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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

See Cirrhosis Quicknotes for more details and dosing

  • 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 (see Cirrhosis Quicknotes for specifics on dosing)

*Nodolol is not offered on the VA formulary