What is the next best step for variceal prophylaxis in a patient with hepatitis C-related cirrhosis, ascites, and hepatic encephalopathy, who is currently taking Lactulose (Lactulose) and Rifaximin (Rifaximin) for encephalopathy, and diuretics for ascites, with laboratory results indicating thrombocytopenia, coagulopathy, mild impaired renal function, and hypoalbuminemia?

From the Guidelines

The next best step for this patient for variceal prophylaxis is non-selective beta blocker therapy. This 42-year-old woman with hepatitis C-related cirrhosis has decompensated liver disease as evidenced by her history of hepatic encephalopathy and ascites, along with laboratory findings consistent with advanced liver disease (MELD score of 20). For primary prophylaxis of variceal bleeding in patients with cirrhosis, non-selective beta blockers such as propranolol or nadolol are considered first-line therapy, as recommended by the Kasl clinical practice guidelines for liver cirrhosis 1. These medications reduce portal pressure by decreasing cardiac output and causing splanchnic vasoconstriction, thereby reducing the risk of variceal bleeding.

While band ligation is also effective for primary prophylaxis, it is typically reserved for patients who cannot tolerate or have contraindications to beta blockers. The combination approach of band ligation followed by beta blockers is generally not recommended for primary prophylaxis. TIPS (transjugular intrahepatic portosystemic shunt) would be excessive at this stage and is typically reserved for patients who have failed other therapies or have refractory bleeding. Given her compensated hemodynamics and absence of contraindications to beta blockers, starting with a non-selective beta blocker is the most appropriate initial approach. However, it's essential to consider the patient's blood pressure and adjust the dosage accordingly, as recommended by the EASL clinical practice guidelines for the management of patients with decompensated cirrhosis 1, which suggests that the use of NSBBs should be based on a critical risk/benefit evaluation in patients with refractory ascites and signs of systemic circulatory dysfunction.

Some key considerations for the use of non-selective beta blockers in this patient include:

• Monitoring blood pressure and adjusting the dosage to avoid hypotension
• Considering the use of carvedilol with caution, as it may cause a systemic haemodynamic depressive effect
• Titration of NSBBs to a target heart rate, while being mindful of the patient's hyperdynamic state and potential for hazardous doses
• Parameters such as severe hyponatraemia, low mean arterial pressure or cardiac output, and increasing SCr to identify more vulnerable patients among those with decompensated cirrhosis, in whom a dose reduction or temporal discontinuation of NSBB treatment should be considered.

From the Research

Patient Profile

• The patient is a 42-year-old woman with hepatitis C-related cirrhosis.
• She has a history of hepatic encephalopathy and ascites.
• Her current medications include Lachlos and Rifaximin for encephalopathy, diuretics, and intermittent large-volume paracenteses for ascites.
• Laboratory studies show a white count of 1.8, INR 1.8, Serum Creatinine 1.2, GFR 58, Sotoviruline 4.0, Serum Albumin 2.7, AST 67, ALT 45, and a Malt score of 20.

Variceal Prophylaxis Options

• The patient requires variceal prophylaxis to prevent bleeding.
• The options for variceal prophylaxis are:
  • Non-selective beta blocker
  • Band ligation
  • Band ligation followed by non-selective beta blocker
  • TIPS (Transjugular Intrahepatic Portosystemic Shunt)

Recommended Approach

• According to the studies 2, 3, 4, non-selective beta blockers and endoscopic band ligation are equally effective in primary prevention of variceal bleeding.
• The study 5 suggests that non-invasive markers of portal hypertension, such as spleen stiffness, can predict hemodynamic response to non-selective beta blocker therapy.
• The study 6 found that carvedilol, a non-selective beta blocker, is as efficacious and safe as standard-of-care interventions for primary and secondary prevention of variceal bleeding.
• Given the patient's profile and the available evidence, the next best step for variceal prophylaxis would be to start with a non-selective beta blocker, as it is a recommended therapy for primary prophylaxis of variceal bleeding 2, 3, 4, 6.

Considerations

• The patient's low blood pressure (90/70 mmHg) should be considered when initiating beta blocker therapy, as it may exacerbate hypotension.
• The patient's ascites and hepatic encephalopathy should also be managed concurrently with variceal prophylaxis.
• Regular monitoring of the patient's condition, including liver function tests and spleen stiffness, may help predict response to therapy and guide adjustments to the treatment plan 5.