Will terlipressin increase blood pressure (BP) in patients with hypotension?

From the Guidelines

Terlipressin can increase blood pressure in patients with hypotension, particularly in those with vasodilatory shock such as septic shock or hepatorenal syndrome, as evidenced by its vasoconstrictive properties and ability to improve renal function in patients with hepatorenal syndrome 1.

Key Points to Consider

• Terlipressin is a vasopressin analog that acts primarily on V1 receptors in vascular smooth muscle, causing vasoconstriction and subsequently increasing blood pressure.
• The typical dosing is 1-2 mg IV every 4-6 hours, which can be titrated based on blood pressure response, and for continuous infusion, doses range from 1.3-5.2 mcg/kg/hour.
• When administering terlipressin, careful monitoring is essential as it can cause significant peripheral and splanchnic vasoconstriction, and potential adverse effects include abdominal cramps, diarrhea, hyponatremia, and cardiac arrhythmias.
• Terlipressin should be used cautiously in patients with coronary artery disease, heart failure, or peripheral vascular disease due to its potent vasoconstrictive properties.
• A sustained increase in mean arterial pressure (MAP) by 5–10 mm Hg with treatment is associated with response to terlipressin, as noted in the study published in Clinical Gastroenterology and Hepatology 1.

Important Considerations for Administration

• Terlipressin is contraindicated in patients with hypoxemia and in patients with ongoing coronary, peripheral, or mesenteric ischemia, and should be used with caution in patients with ACLF grade 3 1.
• Patients with a serum creatinine >5 mg/dL are unlikely to benefit and terlipressin treatment is not advised.
• Judicious use of albumin before and during treatment with terlipressin is necessary to avoid respiratory failure, especially in patients with ACLF grade 3.
• Continuous monitoring for hypoxia with continuous pulse oximetry during the treatment may be required, especially in patients at high risk of respiratory failure.

From the FDA Drug Label

After administration of a single 0. 85 mg dose of terlipressin in patients with hepatorenal syndrome type 1 (HRS-1), an increase in the diastolic, systolic, and mean arterial pressure (MAP), and decrease in heart rate were evident within 5 minutes after dosing and were maintained for at least 6 hours after dosing. The maximum change in blood pressure and heart rate occurred at 1. 2 to 2 hours post dose. For MAP, the estimated maximum effect was an increase of 16.2 mmHg. Terlipressin is thought to increase renal blood flow in patients with hepatorenal syndrome by reducing portal hypertension and blood circulation in portal vessels and increasing effective arterial volume and mean arterial pressure (MAP).

Terlipressin increases blood pressure (BP) in patients with hypotension, specifically those with hepatorenal syndrome.

• The increase in blood pressure is evident within 5 minutes of administration and is maintained for at least 6 hours.
• The maximum increase in mean arterial pressure (MAP) is approximately 16.2 mmHg. 2

From the Research

Terlipressin and Blood Pressure

• Terlipressin is a synthetic analogue of vasopressin, used to treat various conditions, including hypotension 3, 4, 5, 6, 7.
• Studies have shown that terlipressin can increase blood pressure in patients with hypotension, including those with septic shock, refractory hypotension, and traumatic brain injury 3, 4, 5, 6, 7.

Mechanism of Action

• Terlipressin works by stimulating vasopressin receptors, which causes vasoconstriction and increases blood pressure 4, 7.
• The increase in blood pressure is associated with improvements in perfusion, cardiac output, and renal function 3, 5, 6.

Clinical Evidence

• A study published in 2004 reported the successful use of terlipressin in an 8-day-old infant with intractable hypotension due to septic shock, with a significant increase in blood pressure and perfusion 3.
• Another study published in 1999 found that terlipressin was effective in treating refractory hypotension in patients chronically treated with angiotensin-converting enzyme inhibitors or antagonists of the receptor of angiotensin II 4.
• A 2011 study reported the use of terlipressin as rescue therapy in newborns and infants with refractory hypotension, with significant improvements in blood pressure and perfusion 5.
• A 2005 study found that terlipressin improved hemodynamic indices and renal function in critically ill children with septic shock 6.
• A 2007 study reported the use of terlipressin in a patient with severe traumatic brain injury and refractory hypotension, with an increase in cerebral perfusion pressure and a decrease in norepinephrine doses 7.

Key Findings

• Terlipressin can increase blood pressure in patients with hypotension, including those with septic shock, refractory hypotension, and traumatic brain injury 3, 4, 5, 6, 7.
• The increase in blood pressure is associated with improvements in perfusion, cardiac output, and renal function 3, 5, 6.
• Terlipressin may be considered as a rescue therapy in patients with refractory hypotension who do not respond to conventional treatments 3, 4, 5, 6, 7.