Octreotide (Sandostatin)

Emergency & Prehospital

• Suspected acute variceal bleeding (off-label): Start early, before or at endoscopy, per protocol. Hepatology or ED direction sets the rest.
• Sulfonylurea hypoglycemia (off-label): Add it when low glucose recurs after dextrose. Get toxicology or Poison Center advice.

ED / ICU / Transport

• Variceal bleeding after banding: The infusion runs a set period: 2–5 days in AASLD and Baveno VII guidance. Off-label.
• Carcinoid crisis (labeled use): The label allows a rapid IV bolus in emergencies. It states no dose.

Other Uses

• Acromegaly (labeled): It lowers growth hormone and IGF-1 when surgery, irradiation and bromocriptine fall short or can't be done.
• Metastatic carcinoid diarrhea and flushing (labeled)
• VIPoma watery diarrhea (labeled)

Doses vary by protocol; follow local protocols and medical direction.

Available Forms

• 50 mcg/mL in 1 mL (50 mcg) ampul
• 100 mcg/mL in 1 mL (100 mcg) ampul
• 500 mcg/mL in 1 mL (500 mcg) ampul
• Generic products may arrive as multi-dose vials in other strengths, for example 200 mcg/mL and 1,000 mcg/mL in 5 mL vials, total 1,000 and 5,000 mcg. Check the mcg/mL and the total vial content before you draw up.
• Sandostatin LAR Depot (injectable suspension), Bynfezia pen and Mycapssa capsule are long-acting or oral products. None of them is used for acute bleeding or hypoglycemia.

Adult Dosing

Pediatric Dosing

Continuous Infusion

Preparation & Administration

• Dilution: The label allows 50–200 mL of normal saline or D5W, infused over 15–30 min. An IV push over 3 min is also allowed. In emergencies, a rapid bolus is allowed.
• Subcut technique: Rotate the sites. Use the smallest volume that still gives the full dose. That cuts down on pain.
• Stability: It stays stable for 24 hr in normal saline or D5W. It is not compatible with total parenteral nutrition.
• Storage before use: Look for particles and discoloration first. Let it reach room temperature. Don't warm it artificially. Open the ampul just before use, and discard any unused portion.
• Line: per local policy

Contraindications

• Known hypersensitivity to octreotide or any component of the product (label)

Precautions

• Cardiac conduction: Complete AV block has been reported, mostly with IV use at high doses or during continuous infusion. Bradycardia below 50 bpm occurred in 25% of acromegalic patients. QT prolongation and other ECG changes are reported too (label 5.1).
• Glucose: Watch for hypoglycemia or hyperglycemia. Insulin and oral agents may need adjustment.
• Gallbladder and pancreas: Gallstones, sludge, cholecystitis, cholangitis and pancreatitis have all been reported.
• Thyroid: It suppresses TSH. Hypothyroidism can develop during chronic therapy.
• Fat malabsorption: Watch for steatorrhea and loose stools. Vitamin B12 levels can fall.

Hold / Reassess If

• Bradycardia below 50 bpm (label figure), new AV block or syncope: get a 12-lead ECG, notify the provider and hold per local protocol
• Glucose out of range on checks: adjust dextrose or other antidiabetic therapy
• Suspected cholecystitis, cholangitis or pancreatitis: stop octreotide and evaluate (label)
• Dialysis or cirrhosis: the half-life gets longer. Reassess the maintenance interval.

Common

• Nausea, abdominal discomfort, loose stools or diarrhea (34–61% in acromegaly trials; 5–10% with carcinoid tumors and VIPomas)
• Gallstones or sludge: stones or sludge in 52% after 12 months or more of use; less than 2% after 1 month or less
• Hypoglycemia (3%) or hyperglycemia (16%) in acromegaly trials
• Injection-site pain with subcut use

Serious / Life-Threatening

Other ECG changes (label 5.1): QT prolongation, axis shift, early repolarization, low voltage, R/S transition and early R-wave progression are the changes to know. They are not uncommon in acromegalic patients. Any new rhythm or conduction change earns a 12-lead ECG.

Overdose & Toxicity Management

• Reported overdoses: 2,400–6,000 mcg/day IV infusion or 1,500 mcg three times daily subcut; events included arrhythmia, complete AV block, hypotension, cardiac arrest, hypoxia, pancreatitis, lactic acidosis, flushing and diarrhea
• Management: There is no specific antidote. Supportive care is the treatment: cardiac monitoring, glucose checks and hemodynamic support per protocol.
• Poison information: National Poison Control Center, 1-800-222-1222 (label)

Clinically Significant Interactions

IV Compatibility

• Stable 24 hr in normal saline or D5W (label)
• Not compatible with total parenteral nutrition solutions: do not add to TPN (label)
• Verify with an institutional compatibility resource.

• Pediatrics: Safety is not demonstrated in labeled uses. See the Pediatric Dosing table and its info-box. Sulfonylurea dosing for children appears in the table only.
• Neonates: There is no verified neonatal dose. Specialist use only.
• Pregnancy: Human data are limited, and mostly come from acromegaly cases. Most first-trimester exposures were at 100–300 mcg/day. No congenital malformations were reported in cases with a known outcome. Animal studies at up to 7 to 13 times the maximum human dose showed no developmental effects. Use when the benefit justifies the risk (label).
• Lactation: There are no human milk data. In lactating rats, the milk-to-plasma ratio was 0.009. Weigh the infant's risk against the maternal need (label).
• Older Adults: Start at the low end of the range. In older patients the half-life rose 46% and clearance fell 26% (label).
• Renal Impairment: The half-life runs longer on dialysis. Adjust the maintenance dose (label).
• Hepatic Impairment: The half-life runs longer in cirrhosis. Adjust the maintenance dose (label).
• Obesity / Dosing Weight: Adult doses don't change with weight. Pediatric sulfonylurea dosing runs on actual body weight.

• Scope: Provider levels vary, and the rules change by state and agency protocol. Octreotide is usually started in hospital, not in the field.
• Storage & Stability: Refrigerate at 2–8°C and protect from light. It may stay at room temperature for up to 14 days if it is still protected from light (label).
• Carried Concentration: 50, 100 and 500 mcg/mL ampuls. Generic products may arrive as multi-dose vials at other strengths. Confirm the mcg/mL and total vial content before you draw up. The 500 mcg/mL ampul holds ten times the drug in the 50 mcg/mL ampul. Read the strength on every ampul or vial before you draw up.
• Infusions in Transport: pump; line per local policy; bag of 50–200 mL normal saline or D5W, stable 24 hr; record start time and rate.
• Handoff Essentials: time and dose of each bolus, infusion rate and start time, last glucose, bleed status and time of endoscopy.

Mechanism of Action

• Target: somatostatin receptors on pituitary, pancreatic, gut and tumor cells
• Effect: It suppresses growth hormone, insulin, glucagon, gastrin, VIP and serotonin. It also reduces splanchnic blood flow (label).
• Clinical consequence: Fewer carcinoid flushes and watery stools. Less insulin release in sulfonylurea toxicity. Reduced splanchnic flow is the reason it is used for variceal bleeding.

Pharmacokinetics

• Half-life: 1.7–1.9 hr in healthy subjects; longer in dialysis and cirrhosis
• Metabolism and elimination: about 32% excreted unchanged in urine (label)
• Protein binding and volume: about 65% bound in healthy volunteers; volume of distribution 13.6 L (label)

Generic Name

Octreotide acetate

Brand Names

Sandostatin (Novartis); Sandostatin LAR Depot, Bynfezia Pen and Mycapssa (long-acting, pen and oral forms; not for acute use)

Pharmacologic Class

Somatostatin analog

Therapeutic Class

Hormone suppressant; antidiarrheal (labeled); off-label variceal bleeding adjunct

Controlled Substance

Not controlled

ISMP High-Alert

No (confirm against the current ISMP list; see editorFlags)

Look-Alike / Sound-Alike

None commonly reported; check the strength (50, 100, 500 mcg/mL) on each ampul