From the Guidelines
Propranolol is recommended for the prevention of bleeding from esophageal varices in patients with medium or large varices that have not bled, as it significantly reduces the risk of first variceal hemorrhage and mortality. The medication works by reducing portal pressure through decreasing cardiac output and causing splanchnic vasoconstriction, which reduces the risk of variceal rupture and bleeding 1.
Key Considerations
- The typical starting dose of propranolol is 40 mg once a day, which can be adjusted to maximal tolerated doses, as a reduction in heart rate does not correlate with reduction in hepatic venous pressure gradient (HVPG) 1.
- The goal is to reduce the risk of first variceal hemorrhage, and a decrease in HVPG of 12 mmHg essentially eliminates the risk of hemorrhage and improves survival 1.
- Propranolol should be continued indefinitely in patients with high-risk varices, and patients should be monitored for side effects including hypotension, bradycardia, fatigue, and bronchospasm.
- The medication should be avoided in patients with severe bradycardia, heart block, bronchial asthma, or decompensated heart failure.
Alternative Options
- If propranolol is not tolerated, nadolol can be considered as an alternative, as it has similar effects on reducing portal pressure and the risk of variceal hemorrhage 1.
- Selective beta-blockers, such as atenolol and metoprolol, are less effective and are suboptimal for primary prophylaxis of variceal hemorrhage 1.
From the Research
Esophageal Varices and Propranolol
- Esophageal variceal bleeding is a common complication of portal hypertension, and current guidelines recommend beta-blockers for primary prophylaxis 2.
- Propranolol is a non-selective beta-blocker that has been shown to reduce the risk of variceal bleeding in patients with cirrhosis and high-risk esophageal varices 2, 3.
- However, studies have also compared propranolol with other treatments, such as endoscopic variceal ligation (EVL) and carvedilol, in the prevention of variceal bleeding 2, 4, 3.
- A study published in 2010 found that propranolol was associated with a similar risk of variceal bleeding compared to EVL, but with lower severe adverse events 2.
- Another study published in 2014 found that carvedilol was not superior to EVL in preventing first variceal bleed in patients with viral cirrhosis 4.
- However, a more recent study published in 2023 found that carvedilol was more effective than propranolol in primary prevention of variceal hemorrhage 3.
Comparison with Other Treatments
- EVL has been shown to be effective in reducing the risk of variceal bleeding, and may be associated with a lower risk of bleeding compared to propranolol in some patient populations 2, 5.
- Carvedilol has been shown to be more effective than propranolol in reducing portal pressure, and may be associated with a lower risk of variceal bleeding in some patient populations 3, 6.
- Nadolol plus isosorbide mononitrate has also been compared to carvedilol in the prevention of variceal rebleeding, and was found to be associated with a similar risk of bleeding but more severe adverse events 6.
Adverse Events
- Propranolol has been associated with adverse events such as hypotension, nausea, and dyspnea 2, 3.
- EVL has been associated with adverse events such as post-banding ulcer bleed, chest pain, and dysphagia 2, 4.
- Carvedilol has been associated with adverse events such as hypotension, nausea, and dyspnea, but may have a more favorable side effect profile compared to nadolol plus isosorbide mononitrate 3, 6.