What is the recommended dosage and duration of Terlipressin (terlipressin) for hours?

Terlipressin Dosage and Duration for Hepatorenal Syndrome

The recommended dosage of terlipressin for hepatorenal syndrome is 1 mg IV every 6 hours initially, with potential increase to 2 mg every 6 hours on day 4 if creatinine has decreased by less than 30%, for a maximum duration of 14 days. 1, 2

Initial Dosing and Administration

• Terlipressin should be initiated at 0.85 mg (1 vial) intravenously every 6 hours for the first 3 days 2
• Prior to initial dosing, assess patients for ACLF Grade 3 and obtain baseline oxygenation level 2
• Terlipressin can be administered through a peripheral IV line and does not require ICU monitoring 1
• Continuous infusion of terlipressin (starting at 2 mg/day) is an alternative to bolus dosing with similar efficacy and potentially fewer side effects 1, 3

Dose Adjustment Protocol

• On day 4, assess serum creatinine (SCr) versus baseline 2
• If SCr has decreased by at least 30% from baseline, continue terlipressin 0.85 mg every 6 hours 2
• If SCr has decreased by less than 30% from baseline, increase dose to 1.7 mg (2 vials) every 6 hours 2, 4
• If SCr is at or above baseline value, discontinue terlipressin 2

Duration of Treatment

• Continue terlipressin until 24 hours after two consecutive SCr values ≤1.5 mg/dL at least 2 hours apart 1, 2
• Maximum duration of treatment should not exceed 14 days 1, 2
• Treatment can be discontinued earlier if there is no response by day 3 or 4 1

Concomitant Albumin Administration

• Administer albumin (20-40 g/day) during terlipressin treatment 1
• Initial albumin dose of 1 g/kg on the first day, followed by 20-40 g daily 5
• Judicious use of albumin is necessary to avoid volume overload and respiratory complications 1

Monitoring During Treatment

• Monitor oxygen saturation with continuous pulse oximetry 2
• Do not initiate terlipressin in patients with SpO2 <90% 1, 2
• Discontinue terlipressin if SpO2 decreases below 90% 2
• Monitor for ischemic complications (cardiac, peripheral, or mesenteric) 1, 2
• A sustained increase in mean arterial pressure by 5-10 mmHg with treatment is associated with response 1

Contraindications and Precautions

• Terlipressin is contraindicated in patients with hypoxemia (SpO2 <90%) 1, 2
• Avoid in patients with ongoing coronary, peripheral, or mesenteric ischemia 1, 2
• Use with caution in patients with ACLF grade 3 1
• Patients with serum creatinine >5 mg/dL are unlikely to benefit from terlipressin 1, 2
• Benefits may not outweigh risks in patients listed for transplantation with MELD ≥35 1

Predictors of Response

• Baseline bilirubin <10 mg/dL 1
• Baseline serum creatinine <5 mg/dL 1
• Lower stage of acute-on-chronic liver failure 1
• Increase in mean arterial pressure by 5-10 mmHg with treatment 1
• Early response to treatment is associated with better survival 4

Common Adverse Effects

• Respiratory failure (14% vs 5% in placebo) 1
• Abdominal pain, nausea, diarrhea, and dyspnea 2
• Ischemic complications (cardiac, peripheral, or mesenteric) 1
• For every 1 mg/dL drop in serum creatinine with terlipressin, there is a 27% reduction in mortality risk 4

Terlipressin has been shown to improve renal function and decrease the need for renal replacement therapy in patients with hepatorenal syndrome, though it has not been shown to decrease overall mortality 1.