Two Observations Raising Questions about Risk Factors of Cutaneous Necrosis Induced by Terlipressin (Glypressin®)

Abstract

Introduction: Triglycyl lysine vasopressin (terlipressin, Glypressin®) is a potent vasoconstrictive drug which became popular because of its prolonged duration of action, ease of administration and lower incidence of side effects. Ischemic complications are rare but may be life threatening. Observations: Case 1, a 68-year-old man with alcoholic cirrhosis and hepatocellular carcinoma, was admitted due to acute functional renal failure. He was first treated for septic shock with intravenous catecholamines. He then developed hepatorenal syndrome and received terlipressin as intravenous bolus (4 mg/day). Three days later, he presented a diffuse purpuric and necrotic eruption with tongue ischemia. He died from Staphylococcus aureus infection. Case 2, a 74-year-old man with metastatic carcinoma, presented severe renal insufficiency. He developed sepsis and pseudohepatorenal syndrome, which was treated with terlipressin (0.5 mg/h) using an infusion pump. Four days later, he developed an isolated large erythematous and purpuric macular plaque of the scalp near skin metastases. The patient died a few weeks later from tumor progression. In both cases, skin biopsies showed ischemic necrosis caused by thrombosis of superficial dermal capillaries. Conclusion: These cases point to the risk of either widespread or localized necrosis. Although the precise incidence of these events as well as risk factors remain to be determined, hypovolemia, concomitant administration of vasoactive drugs and the mode of administration of terlipressin may influence the occurrence of these complications.

The role of vasoactive agents in the resuscitation of microvascular perfusion and tissue oxygenation in critically ill patients

“…Additional terlipressin to NE in septic shock was accompanied by a rise in bilirubin and aminotransferases [62], but not in pCO 2 g-a [63]. As with AVP, ischemic skin lesions are reported frequently [64].…”

The role of vasoactive agents in the resuscitation of microvascular perfusion and tissue oxygenation in critically ill patients

“…Additional terlipressin to NE in septic shock was accompanied by a rise in bilirubin and aminotransferases [62], but not in p CO 2 g-a [63]. As with AVP, ischemic skin lesions are reported frequently [64]. …”

Terlipressin-Induced Ischemic Skin Necrosis: A Rare Association

“…It can exert vasoconstrictor effects on the systemic circulation; serious ischemic complications are rare and include myocardial infarction, ischemic colitis, and skin necrosis [8–10]. In the English literature to date, terlipressin-induced skin necrosis have been reported in 20 cases, located on the abdominal wall, thigh, leg, calves, fingers, toes, tongue, scalp, scrotum, breast, and esophagus [11–14]. …”