Octreotide: Prevention of Recurrent Gastrointestinal Bleeding in LVAD Patients

Abstract

Background Gastrointestinal (GI) bleeding is a common complication of continuous flow Left Ventricular Assist Device (LVAD) therapy leading to frequent hospitalizations, invasive GI procedures, and reduction of antithrombotic therapies. There is a need for ongoing investigation of GI bleed prevention in LVAD patients in order to understand mechanisms, predictors and optimal medical therapy. Currently, very few pharmacological methods have been found to provide reliable decreased GI bleeding with minimal side effects. Octreotide has shown efficacy in treating and preventing GI and variceal bleeding through decreasing splanchnic blood flow. Our goal was to reduce burdensome GI bleeding events while maintaining maximally tolerated anticoagulation therapy to prevent thrombotic events. Methods The Advanced Heart Failure Team at Moses Cone Hospital has placed over 70s LVADs since inception, May 2013. These patients are a combination of HeartMate II, III and 2 Heart Ware devices. While most LVAD patients are maintained on warfarin with INR goal 2-2.5 and aspirin 81mg daily without difficulty, we have had eight patients with recurrent GI bleeding. This is a single center pre/post evaluation of GI bleeding with use of Octreotide IM 20mg LAR given once a month for a minimum of 6 months. LVAD patients were enrolled after recurrent GI bleeding was diagnosed despite discontinuation of aspirin and reduction of INR goal. To date eight patients have been initiated on our octreotide injection protocol. Results Despite removal of aspirin and reduction in INR goal, these 8 patients suffered recurrent GI bleeding. With the initiation of octreotide injections, the number of GI bleeds was decreased by one half, with 16 bleeds prior to initiation and seven bleeds post. Six of the bleeds occurred in one patient, another patient re-bled once after a year of therapy. Six patients have not re-bled since initiation of octreotide. Treatment time ranged from 2-14 months with an average of 6 months. Though all patients remain off aspirin, all patients have been able to maintain anticoagulation with an INR target in the range of 1.5-2.5 with only one thrombotic event (TIA) diagnosed in this cohort since the initiation of octreotide. Only one patient stopped treatment after two doses due to intolerable diarrhea. Discussion In our cohort, IM octreotide was well tolerated and there was a noticeable decrease in recurrent GI bleeding. Despite our small numbers, these results are encouraging, as it has led to a decreased need for blood transfusions, GI procedures and hospitalization due to GI bleeding.