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Carvedilol effective for cirrhotic patients with esophageal varices

Patients with cirrhosis and esophageal varices who were nonresponsive to propranolol benefited from treatment with carvedilol in a recent study.

Researchers evaluated 104 cirrhotic patients with portal hypertension (PHT) and esophageal varices who received treatment with an escalating dose of propranolol from 40 mg/day to a maximum of 160 mg/day (median dose 100 mg/day). All participants had a baseline hepatic venous pressure gradient (HVPG) greater than 12 mm Hg (mean 20.5 mm Hg).

Responsive patients remained on propranolol. Nonresponders were switched to carvedilol, at a dose escalating from 6.25 mg/day to a maximum of 50 mg/day (median dose 12.5 mg/day). Carvedilol nonresponders subsequently underwent endoscopic band ligation (EBL).

Propranolol response occurred in 36% of the cohort. Among nonresponders, 56% subsequently experienced hemodynamic response to carvedilol, with the remaining participants (29 patients) requiring EBL. Mean HVPG values were 18 ± 1 mm HG while on propranolol and 16 ± 4 mm Hg for those who received carvedilol (P<.01 compared with baseline for both). The decrease in HVPG after carvedilol treatment was significantly larger than that from propranolol (P<.001), and mean HVPG values among hemodynamic responders were significantly lower among carvedilol recipients than propranolol responders (15.1 ± 3.5 mm Hg vs. 15.8 ± 3.2 mm Hg, P=.046).

Over a median follow-up of 19.5 months, 13% of the cohort experienced variceal bleeding, with rates significantly lower among carvedilol responders than propranolol responders (5% of cases vs. 11%, P=.0218). Bleeding also was lower among hemodynamic responders overall than EBL recipients (24%, P=.0429).

Hemodynamic responders trended toward fewer instances of hepatic decompensation than those who underwent EBL (26% of carvedilol and 38% of propranolol vs. 55%, P=.0789). Responders also had fewer deaths (P=.018) and experienced significantly longer transplant-free survival (TFS; P=.0455).

“This study shows that carvedilol is a well-tolerated and highly effective drug for the pharmacological treatment of PHT,” the researchers wrote. “Most importantly, achieving a carvedilol response in propranolol nonresponders is associated with a reduced risk of hepatic decompensation and increased TFS compared to EBL-treated propranolol nonresponders.”