(910) Terlipressin Versus Midodrine/Octreotide and the Need for Renal Replacement Therapy

Introduction: Terlipressin was recently FDA approved in the US for hepatorenal syndrome (HRS) in the fall of 2022. Terlipressin is a synthetic vasopressin analogue that exerts its action on HRS by reducing portal pressure and blood flow and subsequently increasing blood flow to the kidneys. Midodrine and octreotide have been the mainstay of treatment of HRS in the US by causing splanchnic vasoconstriction by alpha1-adrenergic activity and inhibition of glucagon-mediated splanchnic vasodilatation. The US approval of terlipressin was largely based on the phase 3 placebo-controlled trial showing improvement in renal impairment in the CONFIRM trial. Of note, midodrine and octreotide were discontinued prior to randomization of this trial.

Methods: This was a retrospective review of terlipressin vs midodrine/octreotide (M/O) at a large academic medication center between July 2018 to July 2023. Patients in the terlipressin group were all patients receiving the medication since added to hospital formulary. Patients in the M/O group were randomized patients receiving therapy for HRS. The primary outcome was need for renal replacement therapy (RRT) as defined as either continuous renal replacement therapy (CRRT) or intermittent hemodialysis (iHD) while receiving terlipressin vs M/O combination.

Results: This analysis was a total of 45 patients with HRS being treated with either M/O (n=27) vs terlipressin (n=17). Patients had a mean age of 55 years with majority of patients being female sex (27/45 [60%]). Patients had a longer hospital length of stay in the terlipressin group (25.7 +/- 16.1 days) vs M/O group (17.8 +/- 10 days). Pre-treatment SCr as defined by the SCr prior to the first dose of treatment in either group which was higher in the terlipressin group at 3.3 mg/dL vs 2.8 mg/dL in the M/O group. Patients requiring renal replacement therapy (CRRT or iHD) were 8 patients in the M/O group vs 1 patient in the terlipressin group (p=0.048).

Conclusions: In this small retrospective review of US use of terlipressin vs previous M/O combination therapy found lower need of RRT despite having higher initial SCr in the terlipressin group. This is consistent with previous terlipressin literature and the first evaluation in the US.