AGA Clinical Practice Update on the Use of Vasoactive Drugs and Intravenous Albumin in Cirrhosis: Expert Review

Editorial: Shorter course of intravenous terlipressin in acute variceal bleeding ‐ the promise, controversies and future directions

“…Acute variceal bleeding (AVB) is a medical emergency with a 6-week mortality ranging between 7% and 43% in cirrhosis patients. 1 The primary goals in managing AVB are to reduce 6-week mortality, early rebleeding and the length of hospitalisation. Current guidelines recommend vasoactive therapy (terlipressin, octreotide or somatostatin) to be administered for 2-5 days in the setting of AVB 2 ; however, the optimal treatment duration remained debatable because earlier randomised trials were underpowered.…”

“…8 Due to safety concern, the recent AGA practice update recommended octreotide over terlipressin as the first-line vasoactive agent in AVB. 1 Overall, the utility of terlipressin…”

Editorial: Shorter course of intravenous terlipressin in acute variceal bleeding—the promise, controversies and future directions. Author's reply

“…This, coupled with a reduced duration of VA drug therapy, could potentially facilitate earlier patient mobilisation. 6,9 There is a need for larger, multicentric studies with stratified randomisation to identify individuals who would benefit from such an approach.…”

“…This could further support the recommendations made by the Baveno group and the recent AGA guidance. 6,9…”

“…5 As a result, there is a shift towards the use of somatostatin or octreotide, which have a better safety profile. 6 Nevertheless, the pharmacokinetics of octreotide may lead to tachyphylaxis and desensitisation with prolonged use, resulting in short-lasting effects on portal pressures compared to terlipressin. 7 As endoscopic band ligation (EBL) is a very effective modality of endotherapy, an abbreviated duration of VA drug therapy may be sufficient to control variceal bleeding prior to endoscopic management, with no further need for VA drug therapy after haemostasis is achieved.…”