Recommended Dosing of Terlipressin for Various Clinical Conditions
For hepatorenal syndrome (HRS), terlipressin should be started at 1 mg every 4-6 hours by intravenous bolus, with dose escalation to 2 mg every 4-6 hours if serum creatinine does not decrease by at least 25% after 3 days of therapy. 1, 2
Hepatorenal Syndrome (HRS) Dosing
Bolus Administration
- Initial dose: 1 mg every 4-6 hours intravenously 1
- If no response (creatinine reduction <25%) after 3 days: increase to 2 mg every 4-6 hours 1, 2
- Maximum daily dose: 12 mg/day 1
- Treatment duration: Continue until serum creatinine decreases below 1.5 mg/dL (133 μmol/L) 1
- Always administer with albumin: 1 g/kg on first day, followed by 20-40 g/day 1, 3
Continuous Infusion Alternative
- Initial dose: 2 mg/day as continuous intravenous infusion 1, 3
- Continuous infusion provides similar efficacy with lower total daily dose and fewer adverse events 3, 4
- Response rates range from 64% to 76% with either administration method 3
Acute Esophageal Variceal Bleeding
- For acute variceal bleeding: 1-2 mg every 4 hours intravenously 5
- Higher dose (1 mg every 4 hours) shows better control of bleeding with significantly lower transfusion requirements compared to lower dosing (0.2 mg every 4 hours) 5
- Continuous infusion at 4 mg/24 hours is more effective than bolus administration in reducing hepatic venous pressure gradient and controlling bleeding 6
Monitoring and Response Assessment
- Response defined as decrease in serum creatinine to ≤1.5 mg/dL 1, 3
- Median time to response is 14 days, with shorter response time in patients with lower baseline serum creatinine 1
- Monitor for increase in mean arterial pressure of ≥5 mmHg, which predicts response to therapy 1
- Predictors of positive response include: 1, 2
- Baseline bilirubin <10 mg/dL
- Baseline serum creatinine <5 mg/dL
- Lower grades of acute-on-chronic liver failure
Adverse Effects and Precautions
- Cardiovascular or ischemic complications occur in approximately 12% of patients 1
- Continuous infusion reduces adverse events (35.29%) compared to bolus administration (62.16%) 4
- Contraindicated in patients with: 1, 3
- Hypoxemia (SpO2 <90%)
- Ongoing coronary, peripheral, or mesenteric ischemia
- Exercise caution in patients with known cardiac failure or underlying respiratory conditions 1
- Patients with ACLF-3 (acute-on-chronic liver failure grade 3) may experience respiratory compromise 1
Special Populations
- No dose adjustment required for hepatic impairment 7
- No specific dose adjustments recommended for elderly patients, though greater sensitivity cannot be ruled out 7
- Safety and effectiveness not established in pediatric patients 7
Terlipressin is most effective when administered early in the course of HRS, with lower grades of acute-on-chronic liver failure, and in combination with albumin. Continuous infusion offers the advantage of similar efficacy with lower total daily doses and fewer adverse events compared to bolus administration.