Contraindications for Vasopressin Use
Vasopressin is absolutely contraindicated in patients with known allergy or hypersensitivity to 8-L-arginine vasopressin or chlorobutanol, and terlipressin (a vasopressin analog) is contraindicated in patients with hypoxemia, ongoing coronary ischemia, peripheral ischemia, or mesenteric ischemia. 1, 2
Absolute Contraindications
FDA-Labeled Contraindications
- Known allergy or hypersensitivity to 8-L-arginine vasopressin 1
- Chlorobutanol allergy (preservative in vasopressin formulations) 1
Terlipressin-Specific Contraindications (Vasopressin Analog)
- Hypoxemia or worsening respiratory symptoms 2, 3
- Ongoing coronary ischemia 2, 3
- Ongoing peripheral ischemia 2, 3
- Ongoing mesenteric ischemia 2, 3
Relative Contraindications and High-Risk Situations
Cardiovascular Concerns
- Hypovolemia: Norepinephrine is relatively contraindicated in hypovolemic patients, and vasopressin shares similar concerns as it can worsen cardiac output without adequate preload 2
- Decompensated heart failure: Beta blockers are contraindicated in acute pulmonary edema, and vasopressin can worsen cardiac function 2, 1
- Severe cardiac dysfunction: Vasopressin can decrease cardiac output and cause bradycardia 1
Critical Illness Severity
- Acute-on-chronic liver failure grade 3: Terlipressin should be used with extreme caution as benefits may not outweigh risks 2, 3
- Serum creatinine >5 mg/dL: In hepatorenal syndrome, terlipressin benefits may not outweigh risks at this severity 2, 3
- Model for End-stage Liver Disease score ≥35: Benefits questionable in patients listed for transplantation 2, 3
Dosing Restrictions
- High-dose vasopressin (>0.03-0.04 units/min): Should be reserved only for salvage therapy when other vasopressors have failed 2, 4
- Single initial vasopressor use: Vasopressin should NOT be used as the sole initial vasopressor in septic shock; norepinephrine is first-line 2, 4
- Doses >0.04 units/min: May lead to cardiac arrest 5
Clinical Context-Specific Contraindications
Pulmonary Arterial Hypertension
- In critically ill PAH patients, vasopressin should be used cautiously and only at replacement doses (typically for vasopressin-deficient states like sepsis or liver disease) to avoid worsening right ventricular afterload 2
- The priority is maintaining systemic vascular resistance > pulmonary vascular resistance 2
Pregnancy
- Vasopressin may induce uterine contractions 1
Important Warnings and Monitoring Requirements
Adverse Effects Requiring Vigilance
- Ischemic complications: Coronary, mesenteric, skin, and digital ischemia are documented risks 1, 5
- Cardiac effects: Decreased cardiac output, bradycardia, and tachyarrhythmias 1
- Hyponatremia: Common adverse effect requiring monitoring 1
- Reversible diabetes insipidus: Can occur with vasopressin use 1
Critical Pitfalls to Avoid
- Never use vasopressin for variceal hemorrhage: The American Gastroenterological Association explicitly states vasopressin is no longer advised for variceal bleeding due to high cardiovascular risk; octreotide is the preferred agent 2, 6, 4
- Duration limitation: When used for variceal bleeding historically, vasopressin was limited to 24 hours maximum due to severe cardiovascular side effects 6
- Extravasation risk: Can cause tissue necrosis; central line administration is strongly preferred 2