Norepinephrine better than Terlipressin in Septic Shock

Liu ZM, Chen J, Kou Q et el published results of a randomized trial in intensive care medicine comparing Terlipressin with Norepinephrine in septic shock.


Norepinephrine (NE) is first line recommended agent for correcting hypotension in septic shock. Terlipressin is a synthetic long acting analogue of Vasopressin which has higher affinity for V1 receptor. A meta analysis of recent trials suggested that Terlipressin may be better than NE.


617 patients of adult septic shock were randomized to NE or Terlipressin. Patients with malignancy, mesenteric or coronary ischemia, pregnancy were excluded.  Trial conducted in 11 hospitals in China from 2013 to 2016. No difference in baseline characteristics  of two groups.


Terlipressin (0.02 mg  per ml)  and Norepinephrine (0.22 mg per ml) in 5% Dextrose were used. Both medications were odorless and transparent. Each was started 1 ml/ hr and titrated to achieve target blood pressure. This way, Terlipressin was started at 20 microgram /hr with maximum dose of 160 microgram /hr. NE was started at 4 microgram / hr with a maximum of 30 microgram /hr.  If target was not achieved, open label NE was used.


Mortality at 28 days.


Change in SOFA scores at day 7, vasopressor free days and days alive at 28 days. Also , all adverse events.


No difference in mortality in two groups at 28 days. Patients in the terlipressin group had a higher number of serious adverse events(30% vs 12% p= <0.0001).  Most common was digital ischemia, followed by diarrhea.

No difference in terms of serious arrhythmia, hyponatremia and intestinal ischemia.


Terlipressin use in septic shock is associated with more adverse effects such as digital ischemia and diarrhea without improvement in mortality.

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