"Terlipressin in the treatment of septic shock: the earlier the better"?

Terlipressin, a long-acting vasopressinergic V1 agonist, is increasingly used to increase mean arterial blood pressure in the common setting of catecholamine-refractory septic shock. Traditionally, terlipressin has been used as drug of last resort and administered as intermittent high-dose bolus infusion (1-2 mg every 4 to 6 hours). Recent experimental and clinical evidence, however, suggests that terlipressin may also be used as a low-dose continuous infusion (1-2 microg kg(-1) h(-1)) in the early course of the disease. This approach may sufficiently increase systemic blood pressure and thereby prevent unwanted side effects, such as exaggerating increases in peripheral resistance or rebound hypotension. Small-scale clinical studies suggest that low-dose terlipressin, when given as a first-line vasopressor agent, is safe. Randomised, clinical multicenter trials are now needed to investigate whether or not early institution of low-dose continuous terlipressin infusion improves overall outcome of patients suffering from vasodilatory shock states.