What is the recommended dose of octreotide in a child with heart failure and ascites?/nThe question

Fråga: What is the recommended dose of octreotide in a child with heart failure and ascites?

The question concerns an 11-year-old boy with Down´s syndrome and a congenital heart malformation leading to heart failure and secondary ascites. His liver is enlarged with slightly elevated transaminases. He also suffers from profound diarrhoea and intestinal loss of albumin, due to leakage from dilated intestinal lymphatic vessels. To lower intestinal blood flow, enhance lymphatic flow and decrease secretion, medication with subcutaneously administered octreotide (Sandostatin) has been initiated, with a starting dose of 50 ug bid.

The patient has a total body weight of 50 kg and gross ascites.

Sammanfattning: There is no information on paediatric use of octreotide. In patients with ascites and peripheral oedema, an increased dose requirement could be anticipated, due to increased extracellular fluid volumes. However, there is no empirical data supporting this. Since octreotide has a very low toxicity, this patient could probably be given ordinary doses, guided by the clinical effect.

Svar: Subcutaneous octreotide in doses between 100-150 ug bid has been successfully used in patients with primary lymphectasia (1-2). In treatment of acromegaly octreotide doses of 200-600 ug/d are used, guided by plasma growth hormone concentrations (3). Therapeutic drug monitoring is of no value in titrating the optimal dose (4).

The hepatic metabolism of octreotide is extensive and the drug should hence be used cautiously in patients with liver dysfunction (4). However, this should be of small concern in a patient with moderate liver dysfunction secondary to heart failure.

No data specifically addressing the use of octreotide in children was found in Medline, Drugline or standard pharmacological literature. In three adult patients with malignant ascites, doses of 200-600 ug/d were used without adverse effects (5). The drug´s volume of distribution (0.27 L/kg) would indicate a distribution confined to the extracellular fluid of the body, including ascites fluid and peripheral oedema. Consequently, an increased dose requirement per kilo could theoretically be expected in this patient.

An important property of octreotide is its low toxicity (4, 6). No severe or irreversible adverse effects have been reported and the mild ones described (mainly gastrointestinal) are usually transient. 1 Bac BJ, Van Hagen PM, Postema PT, ten Bokum AM, Zondervan PE, van Blankenstein M. Octreotide for protein-losing enteropathy with intestinal lymphangiectasia. Lancet 1995;345:1639. 2 Kuroiwa G, Takayama T, Sato Y, Takahashi Y, Fujita T, Nobukoa A, et al. Primary intestinal lymphangiectasia successfully treated with octreotide. J Gastroenterol 2001;36:129-32. 3 FASS 2001 (The Swedish catalogue of approved medical products) 4 Dollery C Sir, editor. Therapeutic drugs. 2nd ed. Edinburgh: Churchill Livingstone; 1999. 5 Cairns W, Malone R. Octreotide as an agent for the relief of malignant ascites in palliative care patients. Palliat Med 1999;13:429-30. 6 Shulkes A, Wilson JS. Somatostatin in gastroenterology. Br Med J 1994;308:1381-2.