Title: Octreotide Shortage: Vasopressin for Variceal Bleeding<br/>Author: Wesley Oliver<br/><a href='mailto:1911'>[Click to email author]</a><hr/><p dir="ltr" style="line-height:1.2;margin-top:0pt;margin-bottom:0pt;">
<span style="font-size:12px;"><span style="font-family:arial,helvetica,sans-serif;"><span id="docs-internal-guid-17bd4f83-7fff-0b3a-edc2-a0132337b67b"><span style="font-variant-numeric: normal; font-variant-east-asian: normal; vertical-align: baseline; white-space: pre-wrap;">With a national shortage of octreotide an alternative treatment plan had to be implemented at our institution for patients presenting with variceal bleeding.</span></span></span></span></p>
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<span style="font-size:12px;"><span style="font-family:arial,helvetica,sans-serif;"><span style="white-space: pre-wrap;">Drug references recommend a continuous infusion of vasopressin at 0.2 to 0.4 units/minute. Dose may be titrated as needed to a maximum dose of 0.8 units/minute with maximum duration of 24 hours to reduce incidence of adverse effects. Administer IV nitroglycerin concurrently to prevent ischemic complications and monitor closely for signs/symptoms of myocardial, peripheral, and bowel ischemia.</span></span></span></p>
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<span style="font-size:12px;"><span style="font-family:arial,helvetica,sans-serif;"><u><strong><span style="white-space: pre-wrap;">Protocol at our institution:</span></strong></u></span></span></p>
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<span style="font-size:12px;"><span style="font-family:arial,helvetica,sans-serif;"><strong>Vasopressin</strong></span></span></p>
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<span style="font-size:12px;"><span style="font-family:arial,helvetica,sans-serif;"><span style="white-space: pre-wrap;">Initiate vasopressin at 0.2 units/min.</span></span></span></p>
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<span style="font-size:12px;"><span style="font-family:arial,helvetica,sans-serif;"><span style="white-space: pre-wrap;"><span id="docs-internal-guid-17bd4f83-7fff-0b3a-edc2-a0132337b67b"><span style="font-variant-numeric: normal; font-variant-east-asian: normal; vertical-align: baseline; white-space: pre-wrap;">Increase by 0.2 units/min if bleeding is not controlled after one hour (max dose: 0.8 units/min).</span></span></span></span></span></p>
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<span style="font-size:12px;"><span style="font-family:arial,helvetica,sans-serif;"><span style="white-space: pre-wrap;"><span style="font-variant-numeric: normal; font-variant-east-asian: normal; vertical-align: baseline; white-space: pre-wrap;"><span id="docs-internal-guid-17bd4f83-7fff-0b3a-edc2-a0132337b67b"><span style="font-variant-numeric: normal; font-variant-east-asian: normal; vertical-align: baseline; white-space: pre-wrap;">If bleeding controlled for 2 hours, can decrease by 0.2 units/min and reassess.</span></span></span></span></span></span></p>
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<span style="font-size:12px;"><span style="font-family:arial,helvetica,sans-serif;"><span style="white-space: pre-wrap;"><span style="font-variant-numeric: normal; font-variant-east-asian: normal; vertical-align: baseline; white-space: pre-wrap;"><span style="font-variant-numeric: normal; font-variant-east-asian: normal; vertical-align: baseline; white-space: pre-wrap;"><span id="docs-internal-guid-17bd4f83-7fff-0b3a-edc2-a0132337b67b"><span style="font-variant-numeric: normal; font-variant-east-asian: normal; vertical-align: baseline; white-space: pre-wrap;">Limit use to 24 hours.</span></span></span></span></span></span></span></p>
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<span style="font-size:12px;"><span style="font-family:arial,helvetica,sans-serif;"><strong style="font-family: Calibri, sans-serif; font-size: 11pt; white-space: pre-wrap;">Nitroglycerin</strong></span></span></p>
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<span style="font-size:12px;"><span style="font-family:arial,helvetica,sans-serif;"><span style="white-space: pre-wrap;">Use nitroglycerin infusion to prevent adverse effects from vasopressin.</span></span></span></p>
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<span style="font-size:12px;"><span style="font-family:arial,helvetica,sans-serif;"><span style="white-space: pre-wrap;"><span id="docs-internal-guid-17bd4f83-7fff-0b3a-edc2-a0132337b67b"><span style="font-variant-numeric: normal; font-variant-east-asian: normal; vertical-align: baseline; white-space: pre-wrap;">Initiate nitroglycerin at 40 mcg/min, titrate by 40 mcg/min to a max dose of 400 mcg/min.</span></span></span></span></span></p>
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<span style="font-size:12px;"><span style="font-family:arial,helvetica,sans-serif;"><span style="white-space: pre-wrap;"><span style="font-variant-numeric: normal; font-variant-east-asian: normal; vertical-align: baseline; white-space: pre-wrap;">Goal systolic blood press pressure of 90-100 mmHg. Do not start nitroglycerin if SBP <90 mmHg.</span></span></span></span></p>
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<span style="font-size:12px;"><span style="font-family:arial,helvetica,sans-serif;"><span style="white-space: pre-wrap;"><span style="font-variant-numeric: normal; font-variant-east-asian: normal; vertical-align: baseline; white-space: pre-wrap;"><strong><span style="white-space: pre-wrap;">***Please note the vasopressin dose for this indication is significantly higher than the typical dose of 0.03 units/min we use for shock.***</span></strong></span></span></span></span></p>
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<fieldset><legend>References</legend>
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<span id="docs-internal-guid-858fe0d5-7fff-96aa-d39f-28ef350cc3c0"><span style="font-size: 11pt; font-family: Calibri, sans-serif; font-variant-numeric: normal; font-variant-east-asian: normal; vertical-align: baseline; white-space: pre-wrap;">Garcia-Tsao G, Abraldes JG, Berzigotti A, Bosch J. Portal hypertensive bleeding in cirrhosis: risk stratification, diagnosis, and management: 2016 practice guidance by the American Association for the Study of Liver Diseases [published correction appears in Hepatology. 2017;66(1):304]. Hepatology. 2017;65(1):310-335.</span></span></p>
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<span id="docs-internal-guid-858fe0d5-7fff-96aa-d39f-28ef350cc3c0"><span style="font-size: 11pt; font-family: Calibri, sans-serif; font-variant-numeric: normal; font-variant-east-asian: normal; vertical-align: baseline; white-space: pre-wrap;">Terés J, Planas R, Panes J, Salmeron JM, Mas A, Bosch J, Llorente C, Viver J, Feu F, Rodés J. Vasopressin/nitroglycerin infusion vs. esophageal tamponade in the treatment of acute variceal bleeding: a randomized controlled trial. Hepatology. 1990 Jun;11(6):964-8.</span></span></p>
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<span id="docs-internal-guid-858fe0d5-7fff-96aa-d39f-28ef350cc3c0"><span style="font-size: 11pt; font-family: Calibri, sans-serif; font-variant-numeric: normal; font-variant-east-asian: normal; vertical-align: baseline; white-space: pre-wrap;">Vasopressin. Lexicomp. UpToDate. Waltham, MA: UpToDate Inc. Available at: https://www.uptodate.com. Accessed on December 31, 2020.</span></span></p>
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