Vasopressin and terlipressin in adult vasodilatory shock: a systematic review and meta-analysis of nine randomized controlled trials

Abstract

IntroductionCatecholamines are the most used vasopressors in vasodilatory shock. However, the development of adrenergic hyposensitivity and the subsequent loss of catecholamine pressor activity necessitate the search for other options. Our aim was to evaluate the effects of vasopressin and its analog terlipressin compared with catecholamine infusion alone in vasodilatory shock.MethodsA systematic review and meta-analysis of publications between 1966 and 2011 was performed. The Medline and CENTRAL databases were searched for studies on vasopressin and terlipressin in critically ill patients. The meta-analysis was limited to randomized controlled trials evaluating the use of vasopressin and/or terlipressin compared with catecholamine in adult patients with vasodilatory shock. The assessed outcomes were: overall survival, changes in the hemodynamic and biochemical variables, a decrease of catecholamine requirements, and adverse events.ResultsNine trials covering 998 participants were included. A meta-analysis using a fixed-effect model showed a reduction in norepinephrine requirement among patients receiving terlipressin or vasopressin infusion compared with control (standardized mean difference, -1.58 (95% confidence interval, -1.73 to -1.44); P < 0.0001). Overall, vasopressin and terlipressin, as compared with norepinephrine, reduced mortality (relative risk (RR), 0.87 (0.77 to 0.99); P = 0.04). Vasopressin compared with norepinephrine decreased mortality in adult patients (RR, 0.87 (0.76 to 1.00); P = 0.05) and in patients with septic shock (42.5% vs. 49.2%, respectively; RR, 0.87 (0.75 to 1.00); P = 0.05; number needed to treat, 1 to 15). There was no difference in adverse events between the vasopressin and control groups (RR, 0.98 (0.65 to 1.47); P = 0.92).ConclusionsVasopressin use in vasodilatory shock is safe, associated with reduced mortality, and facilitates weaning of catecholamines. In patients with septic shock, use of vasopressin compared with norepinephrine may also decrease mortality.

Septic Shock

“…The administration of vasopressin can reduce norepinephrine dose and has been found to be safe, albeit with no mortality benefit, in subsequent meta-analyses. 57,58 Consensus guidelines suggest vasopressin at a fixed dose (0.03–0.04 U/min) in patients without contraindication who are taking a norepinephrine dose of at least 0.15 μg/kg/minute. There may be select indications for alternative vasopressors such as when tachyarrythmias, limb ischemia, or other adverse effects dictate.…”

Vasopressin and terlipressin in adult vasodilatory shock

“…We have read with interest the study by Serpa Neto and colleagues showing that vasopressin use in vasodilatory shock is associated with reduced mortality [1]. However, we believe there are three aspects that need clarification.…”

“…In relation to the paper recently published by our group on the same topic, the authors correctly state that 'we only analyzed adult patients because pediatric shock has a much lower mortality that adult shock and this may "contaminate" the overall results' [1]. For the main analysis in our article, we computed data from six randomized trials exploring use of vasopressin/terlipressin only in adults [2].…”

Scandinavian SSAI clinical practice guideline on choice of first‐line vasopressor for patients with acute circulatory failure

“…3, Table S5C) 24. Of note, an increased risk of dysrhythmias in patients treated with norepinephrine was suggested (Fig.…”