What is the recommended dose of terlipressin for variceal bleeding?

Terlipressin Dosing for Variceal Bleeding

The recommended dose of terlipressin for variceal bleeding is 2 mg IV every 4 hours for the initial 48 hours until bleeding is controlled, followed by a maintenance dose of 1 mg IV every 4 hours for 2-5 days to prevent rebleeding. 1, 2

Dosing Regimen Details

• Initial phase (first 48 hours):

  • 2 mg IV every 4 hours until bleeding is controlled

• Maintenance phase:

  • 1 mg IV every 4 hours to prevent rebleeding
  • Continue for 2-5 days total duration

• Treatment duration considerations:

  • Standard duration: 2-5 days
  • May consider shorter course (24-72 hours) in selected patients with:
    • Child-Pugh A or B cirrhosis
    • No active bleeding during endoscopy
    • Successful endoscopic variceal ligation 2, 3

Administration Options

• Traditional method: Intravenous bolus injections as described above
• Alternative method: Continuous infusion at 4 mg/24 hours
  • Recent evidence suggests continuous infusion may be more effective at reducing portal pressure with fewer adverse events and at a lower total daily dose 4
  • Continuous infusion resulted in better HVPG response rates (85.4% vs 58.2%) compared to bolus dosing 4

Clinical Considerations

• Terlipressin should be started as soon as variceal bleeding is suspected, before diagnostic endoscopy 1
• Should be administered alongside prophylactic antibiotics 1
• Only one vasoactive agent should be used at a time 1
• Terlipressin has similar efficacy to somatostatin and octreotide in controlling acute variceal hemorrhage 1

Monitoring During Treatment

• Monitor for adverse effects:
  • Oxygen saturation (continuous pulse oximetry recommended)
  • Serum sodium levels
  • Signs of cardiac ischemia
  • Renal function 2

Important Precautions

• Contraindications:

  • Hypoxemia (SpO₂ <90%)
  • Ongoing coronary, peripheral, or mesenteric ischemia 2
  • Use with caution in patients with acute-on-chronic liver failure grade 3 2

• Common adverse effects:

  • Hyponatremia
  • Myocardial ischemia
  • Abdominal pain
  • Diarrhea
  • Hypoxemia 2

Treatment Algorithm

1. Start terlipressin at first suspicion of variceal bleeding
2. Initial dose: 2 mg IV every 4 hours
3. Perform endoscopy within 12 hours
4. After bleeding control:
   • Continue at 1 mg IV every 4 hours
5. Assess patient's Child-Pugh score and bleeding status:
   • For Child-Pugh A/B with no active bleeding: Consider shorter course (2 days)
   • For Child-Pugh C or active bleeding: Continue for full 5-day course
6. Discontinue if SpO₂ <90% or signs of ischemia develop