Attention A T users. To access the menus on this page please perform the following steps. 1. Please switch auto forms mode to off. 2. Hit enter to expand a main menu option (Health, Benefits, etc). 3. To enter and activate the submenu links, hit the down arrow. You will now be able to tab or arrow up or down through the submenu options to access/activate the submenu links.

Viral Hepatitis and Liver Disease

Quick Links
Veterans Crisis Line Badge
My healthevet badge

Varices Prevention and Treatment: Beta-Blockers

for Health Care Providers

Varices Prevention and Treatment: The Use of Beta-Blockers - Cirrhosis

Non-selective beta-blockers lower portal pressure and are key in the management of cirrhosis; however, they should be used cautiously in patients with refractory ascites.

Key concepts

  • Portal hypertension is the main abnormal mechanism that occurs in cirrhosis and the main cause of decompensation (e.g., ascites, GI bleeding)
  • Non-selective beta-blockers (NSBBs) such as propranolol and nadolol* will reduce portal pressure
  • The use of NSBBs lowers the risk of first variceal bleed and also prevents recurrent variceal hemorrhage
  • In patients with an NSBB-induced reduction in portal pressure, there is also a lower rate of other complications of cirrhosis (e.g., ascites, spontaneous bacterial peritonitis) and death
  • In patients with refractory ascites, NSBBs may lead to hypotension, decreased renal perfusion, and death

Key recommendations

  • NSBBs (e.g., propranolol, nadolol*, carvedilol) or endoscopic variceal ligation (EVL), also known as banding, are recommended for patients with cirrhosis and medium/large esophageal varices that have never bled
  • NSBBs are recommended for patients with Child-Turcotte-Pugh class C cirrhosis with small varices that have never bled
  • An NSBB plus EVL is recommended for patients who have recovered from an episode of acute variceal hemorrhage
  • For patients with ascites, dosage of the NSBB should be reduced, and carvedilol should be avoided

NSBBs prevent decompensation

  • In patients with compensated cirrhosis, clinically significant portal hypertension, and no (or small) varices, preliminary results of a placebo-controlled trial indicate that propranolol and carvedilol prevent clinical decompensation
  • Ascites was the main decompensating event prevented by NSBBs
  • There are currently no recommendations to use NSBBs for patients with compensated cirrhosis to prevent decompensation

NSBBs prevent first variceal hemorrhage

  • Many randomized controlled trials (RCTs) have demonstrated that NSBBs (propranolol, nadolol*) compared with placebo prevent first variceal hemorrhage in patients with medium/large varices
  • This benefit is independent of the presence or absence of ascites
  • Many RCTs have demonstrated that NSBBs appear to be as effective as EVL in preventing first variceal hemorrhage
  • Two RCTs have demonstrated that carvedilol is equally or more effective than EVL in preventing first variceal hemorrhage

NSBBs prevent recurrent variceal hemorrhage

  • Many RCTs have demonstrated that NSBB plus ligation is the most effective therapy in the prevention of recurrent variceal hemorrhage
  • NSBBs represent the key element of combination therapy
  • In Child-Turcotte-Pugh class B and C patients who have recovered from variceal hemorrhage, ligation alone is associated with a higher mortality rate compared with combination NSBBs plus ligation

NSBBs in patients with ascites or spontaneous bacterial peritonitis

  • In retrospective cohort studies, NSBBs (propranolol, nadolol*) and carvedilol have shown worsening of renal function or higher mortality in patients with cirrhosis and refractory ascites or spontaneous bacterial peritonitis
  • These adverse outcomes seem to be associated with an NSBB-induced decrease in arterial pressure and with the dosage of NSBB (with dosages of propranolol >160 mg/day associated with a higher mortality)
  • This has led to the recommendation of using lower doses of NSBBs (propranolol, nadolol*) in patients who have cirrhosis and ascites and are trying to avoid carvedilol

*Nodolol is not offered on the VA formulary