Therapy

Give in addition ^a any of 

• terlipression (e.g. 1-2 mg iv every 4 to 6 hours for up to 5 days) ^a  
• octreotide ^a
• somatostatin  (e.g. somatostatin 6 mg in 500 ml saline iv over 24 hours for 5 days) ^a

Why?

• Terlipressin reduces death, persistent bleeding, or the need for a procedure for uncontrolled bleeding or rebleeding compared with placebo. ^a
• Though fewer patients on octreotide have persistent bleeding compared with terlipressin ^a and fewer major complications (e.g. cardiac arrhythmias, hyper/hypotension, cardiac or intestinal ischaemia, aspiration pneumonia, pulmonary oedema) than terlipressin or vasopressin ^a , no drug has been clearly shown to better than another for preventing death, rebleeding or surgery. ^a
• Octreotide plus band ligation reduces rebleeding and need for a balloon tamponade compared with band ligation alone. ^a
• Octreotide plus sclerotherapy reduces rebleeding more than sclerotherapy alone. There is no clear effect on mortality. ^a
• Somatostatin plus sclerotherapy reduces treatment failure (extra transfusions, additional sclerotherapy, balloon tamponade or TIPS, or death) more than sclerotherapy alone. ^a
• Endoscopists find sclerotherapy easier to perform. ^a

Terlipressin reduced death and surgery compared with placebo, but more patients stopped bleeding on octreotide

Patient	Treatment	Comparison	Outcome	CER	OR (95% CI)	NNT (95% CI)
cirrhosis and acute variceal haemorrhage a	terlipressin	placebo	death at days	33%	0.54 (0.36 to 0.82)	8 (5 to 22)
			failing initial haemostasis at days	52%	0.47 (0.32 to 0.70)	5 (4 to 11)
			procedure required for uncontrolled bleeding/ rebleeding at  days	44%	0.58 (0.38 to 0.88)	8 (5 to 32)
	terlipressin	octreotide	failing initial haemostasis at days	23%	1.97 (1.08 to 3.59)	-7 (-72 to -3)

Somatostatin or octreotide added to sclerotherapy reduces treatment failure

Patient	Treatment	Comparison	Outcome	CER	RRR (95% CI)	NNT (95% CI)
bleeding oesophageal varices a	band ligation and octreotide	band ligation	rebleeding at 30 days	38%	78% (39% to 92%)	3 (2 to 7)
bleeding oesophageal varices	band ligation and octreotide	band ligation	balloon tamponade required at 30 days	21%	90% (25% to 99%)	5 (3 to 15)
cirrhosis and upper GI bleeding a	sclerotherapy and somatostatin	sclerotherapy	treatment failure at 5 days	35%	37% (13% to 54%)	5 (3 to 15)
acute variceal bleeding a	sclerotherapy and octreotide	octreotide	rebleeding at 15 days	29%	50% (12% to 72%)	7 (4 to 31)