Somatostatin in gastroenterology

Ultra-rapid, antagonist-precipitated opiate detoxification under general anaesthesia or sedation

Ultra-rapid opiate withdrawal precipitated by naloxone or naltrexone during general anaesthesia or varying degrees of sedation, usually with the addition of α-2 adrenergic agonists, is an increasingly popular technique. As with anaesthesia or effective analgesia for dentistry or obstetrics, it can be justified on general humane principles. It also simplifies and speeds the transition to treatment programmes involving naltrexone. This paper reviews its development and the current range of techniques, including the use of octreotide to prevent diarrhoea. The prospect of avoiding or shortening the worst discomforts of withdrawal may encourage more opiate addicts to attempt detoxification and opiate-free management, including patients who have been successfully rehabilitated on long-term methadone maintenance treatment (MMT). Despite good motivation and preparation, a significant minority of MMT patients consistently fail to complete conventional withdrawal programmes because of increasing physical discomfort. It is emphasized that there is usually more to the treatment of opiate dependence than withdrawal.

Somatostatin v placebo in bleeding oesophageal varices: randomised trial and meta-analysis

OBJECTIVE

To study whether somatostatin or its derivative octreotide is more effective than placebo for treating bleeding oesophageal varices.

METHODS

Randomised, double blind trial and meta-analysis with blinded analysis of data and writing of manuscripts.

SETTING

Departments of medical and surgical gastroenterology in Copenhagen.

SUBJECTS

Patients suspected of bleeding from oesophageal varices and of having cirrhosis of the liver.

MAIN OUTCOME MEASURES

Survival, number of blood transfusions, and use of Sengstaken-Blakemore tube.

RESULTS

86 patients were randomised; in each group 16 died within six weeks (95% confidence interval for difference in mortality--19% to 22%). There were no differences between those treated with somatostatin or placebo in median number of blood transfusions (8 v 5, P = 0.07, 0 to 4 transfusions) or in numbers of patients who needed balloon tamponade (16 v 13, P = 0.54, -11% to 28%). In a meta-analysis of three trials involving 290 patients somatostatin had no effect on survival compared with placebo (P = 0.59, odds ratio 1.16; 0.67 to 2.01). For blood transfusions and use of balloon tamponade there was heterogeneity between the trials with no convincing evidence in favour of somatostatin. No placebo controlled trials have been performed with octreotide.

CONCLUSION

Within the limited power of this study and meta-analysis we were unable to show a clinical benefit of somatostatin in the emergency treatment of bleeding oesophageal varices.