## Drug of Choice for Acute Variceal Bleeding **Key Point:** Terlipressin is the first-line vasoconstrictor for acute variceal bleeding in cirrhosis and is superior to octreotide in reducing mortality. ### Mechanism of Action Terlipressin is a selective vasopressin V1-receptor agonist that: 1. Causes splanchnic vasoconstriction → reduces portal pressure 2. Has minimal systemic vasoconstrictive effects compared to vasopressin 3. Has a longer half-life (4–6 hours) than octreotide (8–10 minutes) ### Comparative Efficacy | Drug | Mechanism | Mortality Reduction | Systemic Effects | Half-life | | --- | --- | --- | --- | --- | | **Terlipressin** | V1 agonist | Yes (proven) | Minimal | 4–6 hours | | Octreotide | Somatostatin analog | No (unproven) | Minimal | 8–10 min | | Propranolol | β-blocker | No (prophylaxis only) | Systemic | Long | | Nitrates | Vasodilator | No (adjunct only) | Systemic | Short | **High-Yield:** Terlipressin is the ONLY vasoconstrictor with proven mortality benefit in acute variceal bleeding (Baveno VI consensus). ### Clinical Application **Dosing:** Terlipressin 2 mg IV bolus, then 1 mg IV every 4–6 hours for up to 48 hours or until bleeding is controlled. **Adjunct:** Always combined with: - Endoscopic variceal ligation (EVL) — gold standard for esophageal varices - Blood product transfusion (target Hb 7–9 g/dL to avoid rebleeding) - Prophylactic antibiotics (ceftriaxone 1 g daily × 7 days) **Clinical Pearl:** Terlipressin should be started immediately upon clinical suspicion of variceal bleeding, even before endoscopy, as it reduces ongoing hemorrhage and improves outcomes. **Warning:** Terlipressin is contraindicated in coronary artery disease and uncontrolled hypertension due to systemic vasoconstriction risk. [cite:Harrison 21e Ch 297]
Sign up free to access AI-powered MCQ practice with detailed explanations and adaptive learning.