Terlipressin Infusion for Bleeding Esophageal Varices

Dosing Regimen

The American Association for the Study of Liver Diseases recommends an initial dose of terlipressin of 2 mg intravenously, followed by a maintenance dose of 1-2 mg intravenously every 4-6 hours for 3-5 days 1, 2, 3, 4
The maintenance dose of 1-2 mg intravenously every 4-6 hours is recommended for a duration of 3-5 days 1, 3, 4

Terlipressin is the only vasoactive drug proven to reduce bleeding-related mortality (RR, 0.66; 95% CI, 0.49–0.88) 1, 2

Hyponatremia is a potential side effect of terlipressin 1, 2
Myocardial ischemia due to coronary artery vasoconstriction is a potential side effect of terlipressin 1, 2
Abdominal pain is a potential side effect of terlipressin 1, 3
Diarrhea is a potential side effect of terlipressin 1, 3

Terlipressin should be initiated as soon as possible when variceal bleeding is suspected, even before diagnostic endoscopy 1, 4
Prophylactic antibiotics (typically ceftriaxone 1g IV daily for up to 7 days) should be administered along with terlipressin 1, 5
Endoscopic therapy (preferably endoscopic variceal ligation) should be performed as soon as possible, ideally within 12 hours of presentation 1, 5
For high-risk patients (Child-Pugh class C with score 10-13 or Child-Pugh class B with active bleeding despite vasoactive therapy), early TIPS placement should be considered 3, 6

A meta-analysis and Korean multicenter RCT found no significant differences in hemostasis rate and survival time between terlipressin, somatostatin, and octreotide 1, 4
However, terlipressin is the only agent proven to reduce bleeding-related mortality 1, 2