When is somatostatin administered?

When to Administer Somatostatin

Somatostatin should be initiated immediately when acute variceal bleeding is suspected in patients with cirrhosis and portal hypertension, even before diagnostic endoscopy is performed. 1

Primary Indication: Acute Variceal Hemorrhage

Somatostatin is administered for the emergency control of bleeding from esophageal or gastric varices in patients with liver cirrhosis and portal hypertension. 1

Timing of Initiation

• Start somatostatin as soon as variceal bleeding is suspected, before endoscopic confirmation 1
• Any cirrhotic patient presenting with upper gastrointestinal bleeding should be presumed to have variceal bleeding until proven otherwise 2
• Early administration is critical because treatment delay increases mortality 2

Dosing Protocol

• Initial dose: 250 μg intravenous bolus 1
• Maintenance: 250 μg/hour continuous intravenous infusion 1
• Duration: Continue for 3-5 days after bleeding is controlled 1

Mechanism and Efficacy

Somatostatin causes selective splanchnic vasoconstriction at pharmacological doses, reducing portal venous inflow and portal pressure. 1, 2

Evidence of Effectiveness

• Somatostatin has comparable efficacy to terlipressin and octreotide for controlling acute variceal hemorrhage, with no significant differences in hemostasis rates or survival 1
• Meta-analyses demonstrate that somatostatin significantly improves control of acute hemorrhage compared to placebo 3
• One randomized controlled trial showed a 41% reduction in the hazard of treatment failure compared to placebo 3

Safety Profile

• Somatostatin has an excellent safety profile and can be used continuously for 5 days or longer 1, 2
• Side effects are minimal: nausea/vomiting, abdominal pain, headache, and hyperglycemia 1
• Significantly fewer adverse events compared to vasopressin, which has been largely abandoned due to serious cardiovascular complications 1, 4

Essential Concurrent Therapies

Somatostatin should never be used as monotherapy. The following must be initiated simultaneously:

• Prophylactic antibiotics (ceftriaxone 1g IV daily or norfloxacin) to reduce infection risk 5, 2
• Restrictive blood transfusion strategy targeting hemoglobin 7-9 g/dL 2
• Volume resuscitation with crystalloids via large-bore IV access 2
• Endoscopy within 12 hours for diagnostic confirmation and endoscopic band ligation 1, 2

Clinical Algorithm

1. Suspect variceal bleeding in any cirrhotic patient with upper GI bleeding
2. Immediately initiate somatostatin (250 μg IV bolus, then 250 μg/hr infusion) 1
3. Start prophylactic antibiotics concurrently 5, 2
4. Perform endoscopy within 12 hours for confirmation and endoscopic treatment 1
5. Continue somatostatin for 3-5 days after bleeding control 1
6. Discontinue if endoscopy reveals non-variceal bleeding 5

Important Caveats

• Somatostatin is NOT recommended for non-variceal upper GI bleeding, as it does not improve outcomes in this setting 2
• While terlipressin is the only vasoactive drug proven to reduce bleeding-related mortality (RR 0.66), somatostatin remains an excellent alternative with comparable hemostasis rates and superior safety 1
• Beta-blockers should NOT be used acutely during active bleeding, as they decrease blood pressure and blunt compensatory tachycardia 1, 2
• Some older studies showed conflicting results regarding somatostatin efficacy 6, but more recent meta-analyses and guidelines support its use based on the totality of evidence 1