What is the typical starting infusion dose of octreotide (somatostatin analogue) for a patient?

Octreotide Infusion Dosing

The standard starting infusion dose of octreotide is 50 μg/hour by continuous intravenous infusion, typically preceded by an initial IV bolus of 50 μg. 1, 2, 3

Standard Continuous Infusion Protocol

• Begin with an IV bolus of 50 μg followed immediately by continuous infusion at 50 μg/hour 1, 2, 3
• This dosing regimen is supported by multiple high-quality guidelines including FDA labeling and is considered the standard approach across various clinical scenarios 3
• The infusion can be safely continued for 2-5 days without significant adverse effects 2

Clinical Context-Specific Dosing

Perioperative Management for Neuroendocrine Tumors

• For patients with carcinoid syndrome undergoing surgery or procedures, initiate the 50 μg/hour infusion 12 hours before the procedure and continue for 24-48 hours afterward 4, 1
• This prophylactic approach prevents potentially life-threatening carcinoid crisis, even in patients already receiving long-acting somatostatin analogues 4, 1
• Always have short-acting octreotide available even for non-syndromic patients with small bowel NETs, as unexpected carcinoid crisis can occur 4

Emergency Carcinoid Crisis Management

• In acute carcinoid crisis, administer bolus doses of 100-500 μg IV, followed by continuous infusion at 50 μg/hour 4
• Some specialized centers use higher infusion rates (up to 500 μg/hour) for severe crises, though standard dosing (50 μg/hour) is effective in most cases 5
• Antihistamines and corticosteroids may provide additional benefit during crisis management 4

Variceal Hemorrhage

• Use the same standard protocol: 50 μg IV bolus followed by 50 μg/hour continuous infusion for 2-5 days 6, 2
• This causes splanchnic vasoconstriction and is safe for continuous use up to 5 days 6

Severe Diarrhea (Chemotherapy-Induced, Malignant Bowel Obstruction)

• For refractory diarrhea, start at 25-50 μg/hour by continuous IV infusion 4, 6
• Can escalate to 100-500 μg/day in divided doses or by continuous infusion if initial dosing inadequate 4, 6
• For malignant bowel obstruction, doses of 0.3-0.6 mg/day (300-600 μg/day) by continuous infusion or subcutaneous bolus effectively control symptoms 7

Dose Escalation Strategy

• If 50 μg/hour infusion is insufficient, increase incrementally based on clinical response 3
• For functional NETs with persistent symptoms, doses can be increased up to 500 μg three times daily (or equivalent continuous infusion rate) 6, 3
• Doses above 750 μg/day are rarely needed and have limited supporting evidence 3

Critical Pitfalls to Avoid

• Do not use octreotide in Total Parenteral Nutrition (TPN) solutions - it forms a glycosyl conjugate that decreases efficacy 3
• Exercise caution in insulinoma patients - octreotide may worsen hypoglycemia in patients without SSTR2-positive tumors; diazoxide (200-600 mg orally daily) is preferred 1, 6
• Avoid premature discontinuation in variceal bleeding before achieving hemodynamic stability 2
• Monitor for cardiac conduction abnormalities when administering IV octreotide, as higher-degree AV blocks can occur 6

Preparation and Administration

• Octreotide is stable in sterile isotonic saline or dextrose 5% in water for 24 hours 3
• Can be diluted in 50-200 mL and infused over 15-30 minutes, or given by IV push over 3 minutes 3
• In emergency situations (carcinoid crisis), may be given by rapid bolus 3

Transition to Maintenance Therapy

• After stabilization on continuous infusion, transition to subcutaneous dosing (100-150 μg three times daily) or long-acting formulations (octreotide LAR 20-30 mg IM every 4 weeks) 6
• Allow 10-14 days after LAR injection to achieve therapeutic levels; bridge with short-acting octreotide during this period 6