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 2022 expert review in Clinical Gastroenterology and Hepatology 1. The treatment with terlipressin can also be administered by continuous intravenous infusion at a lower starting dose of 2 mg/d, which may reduce ischemic side effects, and the dose can be increased gradually every 24–48 hours up to a maximum dose of 12 mg/d, or reversal of hepatorenal syndrome (HRS) 1. Key considerations for terlipressin administration include:
- Monitoring serum creatinine levels to assess response to therapy
- Adjusting the dose based on clinical response and potential side effects
- Avoiding use in patients with a serum creatinine ≥5 mg/dL or oxygen saturation of <90% due to Food and Drug Administration restrictions 1 It is essential to carefully evaluate the patient's condition and adjust the terlipressin dose accordingly to minimize potential side effects and optimize treatment outcomes.
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 dose 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) decreases by less than 30% from the baseline value on Day 4 of therapy 2.
From the Research
Terlipressin Dose
- The optimal dose of terlipressin is still a topic of debate, with different studies suggesting varying dosing regimens 3, 4, 5, 6.
- A study published in 2023 found that continuous infusion of terlipressin at a dose of 4 mg/24 hours was effective and safer than intravenous bolus injections in reducing portal pressure and controlling acute variceal bleeding 3.
- Another study from 1992 compared the efficacy of terlipressin and somatostatin in bleeding esophageal varices, with terlipressin administered as a 2 mg initial dose followed by 1 mg every 4 hours for 24 hours 4.
- A review article from 2009 discussed the use of terlipressin in septic shock, highlighting its potential as a pressor agent, but also noting the need for caution due to its potential to contribute to vasoconstriction and decreased cardiac output 7.
- A systematic review and meta-analysis published in 2025 compared the efficacy and safety of 12-24 hours versus 72 hours of intravenous terlipressin therapy in patients with acute esophageal variceal bleeding, finding no significant differences in rebleeding rates or mortality between the two treatment durations 5.
- A study from 2017 compared 12-hour with 72-hour terlipressin therapy for bleeding esophageal varices, finding similar results between the two treatment durations in preventing rebleeding after endoscopic therapy 6.