Octreotide Dosing for Variceal Bleeding
For acute variceal bleeding, administer octreotide as an initial 50 μg IV bolus followed by continuous IV infusion at 50 μg/hour for 2-5 days. 1
Initial Bolus Dosing
- Give 50 μg IV bolus immediately upon suspicion or confirmation of variceal hemorrhage, before diagnostic endoscopy 1, 2
- The bolus can be repeated within the first hour if ongoing bleeding persists 1, 2
- Start octreotide as soon as possible, together with antibiotics (ceftriaxone 1g IV daily), before endoscopy is performed 1, 2
Continuous Infusion Protocol
- Maintain continuous IV infusion at 50 μg/hour following the initial bolus 1, 2
- This infusion rate remains constant throughout the treatment period without dose escalation 1
Duration of Therapy
The optimal duration is 2-5 days, with the specific length determined by clinical factors: 1, 2
- 2 days may be sufficient for selected patients with Child-Pugh class A or B cirrhosis who have no active bleeding identified during endoscopy 2, 3
- Continue for up to 5 days in patients with more severe liver disease, ongoing bleeding concerns, or Child-Pugh class C cirrhosis 1, 2
- A randomized trial demonstrated that 2 days of octreotide infusion following endoscopic therapy is as efficacious as 5 days in preventing early rebleeding (4.8% vs 8.6%, p>0.05), with significantly better cost-effectiveness (2.5 times less expensive) 3
Clinical Context and Rationale
Octreotide is the only vasoactive drug available in the United States for managing variceal hemorrhage 1, 2
Mortality Benefit
- Early octreotide administration reduces mortality by 26% (relative risk 0.74) in patients with variceal hemorrhage 2
- Meta-analysis of 11 trials showed octreotide significantly improves control of acute hemorrhage 1
Efficacy Evidence
- Initial bleeding control is achieved in 73-88% of patients within 6 hours 4, 5
- When combined with endoscopic variceal ligation, octreotide reduces recurrent bleeding from 38% to 9% (p=0.0007) 6
- Octreotide is as effective as vasopressin but with significantly fewer side effects (3/24 vs 11/24 patients) 5
Integration with Endoscopic Therapy
- Perform endoscopy within 12 hours of presentation, but do not delay octreotide initiation while waiting for endoscopy 1, 2
- Discontinue octreotide if endoscopy reveals non-variceal upper GI bleeding, as it is not recommended for routine management of non-variceal sources 2
- Continue octreotide for the full planned duration after endoscopic variceal ligation is performed 1, 6
Common Pitfalls and Monitoring
Monitor for common side effects including: 2
- Nausea/vomiting
- Abdominal pain
- Headache
- Hyperglycemia (monitor glucose levels, as octreotide affects glucose metabolism) 2
Critical caveat: If bleeding is not controlled within the first 12 hours after commencing octreotide, consider adding hourly bolus doses of 50 μg for 24 hours superimposed on the continuous infusion 7