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Gastrointestinal Emergency Pregnancy: Contraindicated in pregnancy — uterotonic and vasopressor effects; risk of foetal ischaemia

Terlipressin

Brand names: Glypressin, Variquel

Adult dose

Dose: 2 mg every 4 hours (body weight above 50 kg); 1 mg every 4 hours (body weight 35–50 kg)
Route: IV bolus
Frequency: Every 4 hours for up to 72 hours
Max: 2 mg per dose
Reduce to 1 mg every 4 hours once bleeding controlled. For hepatorenal syndrome: 0.5–1 mg every 4–6 hours with IV albumin 20–40 g/day

Paediatric dose

Dose: Seek specialist opinion N/A/kg
Route: IV
Frequency: N/A
Max: N/A
Not established in paediatrics; seek specialist hepatology opinion

Dose adjustments

Renal

Use with caution — HRS treatment requires careful monitoring; no specific dose reduction but HRS-related changes alter handling

Hepatic

Use in advanced cirrhosis is the primary indication; monitor for systemic ischaemia more carefully in Child-Pugh C

Paediatric weight-based calculator

Not established in paediatrics; seek specialist hepatology opinion

Clinical pearls

  • Mechanism: synthetic vasopressin analogue — vasoconstricts splanchnic circulation by V1 receptor activation, reducing portal pressure and variceal blood flow; prodrug converted to lysine-vasopressin
  • Variceal haemorrhage: BAVENO VII consensus — terlipressin + endoscopic band ligation is standard of care; start immediately in ED before endoscopy; continue for up to 72 hours post-endoscopy; reduces mortality vs placebo
  • Hepatorenal syndrome (HRS-AKI): terlipressin + albumin — CONFIRM trial NEJM 2021 showed reversal of HRS-1 in 32% vs 17% placebo; target is to reverse renal dysfunction
  • MHRA 2021: new warning about respiratory failure, particularly in patients with ACLF (acute-on-chronic liver failure); discontinue if SpO2 falls
  • Avoid in ACLF grade 3 — high mortality risk without proportionate HRS benefit; use clinical judgement
  • Timing: initiate in ED as soon as variceal haemorrhage suspected — do not wait for endoscopy confirmation; pair with prophylactic antibiotics (ceftriaxone 1 g/day)

Contraindications

  • Ischaemic heart disease, peripheral arterial disease, mesenteric ischaemia
  • Bradycardia or prolonged QT
  • Hyponatraemia below 130 mEq/L (relative — worsens with fluid overload)
  • Pregnancy
  • Asthma (bronchospasm risk)

Side effects

  • Abdominal cramps and diarrhoea (smooth muscle contraction)
  • Pallor, facial flushing
  • Hypertension
  • Bradycardia
  • Chest pain and myocardial ischaemia
  • Peripheral limb ischaemia
  • Hyponatraemia
  • Respiratory failure (rare)

Interactions

  • Beta-blockers (additive bradycardia — monitor ECG)
  • Drugs prolonging QT (additive — check ECG)
  • Moxifloxacin, haloperidol (QTc prolongation)

Monitoring

  • ECG (QT prolongation, bradycardia, ischaemia)
  • Blood pressure
  • SpO2 and respiratory status (respiratory failure MHRA warning)
  • Serum sodium
  • Renal function and urine output (HRS monitoring)
  • Clinical signs of ischaemia

Reference: BNFc; BNF 90; BAVENO VII Consensus; CONFIRM trial NEJM 2021;384(9):818-828; MHRA 2021 DSU; BSG Guidelines on Variceal Haemorrhage. Verify against your local formulary and the latest BNF before prescribing.

Related

Curated clinical cross-links plus same-class fallbacks.

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