admittomedicine

octreotide

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The Splanchnic Vasodilation Blocker

Second-line therapy for HRS-AKI when combined with Midodrine. Use only as bridge to ICU or when ICU admission is inappropriate.

  • Mechanism: Synthetic somatostatin analog (long-acting). Reduces splanchnic vasodilation by inhibiting vasodilatory peptides (VIP, glucagon, substance P). Synergistic with Midodrine: Octreotide reduces splanchnic pooling; Midodrine provides systemic vasoconstriction. Not a direct vasoconstrictor: Works by reducing pathological vasodilation rather than causing vasoconstriction.

  • Dosing: HRS (SC): SC q8h. HRS (IV): continuous infusion. Always combined with Midodrine in HRS therapy (synergistic effect).

  • PK: Onset: 30–60 minutes (SC), immediate (IV). Half-life: ~1.5 hours (SC), shorter (IV). Metabolism: Hepatic (minimal). Elimination: Renal (60%), biliary (40%).

indications

  • Hepatorenal Syndrome (HRS-AKI) – Second-line therapy (combined with Midodrine). Ward-based therapy when ICU admission is inappropriate or as bridge to ICU.
  • Other Uses: Variceal bleeding (reduces portal pressure), acromegaly, carcinoid syndrome, VIPomas.

evidence & efficacy

  • HRS Efficacy: Significantly inferior to Terlipressin and Norepinephrine when used alone or with Midodrine.
  • Octreotide Alone: Not effective for HRS; multiple studies show no benefit when used without Midodrine.
  • Response Rate (with Midodrine): Lower than vasopressin analogs (~20–30% vs 40–50%).
  • Limitation: No large RCTs demonstrating efficacy in HRS; evidence primarily from small studies and case series.

cautions

contraindications

  • Hypersensitivity to somatostatin analogs
  • Cholelithiasis (increases risk of gallstones)
  • Diabetes (may affect glucose control)
  • Renal impairment (dose adjustment may be needed)
  • Adverse Effects: GI (nausea, diarrhea, abdominal pain, cholelithiasis), hyper/hypoglycemia, injection site reactions (SC route).

special considerations (canada/royal college)

  • Role: Use only as bridge to ICU or when ICU admission is deemed inappropriate (Goals of Care discussions).
  • Combination Therapy: Always used with Midodrine in HRS (synergistic effect – Octreotide reduces splanchnic pooling, Midodrine provides systemic vasoconstriction).
  • Limitation: Significantly inferior efficacy compared to IV vasoconstrictors; not recommended as first-line.

exam pearl

Octreotide + Midodrine is the “ward therapy” option when ICU/Norepinephrine is not available or appropriate. Octreotide alone is not effective for HRS.

clinical pearl

Monitor for cholelithiasis with prolonged use; consider gallbladder ultrasound if symptoms develop.

related pages: Hepatorenal syndrome (HRS-AKI)