title: A randomized trial comparing terlipressin and noradrenaline in patients with cirrhosis and septic shock.
abstract: The choice of vasopressor for treating cirrhosis with septic shock is unclear. While noradrenaline in general is the preferred vasopressor, terlipressin improves microcirculation in addition to vasopressor action in non-cirrhotics. We compared the efficacy and safety of noradrenaline and terlipressin in cirrhotics with septic shock.
  
  
  
  Cirrhotics with septic shock underwent open label randomization to receive either terlipressin (n=42) or noradrenaline (n=42) infusion at a titrated dose. The primary outcome was mean arterial pressure (MAP) >65 mm Hg at 48 h.
  
  
  
  Baseline characteristics were comparable between the terlipressin and noradrenaline groups.SBP and pneumonia were major sources of sepsis. A higher proportion of patients on terlipressin were able to achieve MAP >65 mm of Hg (92.9% vs 69.1% P=.005) at 48 h. Subsequent discontinuation of vasopressor after hemodynamic stability was better with terlipressin (33.3% vs 11.9%, P<.05). Terlipressin compared to noradrenaline prevented variceal bleed (0% vs 9.5%, P=.01) and improved survival at 48 h (95.2% vs 71.4%, P=.003). Percentage lactate clearance (LC) is an independent predictor of survival [P=.0001, HR=3.9 (95% CI: 1.85-8.22)] after achieving the target MAP.Therapy related adverse effect were comparable in both the arms (40.5% vs 21.4%, P=.06), mostly minor (GradeII-88%) and reversible.
  
  
  
  Terlipressin is as effective as noradrenaline as a vasopressor in cirrhotics with septic shock and can serve as a useful drug. Terlipressin additionally provides early survival benefit and reduces the risk of variceal bleed. Lactate clearance is a better predictor of outcome even after achieving target MAP, suggesting the role of microcirculation in septic shock.
authors.affiliation: Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India.
authors.forename: Ashok
authors.initials: A
authors.lastname: Choudhury
authors.affiliation: Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India.
authors.forename: Chandan K
authors.initials: CK
authors.lastname: Kedarisetty
authors.affiliation: Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India.
authors.forename: Chitranshu
authors.initials: C
authors.lastname: Vashishtha
authors.affiliation: Department of Critical care, Institute of Liver and Biliary Sciences, New Delhi, India.
authors.forename: Deepak
authors.initials: D
authors.lastname: Saini
authors.affiliation: Department of Pulmonology, Institute of Liver and Biliary Sciences, New Delhi, India.
authors.forename: Sachin
authors.initials: S
authors.lastname: Kumar
authors.affiliation: Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India.
authors.forename: Rakhi
authors.initials: R
authors.lastname: Maiwall
authors.affiliation: Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India.
authors.forename: Manoj K
authors.initials: MK
authors.lastname: Sharma
authors.affiliation: Department of Research, Institute of Liver and Biliary Sciences, New Delhi, India.
authors.forename: Ajeet S
authors.initials: AS
authors.lastname: Bhadoria
authors.affiliation: Department of Research, Institute of Liver and Biliary Sciences, New Delhi, India.
authors.forename: Guresh
authors.initials: G
authors.lastname: Kumar
authors.affiliation: Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India.
authors.forename: Yogendra K
authors.initials: YK
authors.lastname: Joshi
authors.affiliation: Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India.
authors.forename: Shiv K
authors.initials: SK
authors.lastname: Sarin
mesh_terms: D000328:Adult; D005260:Female; D006439:Hemodynamics; D006801:Humans; D007194:India; D053208:Kaplan-Meier Estimate; D019344:Lactic Acid / Q000097:blood; D008103:Liver Cirrhosis / Q000150:complications*; D016015:Logistic Models; D008236:Lypressin / Q000008:administration & dosage / Q000009:adverse effects / Q000031:analogs & derivatives*; D008297:Male; D008833:Microcirculation; D008875:Middle Aged; D009638:Norepinephrine / Q000008:administration & dosage* / Q000009:adverse effects; D012772:Shock, Septic / Q000188:drug therapy*; D000077585:Terlipressin; D014662:Vasoconstrictor Agents / Q000008:administration & dosage*
chemical_list: D014662:Vasoconstrictor Agents; D019344:Lactic Acid; D008236:Lypressin; D000077585:Terlipressin; D009638:Norepinephrine
keywords: cirrhosis; septic shock; terlipressin; vasopressor