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Higher dose of prophylactic beta-blockers may lessen variceal bleeding

Patients with cirrhosis who received a higher dose of nonselective beta-blockers or dose titration during primary prophylaxis were less likely to experience first variceal bleeding compared with patients on a lower dose, according to published findings.

“Nonselective beta blockers are effective in primary prophylaxis against variceal bleeding; however, in a large portion of patients these medications are not being used effectively to achieve this benefit,” Richa Shukla, MD, of the section of gastroenterology and hepatology, Baylor College of Medicine and Michael E. DeBakey Veterans Affairs Medical Center, Houston, told Healio.com/Hepatology.

Shukla and colleagues, including Fasiha Kanwal, MD, MHSH, of Baylor College of Medicine and Michael E. DeBakey Veterans Affairs Medical Center, performed a retrospective cohort study looking at 5,775 patients with cirrhosis without prior variceal bleeding who began treatment with a nonselective beta-blocker; 92.8% received propranolol (n = 5,361) and 7.2% received nadolol (n = 414). All patients were enrolled at a Veterans administration facility between 2008 and 2013 and followed to monitor the occurrence of variceal bleeding within 12 months of primary prophylaxis.

Richa Shukla

“Prior studies have demonstrated the efficacy of nonselective beta-blockers in preventing first variceal bleeding in patients with cirrhosis. However, little is known about the overall effectiveness of [nonselective beta-blockers] in routine clinical care,” the researchers wrote.

The researchers found that 11.7% of patients (n = 678) developed variceal bleeding and patients who were younger, had ascites, greater medical comorbidity and higher MELD scores had increased risk for bleeding.

The average daily dose of beta-blocker was more than 60 mg in 18.5% of patients. Approximately 18% of all patients experienced a change in the daily dose from baseline during the follow-up study period (n = 1,044). Of those who experienced a change in dosage, 10.3% of the total had an upward titration and 7.8% of the total had decrease in daily dose. Patients with lower than average beta-blocker dose were more likely to bleed compared with higher dosed patients (64.5% received less than 40 mg per day vs. 58.1%; CI, 0.51– 0.81) and patients without any dose titration (86.3% vs. 81.1%). The risk of variceal bleeding was 36% lower in patients who received a 60 mg dose or higher.

Patients who achieved hemodynamic response (adjusted HR = 0.75; 95% CI, 0.57–1.0) also had lower risk for bleeding.

The researchers found several clinical and demographic patient factors related to a higher risk of variceal bleeding, which may help to identify special populations requiring close monitoring as well.

“Clinicians should carefully monitor patients on nonselective beta-blockers and be proactive about titrating these medications in order to meet recommended hemodynamic parameters,” Shukla said. “Certain populations identified in this manuscript (i.e. younger patients, those with greater medical comorbidities and those with decompensated cirrhosis) may require even more careful monitoring due to higher risk of bleeding.”

Disclosure: The researchers report no relevant financial disclosures.