Beta-blockers in cirrhosis: Friend and foe?†

Florence Wong 1,*,‡, Francesco Salerno 2

DOI: 10.1002/hep.23852
Copyright © 2010 American Association for the Study of Liver Diseases

Author Information
1 Department of Medicine, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
2 The Policlinico IRCCS San Donato and Dipartimento di Scienze Medico-Chirurgiche, Università di Milano, Italy

Email: Florence Wong (florence.wong@utoronto.ca)

*Correspondence: Florence Wong, 9N/983, Toronto General Hospital, University of Toronto, 200 Elizabeth Street, Toronto, Ontario M5G2C4, Canada

†There is no financial support for this article

‡Ph: 416-340 3834; Fax: 416-340 5019

Publication History
Accepted manuscript online: 29 JUL 2010 12:00AM EST
Manuscript Accepted: 8 JUL 2010
Manuscript Received: 29 JUN 2010

Keywords:
propranolol;non-selective beta-blockers;cirrhosis;refractory ascites;sepsis;variceal bleed

Abstract

Patients with cirrhosis are at risk for developing complications that can negatively impact their survival (1). These complications include the development of hepatocellular carcinoma (HCC), sepsis, renal failure and gastrointestinal bleeding, mainly variceal. The risk of bleeding is mainly related to the development of varices from portal hypertension. Bleeding from varices, whether esophageal or gastric, is associated with a mortality risk of 40% at 1 year (2).

Twenty-nine years ago, a randomized controlled trial (RCT) from France involving 74 patients with cirrhosis with a history of gastrointestinal bleeding showed that propranolol, a non-selective beta-blocker (NSBB), significantly reduced the risk of re-bleeding from esophageal varices (3). Since then, 615 papers have been published in the English literature on the use of propranolol or nadolol (the other NSBB) in cirrhosis, both for primary and secondary prophylaxis. In fact, NSBBs have become one of the most effective preventative therapies in patients with cirrhosis (4). The advantage of using NSBBs, however, must be weighed against the risks associated with their chronic use. NSBBs are contraindicated in patients with refractory asthma, respiratory failure, advanced atrio-ventricular block and severe arterial hypotension. In order to improve the risk/benefit ratio, administration of beta blockers is recommended only in patients with a substantial risk of bleeding such as those patients with medium or large varices or patients with small esophageal varices who are Child-Pugh class C (5,6). If possible, hepatic venous pressure gradient (HVPG) should be measured before and 1-2 months after NSBB administration to identify responders (those with a final HVPG <12mmHg or those who show a decrease of ≥20% in HVPG versus the pre-treatment value) who are most likely to benefit from NSBB prophylaxis. Non-responders should discontinue therapy so to prevent the development of side effects when their chances of any therapeutic benefits are small (7). (HEPATOLOGY 2010.)

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