From the Guidelines
Terlipressin is not contraindicated in patients receiving norepinephrine (noradrenaline) support, and these medications can be used together in clinical practice. However, caution is warranted as both drugs are vasoconstrictors that work through similar mechanisms. Terlipressin is a vasopressin analog that primarily acts on V1 receptors causing vasoconstriction, while norepinephrine acts on alpha-adrenergic receptors to produce vasoconstriction. When used concurrently, there is potential for additive vasoconstrictive effects, which may increase the risk of peripheral ischemia, cardiac events, or excessive blood pressure elevation. If both medications are needed, careful hemodynamic monitoring is essential, including frequent blood pressure checks, assessment of peripheral perfusion, and monitoring for signs of end-organ ischemia. Dosing of either agent may need to be adjusted based on the patient's response. In hepatorenal syndrome or variceal bleeding, where terlipressin is commonly used, the addition of norepinephrine may be necessary for hemodynamic support, but the combined vasoconstrictive effects should be closely monitored to minimize adverse events, as suggested by the most recent study 1.
Some key points to consider when using terlipressin and norepinephrine together include:
- Monitoring for signs of ischemia, such as arrhythmia, angina, and splanchnic and digital ischemia, as reported in the study 1
- Adjusting dosing based on patient response and hemodynamic monitoring, as recommended in the study 1
- Being aware of the potential for increased risk of respiratory failure, particularly in patients with ACLF grade 3, as noted in the study 1
- Using judicious amounts of albumin before and during treatment with terlipressin, as suggested in the study 1
Overall, while terlipressin and norepinephrine can be used together, careful monitoring and adjustment of dosing are necessary to minimize the risk of adverse events, as supported by the evidence from the study 1.
From the Research
Terlipressin Contraindication in Patients on Noradrenaline Support
- There is no direct evidence to suggest that terlipressin is contraindicated in patients on noradrenaline support 2, 3, 4, 5, 6.
- In fact, a study published in 2023 found that the combination of terlipressin and noradrenaline infusion resulted in a non-significantly higher rate of hepatorenal syndrome (HRS) resolution with significantly fewer adverse effects in HRS patients who did not respond to terlipressin within 48 hours 4.
- Another study published in 2023 found that the combination therapy of terlipressin and noradrenaline exhibited potential benefits in the treatment of adult patients suffering from septic shock, including improvements in cardiac output and central venous pressure 5.
- However, it is essential to note that the use of terlipressin in combination with noradrenaline may increase the risk of peripheral ischemia 5.
- The cost-effectiveness of terlipressin for HRS has been evaluated, and the results suggest that terlipressin is cost-effective compared to other unapproved treatments, including noradrenaline and midodrine/octreotide 6.
Key Findings
- The combination of terlipressin and noradrenaline may be beneficial in the treatment of HRS and septic shock.
- The use of terlipressin in combination with noradrenaline may increase the risk of peripheral ischemia.
- Terlipressin is cost-effective compared to other unapproved treatments for HRS.
- There is no direct evidence to suggest that terlipressin is contraindicated in patients on noradrenaline support.