REBEL Cast Ep 48: Octreotide and Somatostatin for Undifferentiated Upper Gastrointestinal Bleed

Recently I was asked to speak at the Texas College of Emergency Physicians (TCEP) conference April 2018. The particulars of this session were, five, 10 minute lectures on new indications for old drugs. My topic was the use of octreotide and somatostatin for undifferentiated upper gastrointestinal bleeding. This is a particular topic I have been getting more and more requests for, but didn’t really know the evidence behind why I was doing it. Does it help my patients or just another expensive medication, that takes up an IV with no clear patient oriented outcome?

REBEL Cast Episode 48 – Octreotide and Somatostatin for Undifferentiated Upper Gastrointinal Bleeds

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Initial Care of Undifferentiated Upper GIB:

2 Large Bore (16 – 18g), proximal peripheral IVs

1 – 2 Liters of Crystalloid Fluids — This will be patient dependent

PRBCs Use a restrictive transfusion strategy

PPI – We have discussed this on REBEL EM before, but the bottom line is 1x bolus with no drip. No benefit in mortality, rebleeding, or need for surgery.

Octreotide or Somatostatin – Is there evidence to support use?

Pros of Somatostatin and Octreotide in Undifferentiated Upper GIB:

Decrease Portal/Splanchnic Pressure –> Potential to Decrease Bleeding and Rebleeding

Decrease Acid Secretion –> Prevent Clot Dissolution

Few Adverse Effects

Cons of Somatostatin and Octreotide in Undifferentiated Upper GIB:

Expensive Medication –> Approximately $8,000 dollars for 24 hours of use

Takes up an IV

Evidence is Older, Smaller Trials –> Majority of studies were published before 1995

Lack of Mortality Data to Support Use

Opportunity cost –> Distracts from important interventions and uses nursing time up that could be used elsewhere

Does Somatostatin or Octreotide Improve Clinically Relevant Outcomes in Undifferentiated Upper Gastrointestinal Bleeding?

Bleeding

Rebleeding

Need for Surgery

Mortality

Doing a Pubmed search, there were really only two trials that answered this question:

Thomas F et al. Somatostatin or Octreotide Compared with H2 Antagonists and Placebo in the Management of Acute Non-Variceal Upper GI Hemorrage: A Meta-Analysis. Ann Intern Med 1997. This is the best evidence we have to support the use of octreotide in undifferentiated upper GIB Want to know what else happened in 1997: Dolly the sheep was cloned, OJ Simpson was found guilty, Movie releases included: Titanic, Good Will Hunting, Men in Black and Air Force One 14 Trials were reviewed totaling approximately 1800 patients. Only 2 trials with just over 300 patients compared octreotide alone (one study to placebo and the other study to ranitidine. These two trials were published in 1989 and 1995 respectively We went through each of the individual studies and calculated the results of the clinically relevant outcomes for studies including somatostatin and octreotide and octreotide alone.



Archimandritis A et al. Ranitidine vs Ranitidine Plus Octreotide in the Treatment of Acute Non-Variceal Upper Gastrointestinal Bleeding: A Prospective Randomised Study. Current Medical Research and Opinion 2000. 84 patients No difference in PRBCs Required or Need for Surgery No Mortality Data



Clinical Bottom Line: Until newer studies are published showing either harm or no clinical benefit, at this time the use of octreotide in non-variceal upper gastrointestinal hemorrhage appears to benefit bleeding and need for surgery (Especially in the sickest patients: Hemodynamically unstable, requiring transfusion, large volume hematemesis). Unfortunately, we just do not have mortality data to help guide this decision nor do we know the optimal length of time to continue the infusion.

References:

Thomas F et al. Somatostatin or Octreotide Compared with H2 Antagonists and Placebo in the Management of Acute Non-Variceal Upper GI Hemorrage: A Meta-Analysis. Ann Intern Med 1997. PMID: 9412308 Archimandritis A et al. Ranitidine vs Ranitidine Plus Octreotide in the Treatment of Acute Non-Variceal Upper Gastrointestinal Bleeding: A Prospective Randomised Study. Current Medical Research and Opinion 2000. PMID: 11191007

For More on This Topic Checkout:

Post Peer Reviewed By: Anand Swaminathan (Twitter: @EMSwami)