Rendu-Osler disease: treatment with oestrogen/progestagen versus octreotide

Role of octreotide in small bowel bleeding

Gastrointestinal bleeding accounts for a drastic negative impact on the quality of the patients’ lives as it requires multiple diagnostic and therapeutic interventions to identify the source of the bleeding. Small bowel bleeding is the least common cause of gastrointestinal bleeding. However, it is responsible for the majority of complaints from patients with persisting or recurring bleeding where the primary source of bleeding cannot be identified despite investigation. A somatostatin analog known as octreotide is among the medical treatment modalities currently used to manage small bowel bleeding. This medication helps control symptoms of gastrointestinal bleeding by augmenting platelet aggregation, decreasing splanchnic blood flow, and antagonizing angiogenesis. In this review article, we will highlight the clinical efficacy of octreotide in small bowel bleeding and its subsequent effect on morbidity and mortality.

Systemic Antiangiogenic Therapies for Bleeding in Hereditary Hemorrhagic Telangiectasia: A Practical, Evidence-Based Guide for Clinicians

Management of bleeding in hereditary hemorrhagic telangiectasia (HHT), the second most common hereditary bleeding disorder in the world, is currently undergoing a paradigm shift. Disease-modifying antiangiogenic therapies capable of achieving durable hemostasis via inducing telangiectasia regression have emerged as a highly effective and safe modality to treat epistaxis and gastrointestinal bleeding in HHT. While evidence to date is incomplete and additional studies are ongoing, patients presently in need are being treated with antiangiogenic agents off-label. Intravenous bevacizumab, oral pazopanib, and oral thalidomide are the three targeted primary angiogenesis inhibitors, with multiple studies describing both reassuring safety and impressive effectiveness in the treatment of moderate-to-severe HHT-associated bleeding. However, at present there is a paucity of guidance in the literature, including the published HHT guidelines, addressing the practical aspects of antiangiogenic therapy for HHT in clinical practice. This review article and practical evidence-based guide aims to fill this unaddressed need, synthesizing published data on the use of antiangiogenic agents in HHT, relevant data for their use outside of HHT, and expert guidance where evidence is lacking. After a brief review of principles of bleeding therapy in HHT, guidance on hematologic support with iron and blood products, and alternatives to antiangiogenic therapy, this article examines each of the aforementioned antiangiogenic agents in detail, including patient selection, initiation, monitoring, toxicity management, and discontinuation. With proper, educated use of antiangiogenic therapies in HHT, patients with even the most severe bleeding manifestations can achieve durable hemostasis with minimal side-effects, dramatically improving health-related quality of life and potentially altering the disease course.

Hereditary hemorrhagic telangiectasia: systemic therapies, guidelines, and an evolving standard of care

Hereditary hemorrhagic telangiectasia (HHT) management is evolving because of the emergence and development of antiangiogenic therapies to eliminate bleeding telangiectasias and achieve hemostasis. This progress is reflected in recent clinical recommendations published in the Second International Guidelines for the Diagnosis and Treatment of HHT, in which systemic therapies including antiangiogenics and antifibrinolytics are now recommended as standard treatment options for bleeding. This review highlights the new recommendations especially relevant to hematologists in managing bleeding, anticoagulation, and anemia in patients with HHT.

Gastrointestinal bleeding from vascular malformations: Is octreotide effective to rescue difficult-to-treat patients?

Gastrointestinal vascular malformations are responsible for 2-8% of all cases of bleeding and 30-40% of all obscure hemorrhages, being the most frequent cause of occult bleeding in older people. The aim of this review was to provide an up-to-date report about the use of octreotide in bleeding from both hereditary and acquired vascular malformations of the gastrointestinal tract. A systematic literature search was performed, using the keywords "gastrointestinal vascular malformation", "octreotide", "angiodysplasia", "portal hypertensive gastropathy", "gastric antral vascular ectasia", and "hereditary vascular malformations". The first line therapy of acute/chronic bleeding from digestive vascular malformations is endoscopy, followed by angiographic embolization and surgical resection when this is unsuccessful. In the setting of difficult-to-treat patients, octreotide has been proposed as an alternative therapeutic strategy. Studies reported in the literature show a high efficacy and safety of octreotide, but described only a small number of enrolled patients, heterogeneous therapeutic schedules and short-term follow-up, with the exception of acute bleeding from esophageal varices. As a consequence, the use of octreotide is not approved in this setting and it is currently still prescribed as an off-label drug. Studies in larger populations are needed to confirm the promising results observed in the small case series reports, so as to provide physicians with a treatment option for patients without available alternatives. Octreotide could also determine a strong decrease in the management costs of these clinical conditions, and especially, could dramatically reduce hospital admission costs.