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Patients taking beta-blockers for variceal bleeding may be more prone to rebleeding

Variceal bleeding occurring in patients with cirrhosis while they are taking beta-blockers is more likely to reoccur than it is in patients not on the treatment at initial bleeding, according to recent study results.

Researchers in Spain evaluated data from 89 patients with cirrhosis treated for acute esophageal variceal bleeding. Among them, 34 already had been receiving treatment with propranolol, a nonselective beta-blocker (NSBB), for a median of 13 months before their first occurrence of bleeding and incorporation into the study. All participants underwent endoscopic band ligation (EBL) and subsequent NSBB treatment (propranolol and nadolol), with follow-up at 1, 3 and 6 months, and then at 6-month intervals for 2 years.

Twenty-six cases of bleeding occurred across the groups, including 14 in the initial NSBB cohort and 12 in the noninitial NSBB cohort, and 21 of these occurrences were variceal rebleeding. A significantly larger proportion of patients already taking NSBBs experienced additional bleeding, both from any cause (48% vs. 24%, P=.01) and from variceal rebleeding specifically (39% vs. 17%, P<.01) at 2 years. Initial NSBB treatment was found through multivariate analysis to be an independent predictor of rebleeding (adjusted HR=2.37; 95% CI, 1.10-5.11), along with bilirubin serum levels (HR=1.13; 95% CI, 1.06-1.21).

Eleven participants died, seven (21%) in the NSBB group; four (7%) in the noninitial NSBB group. Causes included liver failure and bleeding in three patients each, two cases of sepsis and two of hepatocellular carcinoma. Transplant-free survival was more likely in patients in the noninitial NSBB group (88% of patients vs. 66% in the NSBB group, P=.02). Initial NSBB treatment, along with Child-Turcotte-Pugh class, were independently associated with transplant-free survival through multivariate analysis (adjusted HR=4.24; 95% CI, 1.31-13.71 for NSBB; adjusted HR=16.26; 95% CI, 2.70-97.70 for Child-Turcotte-Pugh class C vs. A).

“Patients who survive an acute variceal bleeding episode while on primary prophylaxis with NSBB constitute a distinct group with increased risk of rebleeding and death despite being treated with current recommended therapy adding EBL to NSBB,” the researchers concluded. “This suggests that these patients might require an alternative, more effective treatment. The optimal management of these patients should be evaluated in future [randomized controlled trials].”