Is nadolol (beta blocker) appropriate for secondary prevention in patients with esophageal varices from alcoholic cirrhosis and portal hypertension (hypertension)?

From the Guidelines

Nadolol is appropriate for secondary prevention in patients with esophageal varices from alcoholic cirrhosis and portal hypertension, and it should be used in combination with endoscopic band ligation of varices. According to the most recent and highest quality study 1, patients with a history of variceal bleeding should continue secondary prophylaxis, which includes endoscopic band ligation plus a non-selective beta-blocker (NSBB) such as nadolol. Nadolol works by decreasing portal pressure through reduction of cardiac output and splanchnic blood flow, thereby reducing the risk of rebleeding from esophageal varices. The medication should be started at 40 mg daily and titrated up to a maximum of 80-160 mg daily as tolerated, with the goal of reducing the heart rate by 25% or to 55-60 beats per minute.

Some key points to consider when using nadolol for secondary prevention include:

• Monitoring for potential side effects, including hypotension, bradycardia, fatigue, and bronchospasm 1
• Contraindications, such as severe bradycardia, heart block, or decompensated heart failure
• The importance of complete abstinence from alcohol, as continued drinking will worsen portal hypertension and increase bleeding risk regardless of medication therapy
• The need for regular follow-up and endoscopic evaluation to assess the effectiveness of treatment and to monitor for signs of variceal recurrence or other complications.

It's also important to note that the use of nadolol for secondary prevention is supported by earlier guidelines, such as those from the British Society of Gastroenterology 1, which recommend the use of non-selective beta-blockers, such as nadolol, in combination with endoscopic therapy for the prevention of variceal rebleeding. However, the most recent study 1 provides the strongest evidence for the use of nadolol in this context, and its recommendations should be prioritized.

From the Research

Secondary Prevention of Variceal Bleeding

• The use of nadolol in secondary prevention of variceal bleeding in patients with esophageal varices from alcoholic cirrhosis and portal hypertension is supported by several studies 2, 3, 4, 5, 6.
• According to the study by 4, the current recommendation for secondary prophylaxis is to receive a combination of non-selective beta-blockers (NSBB) and endoscopic variceal ligation.
• Nadolol, a non-selective beta-blocker, has been shown to be effective in reducing the risk of variceal bleeding in patients with cirrhosis and portal hypertension 3, 6.
• The study by 3 found that nadolol was superior to isosorbide mononitrate in preventing the first variceal bleeding in cirrhotic patients with ascites.
• However, the study by 2 found that endoscopic variceal ligation was similar to the combination of nadolol plus isosorbide-5-mononitrate in preventing the first variceal bleeding in patients with cirrhosis.

Efficacy and Safety of Nadolol

• The efficacy and safety of nadolol in preventing variceal bleeding have been evaluated in several studies 2, 3, 6.
• The study by 6 found that variceal ligation was as effective and as safe as treatment with nadolol for prevention of first variceal bleeding in patients with cirrhosis.
• The study by 2 found that the combination of nadolol plus isosorbide-5-mononitrate was similar to endoscopic variceal ligation in preventing the first variceal bleeding in patients with cirrhosis.
• However, the study by 3 found that nadolol was less tolerated than isosorbide mononitrate in patients with ascites, but was more effective in preventing variceal bleeding.

Combination Therapy

• The use of combination therapy with nadolol and endoscopic variceal ligation has been recommended for secondary prophylaxis of variceal bleeding 4.
• The study by 5 found that combination therapy with beta-blockers and endoscopic treatment was effective in reducing the rate of re-bleeding in patients with cirrhosis and portal hypertension.
• However, the study by 2 found that the combination of nadolol plus isosorbide-5-mononitrate was similar to endoscopic variceal ligation in preventing the first variceal bleeding in patients with cirrhosis.