‘Lack of quality evidence’ to support prolonged vasoconstrictor use for variceal bleeding
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Key takeaways:
- Risks for rebleeding and mortality were similar regardless of vasoconstrictor therapy duration.
- Data support discontinuation of vasoconstrictors shortly after endoscopic variceal ligation.
PHILADELPHIA — Use of vasoconstrictors for up to 120 hours following endoscopic variceal ligation for acute variceal bleeding failed to demonstrate additional benefits vs. early discontinuation, according to data.
“The current guidelines recommend continuing vasoconstrictors for 3 to 5 days after endoscopic variceal ligation (EVL) for acute variceal bleeding (AVB),” Sushrut Ingawale, MD, DNB, MBBS, FCPS, MNAMS, a second-year internal medicine resident at Quinnipiac University Frank H. Netter MD School of Medicine and St. Vincent’s Medical Center, told Healio. “However, these recommendations were based on data from studies on sclerotherapy. The appropriate duration of vasoconstrictor treatment post-EVL is highly debatable.”
To compare outcomes based on treatment duration, Ingawale and colleagues conducted a systematic review and meta-analysis of 11 randomized controlled trials, which included 816 patients who underwent EVL.
The researchers stratified therapy duration into three groups — less than 24 hours (group 1), 24 to 72 hours (group 2) and 72 to 120 hours (group 3) — with a primary outcome of risk for rebleeding and mortality.
According to results presented at the ACG Annual Scientific Meeting, there was no difference between groups 1 and 2 in risk for rebleeding (RR = 1.36; 95% CI, 0.48-3.52 and RR = 1.34; 95% CI, 0.42-4.54, respectively) compared with group 3, with similar findings when comparing mortality risk at day 5 (RR = 0.66; 95% CI, 0.09-2.52 and RR = 1.08; 95% CI, 0.15-6.43) and day 30 (RR = 1.18; 95% CI, 0.51-2.51 and RR = 0.98; 95% CI, 0.36-2.52).
“The present network meta-analysis showed that rebleeding and mortality were similar for short or longer duration of vasoconstrictor therapy in patients with cirrhosis and AVB,” Ingawale said. “Thus, there is a lack of quality evidence to support the continuation of vasoconstrictors after EVL.”
In addition, surface under the cumulative ranking curve plot analysis showed that group 3 ranked highest for rebleeding (72.6), followed by groups 2 (40.5) and 1 (36.8), whereas group 1 ranked highest for 5-day mortality (71.3 vs. group 3: 41.4 and group 2: 37.5) as did group 2 for 30-day mortality (60.4 vs. group 3: 57.9 and group 1: 31.7).
Researchers noted there no “significant inconsistency” or publication bias.
“Given the failure of additional benefits from prolonged continuation of vasoconstrictors after EVL, we believe these data support the clinical practice of discontinuation of vasoconstrictors early after EVL, facilitating early discharge from the hospital and reducing the cost and burden on health care facilities,” Ingawale told Healio. “Additional studies are required to identify the subset of patients at risk for failure to control bleeding who might benefit from the continuation of vasoconstrictors.”
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Ingawale S, et al. Comparative outcomes based on the duration of vasoconstrictors after endoscopic variceal ligation in acute variceal bleeding: A systematic review and network meta-analysis of randomized studies. Presented at: ACG Annual Scientific Meeting; Oct. 25-30, 2024; Philadelphia (hybrid meeting).
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