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
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]