In this episode, I’ll discuss when to use octreotide for upper GI bleeding.
Octreotide is a long-acting analog of somatostatin. It inhibits the release of many endocrine peptides including insulin and glucagon. In addition, it inhibits the release of gastric acid. Because glucagon is a vasodilator, octreotide indirectly decreases splanchic blood flow by its action inhibiting the release of glucagon.
There are two scenarios when octreotide can be considered for a patient with an upper GI bleed:
- When endoscopy is unavailable or contraindicated
- When variceal bleeding can be reasonably suspected
For non-variceal bleeding, octreotide has a very limited role due to the lack of evidence supporting its use. If endoscopy is unavailable, or if a patient is too unstable to undergo endoscopy, octreotide use may be considered.
The best data for the use of octreotide is in variceal bleeding. It does not provide a benefit in terms of decreased mortality, but it does affect other meaningful outcomes. A meta-analysis of over 800 patients found that a little over 1 unit of blood products was saved per each patient treated. A small prospective randomized trial comparing octreotide with vasopressin found that octreotide resulted in more initial hemostasis, less re-bleeding, and nearly twice the rate of complete control of bleeding within 24 hours.
Variceal bleeding occurs as a result of liver cirrhosis, so it is reasonable to start octreotide in patients who are known to or who may have cirrhosis. This would include patients with known or suspected alcoholic liver disease or patients with jaundice, ascites, or hepatic encephalopathy.
One of the reasons octreotide may work well in this patient population is its ability to inhibit meal-induced increases in the portal venous pressure of cirrhotic patients with portal hypertension. Blood in the lumen of the GI tract may stimulate a meal response due to the level of protein found in the blood. This, in turn, increases splanchic blood flow which could increase the risk of persistent or recurrent variceal bleeding.
If endoscopy reveals that upper GI bleeding is non-variceal, octreotide can be stopped.
Otherwise, octreotide is typically continued for 5 days based on the results of the European Acute Bleeding Oesophageal Variceal Episodes (ABOVE) trial and another study published in NEJM in 1995.
Members of my Hospital Pharmacy Academy have access to my in-depth training on the pharmacist’s role in treating acute upper GI bleeding. In this training, I cover antibiotic use, vasopressor use, acid suppression therapy, when to resume anticoagulation, and much more. This is in addition to over 200 other in-depth training videos, weekly literature digests to help you stay up to date, full-text journal access and forums to interact with me and the other members. The purpose of the Academy is to increase the confidence and clinical skills of hospital-based pharmacists in the areas of critical care, emergency medicine, infectious disease, and general hospital pharmacy. To learn more go to pharmacyjoe.com/academy.
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