Friday, December 11, 2020

Administration Guide : Terlipressin

TERLIPRESSIN  1 MG INJECTION

HIGH ALERT MEDICATION

ROUTE

DILUTION

RUN RATE

INTRAVENOUS Bolus

Undiluted 1

Over 1 min 2,3,6

INTRAVENOUS Infusion

 

(Typically for Type 1 Hepatorenal Syndrome)

In studies, 1-3 mg was taken and diluted in (qs up to) 50 mL D5

Run over 24 hrs

 

Run rate = 2.08 mL/hr

1 mg in 50 mL D5 = 0.02 mg/mL 7

2 mg in 50 mL D5 = 0.04 mg/mL 8,9

3 mg in 50 mL D5 = 0.06 mg/mL 10

DILUENT

Usually NOT required

If further dilution is required, suggest to use D5 (better stability than NS) 7

STABILITY

Unopened: Store at 2-8°C in original packaging 1,4,5

Stability: Use immediately 2,4 , however, solution of 2mg/50ml has been shown to be stable for up to 24 hrs at room temperature.11

REMARKS

§ Caution: Hypertension, atherosclerosis, cardiac dysrhythmias or coronary insufficiency. 4

§ Contraindication: unstable angina, recent MI, septic shock with low cardiac output, pregnancy. 5

DOSE

1 mg terlipressin acetate = 0.85 mg terlipressin free base ; typical dosing is based on terlipressin acetate

 

Bleeding Oesophageal Varices 1,3-5

* Initial dose: IV 2 mg STAT or 2 mg q4-6h until bleeding has been controlled for at least 24 hours or up to 36-72 hours. Some manufacturers provide dosage adjustments based on body weight: 2,5,6

< 50 kg = 1 mg

50-70 kg = 1.5 mg

> 70 kg = 2 mg

 * Maintenance dose: 1-2 mg q4-6h for 2-5 days (typically 1 mg/dose).

 * Notes from other references:

·         After the initial dose, may consider reduce dose to 1 mg q4h for those with body weight <50 kg or if adverse effects occur. 1

·         From FUKKM: Maximum daily dosage: 120-150 mcg/kg body weight. 2,3

 

Type 1 Hepatorenal Syndrome (Off label)1

ü  DO NOT USE SURGICAL STOCK unless authorised by HKGU surgeon.

ü  Need to obtain approval for Ubat Kelulusan Khas (UKK) / KPK for both terlipressin and human albumin.

*1 mg QID via slow bolus inj, may be increased up to max 2 mg 4-6 hourly if serum creatinine has not been reduced by at least 25% after 3 days. Max duration of treatment: 2 weeks.5

*Increasing evidence has shown that continuous infusion demonstrating a similar rate of response (more stable lowering effect on portal pressure) but lower adverse effects than the administration of the drug by i.v. boluses.8


Shock (Off label) 4

1-2 mg of terlipressin acetate by IV injection produced a progressive increase in mean arterial pressure over 10-20 minutes, that was sustained at least 5 hours, allowing reduction or cessation of noradrenaline therapy. 4

REFERENCES

1.          Product leaflet (GLYPRESSIN - Ferring)

2.          https://www.drugs.com/uk/terlipressin-acetate-1-mg-solution-for-injection-leaflet.html [Accessed 16 Nov 2020]

3.          Formulari Ubat Kementerian Kesihatan Malaysia: Online [Accessed 16 Nov 2020]

4.          Alistair G., Jane W., Vincent G., Lynn B. Injectable Drugs Guide. London:(PhP) Pharmaceutical Press

5.          Mimsgateway: Drug Information: Terlipressin [ Accessed 17 Nov 2020]

6.          UptoDate [Multi Drug National] : Drug Information: Terlipressin [Acessed 17 Nov 2020]

7.          Rodriguez-Nunez et al. Terlipressin Continuous Infusion: Please Mind the Solvent! Current Drug Targets, 2009, Vol. 10, No. 6 577

8.          Cavallin M et al. Terlipressin Given by Continuous Intravenous Infusion Versus Intravenous Boluses in the Treatment of Hepatorenal Syndrome: A Randomized Controlled Study. Hepatology, Vol.63, No.3, 2016.

9.          Angeli P et al. Switch therapy with ciprofloxacin vs. intravenous ceftazidime in the treatment of spontaneous bacterial peritonitis in patients with cirrhosis: similar efficacy at lower cost. Aliment Pharmacol Ther, 23, 75–84

10.      Hospital Selayang Terlipressin Administration Protocol [Accessed on 2 Dec 2020]

11.      An investigation of reconstituted terlipressin infusion stability for use in hepatorenal syndrome. Nature (2020) 10:21037. https://doi.org/10.1038/s41598-020-78044-4

12.      Jha et al. Comparison of continuous versus intermittent infusions of terlipressin for the control of acute variceal bleeding in patients with portal hypertension: An open-label randomized controlled trial. Indian Journal of Gastroenterology Vol. 37, pg 313–320(2018)


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