Thursday, February 7, 2013

Managing A Bloody Mess: Octreotide for Undifferentiated Gastrointestinal Bleed

An elderly female patient rolls into the emergency department as a trauma. The story from the paramedics is that she had a witnessed fall, and she was initially alert and answering questions appropriately. However, en route to the hospital, her mental status became altered and she began to go "in and out." She became combative and because the paramedics feared that her airway would become unprotected, the decision was made to intubate the patient. Her medication list is found with her personal belongings, which reveals that she is taking aspirin 81 mg PO qdaily and clopidogrel 75 mg PO qdaily. Initial blood pressure of 60/40 mmHg, and two liters of normal saline are running wide open. The primary and secondary surveys are conducted, and the point-of-care hemoglobin measurement is 6.6 mg/dL, and so the trauma attending orders 2 units of packed red blood cells. A nasogastric tube is placed, which evacuates nearly 500 mL of bright red blood.

The trauma attending addresses you, the emergency medicine pharmacist, and requests an IV bolus of pantoprazole 80 mg and an IV bolus of octreotide 50 mcg. You can certainly understand the role of pantoprazole in this setting, but is the use of octreotide justified here?

Octreotide is a somatostatin analog that elicits several actions in the management of acute gastrointestinal bleeding:
  • Inhibition of the secretion of acid and pepsin, which prevents dissolution of blood clots that form at the site of the bleed
  • Reduction of gastroduodenal mucosal blood flow
  • Binding to somatostatin receptors on endothelial cells to induce prolonged splanchnic vasoconstriction
It has been used to control bleeding of esophageal varices, which is common in alcoholic patients or those patients with known or suspected chronic liver disease. However, the consensus guidelines for the management of non-variceal acute upper gastrointestinal bleeding do not recommend the routine use of octreotide (Grade IC recommendation with no change in 2010 updated guidelines). The guidelines go on to state that the use of octreotide (or other somatostatin analogs) may be considered in those patients with uncontrollable bleeding who are awaiting endoscopy or awaiting the OR or for whom surgery is contraindicated.

Several studies have demonstrated that octreotide reduces the risk of persistent bleeding and recurrent bleeding from variceal and non-variceal upper gastrointestinal bleeds.1,2 One review found that somatostatin analogs did not demonstrate any mortality benefit, although the need for blood transfusion may be reduced. An interesting article evaluates the evidence surrounding the use of octreotide in non-variceal upper gastrointestinal bleeding.

I believe that in such a scenario as the one described here where there is very little information provided regarding the patient's past medical history and the source of the gastrointestinal bleed is unknown, it is not unreasonable to administer octreotide. It has a relatively quick onset of action (less than 30 minutes) and it is relatively easy to administer. Be sure to follow the IV bolus of octreotide with an IV infusion at a rate of 50 mcg/hr.

1. Imperiale TF, Birgisson S. Somatostatin or octreotide compared with H2 antagonistsand placebo in the management of acute nonvariceal upper gastrointestinal hemorrhage: a meta-analysis. Ann Intern Med 1997; 127:1062-1071. [PMID: 9412308]
2. Jenkins SA, Shields R, Davies M, et al. A multicentre randomised trial comparing octreotide and injection sclerotherapy in the management and outcome of acute variceal haemorrhage. Gut 1997; 41:526-533. [PMID: 9391254]

6 comments:

  1. A timely post to try and answer a clinical question we had this past week. Here's my followup- With undifferentiated UGI bleed, what's the head to head utility of pantoprozole IV vs octreotide? In other words, there is limited or negative data only for both. My uneducated gist is that pantoprozole DOESN'T seem to work, while octreotide, DOES. So mostly GI only asks for the former, unlike your case scenario above. Thoughts?

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  2. There was one head-to-head prospective, randomized, placebo-controlled study that compared the effects of somatostatin versus pantoprazole in inhibiting gastric acid secretion in the setting of peptic ulcer bleed. Both agents were given over the course of 24 hours. Baseline gastric pH of patients with endoscopic stage IIc and III peptic ulcer bleed was compared to gastric pH during infusion. Both somatostatin and pantoprazole managed to maintain gastric pH at a level greater than 4.0. However, during the first half of the treatment (12 hours), somatostatin was more effective in maintaining a gastric pH between 4.0 and 5.4 than pantoprazole. [PMID: 16036503]

    There have not been any head-to-head studies conducted that I was able to find that have looked at the clinical utility of IV pantoprazole versus octreotide in undifferentiated GI bleed. It would be interesting to see the results should such a study be performed, especially since we have such a study as described above to justify comparing the effects and clinical outcomes associated with these two agents in the setting of gastrointestinal bleed of unknown origin.

    I do want to emphasize that octreotide is most effective when used as adjunct therapy in the setting of endoscopic sclerotherapy to prevent rebleeding.

    Thank you for your feedback.

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  3. Pantoprazole may also be used to prevent ulcers .To evaluate the efficacy of pantoprazole in preventing gastrointestinal lesions in patients with rheumatic diseases receiving continuous long term treatment.

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  4. Just curious, as to exactly how the octreotide 50mcg IV bolus is administered? Is it just IVP over 3 minutes (undiluted) as drug references state? Have you observed any bradycardia from bolus dosing? How nursing protocol has the bolus to be given over 10 minutes via IVPB similar to amiodarone 150mg IV bolus. Any insight is greatly appreciated. Thank you.

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  5. Thank you for your question. We usually have the nurses push the undiluted bolus dose over 3 minutes. We do not typically infuse the bolus as an IV piggyback over an extended period of time. I personally have not observed bradycardia from the bolus dose. In doing a quick review of the literature, it seems that the bradycardia associated with octreotide is dose-related and typically occurs with bolus doses greater than 100 mcg (though, that is not to say that it never occurs with doses less than 100 mcg). I do not think it would be unreasonable to administer via IV piggyback over an extended period of time, especially in the patient who is already hemodynamically unstable.

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  6. we have shortage for all PPIs so Is there any special dosing for H2 blocker to be given instead to be equipotent ?

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