What is the recommended splanchnic vasoconstrictor for a patient with bleeding esophageal varices or shock?

Recommended Splanchnic Vasoconstrictor for Bleeding Esophageal Varices

Terlipressin is the recommended first-line splanchnic vasoconstrictor for bleeding esophageal varices, administered at 2 mg IV every 4 hours initially, then reduced to 1 mg IV every 4 hours for 2-5 days total duration. 1

Why Terlipressin is Preferred

Terlipressin is the only vasoactive drug proven to reduce bleeding-related mortality (relative risk 0.66), making it superior to other splanchnic vasoconstrictors. 2, 1 The drug works as a synthetic vasopressin analog with a longer half-life and significantly fewer adverse effects compared to vasopressin, particularly avoiding the severe cardiovascular complications like mesenteric and myocardial ischemia that limit vasopressin use. 2

Dosing Protocol

• Initial phase (first 48 hours): 2 mg IV every 4 hours until bleeding is controlled 2, 1
• Maintenance phase: 1 mg IV every 4 hours 2, 1
• Total duration: 2-5 days, with shorter courses (2 days) acceptable in Child-Pugh class A or B patients without active bleeding at endoscopy 1
• Start immediately when variceal bleeding is suspected, even before endoscopic confirmation 1

Alternative Agents When Terlipressin Unavailable

If terlipressin is not available, octreotide or somatostatin are acceptable alternatives with comparable efficacy for hemostasis and survival, though they lack the mortality benefit. 2

• Octreotide: 50 μg IV bolus, then 50 μg/hr continuous infusion 2
• Somatostatin: 250 μg IV bolus, then 250 μg/hr continuous infusion 2

Both have excellent safety profiles with minimal side effects (nausea, abdominal pain, hyperglycemia) compared to terlipressin's risk of hyponatremia and myocardial ischemia. 2

Critical Contraindications to Terlipressin

Do not use terlipressin in patients with: 1

• Hypoxia or oxygen saturation <90%
• Active coronary, peripheral, or mesenteric ischemia
• Worsening respiratory symptoms

Essential Combination Therapy

Terlipressin should never be used as monotherapy. The standard approach requires three simultaneous components: 1

1. Vasoactive drug therapy (terlipressin) started immediately
2. Endoscopic band ligation performed within 12 hours
3. Prophylactic antibiotics (ceftriaxone 1 g IV every 24 hours for up to 7 days)

This combination achieves 77% five-day hemostasis versus only 58% with endoscopy alone. 1

Special Considerations for Shock States

In patients presenting with hypotension (systolic BP <90 mmHg or MAP <65 mmHg), temporarily suspend any existing beta-blocker therapy, as these agents are contraindicated in hypotensive states despite their role in variceal bleeding prophylaxis. 2

Why Not Vasopressin

Vasopressin is no longer recommended due to its short half-life requiring continuous infusion and significant systemic vasoconstriction causing mesenteric or myocardial ischemia. 2 Terlipressin has replaced it entirely in clinical practice due to superior safety and efficacy profiles.

Monitoring and Adjustment

• In patients with poor response, the maintenance dose can be increased to 2 mg IV every 4 hours 1
• Patients with Child-Pugh class C cirrhosis or active bleeding during endoscopy may require the full 5-day treatment duration 1
• Common adverse effects include abdominal pain, nausea, respiratory failure, and diarrhea, with an incidence of 24.32% with 5-day courses versus 10.8% with 2-day courses 1