Variceal bleeding vasopressin

Octreotide is the preferred vasoactive agent employed in the medical management of variceal bleeding. Vasopressin... 

Vasopressin and desmopressin are treatments of choice for pituitary diabetes insipidus. The dosage of desmopressin is 10-40 meg (0.1-0.4 mL) in two to three divided doses as a nasal spray or, as an oral tablet, 0.1-0.2 mg two to three times daily. The dosage by injection is 1-4 meg (0.25-1 mL) every 12-24 hours as needed for polyuria, polydipsia, or hypernatremia. Bedtime desmopressin therapy, by intranasal or oral administration, ameliorates nocturnal enuresis by decreasing nocturnal urine production. Vasopressin infusion is effective in some cases of esophageal variceal bleeding and colonic diverticular bleeding. 

Terlipressin, a long-acting vasopressin analogue, is metabolized to the active drug lysine vasopressin. The use of terlipressin to treat acute variceal bleeding has been reviewed (2,3). 

Vasopressin and desmopressin are the alternative treatments of choice for pituitary diabetes insipidus. Bedtime desmopressin therapy ameliorates nocturnal enuresis by decreasing nocturnal urine production. Vasopressin infusion is effective in some cases of esophageal variceal bleeding and colonic diverticular bleeding. 

Terlipressin has similar, but less pronounced, systemic hemodynamic effects to vasopressin, including increases in mean arterial pressure and reduced heart rate (6). Of 105 patients who had continuous terlipressin infusions for variceal bleeding in a multicenter study, lower limb ischemia developed in two and cardiac ischemia in one (7). 

Active bleeding. Acutely bleeding varices can be treated by injection sclerotherapy, by tamponade and by infusion systemically of vasopressin analogues or octreotide (which reduce variceal pressure). Results of controlled trials generally reflect efficacy in oesophageal rather than gastric variceal disease, which form a minority of cases, and can be more difficult to manage. 

Vasopressin Available for treatment of diabetes insipidus and sometimes used to control bleeding from esophageal varices ... 

Although vasopressin and its analogues have been used in the acute management of bleeding esophageal varices, they do not reduce mortality (2,3) and the rate of adverse effects is higher than with octreotide (3). 

Vasopressin [vay soe PRESS in] (antidiuretic hormone, ADH), is structurally related to oxytocin (Figure 25.5). The chemically-synthesized nonapeptide has replaced that extracted from animal posterior pituitaries. Vasopressin has both antidiuretic and vasopressor effects. In the kidney it binds to the V2 receptor to increase water permeability and resorption in the collecting tubules. Thus the major use of vasopressin is to treat diabetes insipidus. It also finds use in controlling bleeding due to esophageal varices or colonic diverticula. Other effects of vasopressin are mediated by the Vi receptor, found in vascular smooth muscle, liver and other tissues. As might be expected the major toxicity is water intoxication and hyponatremia. Headache, bronchoconstriction and tremor also can occur. Caution must be used in treating patients with coronary artery disease, epilepsy and asthma. 

In bleeding oesophageal varices in hepatic cirrhosis, use is made of the vasoconstrictor effect of vasopressin (as terlipressin, a vasopressin prodrug) see page 654. 

Volume replacement should not increase the CVP beyond 4-5 cm H2O or the haematocrit beyond 35%, since there is a danger of recurrent bleeding from the oesophageal varices in the event of overcompensation. Haemostasis parameters (e.g. thrombocyte count. Quick s value, fibrinogen, AT III) must be continually monitored, so that any need for volume replacement is recognized immediately. A torsade de pointes (special form of ventricular tachycardia) may arise in the case of an electrolyte imbalance combined with vasopressin and neuroleptics. (88) (s. fig. 19.8)... 

Faigel, D.O., Metz, D.C., Kochman, M.L. Torsade de pointes complicating the treatment of bleeding esophageal varices association with neuroleptics, vasopressin, and electrolyte imbalance. Amer. J. Gastroenterol. 1995 90 822-824... 

Soderlund, C., Magnusson, I., Torngren, S., Lundell, L. Terlipressin (Triglycyl-lysine-vasopressin) controls acute bleeding oesophageal varices. A double-blind, randomized, placebo-controlled trial. Scand. X Gastroenterol. 1990 25 622—630... 

I. V. Infusion The intravenous infusion of vasopressin (Pitressin), the preferred treatment for bleeding from esophageal varices, is at times effective in the management of diffuse gastrointestinal hemorrhage as seen in patients with leukemia and lymphoma. Vasopressin causes vasoconstriction and contraction of the bowel wall smooth muscle. It also has a weak antidiuretic effect. Once the site of bleeding has been identified, an infusion of vasopressin is started at a rate of 0.2 units/min which can be increased in 0.1 unit increments up to 0.6 units/min which is seldom used. This dose can result in intestinal myocardial and/or peripheral vascular ischemic complications. 

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