Sandostatin causing reversible thrombocytopenia

The Clinical Challenge of Refractory Octreotide-Induced Thrombocytopenia in Active Gastrointestinal Bleeding: A Case Report

The association between octreotide and thrombocytopenia has been documented in the literature but it remains a rare finding. We are reporting a 59-year-old female patient with alcoholic liver cirrhosis who presented with the gastrointestinal tract (GIT) bleeding secondary to esophageal varices. Initial management involved fluid and blood products resuscitation and initiation of both octreotide and pantoprazole infusion. However, the abrupt onset of severe thrombocytopenia was evident within a few hours of admission. Platelet transfusion and discontinuation of pantoprazole infusion failed to correct the abnormality prompting the holding off of octreotide. However, this also failed to control the decline in platelet count and prompted intravenous immunoglobulin (IVIG). This case helps to remind clinicians to closely monitor platelet count once octreotide is initiated. This allows early detection of the rare entity of octreotide-induced thrombocytopenia, which can be life-threatening with extremely low platelet count nadir.

Octreotide-Associated Neutropenia

Drug-induced neutropenia and agranulocytosis are rare adverse events but can be fatal. Neutropenia can be induced by a myriad of drugs from almost every pharmacologic class. Octreotide is a somatostatin analog that has been used to treat variceal bleeding, acromegaly, and severe diarrhea associated with metastatic tumors, and to reduce symptoms in the setting of malignant bowel obstruction and pseudoobstruction. The most common adverse effects associated with octreotide include pain at the injection site and gastrointestinal effects such as loose stools, cramping, and nausea; neutropenia is not currently listed as an adverse effect of the drug. We describe the case of an 87-year-old man who developed neutropenia immediately after administration of three doses of subcutaneous octreotide. He presented to the hospital with a history of constipation and straining for 3 days. He was admitted, and laxatives, suppositories, and enemas were administered over the next 3 days to induce a bowel movement; however, they were ineffective. Bowel obstruction secondary to a mass was confirmed by computed tomography; the mass was eventually diagnosed as colon cancer. Octreotide 100 µg subcutaneously every 8 hours was started for the obstruction on the evening of hospital day 4. After the patient had received 3 doses of octreotide, his white blood cell count (WBC) had decreased from 4.1 × 10³ /mm³ (neutrophils 75.4%, absolute neutrophil count [ANC] 3.1 × 10³ /mm³ ) on admission to 1.6 × 10³ /mm³ (neutrophils 62%, ANC 0.99 × 10³ /mm³ ) on day 5. Given the temporal relationship of octreotide and neutropenia as well as the lack of a reasonable alternative cause, it was suspected that octreotide was the most likely culprit of the patient's neutropenia. Octreotide was subsequently discontinued, and his WBC increased to 4.9 × 10³ /mm³ (neutrophils 66.3%, ANC 3.2 × 10³ /mm³ ) the next day. The remainder of the patient's hospitalization was not significant for any further hematologic abnormalities. His WBC and ANC (WBC 6.7 × 10³ /mm³ , neutrophils 83.2%, ANC 5.6 × 10³ /mm³ ) remained stable 30 days after the incident. Use of the Naranjo Adverse Drug Reaction Probability Scale indicated a probable relationship (score of 5) between the patient's development of neutropenia and octreotide therapy. To our knowledge, this report highlights the first case of octreotide-associated neutropenia. Although the frequency of drug-induced neutropenia remains rare outside of cytotoxic chemotherapy, the importance of recognizing this adverse effect cannot be understated given the mortality risks for neutropenic patients.

Systemic Octreotide Therapy in Prevention of Gastrointestinal Bleeds Related to Arteriovenous Malformations and Obscure Etiology in Atrial Fibrillation

OBJECTIVES

The present study describes the use of octreotide (OCT) in patients with atrial fibrillation (AF) receiving oral anticoagulation (OAC) who have gastrointestinal (GI) bleeding related to arteriovenous malformations (AVMs), as well as its effect on OAC tolerance and subsequent rebleeding.

BACKGROUND

AVMs cause significant GI bleeding, especially in patients with AF who are receiving OAC for stroke prevention. OCT has been shown to minimize recurrent GI bleeds related to AVMs.

METHODS

In a multicenter, observational study, 38 AF patients with contraindications to OAC because of AVM-related GI bleeding were started on 100 μg of subcutaneous OCT twice daily. OAC was resumed in all patients within 48 h. Incidence of recurrent GI bleeds was calculated, and hemoglobin levels were recorded at enrollment and at 3 and 6 months' follow-up.

RESULTS

After a median follow-up of 8 months, 36 patients (mean age 69 ± 8.0 years; mean CHA₂DS₂-VASc score 3 ± 1 and mean HAS-BLED score 3 ± 1) were available for analysis. All were able to successfully resume OAC, and 28 of 36 (78%) remained on OAC at the conclusion of the study, whereas 8 underwent left atrial appendage closure with subsequent OAC discontinuation. No systemic thromboembolic events occurred in follow-up. Of the 28 patients who continued receiving OAC, 19 (68%) were free of recurrent GI bleed, 4 had minor GI bleeds, 4 required transfusion, and 1 required colectomy for GI bleeding. Mean hemoglobin levels in all patients receiving OAC were significantly higher at 3- and 6-month follow-up than at baseline (p < 0.001).

CONCLUSIONS

Subcutaneous OCT therapy is an attractive option in AF patients receiving OAC who have AVM-related GI bleeds. It allows successful reinitiation of OAC as a bridge to left atrial appendage exclusion or short-term relief from bleeding.

Octreotide-induced thrombocytopenia: a case report

Introduction

Thrombocytopenia is an extremely rare complication of octreotide therapy and can be life threatening in the setting of esophageal variceal bleeding. We report a case of octreotide-induced reversible thrombocytopenia in a 54-year-old Caucasian man with alcohol-induced cirrhosis and upper gastrointestinal bleeding.

Case presentation

Our patient's platelet count dropped from 155,000/mm³ upon admission to 77,000/mm³ a few hours after initiation of octreotide therapy and stayed low until the drug's administration was discontinued. Significant recovery was achieved quickly after discontinuation of octreotide.

Conclusions

Thrombocytopenia is a rare but potentially serious side effect of octreotide therapy and may complicate esophageal variceal bleeding. Physicians should be vigilant in identifying this potentially serious condition.