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. Your email address will not be published. Easily remember spectrum of activity with my free visual critical care antibiotic guide:.
Subscribe on iTunes , Android , or Stitcher. Leave a Reply Cancel reply Your email address will not be published. This site uses cookies to ensure you receive the best experience. Continued use of this site indicates your agreement with the terms and privacy policy. Pharmacy Joe. It has an overall inhibitory effect on secretion of multiple hormones, reducing gut motility and gastric emptying, and decreasing splanchnic blood flow.
Octreotide contains the active moiety of somatostatin, and is several times more active than the endogenous hormone. Major Indications The major indications for octreotide use are not things we would treat in the ED. For example, it is used for chronic treatment of acromegaly, carcinoid tumor, and VIPomas. Octreotide is frequently used in the ED for patients with a history of cirrhosis who present with a moderate or severe upper GI bleed presumed to be from a variceal source.
Octreotide inhibits the release of glucagon, which is a splanchnic vasodilator. It therefore reduces splanchnic blood flow and portal venous pressure. The effect on portal pressure, however, is transient, lasting about five minutes even when used as an infusion [1], though it may continue to reduce intestinal blood flow for longer through other mechanisms [2].
The current therapy for acute variceal bleed typically involves octreotide in combination with sclerotherapy or band ligation, along with antibiotic prophylaxis [3]. Treatment with octreotide and sclerotherapy results in lower rates of re-bleeding than use of either therapy alone, though there was no improvement in mortality with the addition of octreotide [4].
Secondary objectives were to determine the effect of using or not octreotide in survival without rebleeding, and hospital stay length between the octreotide and non-octreotide groups.
Also, to compared the general and clinical variables between patients according to 5-day control of bleeding and hospital mortality. Statistical analyses were performed with SPSS Data are presented as absolute value and percentages, mean and standard deviation SD or median and interquartile range IQR as appropriate.
The relationship between the different variables and the risk of developing the endpoints were analyzed by logistic regression. Multivariate logistic regression models were used to calculate adjusted probabilities aOR of 5-day failure to control bleeding, in-hospital mortality and need for transfusion within each CP and MELD strata.
The medical records of three-hundred and sixteen patients were retrospectively searched. Of the patients, were treated with ET plus octreotide octreotide group and were treated with ET alone non-octreotide group. All patients received prophylactic antibiotics at admission or immediately after AVB was confirmed. The study population was male dominant Alcoholic liver disease Baseline characteristics of patients did not differ significantly between the two treatment groups Table 1.
There were no missing data for the variables of interest. Baseline characteristics of patients with acute variceal bleeding according to type of treatment.
Both treatment groups received endoscopic therapy. Virus category includes patients with viral hepatitis alone and patients with viral hepatitis and alcohol NASH: Non-alcoholic steatohepatitis. PBC: Primary biliary cholangitis. GOV: Gastroesophageal varices. The 5-day failure to control bleeding between groups was 7. Outcomes in patients with and without octreotide, in the overall series and in different subgroups.
Bold numbers represent statistical significance. IQR: Interquartile range. Overall, patients in the octreotide group had a lower hospital mortality compared with those not receiving octreotide, 3. Those with severe liver dysfunction in the octreotide group presented lower hospital mortality than those in the non-octreotide group Table 2.
Univariate analysis showed that octreotide was associated with a decreased risk of mortality Table 3 , OR 0. This association between octreotide treatment and survival remained significant at multivariate analysis Table 4 : aOR 0. Univariate analysis for primary clinical outcomes in cirrhotic patients with acute variceal bleeding.
CP: Child-Pugh. OR: Odds Ratio. CI: Confidence interval. Multivariate analysis for primary clinical outcomes in cirrhotic patients with acute variceal bleeding. NA: Not applicable. These predictions were calculated from the logistic regression models including, A octreotide treatment and Child-Pugh score, and B octreotide treatment and MELD. Predicted mortality in patients with cirrhosis treated or not with octreotide across different Child-Pugh score or MELD.
The proportion of patients needing transfusion was In univariate analysis, octreotide was the only factor independently associated with the need for transfusion Table 3 : OR 0. When we compared the number of transfusions between groups based in the baseline hepatic function by CP class and MELD, there was some significant difference Table 2.
We also compared the general and clinical variables between patients according to 5-day control of bleeding, and in-hospital mortality Table 5. Comparison of general and clinical variables between patients according to control of bleeding and hospital mortality. OR: Odds ratio. SD: Standard deviation. The combination of vasoactive agents with EVL is standard therapy for AVB, 9 , 10 , 14 - 18 but it is still uncertain if all patients need vasoactive treatment or if this could be avoided in low-risk patients.
This is especially relevant in environments in which access to drug therapy is limited by its cost. In this study, we have shown that the probability of failure to control bleeding, mortality and need for transfusion during hospitalization in CP-A or MELD 10 in the octreotide group showed better outcomes compared to patients not receiving octreotide in terms of mortality and PRBC transfusion requirements.
The current recommendations of using combined therapy of vasoactive drugs and ET in the setting of AVB, lies on the evidence provided by studies that assessed the 5-day success rate. Several studies have shown that combination therapy improves control of bleeding compared with ET alone, though the effect in survival is still controversial.
ET alone in the subset of patients with CP-A. A previous randomized placebo-controlled doubleblind study comparing endoscopic variceal sclerotherapy alone and in combination with octreotide in patients with low-risk cirrhosis excluding patients with refractory as-cites, CP-C, and chronic encephalopathy and AVB reported a significant difference in the rate of 5-day rebleeding, a shorter hospital stay and number of PRBC units transfused in the combined treatment group.
In addition, due to the small number of patients and since just one patient from each group died during the study, they were not able to provide conclusions regarding mortality. One surprising finding in our study was that octreotide had no impact on control of bleeding but still showed a positive effect in terms of mortality and transfusion requirements. This is supported by the data from a meta-analysis demonstrating that EVL is superior in control bleeding compared to sclerotherapy.
The only determinant of octreotide treatment was the socioeconomic status of the patients, which determined whether they could pay or not for the drug. Thus, the clinical baseline characteristics were comparable between groups treated or non-treated with octreotide. A limitation of our study is the potential indication bias introduced by octreotide treatment.
Though the strongest prognostic determinant in AVB is the baseline liver function, 29 , 30 the determinants for the use of octreotide might have introduced unknown bias that could not be accounted for in the multivariate analysis. Also, though we adjusted the effects of octreotide by the most relevant predictors in a multivariate analysis, there might be residual confounding not captured by the standard variables that were collected in our study e. The authors declare that they have no conflict of interest or financial disclosures.
We received no funding in the preparation of this manuscript. AVB: Acute variceal bleeding. ET: Endoscopic therapy. EVL: Endoscopic variceal ligation. PRBC: Packed red blood cell. ISSN: Previous article Next article. Issue 1. Pages January - February More article options. Download PDF. Corresponding author. This item has received.
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