Letter: Shorter duration of intravenous terlipressin for variceal bleeding in patients with cirrhosis-A promising find

This article is linked to Vaishnav et al papers. To view these articles, visit https://doi.org/10.1111/apt.17868 and https://doi.org/10.1111/apt.17982

Letter: Shorter duration of intravenous terlipressin for variceal bleeding in patients with cirrhosis-A promising find. Author's reply

This article is linked to Vaishnav et al papers. To view these articles, visit https://doi.org/10.1111/apt.17868 and https://doi.org/10.1111/apt.17976

Ischemic skin necrosis following terlipressin therapy: report of two cases and review of the literature

Terlipressin is a synthetic vasopressin analogue that is used in the treatment of bleeding esophageal varices and hepatorenal syndrome in patients with cirrhosis. Hepatorenal syndrome is a form of renal failure seen in patients with cirrhosis, with fatal outcomes. Ischemic adverse effects related to terlipressin are rarely observed. Herein, two cases who developed ischemic skin necrosis due to terlipressin usage are presented. Terlipressin therapy was started in two cirrhotic patients with presumptive hepatorenal syndrome. During the therapy, ecchymotic and necrotic changes were observed on the scrotal regions of both patients. Skin lesions were relieved after terlipressin therapy. Biopsy results were consistent with ischemia. Even if seen rarely, possible emergence of ischemic complications must be considered.

Treatment of the hepatorenal syndrome and hyponatremia in cirrhosis - part II

National guidelines for treatment of ascites, spontaneous bacterial peritonitis, hepatorenal syndrome, and hyponatremia have been approved by the Danish Society of Gastroenterology and Hepatology. Ascites develops in approximately 60% of patients with cirrhosis during a 10 year period and is frequently associated with complications that determine the course of the disease and the prognosis. These evidence-based guidelines are divided in two parts and consider definitions, pathophysiology, diagnostic aspects, treatment, and prophylaxis.

Effects of vasopressinergic receptor agonists on sublingual microcirculation in norepinephrine-dependent septic shock

INTRODUCTION

The present study was designed to determine the effects of continuously infused norepinephrine (NE) plus (1) terlipressin (TP) or (2) arginine vasopressin (AVP) or (3) placebo on sublingual microcirculation in septic shock patients. The primary study end point was a difference of ≥ 20% in the microvascular flow index of small vessels among groups.

METHODS

The design of the study was a prospective, randomized, double-blind clinical trial. NE was titrated to maintain mean arterial pressure (MAP) between 65 and 75 mmHg after establishment of normovolemia in 60 septic shock patients. Thereafter patients (n = 20 per group) were randomized to receive continuous infusions of either TP (1 μg/kg/hour), AVP (0.04 U/minute) or placebo (isotonic saline). In all groups, open-label NE was adjusted to maintain MAP within threshold values if needed. The sublingual microcirculatory blood flow of small vessels was assessed by sidestream dark-field imaging. All measurements, including data from right heart catheterization and norepinephrine requirements, were obtained at baseline and 6 hours after randomization.

RESULTS

TP and AVP decreased NE requirements at the end of the 6-hour study period. The data are medians (25th and 75th interquartile ranges (IQRs)): 0.57 μg/kg/minute (0.29 to 1.04) vs. 0.16 μg/kg/minute (0.03 to 0.37) for TP and 0.40 μg/kg/minute (0.20 to 1.05) vs. 0.23 μg/kg/minute (0.03 to 0.77) for AVP, with statistical significance of P < 0.05 vs. baseline and vs. placebo. There were no differences in sublingual microcirculatory variables, systemic hemodynamics, oxygen transport and acid-base homeostasis among the three study groups during the entire observation period. The proportions of perfused vessels increased in relation to baseline within all study groups, and there were no significant differences between groups. The specific data were as follows (median (IQR)): 9.7% (2.6 to 19.8) for TP, 8.9% (0.0 to 17.8) for AVP, and 6.9% (3.5 to 10.1) for placebo (P < 0.05 vs. baseline for each comparison), as well as perfused vessel density 18.6% (8.6 to 36.9) for TP, 20.2% (-3.0 to 37.2) for AVP, and 11.4% (-3.0 to 19.4) for placebo (P < 0.05 vs. baseline for each comparison).

CONCLUSIONS

The present study suggests that to achieve a MAP of 65 to 75 mmHg in septic patients treated with NE, the addition of continuously infused low-dose TP or AVP does not affect sublingual microcirculatory blood flow. In addition, our results suggest that microcirculatory flow abnormalities are mainly related to other factors (for example, volume status, timing, hemodynamics and progression of the disease) rather than to the vasopressor per se.

TRIAL REGISTRATION

ClinicalTrial.gov NCT00995839.

Hepatorenal syndrome

Hepatorenal syndrome (HRS) is a functional renal failure that often occurs in patients with cirrhosis and ascites. Two different types of HRS have been described. Type 1 HRS develops as a consequence of a severe reduction of effective circulating volume due to both an extreme splanchnic arterial vasodilatation and a reduction of cardiac output. Type 2 HRS is characterized by a stable or slowly progressive renal failure so that its main clinical consequence is not acute renal failure, but refractory ascites, and its impact on prognosis is less negative. Liver transplantation (LT) represents the best therapeutic option in cirrhotic patients with HRS. Nevertheless, other therapeutic options were investigated as 'bridge treatments' towards orthotopic LT or for patients who cannot be candidates for LT. Several pilot studies and two randomized control studies have shown that terlipressin plus albumin improves renal function in patients with type 1 HRS. Terlipressin plus albumin can also improve short-term survival in these patients. Terlipressin was most commonly used by intravenous boluses moving from an initial dose of 0.5-1 mg every 4 h to 3 mg every 4h in cases of nonresponse. Nevertheless, there are some preliminary data showing that terlipressin given by continuous intravenous infusion is better tolerated than when it is given by intravenous boluses. The available data are sufficient to state that the use of terlipressin plus albumin has really changed the management of type 1 HRS. Nevertheless, it should be noted that recovery of renal function can only be achieved in less than 50% of patients with type 1 HRS and that the recovery of renal function may also be partial inpatients who are defined as full responders. Thus, while the optimization of this treatment should be investigated, other therapeutic options should be developed and tested as well.

Long-term treatment of hepatorenal syndrome as a bridge to liver transplantation

BACKGROUND/AIMS

Terlipressin plus albumin is first-line treatment for hepatorenal syndrome (HRS). Therapy lasts from a few days to two weeks, whereas the efficacy and safety of long-term administration remain unsettled.

METHODS

We describe our experience of prolonged terlipressin and albumin treatment as a bridge to liver transplantation in three patients with cirrhosis and recurrent HRS.

RESULTS

The length of treatment ranged from 62 days to eight months. Attempts to suspend terlipressin or to switch treatment to midodrine plus octreotide were consistently associated with a deterioration of serum creatinine and oliguria. No major side-effects were observed. All patients were transplanted, but two died from peri-operative complications.

CONCLUSIONS

These clinical cases suggest that long-term terlipressin administration in selected patients with recurrent HRS awaiting liver transplantation may represent an option to prevent irreversible renal failure and the need for dialysis until an organ becomes available.

Vasopressin in sepsis and septic shock

Arginine vasopressin (AVP) and its synthetic, long-acting analog terlipressin (TP) are potent alternative vasoconstrictors in the treatment of septic patients with catecholamine-refractive vasodilatatory shock. The results from one large randomized clinical trial suggest that AVP plus norepinephrine (NE) infusion is as safe and effective as treatment with NE alone in patients with septic shock. Because the desired effects of vasopressin analogs are basically related to their vasopressinergic effects via the V1a receptor, more selective V1 agonists, such as TP, may be more potent in reversing sepsis-related arterial hypotension. In this regard, recent evidence from small-scale studies suggests that continuous low-dose infusion rather than intermittent bolus injection of TP is associated with fewer side effects, such as depression of cardiac output and rebound arterial hypotension. However, because clinical data on the administration of TP in patients with sepsis are limited, it should not currently be used beyond the scope of controlled trials. The optimal time point for the initiation of therapy with vasopressin analogs has yet to be determined. While AVP and TP are commonly used as last-resort therapies in severe septic shock, some evidence supports the initiation of treatment in a less severe state of the disease.

Double-blind randomized multicenter study comparing the efficacy and safety of 10-day to 5-day terlipressin treatment of bleeding esophageal varices

BACKGROUND/AIMS

The aim of the study was to compare the efficacy and safety of 5-day terlipressin treatment of bleeding esophageal varices to 10-day treatment period.

METHODOLOGY

Of 25 patients with variceal bleeding, 15 were randomized to receive terlipressin for day 1-5 and placebo for day 6-10 (Group A), and 10 to receive terlipressin for day 1-10 (Group B).

RESULTS

The bleeding was stopped in 24 patients (96%). Rebleeding till day 42 was observed in 9 (36%) patients (5 in group A, 4 in group B, ns). 2 patients died in group B (due to rebleeding till day 5) and one in group A (rebleeding between day 5-10). Transfusion needs were lower in group B (2.7 +/- 2.6TU compared to 4.13 +/- 5.8 TU in group A, ns). Serious AE leading to treatment discontinuation were observed in 1 patient in group A (peripheral ischemia) and none in B, non-significant AE in 3 patients in group A (hypertension), and in 3 in group B (hypertension, hyponatremia, epiparoxysm).

CONCLUSIONS

Prolonged treatment with terlipressin did not prove significant decrease of mortality or bleeding recurrence; lower rebleeding rate after day 5 and tendency towards lower transfusion requirements were observed. Prolonged treatment had no influence on AE rate.

A retrospective analysis of Terlipressin infusion in patients with refractory hypotension after cardiac surgery

AIM

The aim of this retrospective study was to evaluate the effectiveness of Terlipressin in the treatment of severe hypotension in cardiosurgical patients and to assess the differences between the groups of survivors and nonsurvivors.

METHODS

The study population was 27 patients who developed hypotension after cardiac surgery.

RESULTS

All surviving patients developed refractory hypotension early after extracorporeal circulation. Of the 9 nonsurvivors, 3 also experienced postcardiotomy hypotension, while the remaining 6 developed severe hypotension during sepsis. Terlipressin given continuously significantly increased the mean arterial pressure and reduced the heart rate in both groups. Norepinephrine requirements decreased significantly among survivors only. The mean pulmonary artery pressure and pulmonary capillary wedge pressure levels remained unchanged or increased insignificantly, while several liver markers in the survivor group significantly increased.

CONCLUSION

Terlipressin given continuously is a potent vasopressor in patients with norepinephrine-resistant postcardiotomy hypotension; however, Terlipressin treatment failed in patients who developed refractory hypotension during sepsis. We cannot recommend this therapy in such patients as it proved to be hemodynamicaly ineffective and may even worsen the circulatory situation.

A case of ischemic skin necrosis after glypressin therapy in liver cirrhosis

Terlipressin is a synthetic analogue of vasopressin, which has been used in the treatment of acute variceal hemorrhage. In contrast to vasopressin, terlipressin can be administered as intermittent injections instead of continuous intravenous infusion. Thus, it has a less adverse reaction than vasopressin. We report a case of ischemic skin complication in a cirrhotic patient treated with terlipressin. A 71-year-old man with liver cirrhosis was admitted because of hematemesis and melena. He was commenced on terlipressin at a dose 1 mg every 6 hours for the treatment of varicieal bleeding. After 36 hours of treatment, skin blistering and ecchymosis was noted on the skin of his upper thigh, scrotal area and trunk. We found that terlipressin was a possible cause of ischemic skin complication based on the skin biopsy finding. Terlipressin may induce a complication of the ischemic event. In spite of rarity, special attention needs to paid on the peripheral ischemic complication of terlipressin.

Terlipressin as rescue treatment of refractory shock in a neonate

Patients with septic shock may develop refractory hypotension despite maximal inotropic support with impairment of clinical outcome. Terlipressin, a long-acting vasopressin analogue, is reported to be effective as rescue treatment of refractory septic shock in adult and paediatric patients, while clinical experience in neonates is definitely scarce. We report a neonate with systemic inflammatory response syndrome after surgery for abdominal neuroblastoma who received terlipressin as rescue treatment after failure of volume load and catecholamines. Terlipressin promptly reversed hypotension and improved tissue perfusion without adverse effects.

CONCLUSION

Terlipressin appears an effective rescue treatment in patients with refractory vasodilatory septic shock. Further studies are required to assess its efficacy and safety in neonatal population.

Employing dobutamine as a useful agent to reverse the terlipressin-linked impairments in cardiopulmonary hemodynamics and global oxygen transport in healthy and endotoxemic sheep

Although arginine vasopressin and terlipressin have been identified as useful nonadrenergic agents to increase systemic blood pressure in catchecholamine-resistant septic shock, the impairments in cardiac index (CI) and global oxygen transport may limit their clinical applicability. The present study was designed as a prospective controlled laboratory experiment to investigate the effects of dobutamine as an adjunct to terlipressin infusion on cardiopulmonary hemodynamics and global oxygen transport in healthy and endotoxemic sheep. Nine adult ewes were instrumented for chronic study using an established protocol. After a baseline measurement in the healthy state had been performed, 1 mg terlipressin was given as bolus infusion. Thirty minutes later, dobutamine was continuously infused at incremental doses (2 and 5 microg x kg(1) x min(1), each for 1 h). After 24 h of recovery, a hypotensive-hyperdynamic circulation was induced and maintained by a continuous infusion of Salmonella typhosa endotoxin (10 ng x kg(1) x min(1)). After 16 h of endotoxemia, the six surviving sheep received terlipressin and dobutamine according to the same protocol that was used in healthy sheep. Compared with baseline, terlipressin infusion was associated with a significant increase in MAP that, however, occurred at the expense of a compromised CI, oxygen delivery index (DO(2)I), and mixed venous oxygen saturation (SvO(2), each P < 0.05). Dobutamine infusion was followed by a dose-dependent increase in CI, DO(2)I, and SvO(2) in both health and endotoxemia (each P < 0.05). Although the higher dosage of dobutamine exerted favorable effects, such as a decrease in pulmonary vascular resistance index (P < 0.05), the associated onset of tachycardia (P < 0.05) and arterial hypotension (P < 0.05) may limit its therapeutic use under septic conditions. This study provides evidence that dobutamine in a dosage of 2 microg x kg(1) x min(1) is useful to reverse the terlipressin-linked depressions in CI, DO(2)I and SvO(2) in ovine endotoxemia without obvious side effects.

The efficacy of terlipressin in comparison with albumin in the prevention of circulatory changes after the paracentesis of tense ascites--a randomized multicentric study

BACKGROUND/AIMS

Postparacentesis circulatory dysfunction is the most severe complication of ascites paracentesis. The aim of our study was to compare the standard treatment with the administration of a vasoconstrictor terlipressin.

METHODOLOGY

Forty-nine patients treated by paracentesis due to tense ascites were randomized for the treatment with albumin (8g/L of removed ascites) or terlipressin (1 mg every four hours for 48 hours). The blood pressure, heart rate, diuresis, electrocardiograph, standard biochemical and hematological parameters, sodium, potassium and nitrogen urinary excretion, aldosterone and renin activity in the blood plasma were monitored for a period of 72 hours.

RESULTS

In any parameter of hemodynamic changes, no statistically significant difference was demonstrated between randomized groups, in particular measurements as well as in the development in the course of the first three days after the intervention. The result suggests similar efficacy of the circulatory dysfunction prevention after the paracentesis in both treatment procedures. In both groups, on the first three days, there was a tendency to improve hemodynamics reflected by the renin-angiotensin-aldosteron system activity. In the terlipressin group, this tendency approached statistically significant levels.

CONCLUSIONS

The administration of terlipressin in a dose of 1 mg every fourth hour performed for a period of 48 hours was as effective as intravenous albumin in preventing hemodynamic changes in patients with tense ascites treated by paracentesis. The treatment was well tolerated.

Beneficial effects of terlipressin in prolonged pediatric cardiopulmonary resuscitation: a case series

OBJECTIVE

Arginine vasopressin was found in experimental and clinical studies to have a beneficial effect in cardiopulmonary resuscitation. The American Heart Association 2000 guidelines recommended its use for adult ventricular fibrillation arrest, and the American Heart Association 2005 guidelines noted that it may replace the first or second epinephrine dose. There is little reported experience with arginine vasopressin in cardiopulmonary resuscitation of children. Terlipressin, a long-acting analog of arginine vasopressin, has recently emerged as a treatment for vasodilatory shock in both adults and in children, but evidence of its effectiveness in the pediatric setting is sparse. The objective of this retrospective study is to describe our experience in adding terlipressin to the conventional protocol in children with cardiac arrest.

DESIGN

Retrospective case series study.

SETTING

An 18-bed pediatric critical care department at a university-affiliated tertiary care children's hospital.

PATIENTS

Seven pediatric patients with asystole, aged 2 months to 5 yrs, who experienced eight episodes of refractory cardiac arrest and did not respond to conventional therapy.

INTERVENTIONS

Addition of terlipressin to epinephrine during cardiopulmonary resuscitation of children.

MEASUREMENTS AND MAIN RESULTS

Return of spontaneous circulation was monitored and achieved in six out of eight episodes of cardiac arrest. One patient died 12 hrs after return of spontaneous circulation, and four patients survived to discharge with no neurologic sequelae.

CONCLUSIONS

The combination of terlipressin to epinephrine during cardiopulmonary resuscitation may have a beneficial effect in children with cardiac arrest. More studies on this drug's safety and efficacy in this setting are mandated.

Terlipressin. Type I hepatorenal syndrome: an extra window of time before liver transplantation

In some patients with type I hepatorenal syndrome, a retrospective study suggests, albeit with a low level of evidence, that terlipressin increases survival time by about a week, which sometimes allows enough time to find a suitable liver donor. Adverse effects due to the vasoconstrictive action of terlipressin require close monitoring during treatment.

Rescue therapy in septic shock--is terlipressin the last frontier?

Use of terlipressin, an analogue of vasopressin, can be considered in septic shock patients with intractable hypotension and high cardiac output in whom fluid resuscitation and high-dose conventional catecholamines have failed. The effects of this agent on organ function are poorly evaluated in humans. The limited number of patients evaluated precludes any analysis of adverse outcomes and prognosis.

[Renal impairment in liver diseases]

Renal failure in patients with liver disease is mostly none-organic: prerenal failure or hepatorenal syndrome (HRS). In addition there is organic renal failure, mostly acute tubular necrosis (ATN). In order to avoid functional renal failure cautious diuretic treatment as well as intravenous albumin substitution following paracentesis are pivotal. For prophylaxis of HRS patients with spontaneous bacterial peritonitis shall be given albumin infusions in addition to antibiotic treatment. Patients with HRS type I exhibit a very poor prognosis. Liver transplantation is the only established therapy with long-term success. To bridge the time to transplantation TIPS or terlipressin and albumin can be used.

[A prospective study comparing the efficacy of early administration of terlipressin and somatostatin for the control of acute variceal bleeding in patients with cirrhosis]

BACKGROUND/AIMS

Terlipressin and somatostatin decrease portal venous pressure and they are used for the treatment of variceal bleeding. However, only a few studies have compared the efficacy of these drugs in combination with other procedures for hemostasis. Therefore, we performed a prospective study to compare the efficacy of terlipressin and somatostatin for controlling acute variceal bleeding when used in combination with other procedures for hemostasis.

METHODS

A total of 98 patients, who presented with variceal bleeding from September 2003 to May 2005, were randomly divided into the somatostatin group or terlipressin group. We compared the 5-day failure rate (defined as failure to control bleeding, rebleeding or death within 5 days of admission) and the 6-week mortality. The prognostic factors for 5-day failure and 6-week mortality were also evaluated.

RESULTS

There were no differences in baseline characteristics between the two groups. The overall 5-day failure rate and the cumulative 6-week mortality were 16.3% and 15.8%, respectively. The five-day failure rate and the cumulative 6-week mortality were not significantly different between the somatostatin and terlipressin groups. Hepatocellular carcinoma, the baseline serum creatinine level and endoscopic treatment for hemostasis were the significant predictors of 5-day failure; the baseline serum creatinine level was the predictor of 6-week mortality.

CONCLUSIONS

Both somatostatin and terlipressin were effective and showed comparable efficacy for the control of the acute variceal bleeding in the setting of a combined therapeutic approach. The baseline serum creatinine level may be a significant predictor for patient failure at 5 days and the 6-week mortality.

Cardiovascular collapse due to massive pulmonary thromboembolism during orthotopic liver transplantation

Severe pulmonary thromboembolism has been occasionally reported during orthotopic liver transplantation, with fatal outcomes occurring in about 50% of cases because of low cardiac output and multiple organ failure. Perioperative alterations in coagulation, insertion of pulmonary artery and other invasive catheters, administration of antifibrinolytic agents, and repeated ischemic insults may all promote the formation of intravascular/cardiac blood clots. We present a case of intraoperative right ventricular failure associated with the presence of a large thrombus wrapped around the pulmonary artery catheter. Identification of risk factors for intraoperative pulmonary thromboembolism warrants a prophylactic medical approach including selective blood component therapy and administration of antifibrinolytics guided by bedside coagulation tests as well as noninvasive hemodynamic monitoring.

Use of subcutaneous DDAVP in infants with central diabetes insipidus

Traditional methods for treating central diabetes insipidus during infancy, such as fluid therapy or the use of intranasal hormone replacement, have significant potential limitations. In a retrospective study of infants with diabetes insipidus, we examined outcome using subcutaneous (sc) DDAVP, and compared this to infants treated with intranasal lysine vasopressin or DDAVP. After in-patient dosage titration, outpatients' serum sodium concentrations were maintained in a narrower range in the sc group compared with the intranasal group, and the percentage of serum sodium concentrations within the normal range was greater in the sc group. There were no significant complications in either group. We conclude that DDAVP administered subcutaneously can be a safe and effective alternative to traditionally recommended treatments of central diabetes insipidus during infancy.

Best evidence topic report. The use of intravenous terlipressin in non-variceal upper GI bleeds

A short cut review was carried out to establish whether terlipressin should be used in upper GI bleeding when variceal bleeding is not suspected as the cause. 556 papers were found, of which none answered the three part question. The clinical bottom line is that there is no evidence for the use of intravenous terlipressin in patients presenting with acute, severe upper GI bleeds unless they have endoscopic evidence of varices or a high clinical index of suspicion is met.

Rescue therapy with terlipressin by continuous infusion in a child with catecholamine-resistant septic shock

A 2-month-old female infant presented with septic shock, refractory to high doses of catecholamines. Continuous infusion of terlipressin at a rate of 10 mcg/kgh produced a significant increase in the mean arterial pressure that was evident within half and hour, so allowing a reduction in the rate of catecholamine infusion. However, 18 h later, the blood pressure fell again and finally the patient died. This case shows the potential value of terlipressin infusion to restore normal mean arterial pressure in children with vasodilatory shock and hypotension refractory to catecholamines.

Effects of somatostatin, terlipressin and somatostatin plus terlipressin on portal and systemic hemodynamics and renal sodium excretion in patients with cirrhosis

BACKGROUND AND AIM

Terlipressin and somatostatin are the most preferable agents for the control of variceal bleeding in cirrhotic patients. The present study evaluated the hemodynamic effects of somatostatin, terlipressin and somatostatin plus terlipressin in cirrhotic patients with portal hypertension, as well as the effect of each regimen on renal sodium excretion.

METHODS

Twenty-four patients with esophageal varices were randomly assigned to receive either an intravenous infusion of a placebo (n = 12) or somatostatin 250 microg/h after an initial bolus of 250 microg (n = 12) for 60 min. Thereafter, each patient received an intravenous injection of terlipressin 2 mg while the intravenous infusion of either somatostatin or placebo was maintained. Portal and systemic hemodynamic parameters, assessed by Doppler sonography, and urinary sodium excretion were evaluated at baseline, 60 min after placebo or somatostatin, and 30 min after terlipressin.

RESULTS

Placebo had no effect on the patients studied. After terlipressin, portal vein velocity, portal flow volume and cardiac output (CO) significantly decreased (0.09 vs 0.15 m/s, 0.56 vs 1 L/min and 6.4 vs 7.6 L/min, respectively [values are medians]), while mean arterial pressure (MAP) and systemic vascular resistance significantly increased (103.3 vs 89.9 mmHg and 1541 vs 1108dyn.s/cm(5), respectively). Fractional sodium excretion significantly increased in patients without ascites (0.43 vs 0.16%) while it did not change in patients with ascites. Somatostatin did not alter portal hemodynamics whereas it significantly reduced MAP, heart rate (HR) and CO (86.9 vs 98.6 mmHg, 65 vs 73 bpm and 8.4 vs 9.1 L/min, respectively) and, in patients with ascites, sodium excretion (0.13 vs 0.23%). The addition of terlipressin to somatostatin induced similar changes to those observed after terlipressin alone. The magnitude of increase in MAP was significantly higher in patients receiving terlipressin alone than in those receiving somatostatin plus terlipressin (15 vs 5.3%), while CO was conversely affected (-28.5 vs-20.9%).

CONCLUSIONS

Combined treatment with somatostatin and terlipressin does not exert an additive portal hypotensive effect in cirrhotic patients as compared to terlipressin alone, whereas somatostatin alone may impair systemic hemodynamics. Compared with somatostatin, terlipressin exerts a more beneficial effect on renal sodium excretion in patients with or without ascites.

Low-dose terlipressin during long-term hyperdynamic porcine endotoxemia: effects on hepatosplanchnic perfusion, oxygen exchange, and metabolism

OBJECTIVE

To investigate whether the vasopressin analog terlipressin might induce hepatosplanchnic ischemia during long-term, hyperdynamic, volume-resuscitated porcine endotoxemia.

DESIGN

Prospective, randomized, controlled experimental study with repeated measures.

SETTING

Investigational animal laboratory.

SUBJECTS

Eighteen pigs were divided into two groups receiving either endotoxin alone (control group, n = 10) or endotoxin and terlipressin (n = 8).

INTERVENTIONS

Pigs were anesthetized, mechanically ventilated, and instrumented and received a continuous intravenous infusion of Escherichia coli endotoxin. Animals were resuscitated with hydroxyethyl starch targeted to maintain mean arterial pressure >60 mm Hg. Twelve hours after the start of the endotoxin infusion, terlipressin (5-15 microg.kg.hr titrated to maintain mean arterial pressure at preendotoxin levels) or its vehicle was administered for 12 hrs.

MEASUREMENTS AND MAIN RESULTS

Terlipressin increased mean arterial pressure and systemic vascular resistances, which was affiliated with a decrease in cardiac output and global oxygen consumption. Terlipressin restored the hepatic artery buffer response, which led to an increase in hepatic artery flow, ultimately resulting in well-maintained liver oxygen delivery, oxygen uptake, and all other variables of regional metabolism and organ function. Terlipressin markedly attenuated the hepatosplanchnic venous acidosis but was associated with pronounced hyperlactatemia.

CONCLUSIONS

During long-term hyperdynamic porcine endotoxemia, the well-known vasoconstrictor properties of terlipressin blunted the progressive decrease in mean arterial pressure without any detrimental effect on hepatosplanchnic perfusion, oxygen exchange, and metabolism. The marked terlipressin-induced hyperlactatemia did not originate from the hepatosplanchnic organs but from extrasplanchnic tissues, possibly muscle and skin.

Hemodynamic effects of terlipressin and high somatostatin dose during acute variceal bleeding in nonresponders to the usual somatostatin dose

OBJECTIVES

High dose of somatostatin infusion achieves a greater reduction of hepatic venous pressure gradient (HVPG) than the usual dose, and terlipressin decreases HVPG through mechanisms other than somatostatin. Our aim was to assess the hemodynamic effects of terlipressin and high somatostatin dose during acute variceal bleeding in nonresponders to the usual somatostatin dose.

METHODS

Hemodynamic studies were performed in 80 patients with cirrhosis and variceal bleeding during the first 3 days of admission. After baseline measurements, somatostatin was administered (250 microg/h with an initial bolus of 250 microg). Patients were considered responders when the HVPG decreased by >10% from baseline (n = 31). Nonresponders were randomized under double-blind conditions to a control group (n = 7), or to receive terlipressin (2 mg IV bolus, n = 22), or high dose of somatostatin (500 microg/h, n = 20). Final measurements were obtained 30 min later.

RESULTS

Terlipressin caused a decrease in HVPG (from 22.2 +/- 5 to 19.1 +/- 5.2, p < 0.01) and heart rate (p < 0.01), while mean arterial pressure increased (p < 0.01). High somatostatin dose also reduced HVPG (from 21.8 +/- 3.4 to 19.6 +/- 3.1, p < 0.01), although this decrease was more pronounced with terlipressin (15%+/- 9%vs 10%+/- 6% from baseline, p= 0.05). Both terlipressin and high somatostatin dose achieved a significantly higher rate of response than that in the control group. A decrease in HVPG >20% was observed in 36% of cases with terlipressin versus 5% with high somatostatin dose (p= 0.02).

CONCLUSIONS

In nonresponders to usual somatostatin dose, both terlipressin and high-dose of somatostatin infusion significantly decreased HVPG and increased the rate of hemodynamic responders. Such effects were greater with terlipressin. Both treatments may be an alternative when standard somatostatin fails.

Acute hemodynamic effects of octreotide and terlipressin in patients with cirrhosis: a randomized comparison

BACKGROUND

Octreotide and terlipressin are widely used in acute variceal hemorrhage to reduce the bleeding rate. They purportedly act by mesenteric arterial vasoconstriction, thus reducing portal venous flow (PVF) and portal pressure. Little is known about the immediate-early hemodynamic effects of these drugs.

AIM

To compare the acute hemodynamic effects of octreotide and terlipressin in patients with cirrhosis.

PATIENTS

Forty-two cirrhotic patients with a history of variceal bleeding were randomized to receive either octreotide 100 microg intravenous bolus followed by a continuous infusion at 250 microg/h (n = 21), or terlipressin 2 mg intravenous bolus (n = 21).

METHODS

Mean arterial pressure (MAP), heart rate (HR), hepatic venous pressure gradient (HVPG), and PVF, assessed by duplex Doppler ultrasonography, were measured before and at 1, 5, 10, 15, 20, and 25 min after the start of drug administration.

RESULTS

Octreotide markedly decreased HVPG (-44.5 +/- 17.8%) and PVF (-30.6 +/- 13.6%) compared to the baseline at 1 min (p < 0.05). Thereafter, both variables rapidly returned toward the baseline, and by 5 min, no significant differences in HVPG (-7.1 +/- 28.9%) and PVF (10.2 +/- 26.2%) were noted. A similar transient effect on MAP and HR was observed. Terlipressin significantly decreased HVPG (-18.3 +/- 11.9%) and PVF (-32.6 +/- 10.5%) at 1 min (p < 0.05) and sustained these effects at all time points. The effects on arterial pressure and HR were also sustained.

CONCLUSIONS

Octreotide only transiently reduced portal pressure and flow, whereas the effects of terlipressin were sustained. These results suggest that terlipressin may have more sustained hemodynamic effects in patients with bleeding varices.

Hemodynamic effects of endobronchial application of ornipressin versus terlipressin

BACKGROUND

Ornipressin and terlipressin, two ADH-derivates, are instilled endobronchially for bronchoscopy- related bleeding without sufficient evidence of efficacy, nor safety.

OBJECTIVES

To compare the immediate hemodynamic effects of ornipressin and terlipressin used for procedure-related bleeding during flexible bronchoscopy.

METHODS

This retrospective study included patients referred for flexible bronchoscopy who needed administration of ornipressin (15 patients) or terlipressin (15 patients) for procedure-related bleeding. Endobronchial ornipressin (5 IU) or terlipressin (0.5 mg) was administered through the bronchoscope when bleeding persisted for 2 min of continuous suction, or when bleeding was considered increasing in time or major. Hemodynamic data were collected before, during and after administration of either drug.

RESULTS

Biopsy-associated hemoptysis requiring medical treatment occurred in 110 (4.2%) of 2,592 bronchoscopies. After administration of ornipressin, no significant change in heart rate or blood pressure was observed. Following terlipressin instillation, heart rate increased from 93 +/- 17 to 101 +/- 22 b.p.m. (p = 0.03), and blood pressure decreased from 107 +/- 14 to 101 +/- 17 mm Hg (p = 0.04). Oxygen saturation under supplemental nasal oxygen was not different in both groups. None of the 110 patients died from bronchoscopy-related hemoptysis or needed further intervention to stop bleeding or prolonged monitoring because of hemodynamic instability.

CONCLUSIONS

In contrast to ornipressin, administration of terlipressin is associated with significant changes in heart rate and blood pressure. However, these changes are of minor clinical importance, and terlipressin can be safely given for bronchoscopy-associated bleeding.

Selective intra-arterial terlipressin infusion stops acute lower gastrointestinal bleeding: a case report and review of the literature

Acute gastrointestinal bleedings are considered clinical emergency events and implicate a difficult medical decision-making process, in particular in poor surgical candidates. Here, we report one case with acute lower gastrointestinal bleeding, for the first time, treated with selective intra-arterial infusion of terlipressin (triglycyl lysine-vasopressin), a long-acting vasopressin analogue. The patient was affected by lung adenocarcinoma with abdominal metastasis and presented severe lower intestinal bleeding. Using selective angiography, the middle colic artery was catheterized and terlipressin was infused as follows: 1.5 mg in bolus (21 microg/kg), then 1.5 mg (21 microg/kg) intra-arterially in 20 min, then 1.5 mg in bolus (21 microg/kg), determining the cessation of the lower gastrointestinal bleeding. Since no cases of intra-arterial selective infusion of terlipressin have been reported in the literature, terlipressin may represent a new useful tool in pharmaco-angiographic strategy. The present case should prompt its consideration for further clinical studies.

Clinical review: Vasopressin and terlipressin in septic shock patients

Vasopressin (antidiuretic hormone) is emerging as a potentially major advance in the treatment of septic shock. Terlipressin (tricyl-lysine-vasopressin) is the synthetic, long-acting analogue of vasopressin, and has comparable pharmacodynamic but different pharmacokinetic properties. Vasopressin mediates vasoconstriction via V₁ receptor activation on vascular smooth muscle. Septic shock first causes a transient early increase in blood vasopressin concentrations; these concentrations subsequently decrease to very low levels as compared with those observed with other causes of hypotension. Infusions of 0.01–0.04 U/min vasopressin in septic shock patients increase plasma vasopressin concentrations. This increase is associated with reduced need for other vasopressors. Vasopressin has been shown to result in greater blood flow diversion from nonvital to vital organ beds compared with adrenaline (epinephrine). Of concern is a constant decrease in cardiac output and oxygen delivery, the consequences of which in terms of development of multiple organ failure are not yet known. Terlipressin (one or two boluses of 1 mg) has similar effects, but this drug has been used in far fewer patients. Large randomized clinical trials should be conducted to establish the utility of these drugs as therapeutic agents in patients with septic shock.

Aberrant adrenal sensitivity to multiple ligands in unilateral incidentaloma with subclinical autonomous cortisol hypersecretion: a prospective clinical study

BACKGROUND

Incidentally discovered adrenal tumours are frequently associated with subclinical autonomous cortisol hypersecretion of unknown origin. Aberrant hormone receptors have been observed in case reports of overt Cushing's syndrome. The question arises as to whether such receptors may be present in the functioning adrenal incidentaloma, which is common and might be a subclinical stage of Cushing's syndrome.

PATIENTS AND METHODS

Twenty-one consecutive patients with a unilateral incidentaloma, the biochemical features of subclinical cortisol hypersecretion and/or the scintigraphic features of an autonomously functioning adrenal adenoma were investigated for plasma cortisol responses to various stimuli: upright posture, meal, combined hypothalamic-hormones, the vasopressin analogue terlipressin, glucagon, angiotensin II, the serotonin 5-HT4 agonist cisapride, and ACTH. Six normal controls were similarly investigated. All subjects were studied during 8 mg per day dexamethasone in order to avoid any ACTH-dependent variation of plasma cortisol.

RESULTS

The most constant responses in adrenal incidentalomas were observed after stimulation by terlipressin (18/20 patients, 28-415% cortisol increase) and cisapride (17/21 patients, 25-364% cortisol increase). Eighteen out of 21 patients responded to several stimuli (cortisol increase >or= 25%), and all responded to at least one stimulus other than ACTH, while such responses were absent in the controls. Plasma ACTH remained suppressed in all subjects throughout the study.

CONCLUSIONS

Aberrant membrane receptors detected by in vivo stimulation tests appear to be common in autonomously functioning unilateral adrenocortical adenomas. These receptors may be involved in the modulation of cortisol secretion in adrenal incidentaloma, with potential therapeutic consequences for the control of subclinical cortisol hypersecretion.

Terlipressin bolus induces systemic vasoconstriction in septic shock

OBJECTIVE

To report the use of a synthetic, long-acting, vasopressin analog, terlipressin, as an effective vasoconstrictor in septic shock.

DESIGN

Case report.

SETTING

A 22-bed pediatric intensive care unit in a tertiary referral center.

PATIENT

An 11-yr-old male with multiple-organism Gram-negative septic shock with high normal cardiac output as assessed by pulse contour analysis and low systemic vascular resistance despite norepinephrine infusion.

INTERVENTION

Two peripherally administered doses of terlipressin (0.5 mg).

MEASUREMENTS AND MAIN RESULTS

Each dose of terlipressin was associated with a rapid increase in systemic vascular resistance, despite weaning and discontinuation of norepinephrine infusion from 0.15 microg.kg(-1).min(-1) lasting approximately 6 hrs.

CONCLUSION

Terlipressin may be useful for sepsis-induced vasodilation.

Terlipressin as rescue therapy for intractable hypotension during neonatal septic shock

OBJECTIVE

To report the successful use of terlipressin in an 8-day-old infant for treatment of intractable hypotension caused by septic shock.

DESIGN

Descriptive case report.

SETTING

An 18-bed pediatric intensive care unit at a tertiary care children's hospital.

PATIENT

An 8-day-old child with intractable hypotension due to septic shock after heart surgery.

INTERVENTIONS

General supportive intensive care including mechanical ventilatory support, volume replacement, and inotropic support with dopamine 20 microg.kg(-1).min(-1), milrinone 0.75 microg.kg(-1).min(-1), and epinephrine 0.8 microg.kg(-1).min(-1).

MEASUREMENTS AND MAIN RESULTS

Terlipressin (7 microg/kg per dose twice daily) was added as rescue therapy because of profound intractable hypotension. Shortly after the beginning of treatment, blood pressure and perfusion dramatically improved.

CONCLUSIONS

There is circumstantial evidence that the administration of terlipressin caused the increase in blood pressure. We suggest that terlipressin should be considered as rescue therapy when high-dose catecholamine therapy does not result in sufficient perfusion pressure. Further investigation is needed to prove terlipressin's effectiveness and safety in infants and children.

Is spontaneous bacterial peritonitis an inducer of vasopressin analogue side-effects? A case report

In recent years, the use of vasopressin analogues in the treatment of hepatorenal syndrome has become an effective therapeutic strategy leading to improved survival and often allowing the completion of liver transplantation. Terlipressin, in particular, has proven to be safe and effective. Due to the limited number of patients treated so far, it is, however, difficult to draw any definite conclusions on the optimal dosage and on the occurrence of side-effects in these patients. The case is reported of an ascitic cirrhotic patient who developed spontaneous bacterial peritonitis followed by a type-I hepatorenal syndrome. Treatment with terlipressin boluses (0.5 mg/4 h) associated with albumin infusion was then started. The course of the disease was monitored by clinical and laboratory means. After 10 boluses of terlipressin, rectorrhagia and severe ischaemic complications involving the skin of the abdomen, lower limbs, scrotus, and penis, occurred. These ischaemic complications improved after terlipressin withdrawal, while renal failure evolved leading to the patient's death. This case report shows that, in patients with type-I hepatorenal syndrome, the use of terlipressin, even at low dosages, may induce life-threatening ischaemic complications and, moreover, suggests that the recent occurrence of spontaneous bacterial peritonitis, even if properly treated, may significantly increase the risk of major ischaemic complications.

[Vasodilatory septic shock refractory to catecholamines: is there a role for terlipressin?]

We report two patients in vasodilatory septic shock refractory to catecholamines in which a continuous infusion of terlipressin was associated with a dramatic increase in systemic arterial blood pressure and short-term survival. Low doses of terlipressin were sufficient in both cases (0.01-0.0 mg h(-1)) to restore blood pressure by increase of systemic vascular resistances. The haemodynamic response was immediate, long-acting, dose-dependent and reversible in a few hours when the drug administration was stopped. A further increase in terlipressin dose regimen markedly decreased cardiac performance. Terlipressin simultaneously induced vasoconstriction within the cutaneous vascular territory, leading to local skin necrosis. The splanchnic vascular territory seemed to be constricted in the same way. Further studies are needed to better understand and precise the role of terlipressin in the treatment of vasodilatory septic shock refractory to catecholamines.

Cyclooxygenase expression in splanchnic hyposensitivity to glypressin of bleeding portal hypertensive rats

BACKGROUND

Prostacyclin mediates, at least partly, the splanchnic vascular hyporesponsiveness to glypressin in bleeding portal hypertensive rats. This study investigated the relative contribution of cyclooxygenase-1 (COX-1) and cyclooxygenase-2 (COX-2) in the splanchnic hyposensitivity to glypressin in rats with portal hypertension induced by partial portal vein ligation (PVL).

METHODS

Fourteen days after the operation, the rats were divided into without- and with-bleeding groups. Three series of PVL rats were used to investigate (i). the haemodynamic effects of glypressin (0.07 mg x kg(-1) intravenously), (ii). COX-1/COX-2 mRNA expression over abdominal aorta and superior mesenteric artery and (iii). plasma levels of 6-keto-prostaglandin-F1alpha. In rats with a hypotensive haemorrhage, 4.5 mL of blood was withdrawn and 50% of the withdrawn blood was re-infused before blood and vessel sampling or the administration of glypressin.

RESULTS

Splanchnic hyposensitivity to glypressin was demonstrated in the haemorrhage-transfused PVL rats with enhanced COX-1 expression of superior mesenteric artery and increased plasma levels of 6-keto-prostaglandin-F1alpha. There were no differences in the COX-2 expression of superior mesenteric artery and COX-1 and COX-2 expressions of abdominal aorta between without- and with-bleeding groups.

CONCLUSION

In portal hypertensive rats with acute haemorrhage, COX-1 over-expression in the superior mesenteric artery plays a role in mediating the splanchnic hyposensitivity to glypressin.

Terlipressin dose response in healthy and endotoxemic sheep: impact on cardiopulmonary performance and global oxygen transport

OBJECTIVE

To determine whether a goal-directed terlipressin infusion increases mean arterial pressure without causing a pulmonary vasopressive effect and whether this response impacts on key parameters of oxygen transport in healthy and endotoxemic sheep.

DESIGN AND SETTING

Prospective controlled trial in a university research laboratory.

ANIMALS AND INTERVENTIONS

Six conscious adult ewes instrumented for chronic study received terlipressin as titrated infusion started with 10 microg x kg(-1) x h(-1) and increased by 5 microg x kg(-1) x h(-1) every 15 min, either until mean arterial pressure was increased by 15 mmHg from baseline, or a maximum of 40 microg x kg(-1) x h(-1) was given. Following 24 h of recovery sepsis was induced and maintained in the same ewes by a continuous infusion of endotoxin ( Salmonella typhosa, 10 ng x kg(-1) min(-1)). After 16 h of endotoxemia the sheep were again treated with terlipressin.

MEASUREMENTS AND RESULTS

Systemic oxygen delivery and consumption were calculated before and after the titration period; hemodynamic parameters were measured every 15 min. The increase in mean arterial pressure was greater during endotoxemia than in healthy controls. In both states terlipressin administration decreased cardiac index and diminished oxygen delivery and consumption. While mean pulmonary arterial pressure remained constant, terlipressin increased the pulmonary vascular resistance index in endotoxemic sheep.

CONCLUSIONS

During ovine endotoxemia titrated terlipressin reversed hypotension but impaired the pulmonary circulation. The observed decrease in oxygen delivery may carry the risk of tissue hypoxia especially in sepsis, where oxygen demand is typically increased.

Terlipressin therapy with and without albumin for patients with hepatorenal syndrome: results of a prospective, nonrandomized study

Vasopressin analogues associated with albumin improve renal function in hepatorenal syndrome (HRS). The current study was aimed at assessing the efficacy of the treatment, predictive factors of response, recurrence of HRS, and survival after therapy. Twenty-one consecutive patients with HRS (16 with type 1 HRS, 5 with type 2 HRS) received terlipressin (0.5-2 mg/4 hours intravenously) until complete response was achieved (serum creatinine level < 1.5 mg/dL) or for 15 days; 13 patients received intravenous albumin together with terlipressin. Twelve of the 21 patients (57%) showed complete response. Albumin administration was the only predictive factor of complete response (77% in patients receiving terlipressin and albumin vs. 25% in those receiving terlipressin alone, P =.03). Treatment with terlipressin and albumin was associated with a remarkable decrease in serum creatinine level, increase in arterial pressure, and suppression of the renin-aldosterone system. By contrast, no significant changes in these parameters were found in patients treated with terlipressin alone. Only 1 patient showed ischemic adverse effects. Recurrence of HRS occurred in 17% of patients with complete response. The occurrence of complete response was associated with an improved survival. In conclusion, terlipressin therapy reverses HRS in a high proportion of patients. Recurrence rate after treatment withdrawal is uncommon. Albumin appears to improve markedly the beneficial effects of terlipressin.