Terlipressin has Stood the Test of Time

Clinical Overview in 2020 and Future Perspectives

Anand V. Kulkarni; Juan Pablo Arab; Madhumita Premkumar; Carlos Benítez; Sowmya Tirumalige Ravikumar; Pramod Kumar; Mithun Sharma; Duvvuru Nageshwar Reddy; Douglas A. Simonetto; Padaki Nagaraja Rao


Liver International. 2020;40(12):2888-2905. 

In This Article

Future Research

Endothelin-1/Nitric oxide ratio aid in predicting response to terlipressin therapy.[103] Urinary values of neutrophil gelatinase-associated lipocalin (NGAL), interleukin-18 (IL-18), kidney injury molecule-1 (KIM-1), liver type fatty acid-binding protein (L-FABP) and albumin can aid in differentiating AKI caused by ATN from non-ATN.[104,105] But none of these biomarkers has been assessed to predict response to terlipressin therapy. More extensive studies are required to ascertain the role of such simple biomarkers in predicting terlipressin response. Studies on the use of terlipressin as an add-on therapy for norepinephrine can be assessed in cirrhotic patients with septic shock. Although previous studies have evaluated the terlipressin response in ACLF with AKI. No studies have compared the response to terlipressin in Western and Eastern ACLF patients with HRS-AKI.[106] Sarcopenia is an important predictor of outcome in cirrhotic patients undergoing liver transplant.[107] Long-term continuous terlipressin infusion (for 51 days) improves the calorie intake and muscle mass in pretransplant patients.[108] The plausible mechanisms proposed are as follows: sustained reduction in portal pressure reduces the gut mucosal oedema, reduces bacterial translocation and associated endotoxemia.[108] This leads to an increase in the enteral absorptive capacity and a decrease in the protein catabolism. Furthermore, terlipressin reduced the paracentesis frequency, thereby preventing protein loss.[108] The study highlighted the importance of continuous terlipressin infusion through an elastomeric infusion pump that may be utilised for refractory ascites and HRS-2. Large, well-conducted randomised trials are required to validate the utility of elastomeric infusion pumps. The role of terlipressin may be evaluated in PoPH and hydrothorax. Terlipressin is a very short-acting drug. Conjugated terlipressin/depot formulations of terlipressin may be developed for HRS-2, and refractory ascites patients. A combination of low-dose terlipressin and midodrine can (to increase the MAP) be used to reduce the terlipressin-related side effects in HRS.