From the Guidelines
Octreotide is the vasoactive drug of choice in the management of variceal hemorrhage due to its safety profile, as evidenced by a 2021 updated systematic review and meta-analysis involving 21 RCTs 1. The recommended dosage is typically an intravenous bolus of 50 micrograms followed by a continuous infusion of 50 micrograms per hour for 2-5 days, as outlined in the standard regimens for the use of vasoactive drugs in the management of acute variceal hemorrhage and prevention of early rebleeding 1. Key considerations in the management of variceal bleeding include:
- Initiating treatment as soon as the diagnosis is suspected, even before endoscopic confirmation
- Using octreotide alongside other interventions such as endoscopic therapy (band ligation or sclerotherapy)
- Monitoring patients for potential side effects including hyperglycemia, nausea, abdominal discomfort, and rarely, QT prolongation
- Considering the combination of endoscopic therapy and vasoactive drugs as the standard of care in acute variceal hemorrhage, as it combines the local haemostatic effect on the varices induced by endoscopic treatment and the portal hypotensive effect achieved with drugs 1. It is also important to note that terlipressin or vasopressin should not be used as first-line treatment due to the increased risk of adverse events, including abdominal pain, chest pain, diarrhea, and hyponatremia 1. In terms of prevention of complications, antibiotic prophylaxis is recommended to reduce the incidence of infections and improve control of bleeding and survival, with ceftriaxone being the first choice in patients with advanced cirrhosis 1. Overall, the use of octreotide in the management of variceal bleeding is supported by the most recent and highest quality evidence, and its safety profile makes it the preferred choice for this indication.
From the Research
Role of Octreotide in Variceal Bleeding Management
- Octreotide, a somatostatin analogue, is useful in the management of acute variceal bleeding, with the absence of important side effects rendering it a safe adjuvant treatment associated with endoscopic treatment 2.
- The medication has demonstrated effectiveness in reducing blood loss and transfusion requirements as both an initial intervention or as adjunctive therapy to endoscopic measures 3.
- Octreotide infusion is effective for control of variceal bleeding and can be started quickly, with a relatively rapid onset of action, and does not require someone with endoscopy training to initiate 3.
Efficacy of Octreotide in Preventing Rebleeding
- Octreotide significantly reduces recurrent bleeding and the need for balloon tamponade in patients with variceal haemorrhage treated by endoscopic variceal ligation 4.
- The relative risk of rebleeding was lower in the combined therapy group (octreotide plus endoscopic variceal ligation) compared to variceal ligation alone 4.
- Octreotide has been effective in halting initial hemorrhage and in preventing reoccurrence of bleeding in randomized controlled trials 5.
Comparison with Other Treatments
- Somatostatin and octreotide appear to be equivalent in terms of therapeutic efficacy, but octreotide is the less expensive option 5.
- A meta-analysis of trials comparing somatostatin or octreotide with other treatments (placebo or H2 antagonists) showed a significant advantage of somatostatin or octreotide in terms of efficacy, but no difference in mortality 6.
- Octreotide may have a role as adjuvant treatment to emergency sclerotherapy for active bleeders, and this must be further investigated 6.