The recommended dose should not be exceeded in any case, since the risk of severe circulatory adverse effects is dose-dependent.
An acute hypertensive crisis, especially in patients with recognized hypertension can be controlled with a vasodilator-type alpha-blocker, e.g. 150 microgram clonidine intravenously.
Bradycardia requiring treatment should be treated with atropine.
Treatment of bleeding oesophageal varices with Haemopressin Torrex (1 mg intravenously and more) may be accompanied by the adverse reactions in Table 1:
Table 1. Adverse reactions reported with treatment of bleeding oesophageal varices with terlipressin
| MedDRA System Organ Class | Adverse Reaction (Preferred Term) |
| Metabolism and nutrition disorders | |
| uncommon (>1/1.000 to <1/100) | hyponatraemia if fluid not monitored |
| very rare (<1/10.000) | hyperglycaemia |
| Nervous system disorders | |
| common (>1/100 to <1/10) | headache |
| uncommon (>1/1.000 to <1/100) | triggering of a convulsive disorder |
| very rare (<1/10.000) | stroke |
| Cardiac disorders | |
| common (>1/100 to <1/10) | ventricular and supra-ventricular arrhythmia, bradycardia, signs of ischaemia in the ECG |
| uncommon (>1/1.000 to <1/100) | angina pectoris, acute hypertension rise, in particular in patients already suffering from hypertension (generally, it decreases spontaneously), atrial fibrillation, ventricular extrasystoles, tachycardia, chest pain, myocardial infarction, fluid overload with pulmonary oedema, cardiac failure, Torsade de Pointes |
| very rare (<1/10.000) | myocardial ischemia |
| Vascular disorders | |
| common (>1/100 to <1/10) | hypertension, hypotension, peripheral ischaemia, peripheral vasoconstriction, facial pallor |
| uncommon (>1/1.000 to <1/100) | intestinal ischaemia, peripheral cyanosis, hot flushes |
| Respiratory, thoracic and mediastinal disorders | |
| uncommon (>1/1.000 to <1/100) | pain in the chest, bronchospasm, respiratory distress, respiratory failure |
| Rare (>1/10.000 to <1/1000) | dyspnoea |
| Gastrointestinal disorders | |
| common (>1/100 to <1/10) | transient abdominal cramps, transient diarrhoea |
| uncommon (>1/1.000 to <1/100) | transient nausea, transient vomiting |
| Skin and subcutaneous tissue disorders | |
| common (>1/100 to <1/10) | paleness |
| uncommon (>1/1.000 to <1/100) | lymphangitis, skin necrosis unrelated to the site of administration |
| Reproductive system and breast disorders | |
| common (>1/100 to <1/10) | abdominal cramps (in women) |
| Pregnancy, puerperium and perinatal conditions | |
| uncommon (>1/1.000 to <1/100) | uterine hypertonus, uterine ischemia |
| not known (cannot be estimated from the available data) | uterine constriction, decreased uterine blood flow |
| General disorders and administration site conditions | |
| uncommon (>1/1.000 to <1/100) | injection site necrosis |
During clinical trials and post-marketing experience, several cases of QT interval prolongation and ventricular arrhythmias including "Torsade de pointes" have been reported.
During post-marketing experience, several cases of cutaneous ischemia and necrosis unrelated to the injection site have been reported.
Reporting of suspected adverse reactions
Reporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions via
Yellow Card Scheme
Website: www.mhra.gov.uk/yellowcard
Preclinical data reveal no special hazard for humans based on conventional studies of single- and repeat-dose toxicity, and genotoxicity. At doses relevant to humans, the only effects observed in animals were those attributed to the pharmacological activity of terlipressin.
Adverse reactions observed in animal studies with possible relevance to clinical use were as follows:
Due to its pharmacological effect on smooth muscles Haemopressin Torrex may induce abortion in the first trimester.
An embryo-fetal study in rats demonstrated no adverse effects of terlipressin. In rabbits abortions occurred, probably related to maternal toxicity, and there were ossification anomalies in a small number of fetuses and a single isolated case of cleft palate.
No carcinogenicity studies have been performed with terlipressin.
Treatment of bleeding oesophageal varices
Pharmacotherapeutic group: Systemic hormonal preparations, posterior pituitary lobe hormones, vasopressin and analogues
ATC-Code: H01BA04
Terlipressin inhibits portal hypertension with simultaneous reduction of blood circulation in portal vessels. Terlipressin contracts smooth oesophageal muscle with consecutive compression of oesophageal varices.
The inactive pre-hormone terlipressin slowly releases bioactive lysine-vasopressin. Metabolic elimination takes place concomitantly and within a period of 4-6 hours. Therefore, concentrations remain continuously above the minimal effective dose and below toxic concentrations.
Specific effects of terlipressin are assessed as follows:
Gastrointestinal system:
Terlipressin increases the tone of vascular and extravascular smooth muscle cells. The increase in arterial vascular resistance leads to decrease of splanchnic hypervolemia. The decrease of the arterial blood supply leads to reduction of pressure in the portal circulation. Intestinal muscles contract concomitantly which increases intestinal motility. The muscular wall of the esophagus also contracts which leads to closure of experimentally induced varices.
Kidneys:
Terlipressin has only 3% antidiuretic effect of the native vasopressin. This residual activity is of no clinical significance. Renal blood circulation is not significantly effected in normovolemic condition. Renal blood circulation is increased, however, under hypovolemic condition.
Blood pressure:
Terlipressin induces a slow haemodynamic effect which lasts 2-4 hours. Systolic and diastolic blood pressure increase mildly. More intense blood pressure increase has been observed in patients with renal hypertension and general blood vessel sclerosis.
Heart:
All studies reported that no cardio-toxic effects were observed, not even under the highest dose of terlipressin. Influences on the heart, such as bradycardia, arrhythmia, coronary insufficiency, occur possibly because of reflex or direct vascular constrictive effects of terlipressin.
Uterus:
Terlipressin causes significant decrease in myometrial and endometric blood flow.
Skin:
The vasoconstrictive effect of terlipressin causes significant decrease in blood circulation of the skin. All studies reported obvious paleness on face and body.
In conclusion, the main pharmacological properties of terlipressin are its haemodynamic effects and its effects on smooth muscle. The centralization effect under hypovolemic condition is a desired side effect in patients with bleeding oesophageal varices.
After bolus intravenous injection terlipressin elimination follows second order kinetics. Plasma half-life was calculated as 8-12 minutes during the distribution phase (0-40 minutes) and 50-80 minutes during the elimination phase (40-180 minutes). The release of lysine-vasopressine is maintained for at least 180 minutes. Due to cleavage of the glycyl groups from terlipressin lysine-vasopressin is slowly released and reaches maximal concentrations after 120 minutes. Urine contains only 1% of the injected terlipressin, which indicates almost complete metabolism by endo- and exopeptidases of liver and kidneys.
Haemopressin Torrex should only be used with caution and under strict monitoring of the patients in the following cases:
- septic shock
- bronchial asthma, respiratory deficiencies
- uncontrolled hypertension
- cerebral or peripheral vascular diseases
- cardiac arrhythmias
- coronary deficiencies or previous myocardial infarction
- chronic renal insufficiency
- elderly patients > 70 years as experience is limited in this group
- pregnancy.
Also hypovolaemic patients often react with an increased vasoconstriction and atypical cardiac reactions.
Due to the weak antidiuretic effect of terlipressin (only 3% of the antidiuretic effect of native vasopressin) especially patients with already disturbed electrolyte metabolism should be monitored for a possible hyponatraemia and hypokalaemia.
In principle the use of the product should be confined to specialist supervision in units with facilities for regular monitoring of the cardiovascular system, haematology and electrolytes.
In emergency situations which require an immediate treatment before sending the patient to a hospital symptoms of hypovolaemia have to be considered.
Terlipressin has no effect on arterial bleeding.
To avoid local necrosis at the injection site, the injection must be administered intravenously.
Skin Necrosis:
During post-marketing experience several cases of cutaneous ischemia and necrosis unrelated to the injection site have been reported. Patients with peripheral venous hypertension or morbid obesity seem to have a greater tendency to this reaction. Therefore, extreme caution should be exercised when administering terlipressin in these patients.
Torsade de pointes:
During clinical trials and post-marketing experience, several cases of QT interval prolongation and ventricular arrhythmias including "Torsade de pointes" have been reported. In most cases, patients had predisposing factors such as basal prolongation of the QT interval, electrolyte abnormalities (hypokalemia, hypomagnesemia) or medications with concomitant effect on QT prolongation. Therefore, extreme caution should be exercised in the use of terlipressin in patients with a history of QT interval prolongation, electrolytic anormalities, concomitant medications that can prolong the QT interval, such as class IA and III antiarrhythmics, erythromycin, certain antihistamines and tricyclic antidepressants or medications that can cause hypokalaemia or hypomagnesemia (e.g. some diuretics).
Special populations:
Particular caution should be exercised in the treatment of children, adolescents and elderly patients, as experience is limited and there is no data available regarding dosage recommendation in these special patient categories.
After reconstitution with the accompanying solvent, this medicinal product contains less than 1 mmol (23 mg) of sodium per 5 ml, i.e. essentially "sodium-free".
No studies on the effects on the ability to drive and use machines have been performed.
| The administration of terlipressin serves the emergency care for acute bleeding oesophageal varices until endoscopic therapy is available. Afterwards the administration of terlipressin for the treatment of oesophageal varices is usually an adjuvant therapy to the endoscopic haemostasis. |
Posology
Adults
Initially 1-2 mg terlipressin acetate (equivalent to 1-2 vials of Haemopressin Torrex) are administered.
Depending on the patient's body weight the dose can be adjusted as follows:
- Weight less than 50 kg: 1 mg.
- Weight 50 kg to 70 kg: 1.5 mg.
- Weight exceeding 70 kg: 2 mg.
After the initial injection, the dose can be reduced to 1 mg every 4 to 6 hours.
The approximate value for the maximum daily dose of Haemopressin Torrex is 120 μg/kg body weight.
Elderly
Haemopressin Torrex should only be used with caution in patients over 70 years.
Children and adolescents
Haemopressin Torrex is not recommended in children and adolescents due to insufficient experience on safety and efficacy
Renal insufficiency
Haemopressin Torrex should only be used with caution in patients with chronic renal failure.
Hepatic insufficiency
A dose adjustment is not required in patients with liver failure.
Method of administration
The therapy is to be limited to 2 - 3 days in adaptation to the course of the disease.
Haemopressin Torrex is dissolved with the accompanying solvent and is applied intravenously.
Reconstitute the powder only in the solvent provided.
Preparation of injection
The entire contents of the solvent ampoule should be slowly added to the powder vial and the vial rolled gently until the powder is completely dissolved. The powder should dissolve within 10 seconds. A clear colourless solution results.
A further dilution to 10 ml with sterile sodium chloride 9 mg/ml (0.9 %) solution for injection is possible.
For single use only. Discard any unused solution.
The solution should be inspected visually for particles and discolouration prior to administration.
Do not use Haemopressin Torrex if you notice
- that the powder does not dissolve in the accompanying solvent
- that the solution discolours after dissolving the powder.
Any unused product or waste material should be disposed of in accordance with local requirements.
