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Terlipressin

Written by The Peptide Record editorialClinical review not yet completedLast reviewed 15 September 2026

Terlipressin (Terlivaz) is a real, recently-approved (2022) vasopressin analog for hepatorenal syndrome — a genuinely new peptide drug with a real efficacy benefit and a real, serious respiratory-failure risk, most pronounced in the sickest patients.

On this page
  1. How it differs from desmopressin
  2. The CONFIRM trial
  3. The boxed warning
  4. Current status

In brief

Should you care? Relevant only in the context of advanced liver disease with a specific, serious kidney complication — this is a hospital-only drug for a life-threatening condition.

The short version

  • Approved September 2022 — the first FDA-approved drug for hepatorenal syndrome.
  • CONFIRM trial: verified kidney-function reversal in 32% of patients vs. 17% on placebo — a real benefit, but survival was not improved.
  • Boxed warning for respiratory failure, with the risk concentrated heavily in patients with the most severe underlying liver failure.

How it differs from desmopressin

Terlipressin is a synthetic vasopressin analog (technically a prodrug, converted in the body to the active moiety). Where this site's desmopressin page covers a vasopressin analog selective for the V2 receptor (antidiuretic effect, used for diabetes insipidus and certain bleeding disorders), terlipressin acts predominantly on V1 receptors, causing splanchnic (gut-region) vasoconstriction. That's the pharmacologic basis for its use in hepatorenal syndrome: in advanced cirrhosis with portal hypertension, splanchnic vasoconstriction raises effective blood volume and renal perfusion pressure, helping failing kidneys recover function.

The CONFIRM trial

The FDA approved terlipressin (as Terlivaz) on 14 September 2022 for adults with hepatorenal syndrome causing rapid kidney function decline (HRS-1), based on the CONFIRM trial (Wong et al., N Engl J Med 2021, PMID 33657294): 300 patients, verified reversal of HRS achieved in 32% of the terlipressin group versus 17% on placebo (p=0.006) — a real, statistically significant renal benefit. The honest caveat: 90-day survival was not improved, and was numerically slightly worse in the terlipressin group (51% mortality vs. 45% on placebo, not statistically significant) — meaning this is an approval built on a real kidney-function benefit, not a proven survival benefit.

The boxed warning

Terlipressin carries a boxed warning for serious or fatal respiratory failure. The risk is sharply concentrated by disease severity: in the CONFIRM trial, respiratory failure was far more common in patients with the most severe grade of acute-on-chronic liver failure than in less severe patients, and this same severe-liver-failure subgroup drove most of the excess mortality risk. The label requires assessing oxygen levels before starting, avoiding use in patients who are already hypoxic or volume-overloaded, and continuous monitoring with discontinuation if oxygen saturation drops.

Current status

Still marketed by Mallinckrodt Pharmaceuticals; no generic identified. Hospital/IV-only administration for a life-threatening condition, with no wellness or grey-market presence.

References

  1. Wong F, Pappas SC, Curry MP, et al. (CONFIRM Study Investigators), "Terlipressin plus Albumin for the Treatment of Type 1 Hepatorenal Syndrome," N Engl J Med 2021;384(9):818-828, PMID 33657294, DOI: 10.1056/NEJMoa2008290.
  2. FDA approval history for Terlivaz (terlipressin), 14 September 2022.