholesterolemia, therefore lower levels of niacin intake is prudent (in either the acid or amide form).  Megadoses of nicotineamide (as well as other water-soluble vitamins) may also have equally detrimental effects.  Since very little documentation exists about the toxicity of large doses of this form (except in mice), it is recommended to stay within close proximity of the RDAs.  The statements regarding various treatment options on our web page are very general, on purpose, since they are not meant to be used as self-treatment unsupervised by a physician or, in the case of nutrition, by a trained professional, but rather informational as to most available treatment today.  Therefore, an amendment to this statement cannot be made.

Occasionally patients get diarrhea from coffee, but it is uncommon.

Xanthines and theobromines, as well as various foods and wines, contain substances that are provocative for carcinoid crisis and hence can interfere with the effectiveness of Sandostatin.  I do agree with Dr. Woltering in recommending carcinoid patients avoid these agents.

No. Bananas and other serotonin containing food need only be avoided when collecting urine for 5HIAA testing.  Tumors make their own serotonin independent of dietary sources.  See page for how to prepare for the urine 5-HIAA test.