Terlipressin 1 mg Dilution and Administration
Terlipressin 1 mg does not require dilution and should be administered as an intravenous bolus directly through a peripheral IV line. 1
Standard Administration Protocol
Direct IV Bolus (FDA-Approved Method)
- Administer 1 mg (1 vial) undiluted as an IV bolus every 6 hours through a peripheral line without requiring central venous access 1
- No dilution is necessary for bolus administration 1
- ICU monitoring is not required for most patients (ACLF grade <3) 1
Dose Escalation Strategy
- Increase to 2 mg every 6 hours on day 4 if serum creatinine has not decreased by ≥30% from baseline 1
- Maximum treatment duration is 14 days 1
- Discontinue 24 hours after creatinine decreases to <1.5 mg/dL 1
Alternative Continuous Infusion Method
Preparation for Continuous Infusion
- Dilute in normal saline for continuous IV infusion starting at 2 mg/24 hours (not FDA-approved in the United States but widely used internationally) 1, 2, 3
- This method provides equal efficacy at lower total daily doses with fewer ischemic side effects compared to bolus dosing 2, 3
- Can escalate up to 12 mg/day if inadequate response 2, 4
Stability Data for Infusion
- Terlipressin reconstituted in infusion devices remains physically and chemically stable for up to 7 days at 2-8°C and subsequently at 22.5°C for 24 hours 5
- Retains >90% of original concentration under these storage conditions 5
Mandatory Concurrent Albumin Administration
Always administer albumin with terlipressin as monotherapy is significantly less effective (25% vs 77% response rate) 2, 6:
- Day 1: 1 g/kg IV (maximum 100 g) 1, 2, 4
- Subsequent days: 20-40 g/day IV until treatment completion 1, 2
Critical Pre-Administration Assessment
Absolute Contraindications
- SpO₂ <90% on room air or supplemental oxygen 1, 6
- Active coronary, peripheral, or mesenteric ischemia 1, 6
- Serum creatinine >5 mg/dL (unlikely to benefit) 1, 6
Patient Selection Criteria
- Assess ACLF grade before initiation 1, 2
- Evaluate volume status to avoid excessive albumin administration 1
- Obtain baseline ECG to screen for ischemic heart disease 2
Monitoring Requirements
Standard Monitoring (ACLF Grade <3)
- Vital signs including pulse oximetry every 2-4 hours (continuous pulse oximetry not required outside ICU) 1, 2, 4
- Daily serum creatinine monitoring 2, 4
- Monitor for ischemic complications (occur in ~12% of patients): abdominal pain, chest pain, digital ischemia, arrhythmias 1, 2
ICU-Level Monitoring Required
- Patients with ACLF grade 3 (≥3 organ failures) require ICU admission due to increased respiratory failure risk (14% vs 5% placebo) 1, 2
Common Pitfalls to Avoid
Volume Overload Risk
- Judicious albumin use is critical as excessive volume expansion increases respiratory failure risk (11% vs 2% placebo) 1
- Reassess need for continued albumin after 1-2 days based on volume status 1
- Consider point-of-care ultrasonography for volume assessment 1
Inadequate Dose Escalation
- Do not continue same dose beyond day 3-4 if creatinine reduction is <25-30% 1, 2
- Early dose escalation improves response rates 2, 6
Predictors of Treatment Response
Favorable Prognostic Factors
- Baseline bilirubin <10 mg/dL 2, 6
- Baseline serum creatinine <5 mg/dL 2, 6
- Mean arterial pressure increase ≥5-10 mmHg by day 3 2
- Lower ACLF grade 2, 4