What is the optimal beta blocker (β-blocker) dose for managing varices (esophageal varices)?

From the Guidelines

For medical management of esophageal varices, the recommended beta-blocker regimen is propranolol or nadolol, with propranolol started at 20mg twice daily and titrated up every 2-3 days to a maximum of 320mg daily, and nadolol begun at 20-40mg once daily with a maximum of 160mg daily, as stated in the most recent guidelines 1. The goal of this treatment is to reduce the resting heart rate by 25% or to 55-60 beats per minute, whichever comes first, while maintaining systolic blood pressure above 90mmHg, as recommended by the guidelines 1. Some key points to consider when using beta-blockers for variceal management include:

• The maximum dose of propranolol is 320 mg daily in patients without ascites and 160 mg daily in patients with ascites, while the maximum dose of nadolol is 160 mg daily in patients without ascites and 80 mg daily in patients with ascites, as outlined in the guidelines 1.
• Carvedilol is an alternative option, starting at 6.25mg daily and increasing to 12.5mg daily if tolerated, although its use may be limited in certain situations, such as in patients with severe liver dysfunction, as noted in the studies 1.
• Treatment with beta-blockers should be continued indefinitely, as this is a chronic condition requiring long-term management, and discontinuation can increase the risk of variceal bleeding and mortality, as highlighted in the guidelines 1.
• Regular monitoring of heart rate, blood pressure, and potential side effects like fatigue, erectile dysfunction, and bronchospasm is essential, with dose adjustments made accordingly, to minimize the risk of adverse effects and optimize treatment outcomes, as recommended by the studies 1.

From the Research

Medical Management of Varices with Beta Blockers

• The use of beta blockers, such as nadolol and propranolol, is recommended for the primary prophylaxis of variceal bleeding in patients with cirrhosis and esophageal varices 2, 3, 4.
• The dose of nadolol can be titrated to achieve a 20-25% decrease in resting heart rate, with a maximum dose of 160 mg daily 2.
• The addition of isosorbide mononitrate to nadolol may decrease the rate of variceal bleeding in patients with cirrhosis and varices, compared with nadolol alone 2, 5.
• However, the long-term use of this combination may not be beneficial in all patients, and the decision to use it should be made on a case-by-case basis 4, 5.

Efficacy of Beta Blockers in Preventing Variceal Bleeding

• Beta blockers have been shown to be effective in preventing first variceal bleeding in patients with cirrhosis, with a reduction in risk of 40-50% 3, 4.
• The efficacy of beta blockers in preventing variceal bleeding may be greater in patients with large varices or those with a high risk of bleeding 3, 4.
• Nadolol has been shown to be superior to isosorbide mononitrate in preventing the first variceal bleeding in cirrhotic patients with ascites 6.

Safety and Tolerability of Beta Blockers

• Beta blockers are generally well-tolerated, but may cause side effects such as hypotension, headache, and fatigue 2, 4, 6.
• The use of beta blockers may be contraindicated in patients with certain medical conditions, such as asthma or heart failure 6.
• The decision to use beta blockers should be made on a case-by-case basis, taking into account the individual patient's medical history and risk factors 2, 3, 4, 5, 6.