Comparison of 1‐day versus 3‐day intravenous terlipressin in cirrhosis patients with variceal bleeding: A pilot randomised controlled trial

Abstract

SummaryBackgroundIn cirrhosis patients with acute variceal bleeding (AVB), the optimal duration of vasoconstrictor therapy after endoscopic haemostasis is unclear.AimsWe aimed to compare efficacy of 1‐day versus 3‐day terlipressin therapy in cirrhosis patients with AVB post‐endoscopic intervention. The primary objective was to compare rebleeding at 5 days between the two arms. Secondary objectives included rebleeding and mortality rates at 6 weeks.MethodsIn this open‐label, randomised controlled trial, cirrhosis patients with AVB were randomised to either 1‐day or 3‐day terlipressin therapy.ResultsA total of 150 cirrhosis patients with AVB were recruited to receive either 1 day (n = 75) or 3 days (n = 75) of terlipressin therapy. One patient from 1‐day arm was excluded. Modified intention‐to‐treat analysis included 149 patients. Baseline characteristics were comparable between the two groups. Rebleeding at 5 days: 3 (4.1%; 95% confidence interval [CI]: 0.4–9.0) versus 4 (5.3%; 95% CI: 2.0–10.0), risk difference (RD) p = 0.726 and 5‐day mortality rates: 1 (1.4%; 95% CI: 0–7.3) versus 1 (1.3%; 95% CI: 0.2–7.0), RD p = 0.960 were similar. Rebleeding at 42 days: 9 (12.2%; 95% CI: 7.0–20.0) versus 10 (13.3%; 95% CI: 7.0–20.0), RD p = 0.842 and mortality at 42 days: 5 (6.8%; 95% CI: 3.0–10.0) versus 4 (5.3%; 95% CI: 2.0–10.0), RD p = 0.704 were also similar. Patients in the 1‐day terlipressin therapy arm experienced significantly fewer adverse effects compared with those receiving 3 days of terlipressin therapy: 28 (37.8%) versus 42 (56%), p = 0.026.ConclusionsOur results suggest that 1 day of terlipressin therapy is associated with similar 5‐day and 42‐day rebleeding rates, 42‐day mortality and an overall superior safety profile compared with 3‐day of terlipressin therapy. These findings require to be validated in double‐blinded, larger, multiethnic and multicentre studies across the various stages of cirrhosis (CTRI/2019/10/021771).

Letter: Shorter duration of intravenous terlipressin for variceal bleeding in patients with cirrhosis—A promising find. Author's reply

“…We thank Nedumannil et al 1 for their comments on our clinical trial. 2 In recent times, there has been a change in the management protocols of acute variceal bleeding (AVB) in cirrhosis proposed by various expert societies, promoting abbreviated courses of vasoactive (VA) therapy in a select subgroup of patients with liver cirrhosis. 3 Multiple clinical trials have shown the efficacy of a shorter duration of VA drugs to be similar to that of a conventionally accepted duration of 3-5 days, in terms of rebleeding rates and 6-week mortality.…”