Embolia cutis medicamentosa : an unusual adverse reaction to terlipressin

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Abstract

Terlipressin is a synthetic long-acting analog of vasopressin widely used to control variceal bleeding by lowering portal venous pressure. We report an unusual adverse reaction to terlipressin in a 78-year-old patient with esophageal variceal bleeding who developed skin necrosis soon after treatment initiation. Skin biopsy revealed embolia cutis medicamentosa.

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Vasopressin and terlipressin: pharmacology and its clinical relevance.

K. F. Yoong, P Kam, S. Williams (2004)

Vasopressin and its analogue, terlipressin, are potent vasopressors that may be useful therapeutic agents in the treatment of cardiac arrest, septic and catecholamine-resistant shock and oesophageal variceal haemorrhage. The aim of this article is to review the physiology and pharmacology of vasopressin and summarise its efficacy and safety in clinical trials and its subsequent therapeutic use. Recent studies indicate that the use of vasopressin during cardiopulmonary resuscitation may improve the survival of patients with asystolic cardiac arrest. Vasopressin deficiency can contribute to refractory shock states associated with sepsis, cardiogenic shock and cardiac arrest. Low doses of vasopressin and terlipressin can restore vasomotor tone in conditions that are resistant to catecholamines, with preservation of renal blood flow and urine output. They are also useful in reducing bleeding and mortality associated with oesophageal variceal haemorrhage. The long-term outcome of the use of these drugs is not known.

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Two observations raising questions about risk factors of cutaneous necrosis induced by terlipressin (Glypressin).

Hala Mégarbané, Selim Aractingi, Olivier Chosidow … (2008)

Triglycyl lysine vasopressin (terlipressin, Glypressin) is a potent vasoconstrictive drug which became popular because of its prolonged duration of action, ease of administration and lower incidence of side effects. Ischemic complications are rare but may be life threatening. Case 1, a 68-year-old man with alcoholic cirrhosis and hepatocellular carcinoma, was admitted due to acute functional renal failure. He was first treated for septic shock with intravenous catecholamines. He then developed hepatorenal syndrome and received terlipressin as intravenous bolus (4 mg/day). Three days later, he presented a diffuse purpuric and necrotic eruption with tongue ischemia. He died from Staphylococcus aureus infection. Case 2, a 74-year-old man with metastatic carcinoma, presented severe renal insufficiency. He developed sepsis and pseudohepatorenal syndrome, which was treated with terlipressin (0.5 mg/h) using an infusion pump. Four days later, he developed an isolated large erythematous and purpuric macular plaque of the scalp near skin metastases. The patient died a few weeks later from tumor progression. In both cases, skin biopsies showed ischemic necrosis caused by thrombosis of superficial dermal capillaries. These cases point to the risk of either widespread or localized necrosis. Although the precise incidence of these events as well as risk factors remain to be determined, hypovolemia, concomitant administration of vasoactive drugs and the mode of administration of terlipressin may influence the occurrence of these complications. Copyright 2009 S. Karger AG, Basel.

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Ischaemic complications of Glypressin in liver disease: a case series.

Neil Cullen, Sally P. A. McCormick, Sarah Hegarty … (2007)

To report three cases of extensive skin necrosis in cirrhotic patients treated with the vasoconstrictor agent terlipressin (Glypressin). We identified three patients who developed skin necrosis and determined any factors, which put them at an increased risk of doing so. Two patients were obese and developed extensive abdominal wall skin necrosis. The third patient had lower limb chronic venous insufficiency and developed extensive necrosis of both lower limbs. With increasing clinical use of terlipressin and an increasing incidence of obesity and non-alcoholic fatty liver disease-related cirrhosis, the incidence of these serious complications is likely to rise. Earlier recognition and treatment may lead to improved outcome.

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Author and article information

Journal

Journal ID (nlm-ta): Ann Gastroenterol

Journal ID (iso-abbrev): Ann Gastroenterol

Title: Annals of Gastroenterology

Publisher: Hellenic Society of Gastroenterology (Greece )

ISSN (Print): 1108-7471

ISSN (Electronic): 1792-7463

Publication date (Print): 2017

Publication date (Electronic): 11 May 2017

Volume: 30

Issue: 6

Pages: 700-703

Affiliations

[a ]Hepatogastroenterology Unit, 2 ^nd Department of Internal Medicine – Propedeutic, Research Institute and Diabetes Center (Polychronis Gatos-Gatopoulos, George D. Dimitriadis, Konstantinos Triantafyllou), Athens, Greece

[b ]2 ^nd Department of Pathology (Stephanos Kostantoudakis, Ioannis G. Panayiotides), Medical School, National and Kapodistrian University of Athens, Attikon University General Hospital, Athens, Greece

Author notes

Correspondence to: Dr. Konstantinos Triantafyllou, MD, PhD, FEBGH, Associate Professor of Gastroenterology, Hepatogastroenterology Unit, 2 ^nd Dept. of Internal Medicine, Research Institute and Diabetes Center, Medical School, National and Kapodistrian University of Athens, Attikon University Hospital, 1 Rimini Street, 12464 Athens, Greece, e-mail: ktriant@ 123456med.uoa.gr

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Publisher ID: AnnGastroenterol-30-700

DOI: 10.20524/aog.2017.0158

PMC ID: 5670294

PubMed ID: 29118569

SO-VID: 00e2d4dd-7823-4b3a-83d3-7ab45f0dc4a4

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This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3.0 Unported, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Embolia cutis medicamentosa: an unusual adverse reaction to terlipressin

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Karger: Dermatology

Most cited references 8

Vasopressin and terlipressin: pharmacology and its clinical relevance.

Two observations raising questions about risk factors of cutaneous necrosis induced by terlipressin (Glypressin).

Ischaemic complications of Glypressin in liver disease: a case series.

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