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Peptide

Terlipressin (Terlivaz)

Terlipressin is a synthetic vasopressin analog with preferential V1 receptor activity used for hepatorenal syndrome and variceal bleeding. FDA-approved September 2022 as the first and only drug for HRS-AKI in the US. CONFIRM trial (n=300): HRS reversal 32% vs 17% placebo (P=0.012). Also highly effective for acute variceal bleeding - Cochrane meta-analysis showed 34% relative reduction in mortality vs placebo. SAFETY CONCERN: Black box warning for respiratory failure risk - avoid if oxygen saturation <90%.

Research notice. This page is for education and research. Peptides may not be FDA-approved for human use and may only be legally available for research. Talk to a qualified clinician before considering any peptide.

Best evidence
Grade A
Conditions studied
2
Outcomes
11
Graded outcomes
6320

Evidence by condition

  • Strong
  • Moderate
  • Limited
  • Very limited

2 conditions, plus general outcomes

Hepatorenal Syndrome

Hepatorenal Syndrome: outcomes studied for Terlipressin (Terlivaz)
GradeOutcomeEffectSizeStudiesPeopleStudies list
HRS Reversal (Pooled Analysis)

Pooled OT-0401 + REVERSE trials (n=308): HRS reversal 27% terlipressin vs 14% placebo (P=0.004). Mean serum creatinine difference -53.0 umol/L favoring terlipressin (P<0.0001). Consistent effect across both trials.

Improves (the measure goes up)Large effect12 studies

Studies that measured hrs reversal (pooled analysis)

and 2 more in the citations list

HRS Reversal (CONFIRM Trial)

CONFIRM Phase 3 trial (n=300): Verified HRS reversal achieved in 32% terlipressin vs 17% placebo (P=0.012). Led to FDA approval. Mean serum creatinine improvement significantly greater with terlipressin. Effects maintained through study duration.

Improves (the measure goes up)Large effect9 studies

Studies that measured hrs reversal (confirm trial)

Serum Creatinine Improvement

CONFIRM trial: Significant improvement in renal function with terlipressin vs placebo. 29% achieved kidney function improvement vs 16% placebo. Early treatment (<48h from diagnosis) associated with better outcomes.

Improves (the measure goes up)Moderate effect7 studies

Studies that measured serum creatinine improvement

Respiratory Failure Risk

SAFETY CONCERN: CONFIRM trial showed increased serious respiratory adverse events with terlipressin. Black box warning: Risk of respiratory failure. Avoid use if oxygen saturation <90%. Higher risk in ACLF grade 3 patients. Patients with SCr >5 mg/dL unlikely to benefit.

Worsens (the measure goes up)Moderate effect7 studies

Studies that measured respiratory failure risk

Variceal Bleeding

Variceal Bleeding: outcomes studied for Terlipressin (Terlivaz)
GradeOutcomeEffectSizeStudiesPeopleStudies list
Bleeding Control (Variceal)

2018 meta-analysis (30 RCTs, 3344 patients): Terlipressin significantly improved bleeding control within 48h vs no vasoactive drug (OR 2.94, P=0.0008). Reduced need for emergency procedures (RR 0.72 vs placebo).

Improves (the measure goes up)Large effect8 studies

Studies that measured bleeding control (variceal)

Mortality Reduction (Variceal Bleeding)

Cochrane meta-analysis (7 RCTs, 443 patients): Terlipressin reduced all-cause mortality vs placebo (RR 0.66, 95% CI 0.49-0.88). 34% relative risk reduction. The only vasoactive agent proven to reduce mortality in acute variceal hemorrhage.

Improves (the measure goes down)Large effect6 studies

Studies that measured mortality reduction (variceal bleeding)

General

General: outcomes studied for Terlipressin (Terlivaz)
GradeOutcomeEffectSizeStudiesPeopleStudies list
Kidney Function

39 human trials and systematic reviews support this finding. Evidence includes systematic reviews/meta-analyses. Human clinical trial data available.

Improves (the measure goes up)Moderate effect14 studies

Studies that measured kidney function

and 4 more in the citations list

Liver Protection

49 human trials and systematic reviews support this finding. Evidence includes systematic reviews/meta-analyses. Human clinical trial data available.

Improves (the measure goes up)Moderate effect12 studies

Studies that measured liver protection

and 2 more in the citations list

Sepsis Outcomes

5 human trials and systematic reviews support this finding. Evidence includes systematic reviews/meta-analyses. Human clinical trial data available.

Improves (the measure goes down)Small effect7 studies

Studies that measured sepsis outcomes

Pulmonary Function

3 human trials and systematic reviews support this finding. Evidence includes systematic reviews/meta-analyses. Human clinical trial data available.

Improves (the measure goes up)Small effect5 studies

Studies that measured pulmonary function

Safety/Tolerability

3 human trials and systematic reviews support this finding. Evidence includes systematic reviews/meta-analyses. Human clinical trial data available.

Improves (the measure goes up)Small effect5 studies

Studies that measured safety/tolerability

Key findings

  • HRS Reversal (Pooled Analysis)Hepatorenal SyndromeImproves (the measure goes up)
  • HRS Reversal (CONFIRM Trial)Hepatorenal SyndromeImproves (the measure goes up)
  • Bleeding Control (Variceal)Variceal BleedingImproves (the measure goes up)

Safety notes in the studies

  • SAFETY CONCERN: CONFIRM trial showed increased serious respiratory adverse events with terlipressin.
  • Black box warning: Risk of respiratory failure.
  • Avoid use if oxygen saturation <90%.

Studies cited

37 studies from PubMed

  1. Multisystem hemodynamic effects of terlipressin in cirrhosis: A scoping review.Journal of critical care, 2025 · PMID 39955856
  2. Terlipressin for the treatment of hepatorenal syndrome: a meta-analysis of randomized controlled trials.European journal of gastroenterology & hepatology, 2025 · PMID 40207491
  3. Terlipressin Administration Strategies in Hepatorenal Syndrome-Acute Kidney Injury: A Narrative Review of Continuous Infusion and Intermittent Bolus Approaches.Pharmacotherapy, 2025 · PMID 41314419
  4. Terlipressin use in HRS-AKI and respiratory failure.Intensive care medicine, 2024 · PMID 39073583
  5. Safety and efficacy of continuous terlipressin infusion in HRS-AKI in a transplant population.Liver transplantation : official publication of the American Association for the Study of Liver Diseases and the International Liver Transplantation Society, 2024 · PMID 38771635
  6. Incidence and type of adverse events in patients with cirrhosis receiving terlipressin: A systematic review and meta-analysis.Hepatology communications, 2024 · PMID 39298544
  7. Comparative efficacy of terlipressin and norepinephrine for treatment of hepatorenal syndrome-acute kidney injury: A systematic review and meta-analysis.PloS one, 2024 · PMID 38285703
  8. Early treatment with terlipressin in patients with hepatorenal syndrome yields improved clinical outcomes in North American studiesClin Gastroenterol Hepatol, 2023 · PMID 36633470
  9. Terlipressin and the Treatment of Hepatorenal Syndrome: How the CONFIRM Trial Moves the Story ForwardAm J Kidney Dis, 2022 · PMID 34606933
  10. Respiratory events with terlipressin and albumin in hepatorenal syndrome: A review and clinical guidance.Liver international : official journal of the International Association for the Study of the Liver, 2022 · PMID 35838488
  11. Terlipressin use and respiratory failure in patients with hepatorenal syndrome type 1 and severe acute-on-chronic liver failure.Alimentary pharmacology & therapeutics, 2022 · PMID 35995728
  12. Efficacy and Safety of Vasopressin and Terlipressin in Preterm Neonates: A Systematic Review.International journal of environmental research and public health, 2022 · PMID 36360641
  13. [Effect of terlipressin on prognosis of adult septic shock patients: a Meta-analysis].Zhonghua wei zhong bing ji jiu yi xue, 2020 · PMID 32274994
  14. Role of Terlipressin in Cirrhotic Patients with Ascites and without Hepatorenal Syndrome: A Systematic Review of Current Evidence.Canadian journal of gastroenterology & hepatology, 2020 · PMID 32676484
  15. Effectiveness of Terlipressin on Modulation of Portal Vein Pressure after Hepatic Resections in Non-Cirrhotic Patients. A Systematic Review and Meta-Analysis of Randomised Controlled Trials.Chirurgia (Bucharest, Romania : 1990), 2020 · PMID 33378629
  16. Terlipressin for the treatment of acute variceal bleeding: A systematic review and meta-analysis of randomized controlled trialsMedicine (Baltimore), 2018 · PMID 30508958
  17. Terlipressin or norepinephrine, or both in septic shock?Intensive care medicine, 2018 · PMID 30006892
  18. Terlipressin in the treatment of hepatorenal syndrome: A systematic review and meta-analysis.Medicine, 2018 · PMID 29668606
  19. Reversal of hepatorenal syndrome type 1 with terlipressin plus albumin vs. placebo plus albumin in a pooled analysis of the OT-0401 and REVERSE randomised clinical studiesAliment Pharmacol Ther, 2017 · PMID 28370090
  20. Terlipressin versus noradrenaline in the treatment of hepatorenal syndrome: systematic review with meta-analysis and full economic evaluation.European journal of gastroenterology & hepatology, 2016 · PMID 26649801
  21. Terlipressin versus norepinephrine in the treatment of hepatorenal syndrome: a systematic review and meta-analysis.PloS one, 2014 · PMID 25203311
  22. Survival benefits of terlipressin and non-responder state in hepatorenal syndrome: a meta-analysis.Indian journal of pharmacology, 2013 · PMID 23543867
  23. Vasopressin and terlipressin in neonates and children with refractory septic shock.Current drug metabolism, 2013 · PMID 23439212
  24. Terlipressin for hepatorenal syndrome.The Cochrane database of systematic reviews, 2012 · PMID 22972083
  25. Terlipressin in hepatorenal syndrome: a systematic review and meta-analysis.International urology and nephrology, 2011 · PMID 20306131
  26. Terlipressin in hepatorenal syndrome: Evidence for present indications.Journal of gastroenterology and hepatology, 2011 · PMID 21199521
  27. Terlipressin in hepatorenal syndrome.The Annals of pharmacotherapy, 2011 · PMID 21386023
  28. Terlipressin therapy for reversal of type 1 hepatorenal syndrome: a meta-analysis of randomized controlled trials.Journal of gastroenterology and hepatology, 2010 · PMID 20074149
  29. Terlipressin for hepatorenal syndrome: A meta-analysis of randomized trials.The International journal of artificial organs, 2009 · PMID 19440988
  30. Terlipressin: a promising vasoactive agent in hemodynamic support of septic shock.Expert opinion on pharmacotherapy, 2009 · PMID 19735216
  31. A randomized, prospective, double-blind, placebo-controlled trial of terlipressin for type 1 hepatorenal syndromeGastroenterology, 2008 · PMID 18471513
  32. Pharmacology, clinical efficacy and safety of terlipressin in esophageal varices bleeding, septic shock and hepatorenal syndromeExpert Rev Gastroenterol Hepatol, 2008 · PMID 19072411
  33. Meta-analysis: terlipressin therapy for the hepatorenal syndrome.Alimentary pharmacology & therapeutics, 2006 · PMID 16948805
  34. Terlipressin for hepatorenal syndrome.The Cochrane database of systematic reviews, 2006 · PMID 17054242
  35. Terlipressin: vasopressin analog and novel drug for septic shock.The Annals of pharmacotherapy, 2006 · PMID 17148649
  36. Terlipressin for acute esophageal variceal hemorrhageCochrane Database Syst Rev, 2003 · PMID 12535432
  37. Systematic review: terlipressin in acute oesophageal variceal haemorrhageAliment Pharmacol Ther, 2003 · PMID 12492732