From the Guidelines
Vasopressin analogues, such as terlipressin, are the most effective treatment for hepatorenal syndrome (HRS) and should be administered promptly in combination with albumin to improve renal function and short-term survival. The use of terlipressin in HRS has been extensively studied, and it has been shown to improve renal function in patients with type 1 HRS, with a response rate of 40-50% 1. The standard dosing regimen for terlipressin is 1 mg every 4-6 hours, which can be increased to a maximum of 2 mg every 4-6 hours if there is no reduction in serum creatinine of at least 25% compared to the baseline value at day 3 of therapy 1.
Some key points to consider when using terlipressin include:
- The importance of combining terlipressin with albumin to improve the efficacy of treatment on circulatory function 1
- The need for careful clinical screening, including electrocardiogram, before starting treatment due to the risk of cardiovascular ischemic complications 1
- The potential for terlipressin to be administered by continuous intravenous infusion, which has been shown to have a similar rate of response but lower adverse effects compared to administration by intravenous boluses 1
- The importance of monitoring patients closely for signs of circulatory overload and cardiovascular ischemic complications, which have been reported in up to 45-46% of patients when the drug is delivered by intravenous boluses 1
Overall, the use of terlipressin in combination with albumin is a crucial component of the management of HRS, and its effectiveness has been consistently demonstrated in the literature 1.
From the Research
Overview of Selexipag
- Selexipag is an orally administered selective prostacyclin receptor agonist for the treatment of pulmonary arterial hypertension (PAH) 2, 3, 4, 5, 6.
- It is rapidly hydrolyzed to a long-acting metabolite that binds with high selectivity to IP receptors, resulting in vasodilation, inhibition of platelet aggregation, and antiinflammatory effects 2, 5.
Clinical Efficacy
- Selexipag has been shown to significantly reduce the occurrence of the composite primary outcome (all-cause mortality and development of PAH-related complications) in clinical trials 2, 3, 4.
- It has also been demonstrated to improve exercise capacity in the form of the 6-minute walk distance 3, 4.
- Selexipag is indicated for use in patients with World Health Organization functional class (FC) II or III disease 2.
Safety and Tolerability
- Selexipag has a dose-dependent adverse-effect profile that includes nausea, vomiting, diarrhea, headache, and musculoskeletal pain 2, 3.
- It is generally well tolerated, with the most common adverse effects being headache, diarrhea, jaw pain, and nausea 3.
Place in Therapy
- Selexipag is an oral prostacyclin IP receptor agonist approved for use as monotherapy or in combination with other therapies to slow PAH progression and reduce the risk of hospitalization in patients with FC II or III symptoms 2, 6.
- It should be added as a triple oral combination therapy in case of insufficient response to oral combination therapy with endothelin receptor antagonist and phosphodiesterase 5 inhibitor 6.