What is the use of Terlipressin (Vasopressin analogue)?

From the Guidelines

Terlipressin should be used as a first-line treatment for hepatorenal syndrome (HRS) in patients with advanced liver disease, with a typical dosing regimen of 1-2 mg intravenously every 4-6 hours for 3-14 days, depending on clinical response. This recommendation is based on the most recent and highest quality study available, which demonstrated that terlipressin is effective in reversing HRS in 36% to 44% of patients 1. The use of terlipressin has been shown to improve renal function and reduce mortality in patients with HRS, with a 27% reduction in relative risk of mortality for every 1 mg/dL drop in serum creatinine 1.

Key Considerations for Terlipressin Use

• The dose of terlipressin should be increased to a maximum of 2 mg every 4-6 hours if there is no reduction in serum creatinine at day 3 of therapy by at least 25% compared to the baseline value 1.
• Alternatively, clinicians can administer terlipressin by continuous intravenous infusion at a lower starting dose of 2 mg/d, which may reduce ischemic side effects and increase the dose gradually every 24-48 hours up to a maximum dose of 12 mg/d, or reversal of HRS 1.
• Terlipressin treatment does not require ICU monitoring and can be administered intravenously through a peripheral line 1.
• Patients should be monitored for fluid status, electrolytes, and signs of tissue ischemia during treatment, and terlipressin is contraindicated in patients with severe cardiovascular disease 1.

Predictors of Response to Terlipressin

• Markers of better liver function, such as a bilirubin of ≤ 10 mg/dL, are associated with a higher response rate to terlipressin 1.
• Better kidney function, as indicated by a serum creatinine of ≤ 5 mg/dL, is also associated with a higher response rate to terlipressin 1.
• An increase in the mean arterial pressure (MAP) of ≥ 5 mm Hg with treatment is associated with response to terlipressin 1.
• Lower grades of acute-on-chronic liver failure (ACLF) are associated with a higher probability of response to terlipressin 1.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Terlipressin Overview

• Terlipressin is a vasopressin agonist used to treat various conditions, including esophageal varices bleeding, septic shock, and hepatorenal syndrome 2.
• It works by increasing systemic vascular resistance, particularly in the splanchnic area, resulting in a decrease of portal pressure 2.

Hepatorenal Syndrome Treatment

• Terlipressin is a commonly used drug for the treatment of hepatorenal syndrome, with a success rate of up to 75% when combined with volume expansion 2.
• The use of terlipressin in hepatorenal syndrome can achieve reversal of the condition in approximately 40% of patients 3.
• Norepinephrine plus albumin has been shown to be more effective than midodrine and octreotide plus albumin in improving renal function in patients with hepatorenal syndrome 4.
• Noradrenaline has been found to be as safe and effective as terlipressin, but less expensive, in the treatment of hepatorenal syndrome 5.

Administration and Safety

• Terlipressin can be administered as a bolus or continuous infusion, with the latter allowing for a lower daily dose and fewer side effects 3, 6.
• The use of terlipressin is associated with ischemic side effects and potential for respiratory failure development, requiring careful patient selection and close monitoring 3.
• Continuous infusion-based administration of terlipressin has been shown to be safe and effective, with emerging indications for its use in decompensated cirrhosis and refractory ascites 6.