When is the use of beta-blockers recommended in patients with hepatic cirrhosis?

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Portal hypertension is the most common complication of liver cirrhosis and is considered the key point for the triggering of ascites, encephalopathy and esophageal varices and, in this way, it is considered a milestone for decision making, with its diagnosis being fundamental in the follow-up of cirrhotic patients.

How can we diagnose portal hypertension?

The gold standard for defining portal hypertension is the measurement of the hepatic venous pressure gradient (HPVG). Values above 5mmHG define portal hypertension. When this gradient exceeds 10mmHg, we consider that portal hypertension is clinically significant (HPCS), with the patient prone to the appearance of decompensations. The presence of esophageal varices in patients diagnosed with cirrhosis also implies the presence of clinically significant portal hypertension regardless of the venous gradient measurement.

As the measurement of the hepatic venous pressure gradient is not a routine practice, in addition to being an invasive examination, it is admitted that, liver stiffness values ? 25 kPa obtained through transient hepatic elastography, are defining of HPCS, with specificity and positive predictive value > 90%. As it is a non-invasive examination, capable of providing such information, transient hepatic elastography has been increasingly used in the follow-up of compensated cirrhotic patients in order to provide data so that the pharmacological treatment of portal hypertension can be instituted early, without the need for serial endoscopies or even the measurement of the hepatic venous pressure gradient.

And what is the role of beta-blockers in the treatment of patients with liver cirrhosis?

Non-selective beta-blockers (propranolol, nadolol and carvedilol), have been used routinely, with proven benefits in the primary prophylaxis of bleeding from risk varices and as an adjunct in the secondary prophylaxis of varicose bleeding.

Patients at high risk for bleeding are those with thin-caliber esophageal varices with red color signs, medium and large caliber varices, gastric varices and decompensated patients in ascites with varices of any size.

Carvedilol is a non-selective beta-blocker, with alpha-1 blocking activity and appears to be more effective than traditional beta-blockers in reducing portal hypertension, having been recommended in the last Baveno VII consensus, as the beta-blocker of choice in the treatment of portal hypertension. Its currently recommended dose is 12.5mg/day, divided into two doses and patients should be monitored for their main adverse effects such as asthenia, dyspnea and low blood pressure (SBP< 90mmHG).

The PREDESCI study showed that the use of beta-blockers, especially carvedilol, in cirrhotic patients with clinically significant portal hypertension (HPVG> 10mmHG) reduced the chance of decompensation in ascites by up to 40% in a subgroup of patients with thin-caliber varices without red color signs, implying an improvement in survival.

The use of beta-blockers in patients with portal hypertension without varices has no clearly proven benefits. Pre-primary prophylaxis, that is, the use of this medication in compensated cirrhotic patients, did not show benefit in the appearance of varices, however, the use in patients with HPCS, even in the absence of varices, has been an increasingly routine practice, suggested in the latest consensuses, with the aim of reducing long-term decompensation.

In summary…

In patients diagnosed with liver cirrhosis, the use of beta-blockers, preferably carvedilol, is indicated in:

• patients without ascites with thin-caliber esophageal varices without red color signs – for prevention of decompensation in ascites;
• decompensated patients in ascites with thin-caliber esophageal varices without red color signs – for primary prophylaxis of bleeding;
• thin-caliber varices with red color signs, medium and large caliber varices and gastric varices– as primary prophylaxis;
• thin-caliber varices with red color signs, medium and large caliber varices and gastric varices – as secondary prophylaxis associated with elastic ligation;
• recurrent bleeding from portal hypertensive gastropathy;
• patients with clinically significant portal hypertension ( LMS ? 25 kPa).

References

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How to cite this article

Ramos JSD, When is the use of beta-blockers recommended in patients with liver cirrhosis? Gastropedia 2023 Vol 2. Available at: gastropedia.com.br/gastroenterology/when-is-the-use-of-beta-blockers-recommended-in-patients-with-liver-cirrhosis/