Review: Somatostatin or octreotide reduces transfusion needs but not other outcomes in acute bleeding esophageal varices
ACP J Club. 1998 Jan-Feb;128:9. doi:10.7326/ACPJC-1998-128-1-009
Gøtzsche PC. Somatostatin or octreotide vs placebo or no treatment in acute bleeding oesophageal varices. In: The Cochrane Database of Systematic Reviews. In the Cochrane Library [database on disk and CD-ROM]. The Cochrane Collaboration; Issue 3. Oxford: Update Software; 1997.
To determine, using meta-analysis, whether somatostatin or octreotide improves survival and reduces blood transfusion needs in patients with suspected or verified acute or recent bleeding from esophageal varices.
Studies were identified with MEDLINE from 1966 forward by using various spellings of the terms somatostatin or octreotide with variceal, varices, bleeding, hemorrhage, esophageal, hematemesis, and melena. Abstracts of conferences and bibliographies of studies, review articles, and editorials were reviewed and manufacturers were contacted.
Studies were included if they compared somatostatin or octreotide with placebo or no treatment and if patients had acute bleeding from esophageal varices. Trials that evaluated long-term rebleeding rates or studied stable patients were excluded.
Data were extracted on the nature, dosage, and duration of treatments; study methods and quality; number of patients; follow-up rates; initial hemostasis; and rebleeding. The most common treatments were somatostatin infusion of 250 µg/h for up to 5 days preceded by a bolus dose of 250 µg and octreotide, 25 µg/h for 5 days preceded by a bolus dose of 50 µg.
Intention-to-treat analysis was used. 6 trials that studied 615 patients were included. The weighted mean difference was 1.2 fewer units of blood (95% CI 0.8 to 1.7) needed per patient in the somatostatin or octreotide groups compared with patients in the control groups. The groups did not differ for mortality (64 deaths in the experimental groups vs 61 deaths in the control groups, P = 0.9), the rate of balloon tamponade (P = 0.33), the number of patients in whom initial hemostasis failed (P = 0.48), or the number of patients with rebleeding (P = 0.49).
Somatostatin or octreotide reduces the average amount of blood needed for transfusion in patients with acute bleeding esophageal varices when compared with placebo or no treatment. The groups did not differ for all other outcomes, including mortality.
Source of funding: Rigshospitalet, Copenhagen Hospital Corporation.
For article reprint: Dr. P.C. Gøtzsche, Director, Chief Physician, The Nordic Cochrane Centre, Department 7112, Rigshospitalet, Tagensvej 18 B, DK-2200 Copenhagen North, Denmark. FAX 45-3545-7007.
The benefit of pharmacologic therapy for bleeding esophageal varices has been difficult to prove in randomized, placebo-controlled trials. This is not surprising when mortality is the end point, because it is the liver disease itself that is usually paramount to life or death. It has also been difficult to prove that softer end points, such as transfusion needs, could be improved with drug therapy. Indeed, in a previous meta-analysis, the same author and his colleagues found no differences in transfusion requirements after treatment with somatostatin or placebo (1). The present meta-analysis includes 3 new studies and reports that somatostatin or octreotide therapy results in a mean reduction in transfusion requirements of approximately 1 unit of blood. What accounts for the difference? 2 of the 3 new studies treated patients with sclerotherapy or variceal ligation before randomization to octreotide or placebo (2, 3). Thus, octreotide had a “running sta! rt,” perhaps allowing it to be more effective than when used de novo.
Saving 1 unit of blood may not in itself justify the routine use of octreotide after endoscopic therapy, but less need for repeated endoscopy and shorter hospital stays might. 2 new studies (2, 3) have noted fewer episodes of continued bleeding or in-hospital rebleeding, but hospital stay and costs were not analyzed.
I am swayed by the newer studies that more closely reflect what is done in clinical practice. Because octreotide is quite safe and not expensive, I recommend its use after endoscopic therapy in patients with acute bleeding from esophageal varices.
Walter L. Peterson, MD
Veterans Affairs Medical CenterDallas, Texas, USA
Walter L. Peterson, MD
Veterans Affairs Medical Center
Dallas, Texas, USA