Is terlipressin (Terlipressin) contraindicated with inotropes (inotropic agents)?

From the Guidelines

Terlipressin is not contraindicated with inotropes, and they can be used together in clinical practice, particularly in patients with hepatorenal syndrome or septic shock. According to the most recent study 1, terlipressin, a vasopressin analog, causes vasoconstriction primarily in the splanchnic circulation, while inotropes like dobutamine or milrinone improve cardiac contractility. This combination can be beneficial when both vasopressor support and cardiac output enhancement are needed. For example, in hepatorenal syndrome, terlipressin (typically 1-2 mg IV every 4-6 hours) may be used alongside an inotrope if the patient has concurrent cardiac dysfunction. Similarly, in septic shock, terlipressin may complement inotropic therapy when patients require multiple hemodynamic supports. However, careful hemodynamic monitoring is essential when using this combination, as the vasoconstrictor effects of terlipressin could potentially reduce cardiac output in some patients, especially those with severe heart failure. Dose adjustments of either agent may be necessary based on the patient's hemodynamic response and clinical condition.

Some key considerations when using terlipressin with inotropes include:

• Monitoring for ischemic complications such as arrhythmia, angina, and splanchnic and digital ischemia 1
• Avoiding use in patients with hypoxemia, ongoing coronary, peripheral, or mesenteric ischemia, and significant vascular disease 1
• Using with caution in patients with ACLF grade 3 and closely monitoring for respiratory failure 1
• Judicious use of albumin before and during treatment with terlipressin to minimize the risk of respiratory failure 1

Overall, the use of terlipressin with inotropes requires careful consideration of the patient's individual clinical condition and close monitoring of their hemodynamic response. By using this combination judiciously, clinicians can provide effective support for patients with complex hemodynamic needs.

From the Research

Terlipressin and Inotropes

• The use of terlipressin with inotropes, such as norepinephrine, has been studied in the treatment of septic shock 2.
• The combination of terlipressin and norepinephrine has shown potential benefits, including improved cardiac output and central venous pressure 2.
• However, the use of terlipressin with inotropes also carries risks, such as an elevated risk of peripheral ischemia 2.
• There is no clear contraindication for the use of terlipressin with inotropes, but caution should be exercised due to the potential for vasoconstriction and decreased cardiac output 3, 4.

Mechanism of Action

• Terlipressin is a vasopressin analog that acts as a V1 receptor agonist, causing vasoconstriction and increasing blood pressure 5, 3, 4, 6.
• Inotropes, such as norepinephrine, work by increasing cardiac contractility and heart rate, which can also increase blood pressure 2.
• The combination of terlipressin and inotropes may have additive or synergistic effects on blood pressure and cardiac output 2.

Clinical Use

• Terlipressin is used in the treatment of septic shock, particularly in cases where patients are refractory to conventional vasopressor treatment 5, 3, 4, 6.
• The use of terlipressin with inotropes may be considered in patients with septic shock who require additional hemodynamic support 2.
• However, further studies are needed to establish the safety and efficacy of this combination therapy 5, 3, 4, 6.