P101 Clinical audit evaluating the prescribing and monitoring of terlipressin in the management of both hepato-renal syndrome and variceal bleeding in patients admitted to London North West University Healthcare NHS Trust

<h3></h3> Patients hospitalised with type 1 hepatorenal syndrome (HRS) and/or a first episode of variceal bleeding (VB) have an approximate 20% mortality risk.Terlipressin is a splanchnic vasoconstrictor widely used in the treatment of both type 1 HRS and VB. An alert issued by the Medicines and Healthcare products regulatory agency (MHRA) in March 2023 following the CONFIRM trial highlighted potentially serious adverse effects with terlipressin use in type 1 HRS.The aim of this audit was to evaluate local prescribing and monitoring following terlipressin prescription for these conditions, both before and after the MHRA alert. Standards for assessment were based on guidelines from the European Association for the Study of the Liver (EASL) and International Club of Ascites (ICA) for the management of HRS. Data was collected retrospectively using the Omnicell automated medication management system, to generate a list of patients prescribed terlipressin in our Trust in group A: from March 2022 to February 2023 (prior to MHRA alert); and group B, between March 2023 to February 2024 (after MHRA alert released). 193 patient records were identified - 62 were excluded due to death or incomplete data, 131 patients were included in the study. Clinical records were analysed retrospectively. Compliance with 4 standards was compared for HRS pre- and post- MHRA alert (see figure 1). 32 patients were diagnosed with type 1 HRS: 20 patients from March 2022 to February 2023 and 12 patients from March 2023 to February 2024.Total compliance rate to standard 1 for all 131 patients included was 74% (n= 67) for both indications, compared to 92% (n=38) after the MHRA alert (figure 1). Standard 2 showed 90% (n=18) of prescriptions for HRS in group A were within the correct dose range, compared to 83% (n=10) for group B. Clinical review assessing response within 72 hours (standard 3) was found in 90% (n=18) of group A, compared to 92% (n=11) of group B. MHRA recommendations for monitoring of clinical parameters, renal biochemistry and fluid balance whilst on terlipressin treatment (standard 4) all improved post alert in HRS patients. Clear improvements have been observed in current practice post alert. Failure to both document indication for Terlipressin and to perform clinical review may contribute to unnecessarily prolonged duration of treatment. Absence of appropriate monitoring such as fluid balance can result in an increased side effects and morbidity. Further recommendations include implementation of local guideline, feedback, and education to the multidisciplinary team.