What is the dosage of Terlipressin (Vasopressin analogue)?

From the Guidelines

Terlipressin should be initiated as a bolus dose of 1 mg every 4–6 hours, with a total daily dose of 4–6 mg, and increased to a maximum of 2 mg every 4–6 hours if there is no reduction in serum creatinine at day 3 of therapy by at least 25% compared to the baseline value, as recommended by the most recent guidelines 1. The dosage of terlipressin is crucial in the management of hepatorenal syndrome, and the most recent evidence suggests that a bolus dose of 1 mg every 4–6 hours is the most effective and safe initial dose.

• The dose can be increased to a maximum of 2 mg every 4–6 hours if there is no response to the initial dose, as seen in the study by 1.
• Continuous infusion of terlipressin has similar efficacy with lower total daily dose and fewer side effects, as noted in the study by 1.
• Predictors of response to terlipressin include a baseline bilirubin of <10 mg/dL, a baseline serum creatinine of <5 mg/dL, and lower stage of acute-on-chronic liver failure, as reported in the study by 1.
• Patients on terlipressin need to be monitored for the development of ischemic complications such as arrhythmia, angina, and splanchnic and digital ischemia, as warned by the study by 1. The most recent and highest quality study, published in 2022, provides the best evidence for the dosage of terlipressin, and its findings should be prioritized in clinical practice, as seen in the study by 1.
• The study by 1 provides the most up-to-date and evidence-based recommendation for the dosage of terlipressin, and its findings should be followed in clinical practice.
• The other studies, such as 1, 1, 1, and 1, provide additional information and context, but the study by 1 is the most relevant and reliable source for determining the dosage of terlipressin.

From the FDA Drug Label

Patients received 1 mg terlipressin acetate (equivalent to TERLIVAZ 0. 85 mg) or placebo every 6 hours administered as an IV bolus injection over 2 minutes for a maximum of 14 days. On Day 4 of therapy, if SCr decreased by less than 30% from the baseline value, the dose was increased to 2 mg terlipressin acetate (equivalent to TERLIVAZ 1. 7 mg) every 6 hours.

The recommended dosage of terlipressin is 0.85 mg (equivalent to 1 mg terlipressin acetate) administered every 6 hours as an IV bolus injection, with a possible increase to 1.7 mg (equivalent to 2 mg terlipressin acetate) every 6 hours if serum creatinine (SCr) does not decrease by at least 30% from the baseline value by Day 4 of therapy 2.

From the Research

Terlipressin Dosage

• The dosage of terlipressin varies depending on the indication and administration method.
• For the treatment of hepatorenal syndrome, terlipressin can be administered as a continuous intravenous infusion or as intravenous boluses 3.
• The initial dose of terlipressin for continuous intravenous infusion is 2 mg/day, which can be increased to a final dose of 12 mg/day if necessary 3.
• For intravenous boluses, the initial dose is 0.5 mg every 4 hours, which can also be increased to a final dose of 12 mg/day if necessary 3.
• The mean daily effective dose of terlipressin was found to be lower in the continuous intravenous infusion group (2.23 ± 0.65 mg/day) compared to the intravenous bolus group (3.51 ± 1.77 mg/day) 3.
• In patients with cirrhosis and variceal bleeding, the use of terlipressin reduces the portal vein pressure and decreases the pressure in esophageal varices, with the dosage not specified in the study 4.

Administration Methods

• Terlipressin can be administered as a continuous intravenous infusion or as intravenous boluses 3.
• Continuous intravenous infusion is better tolerated than intravenous boluses, with a lower rate of adverse events (35.29% vs 62.16%) 3.
• The rate of response to treatment, including both complete and partial response, was not significantly different between the two administration methods (76.47% vs 64.85%) 3.

Indications

• Terlipressin is used for the treatment of hepatorenal syndrome, variceal bleeding, and septic shock 4, 5, 6, 7.
• It has also been used for the treatment of refractory ascites, hepatic hydrothorax, paracentesis-induced circulatory dysfunction, and perioperatively during liver transplantation, although it is not yet recommended for these indications 6, 7.