Which is the better treatment for esophageal varices—octreotide or vasopressin? Additionally, what is the adult dose for these medications?
—Marangely Rodriguez, MD, Naguabo, P.R.

Octreotide is preferable to vasopressin for the initial treatment of active variceal bleeding mostly because the side-effect profile of vasopressin limits its use. In addition to decreasing portal pressure by causing splanchnic vasoconstriction, octreotide can reduce variceal bleeding, stabilize the patient, and allow for better visualization of the esophageal lumen during endoscopy.

Administration is with a 50-µg bolus followed by 50 µg/hr IV for five days. On the other hand, vasopressin results in systemic and cardiac vasoconstriction in addition to splanchnic vasoconstriction and can therefore result in general tissue ischemia even when it is used concomitantly with IV nitroglycerin.

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Terlipressin, an alternative agent available in other countries but not in the United States, is a synthetic analog of vasopressin, but unlike vasopressin, terlipressin has a long half-life. Administration as intermittent injections instead of continuous IV infusion allows terlipressin to be used in emergency departments or even at home.

Terlipressin has a safer adverse-reactions profile than the other agents. Most significantly, a Cochrane review on terlipressin demonstrated mortality benefit compared with placebo, while neither octreotide nor vasopressin has been found to improve mortality in any study or meta-analysis (Cochrane Database Syst Rev. 2003[1]:CD002147).
—Susan Kashaf, MD, MPH (116-5)