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Three Part Question

In [adults with known varices] is [terlipressin or sclerotherapy] more effective at [reducing acute bleeding and mortality]?

Clinical Scenario

A 56 year old patient with known oesophageal varices presents to the Emergency department with a large haematemesis. Despite your best efforts you cannot organise endoscopy in less than 4 hours. You wonder whether terlipressin (glypressin) is an effective alternative to sclerotherapy.

Search Strategy

MEDLINE using the OVID interface 1966 to January Week 1 2006
Embase using the OVID interface 1980 to 2006 Week 02
The Cochrane Library Issue 4 2005
OVID:[varice$.mp. OR exp Gastrointestinal Hemorrhage/ OR exp "Esophageal and Gastric Varices"/] AND [sclerotherapy.mp. or exp Sclerotherapy/ OR exp Hemostasis, Endoscopic/] AND [glypressin.mp. OR terlipressin.mp. OR vasopressin.mp. OR exp Vasopressins/] LIMIT to Humans and English Language and Abstracts only
Cochrane:[esophageal and gastric varices {MeSH explode all trees}] AND [sclerotherapy {MeSH explode all trees}] AND [vasopressins {MeSH explode all trees} OR glypressin {all fields} OR terlipressin {all fields} OR lypressin {all fields}]

Search Outcome

327 papers found of which 3 were relevant. One meta-analysis and one Cochrane review (by the same authors) referred to the single RCT quoted below

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Escorsell, A et al 2000 Spain	219 cirrhotic patients with endoscopy proven variceal bleeding.	Multi-centre unblinded randomised controlled trial	48-hour failure to control bleeding	Failure rates were 33% for terlipressin and 32% for sclerotherapy (not significant)	Not blinded ie assessors of outcomes not clearly blinded to treatment allocation. Intention-to-treat analysis not stated
			5 day rebleeding rate	Rebleeding rates were the same (14% vs 14%)
			42 day mortality rate	26 out of 105 terlipressin patients died versus 19 of the 114 sclerotherapy patients (not significant)
			Pre-defined side effects	Trend towards more side effects with sclerotherapy (30% v 20%, p=0.6)

Comment(s)

Only one randomised controlled trial was found. No significant difference in control of bleeding or mortality was demonstrated; there was a trend towards fewer side effects with terlipressin.

Clinical Bottom Line

Terlipressin (glypressin) may well be as effective as sclerotherapy for acute variceal bleeds. It could be considered when there is a delay to endoscopy. Many centres now use band ligation rather than sclerotherapy; this has not been compared to vasoactive drugs.

References

1. Escorsell A et al Multicenter Randomised Controlled Trial of Terlipressin versus Sclerotherapyin the Treatment of Acute variceal Bleeding: the TEST study Hepatology 2000;32:471-476