What is the dose of terlipressin for acute variceal bleeding?

From the Guidelines

For variceal bleeding, terlipressin is typically administered at an initial dose of 2 mg intravenously every 4 hours for the first 48 hours, followed by 1 mg every 4 hours thereafter, as recommended by the most recent and highest quality study 1. This medication should be started as soon as variceal bleeding is suspected, even before endoscopic confirmation. The goals of therapy in acute variceal hemorrhage (AVH) include the control of bleeding, as well as the prevention of early recurrence and the prevention of six-week mortality. Terlipressin works by causing splanchnic vasoconstriction, which reduces portal pressure and blood flow to the varices, helping to control bleeding. It's particularly useful in patients with cirrhosis and portal hypertension. The medication should be used alongside other treatments including endoscopic therapy (band ligation or sclerotherapy) and antibiotics (typically ceftriaxone 1g daily). Some key points to consider when using terlipressin include:

• Dose adjustment is necessary in patients with renal impairment
• Terlipressin should be used cautiously in patients with coronary artery disease, arrhythmias, or peripheral vascular disease due to its vasoconstrictive properties
• Patients should be closely monitored for side effects, particularly cardiovascular complications and fluid retention Other vasoactive drugs such as somatostatin and octreotide can also be used, but terlipressin is preferred due to its efficacy and safety profile, as shown in the study 1. In addition to vasoactive drugs, endoscopic therapy and antibiotics are essential components of the management of variceal bleeding, as recommended by the study 1. Overall, the use of terlipressin in variceal bleeding is supported by strong evidence, and it should be used as part of a comprehensive treatment plan that includes endoscopic therapy and antibiotics.

From the FDA Drug Label

DOSAGE AND ADMINISTRATION Prior to initial dosing, assess patients for ACLF Grade 3 and obtain patient baseline oxygenation level. Monitor patient oxygen saturation with pulse oximetry. (2.1) Recommended Dosage Regimen: (2.2) Days 1 to 3 administer TERLIVAZ 0. 85 mg (1 vial) intravenously every 6 hours. Day 4: Assess serum creatinine (SCr) versus baseline. If SCr has decreased by at least 30% from baseline, continue TERLIVAZ 0.85 mg (1 vial) intravenously every 6 hours. If SCr has decreased by less than 30% from baseline, dose may be increased to TERLIVAZ 1. 7 mg (2 vials) intravenously every 6 hours. If SCr is at or above baseline value, discontinue TERLIVAZ. Continue TERLIVAZ until 24 hours after two consecutive SCr ≤1.5 mg/dL values at least 2 hours apart or a maximum of 14 days. The recommended dose of terlipressin for variceal bleeding is:

• 0.85 mg intravenously every 6 hours for the first 3 days
• The dose may be increased to 1.7 mg intravenously every 6 hours on day 4 if serum creatinine has decreased by less than 30% from baseline 2 Key points:
• The dose is adjusted based on serum creatinine levels
• Treatment is continued until 24 hours after two consecutive serum creatinine values ≤1.5 mg/dL or a maximum of 14 days

From the Research

Variceal Bleeding Management

The management of variceal bleeding involves a combination of pharmacological, endoscopic, and radiologic interventions.

• The use of vasoactive drugs such as terlipressin, somatostatin, and octreotide is recommended to control acute variceal bleeding 3, 4, 5.
• Early endoscopy is essential for diagnosis and treatment of variceal bleeding, with variceal band ligation being the most effective therapy for oesophageal varices 3.
• The evidence suggests that terlipressin, somatostatin, and octreotide have similar efficacy in controlling variceal bleeding, with no significant difference in hemostatic effects and safety 4.

Terlipressin Dosage

There is no specific information on the dosage of terlipressin for variceal bleeding in the provided studies.

• However, the studies suggest that terlipressin is effective in controlling variceal bleeding when used as part of a treatment regimen that includes endoscopic therapy and other interventions 3, 4, 5.
• The optimal duration of terlipressin treatment is not well established, but one study found no difference between 2 and 5 days of octreotide treatment 6.

Treatment Outcomes

The treatment outcomes for variceal bleeding depend on various factors, including the severity of the bleeding, the presence of cirrhosis, and the effectiveness of the treatment regimen.

• The studies suggest that early treatment with vasoactive drugs and endoscopic therapy can improve outcomes and reduce mortality in patients with variceal bleeding 3, 4, 6.
• The use of antibiotics and transfusion strategies guided by thromboelastography can also improve outcomes in patients with variceal bleeding 6.