Research shows need for guideline adjustment when treating variceal bleeding

Researchers at the Medical University of South Carolina have revealed the need to clarify current treatment guidelines for octreotide therapy following an esophageal variceal hemorrhage in a recent study appearing in The American Journal of Medical Sciences.

Patients with cirrhosis often develop abnormal veins known as varices in the esophagus that can bleed and require immediate intervention. The current treatment calls for the banding of varices where endoscopists obliterate these veins with small rubber bands, essentially quashing the bleed by cutting off access.

After the procedure, patients are then treated with octreotide therapy, typically for 3 to 5 days. Current guidelines recommend at least 3 days of octreotide treatment.

Don Rockey, M.D., director of the MUSC Digestive Disease Research Core Center, says esophageal varices are caused by high pressure in the portal vein, which carries blood from the abdomen to the liver. Previous studies have shown that octreotide is effective in reducing portal pressure which then reduces the severity of esophageal variceal bleeding. Although octreotide is essential when these patients first show symptoms, Rockey’s team hypothesized that 3–5 days of treatment, especially after banding, was not necessary.

They set out to compare octreotide therapy for 72 hours and for 24 hours to determine whether anything was gained by prolonged treatment.

Rockey and his team found that their patients had the same success rate when treated for 24 hours compared to 72 hours. There was no difference in the need for transfusion, ventilation or vasopressors, and there was no difference in the rate of infection.

“These results are important,” says Rockey,” because they have the potential to change the way we practice. The data has already changed the way I practice.”

The study additionally found that by treating patients for 3 days after banding instead of 1, patients were in the hospital for longer than necessary, which carries its own risks. The National Institutes of Health in the U.S. and the National Health Service in the U.K. cite sleep deprivation, an increased risk of infections, and an increased risk of falls in elderly patients as examples of the potential negative effects of staying in the hospital longer than is needed.

Rockey’s randomized clinical trial provides important insight into treatment for varices and supports the goal of reducing hospital stays, costs and patient risk.

“Sometimes in medicine, less is more,” said Rockey. “This is one of those instances where real evidence shines through.”

In the future, Rockey will continue this research with a meta-analysis to further support his latest findings, and he will start practicing 24-hour octreotide therapy in his patients rather than 72.