What is the recommended dose of telipressin (vasopressin analogue) infusion for bleeding esophageal varices?

Recommended Dose of Terlipressin Infusion for Bleeding Esophageal Varices

For bleeding esophageal varices, terlipressin should be administered at an initial dose of 2 mg intravenously, followed by a maintenance dose of 1-2 mg intravenously every 4-6 hours for 3-5 days. 1

Dosing Regimen

• Initial dose: 2 mg intravenously as a bolus 1
• Maintenance dose: 1-2 mg intravenously every 4-6 hours 1
• Duration of therapy: 3-5 days 1

Alternative Administration Method

Recent evidence suggests continuous infusion may be more effective than bolus administration:

• Continuous infusion: 4 mg/24 hours 2
• Benefits of continuous infusion compared to bolus administration:
  • Higher rate of hepatic venous pressure gradient response (85.4% vs 58.2%) 2
  • Lower total daily dose requirement (4.25 mg vs 7.42 mg/24h) 2
  • Fewer adverse events (36.3% vs 56.4%) 2
  • Lower incidence of very early rebleed (1.8% vs 14.5%) 2

Clinical Efficacy

• Terlipressin is the only vasoactive drug proven to reduce bleeding-related mortality (RR, 0.66; 95% CI, 0.49–0.88) 1
• Initial hemostasis rates with terlipressin range from 88-91% 3, 4
• When combined with endoscopic variceal ligation (EVL), terlipressin achieves initial hemostasis rates of up to 98% 5

Treatment Duration Considerations

• Standard recommendation is 3-5 days of therapy 1
• Some evidence suggests that a shorter course (24 hours) of terlipressin may be as effective as a 72-hour course when used as an adjunct to successful endoscopic variceal band ligation 6

Potential Side Effects

• Hyponatremia 1
• Myocardial ischemia due to coronary artery vasoconstriction 1
• Abdominal pain 1
• Diarrhea 1

Important Clinical Considerations

• Terlipressin should be initiated as soon as possible when variceal bleeding is suspected, even before diagnostic endoscopy 1
• It should be administered along with prophylactic antibiotics (typically ceftriaxone 1g IV daily for up to 7 days) 1
• Endoscopic therapy (preferably endoscopic variceal ligation) should be performed as soon as possible, ideally within 12 hours of presentation 1
• For high-risk patients (Child-Pugh class C with score 10-13 or Child-Pugh class B with active bleeding despite vasoactive therapy), early TIPS placement should be considered 1

Comparative Efficacy

• A meta-analysis and Korean multicenter RCT found no significant differences in hemostasis rate and survival time between terlipressin, somatostatin, and octreotide 1
• However, terlipressin is the only agent proven to reduce bleeding-related mortality 1