What is the initial dose and maintenance regimen of octreotide (somatostatin analogue) for acute variceal bleeding?

Octreotide Dosing for Acute Variceal Bleeding

For acute variceal bleeding, administer octreotide as an initial 50 μg IV bolus followed immediately by continuous IV infusion at 50 μg/hour for 2-5 days. 1

Initial Dosing Protocol

• Start with 50 μg IV bolus as soon as variceal bleeding is suspected, even before diagnostic endoscopy is performed 2, 1
• If bleeding continues during the first hour, the initial bolus can be repeated 1
• Begin octreotide simultaneously with volume resuscitation (crystalloids with restrictive transfusion strategy) and antibiotic prophylaxis (ceftriaxone 1g IV daily) 1

Maintenance Infusion

• Continue with 50 μg/hour as a continuous IV infusion immediately after the bolus 2, 1
• This standard infusion rate of 50 μg/hour should be maintained throughout the treatment period 2, 1
• The infusion can be safely continued for 5 days or longer without significant adverse effects 2

Duration of Therapy

• Continue octreotide for 2-5 days after endoscopic confirmation and treatment of the variceal bleeding 1
• A shorter duration of 2 days may be appropriate for selected patients with Child-Pugh class A or B cirrhosis who have no active bleeding identified during endoscopy 1
• For patients with more severe disease or ongoing bleeding risk, extend treatment to the full 5 days 2, 1

Timing Relative to Endoscopy

• Initiate octreotide immediately upon suspicion of variceal bleeding, together with antibiotics and before diagnostic endoscopy 1
• This early administration reduces mortality by 26% (relative risk 0.74) compared to delayed treatment 1
• Continue the infusion during and after endoscopic variceal ligation 3

Alternative Dosing for Refractory Bleeding

• If bleeding is not controlled within the first 12 hours on standard infusion, add hourly bolus doses of 50 μg for 24 hours superimposed on the continuous infusion 4
• This intensified regimen achieved hemostasis in patients who failed initial standard dosing 4

Key Clinical Advantages

• Octreotide is the only vasoactive drug available in the United States for managing variceal hemorrhage 1
• It has similar efficacy to terlipressin/vasopressin in controlling bleeding but with significantly fewer adverse events 1
• Unlike vasopressin (which can only be used for maximum 24 hours), octreotide is safe for continuous use up to 5 days or longer 2

Monitoring and Discontinuation

• Discontinue octreotide if endoscopy reveals non-variceal upper GI bleeding 1
• Monitor for common side effects including nausea/vomiting, abdominal pain, headache, and hyperglycemia 1
• Watch for alterations in glucose metabolism throughout treatment 1

Common Pitfalls to Avoid

• Do not delay octreotide initiation while waiting for endoscopy—start immediately upon clinical suspicion 1
• Do not use octreotide for routine management of non-variceal upper GI bleeding 1
• Do not stop octreotide prematurely; complete at least 2 days of therapy even if bleeding appears controlled 1
• Do not forget to combine with prophylactic antibiotics and arrange endoscopic therapy within 12 hours 1