Vasopressin Analogue (V1 Receptor Agonist) Pregnancy: Contraindicated in pregnancy (§4.3, §4.6). Terlipressin has been shown to cause uterine contractions and increased intrauterine pressure in early pregnancy and may decrease uterine blood flow; it may have harmful effects on pregnancy and the foetus, and spontaneous abortion and malformation have been shown in rabbits. Breast-feeding: it is not known whether terlipressin is excreted in human breast milk and excretion in milk has not been studied in animals — a risk to the suckling child cannot be excluded, so a decision to continue/discontinue breast-feeding or therapy should weigh the benefit of each.

Terlipressin

Brand names: Glypressin, Terlipressin acetate

Used in: Liver Disease & Cirrhosis Gastrointestinal Bleeding

Terlipressin is a synthetic vasopressin analogue used in critical care chiefly for bleeding oesophageal varices and for hepatorenal syndrome.

Auto-extracted from the source labelling — not yet independently clinician-verified. These values were distilled from the UK SPC (or the US label where noted) but have not had a clinician sign-off. Confirm against the current SmPC before prescribing.

Adult dose

Dose: Acute variceal bleeding: initially 2 mg by intravenous injection every 4 hours

Route: Intravenous injection (the injection must be given i.v. to avoid local necrosis at the injection site)

Frequency: Every 4 hours

Max: Treatment should be maintained until bleeding has been controlled for 24 hours, but up to a maximum of 48 hours

Source: UK SPC (eMC) for Terlipressin Acetate 0.12 mg/mL solution for injection (Glypressin), §4.2 (https://www.medicines.org.uk/emc/product/101175/smpc). The only indication with a posology in the fetched §4.2 is ACUTE VARICEAL BLEEDING. DOSE ADJUSTMENT: after the initial dose, the dose can be adjusted to 1 mg i.v. every 4 hours in patients with body weight < 50 kg or if adverse effects occur. MONITORING (§4.4): regular monitoring of blood pressure, ECG or heart rate, oxygen saturation, serum sodium and potassium, and fluid balance is required. Particular care is needed in patients with cardiovascular or pulmonary disease since terlipressin may induce ischaemia and pulmonary vascular congestion; exercise caution in hypertension. Should NOT be used in patients with septic shock with a low cardiac output. Cutaneous ischaemia and necrosis unrelated to the injection site have been reported post-marketing, with a greater tendency in patients with diabetes mellitus and obesity. QT prolongation and ventricular arrhythmias including torsade de pointes have been reported — exercise extreme caution in patients with a history of QT prolongation, electrolyte abnormalities, or concomitant QT-prolonging medicines. ELDERLY AND CHILDREN: particular caution is required as experience is limited, and there are NO data available on dosage recommendations in these groups. PAEDIATRIC: §4.2 states there is no relevant use of Glypressin in the paediatric population — no paediatric dose is given. CROSS-REFERENCE ONLY, DIFFERENT INDICATION AND PRODUCT — the US label in this bundle (TERLIVAZ, Mallinckrodt) is for hepatorenal syndrome, not variceal bleeding, and gives a different regimen: 0.85 mg (1 vial) intravenously every 6 hours by slow IV bolus over 2 minutes on Days 1-3, then on Day 4 assess serum creatinine (SCr) against baseline — if SCr has fallen by at least 30% continue 0.85 mg every 6 hours; if by less than 30% the dose may be increased to 1.7 mg (2 vials) every 6 hours; if SCr is at or above baseline, discontinue. Continue until 24 hours after two consecutive SCr <= 1.5 mg/dL values at least 2 hours apart, or a maximum of 14 days. Obtain baseline SpO2 before the first dose, monitor with continuous pulse oximetry, and do not use in hypoxic patients until hypoxia resolves. Do NOT transfer that US hepatorenal-syndrome regimen to variceal bleeding without clinician sign-off.

Dose auto-extracted from UK Summary of Product Characteristics (SPC) via the eMC; US FDA prescribing information (openFDA / DailyMed) — cross-check; US labelling may differ from UK — not yet clinician-verified. Always confirm against the product SmPC and your local formulary before prescribing.

Contraindications

Contraindicated in pregnancy
Hypersensitivity to terlipressin or to any of the excipients
Should not be used in patients with septic shock with a low cardiac output (§4.4)
US label (TERLIVAZ) additionally contraindicates use in patients experiencing hypoxia or worsening respiratory symptoms, and in patients with ongoing coronary, peripheral or mesenteric ischaemia

Side effects

Most frequently reported in clinical trials: abdominal pain, nausea, diarrhoea, pallor, vomiting and bradycardia
Vascular: vasoconstriction, peripheral ischaemia, pallor, hypertension, cyanosis, hot flush
Cardiac: chest pain, bradycardia, tachycardia, atrial fibrillation, myocardial infarction, torsade de pointes, cardiac failure, ventricular extrasystoles
Respiratory: pulmonary oedema, dyspnoea, respiratory failure, respiratory distress
Skin: skin necrosis unrelated to the site of administration; injection site necrosis
Other: hyponatraemia, headache, intestinal ischaemia, uterine hypertonus, uterine ischaemia

Interactions

Non-selective beta-blockers — the hypotensive effect on the portal vein is increased with terlipressin
Medicinal products with a known bradycardic effect (e.g. propofol, sufentanil) — concomitant treatment may lower heart rate and cardiac output (reflexogenic vagal inhibition of cardiac activity due to elevated blood pressure)
QT-prolonging medicines such as class IA and III antiarrhythmics, erythromycin, certain antihistamines and tricyclic antidepressants — extreme caution, as terlipressin can trigger torsade de pointes
Medicines that may cause hypokalaemia or hypomagnesaemia (e.g. some diuretics) — extreme caution for the same reason

Clinical monograph

How it works

As a long-acting vasopressin (V1 receptor) agonist it causes splanchnic vasoconstriction, reducing portal venous inflow and pressure and improving effective circulating volume in hepatorenal syndrome.

Prescribing in practice

Its vasoconstrictor action can precipitate myocardial, mesenteric, or peripheral ischaemia and significant hyponatraemia, so use cautiously in patients with vascular or ischaemic heart disease.
It is used alongside endoscopic therapy and antibiotic prophylaxis in variceal bleeding rather than as sole treatment.
Monitoring for fluid balance disturbance and electrolyte shifts, particularly sodium, is important during therapy.

Monitoring

Monitor blood pressure, heart rate, serum sodium, fluid balance, and for signs of ischaemia (cardiac, peripheral, and mesenteric) throughout treatment.

Counselling the patient

Explain to the team that serum sodium can fall and should be checked during treatment.
Advise reporting chest pain, abdominal pain, or peripheral colour change promptly as possible ischaemia.
Note that terlipressin is part of a wider bleeding-control plan including endoscopy and antibiotics.

Evidence & guidelines

Terlipressin is recommended for acute variceal haemorrhage and hepatorenal syndrome in UK and international hepatology guidance, used in combination with endoscopic and antibiotic measures.

Reference: CONFIRM trial (Wong et al. NEJM 2021); TACTICS trial (Cavallin et al. J Hepatol 2016); MHRA SPC Glypressin; EASL Clinical Practice Guidelines: Acute-on-Chronic Liver Failure 2023; Drug verified in RxNorm (NLM); confirm dosing against the manufacturer SPC (eMC). Verify against your local formulary and current prescribing references before prescribing. The structured dose values shown have been reviewed by a clinician. Monograph status: clinician-reviewed (2026-07-04).

Curated clinical cross-links plus same-class fallbacks.

Calculators

Myasthenia Gravis Activities of Daily Living (MG-ADL) Scale · Neuromuscular