Abstract / Description of output
Background
Advanced chronic liver disease is an increasing cause of premature morbidity and mortality in the UK. Portal hypertension is the primary driver of decompensation, including the development of ascites, hepatic encephalopathy, and variceal haemorrhage. Non-selective beta blockers (NSBB) reduce portal pressure and are well-established in the prevention of variceal haemorrhage. Carvedilol, a newer NSBB, is more effective at reducing portal pressure due to additional α-adrenergic blockade and has additional antioxidant, anti-inflammatory and anti-fibrotic effects.
Aim
To summarise the available evidence on the use of beta blockers, specifically carvedilol, in cirrhosis, focussing on when and why to start.
Methods
We performed a comprehensive literature search of PubMed for relevant publications.
Results
International guidelines advise use of NSBB in primary prophylaxis against variceal haemorrhage in those with high-risk varices, with substantial evidence of efficacy and comparable with endoscopic band ligation (EBL). NSBB are also well-established in secondary prophylaxis, in combination therapy with EBL. More controversial is their use in patients without large varices, but with clinically significant portal hypertension, where data is mixed. There is gathering evidence, however, that NSBB, particularly carvedilol, reduce the risk of decompensation and improve survival. Whilst caution is advised in patients with advanced cirrhosis and refractory ascites, recent evidence suggests NSBB can continue to be used safely and prematurely stopping may be detrimental.
Conclusions
With increasing evidence of benefit independent of variceal bleeding, namely retardation of decompensation and improvement in survival, it is time to consider whether carvedilol should be offered to all patients with advanced chronic liver disease.
Advanced chronic liver disease is an increasing cause of premature morbidity and mortality in the UK. Portal hypertension is the primary driver of decompensation, including the development of ascites, hepatic encephalopathy, and variceal haemorrhage. Non-selective beta blockers (NSBB) reduce portal pressure and are well-established in the prevention of variceal haemorrhage. Carvedilol, a newer NSBB, is more effective at reducing portal pressure due to additional α-adrenergic blockade and has additional antioxidant, anti-inflammatory and anti-fibrotic effects.
Aim
To summarise the available evidence on the use of beta blockers, specifically carvedilol, in cirrhosis, focussing on when and why to start.
Methods
We performed a comprehensive literature search of PubMed for relevant publications.
Results
International guidelines advise use of NSBB in primary prophylaxis against variceal haemorrhage in those with high-risk varices, with substantial evidence of efficacy and comparable with endoscopic band ligation (EBL). NSBB are also well-established in secondary prophylaxis, in combination therapy with EBL. More controversial is their use in patients without large varices, but with clinically significant portal hypertension, where data is mixed. There is gathering evidence, however, that NSBB, particularly carvedilol, reduce the risk of decompensation and improve survival. Whilst caution is advised in patients with advanced cirrhosis and refractory ascites, recent evidence suggests NSBB can continue to be used safely and prematurely stopping may be detrimental.
Conclusions
With increasing evidence of benefit independent of variceal bleeding, namely retardation of decompensation and improvement in survival, it is time to consider whether carvedilol should be offered to all patients with advanced chronic liver disease.
| Original language | English |
|---|---|
| Journal | Alimentary Pharmacology and Therapeutics |
| Early online date | 24 Jan 2023 |
| DOIs | |
| Publication status | E-pub ahead of print - 24 Jan 2023 |