Recommended Dosing of Terlipressin in Hepatorenal Syndrome
For patients with hepatorenal syndrome, terlipressin should be initiated at a dose of 1 mg intravenously every 4-6 hours, increased to a maximum of 2 mg every 4-6 hours if there is no reduction in serum creatinine of at least 25% by day 3, and continued until serum creatinine decreases below 1.5 mg/dL or for up to 14 days. 1
Initial Dosing and Administration
- Start with terlipressin 1 mg intravenously every 4-6 hours 1
- Always administer with albumin: 1 g/kg on day 1, followed by 20-40 g/day thereafter 1, 2
- Alternative administration method: continuous intravenous infusion at a starting dose of 2 mg/day, which may reduce ischemic side effects 1, 2
Dose Titration
- If no reduction in serum creatinine of at least 25% compared to baseline by day 3, increase the dose to 2 mg every 4-6 hours (maximum 8-12 mg/day) 1
- For continuous infusion protocol: increase dose gradually every 24-48 hours up to a maximum of 12 mg/day 1, 2
Duration of Treatment
- Continue treatment until serum creatinine decreases below 1.5 mg/dL 1
- Maximum treatment duration is typically 14 days 1
- Median time to response is approximately 14 days, with shorter response times in patients with lower baseline serum creatinine 1
Monitoring During Treatment
- Monitor serum creatinine regularly to assess response
- Monitor vital signs, particularly arterial pressure, urine volume, and serum sodium 1
- Continuous pulse oximetry monitoring is recommended; discontinue if SpO2 decreases below 90% 1, 2
- Monitor for ischemic complications (abdominal pain, digital ischemia, cardiac symptoms) 1
- Monitor fluid status carefully to prevent pulmonary edema from albumin administration 1, 2
Response Criteria
- Complete response: final serum creatinine within 0.3 mg/dL from baseline value 1
- Partial response: regression of AKI stage with final serum creatinine ≥0.3 mg/dL from baseline 1
Contraindications and Precautions
- Terlipressin should not be used in patients with serum creatinine ≥5 mg/dL or oxygen saturation <90% 1
- Perform careful clinical screening including ECG before starting treatment 1
- Use with caution in patients with cardiovascular or ischemic conditions 1
- Ischemic complications occur in approximately 12% of patients 1, 2
- Respiratory complications can occur in 8-30% of patients, especially those with baseline hypoxemia 2
Treatment of Recurrence
- If HRS recurs after treatment cessation, a repeat course of therapy should be given 1
The evidence strongly supports terlipressin plus albumin as the most effective treatment for HRS, with response rates of 40-50% 1. Recent guidelines from the American Association for the Study of Liver Diseases (2021) and the American Gastroenterological Association (2022) provide the most up-to-date dosing recommendations 1. While norepinephrine appears to be equally effective, terlipressin remains the preferred agent in most guidelines when available 1.