From the Guidelines
Pharmacotherapy for bleeding varices primarily includes vasoactive medications like octreotide, terlipressin, somatostatin, or vasopressin, which should be initiated as soon as variceal bleeding is suspected, as they have been shown to reduce morbidity and mortality by decreasing portal pressure and preventing rebleeding 1.
Key Medications
- Vasoactive medications: octreotide, terlipressin, somatostatin, or vasopressin
- Antibiotics: ceftriaxone 1g IV daily for 5-7 days to prevent bacterial infections, which are common in cirrhotic patients with variceal bleeding and increase mortality 1
- Proton pump inhibitors: may be used to prevent acid-related mucosal injury, though their benefit is less established
Administration and Dosage
- Octreotide: typically administered as a 50 mcg IV bolus followed by a continuous infusion of 50 mcg/hour for 3-5 days
- Terlipressin, somatostatin, or vasopressin: dosages vary, but should be initiated promptly to stabilize the patient and prevent rebleeding
Rationale
- The aim of medical therapy for acute bleeding from esophageal varices is to reduce splanchnic blood flow and portal pressure, thereby decreasing pressure in the varices and preventing rebleeding 1
- Early administration of vasoactive agents facilitates endoscopy, improves early hemostasis, and lowers rate of rebleeding at 5 days 1
- Combination therapy with endoscopic treatment and vasoactive drugs is more effective than isolated use of either option alone, and is currently considered the standard of care in acute variceal hemorrhage (AVH) 1
From the FDA Drug Label
PACKAGE LABEL. AY PANEL Vial Label (100 mcg/mL): NDC 68462-896-01 Rx only Octreotide Acetate Injection 100 mcg/mL 1 mL contains: 100 mcg octreotide (as acetate) For Subcutaneous or Intravenous Use 1 mL Single-Dose Vial Discard unused portion The FDA drug label does not answer the question.
From the Research
Pharmacotherapy for Bleeding Varices
The pharmacotherapy used for bleeding varices includes:
- Vasopressin, used in combination with nitroglycerin to lessen the harmful side-effects 2
- Terlipressin or somatostatin and its synthetic analogue octreotide 2
- Non-selective beta-blockers, such as nadolol or propranolol, which reduce portal pressure and may lessen the chance of rebleeding 2, 3, 4, 5
- Isosorbide mononitrate (ISMN), which can be used in combination with beta-blockers 3, 6, 4
Rationale for Pharmacotherapy
The rationale for using these pharmacotherapies is to:
- Reduce the hepatic venous pressure gradient (HVPG) below 12 mmHg, which can prevent bleeding 4
- Decrease the risk of variceal bleeding by reducing the HVPG by more than 20% from baseline 4
- Provide an additive effect when used in combination with endoscopic therapy 4
- Prevent rebleeding by using a combination of beta-blockers and ISMN, or endoscopic variceal ligation (EVL) 4
Comparison of Pharmacotherapies
Comparing the different pharmacotherapies:
- Nadolol is superior to ISMN for the prevention of the first variceal bleeding in cirrhotic patients with ascites 3
- The combination of ISMN or spironolactone with non-selective beta-blockers (NSBB) may decrease the risk of variceal bleeding when compared with the use of NSBB alone 6
- Beta-blockers significantly reduce the risk of a first haemorrhage in patients with large varices and improve survival 4, 5