Recommended Dosing Regimen for Terlipressin in Acute Variceal Bleeding
The recommended dosing regimen for terlipressin in acute variceal bleeding is 2 mg intravenously every 4 hours for the first 48 hours, followed by 1 mg intravenously every 4 hours for an additional 3-5 days. 1
Initial Administration
- Terlipressin should be administered as soon as variceal bleeding is suspected, even before endoscopic confirmation
- Initial dose: 2 mg IV every 4 hours for the first 48 hours
- Maintenance dose: 1 mg IV every 4 hours for 3-5 days
- Standard duration of treatment: 5 days total 1
Alternative Administration Methods
Recent evidence suggests that continuous infusion of terlipressin may be more effective and safer than traditional intravenous boluses:
- Continuous infusion: 4 mg/24 hours (approximately 4.25 mg/day) 2
- This method has shown:
- Higher rates of portal pressure reduction (85.4% vs. 58.2%)
- Significantly lower total daily dose (4.25 mg vs. 7.42 mg)
- Fewer adverse events (36.3% vs. 56.4%)
- Lower incidence of very early rebleeding (1.8% vs. 14.5%) 2
Treatment Duration
- Standard duration: 5 days 1
- A shorter course of 24-72 hours may be considered in selected patients with:
- Child-Pugh A or B cirrhosis
- No active bleeding during endoscopy 1
Monitoring and Precautions
Patients receiving terlipressin should be monitored for:
- Oxygen saturation (continuous pulse oximetry recommended)
- Serum sodium levels (risk of hyponatremia)
- Signs of cardiac ischemia
- Renal function 1
Contraindications
Terlipressin is contraindicated in patients with:
- Hypoxemia (SpO₂ <90%)
- Worsening respiratory symptoms
- Ongoing coronary, peripheral, or mesenteric ischemia 1
- Caution in patients with acute-on-chronic liver failure (ACLF) grade 3 1
Combination Therapy
- Terlipressin should be administered alongside endoscopic treatment (band ligation) for optimal efficacy 1
- Prophylactic antibiotics should be administered concurrently 1
- Albumin therapy is typically administered alongside terlipressin 1
Efficacy
- Terlipressin has been shown to reduce mortality in acute variceal bleeding with a relative risk reduction of 34% compared to placebo 3
- It has similar efficacy to somatostatin and octreotide for controlling acute variceal bleeding 1, 4
- Initial hemostasis rates of approximately 98% have been reported when combined with endoscopic variceal ligation 4
This evidence-based dosing regimen provides the optimal balance between efficacy and safety for patients with acute variceal bleeding, with the option of continuous infusion representing a promising alternative to traditional bolus administration.