From the Guidelines
The primary medication for managing portal hypertension is beta-blockers, specifically non-selective beta-blockers like propranolol or nadolol, as they have been shown to reduce portal pressure and prevent variceal bleeding 1.
Recommended Medications
- Non-selective beta-blockers (NSBBs) such as propranolol or nadolol are the first-line treatment for portal hypertension.
- Carvedilol, an NSBB with intrinsic anti-alpha-1 receptor activity, may be a valuable alternative, but its use should be cautious in decompensated patients due to its potential to cause systemic haemodynamic depressive effects 1.
Dosing and Titration
- Propranolol: Start with 20-40 mg twice daily, titrate up to maximum 160-320 mg/day.
- Nadolol: Start with 20-40 mg once daily, titrate up to maximum 160-240 mg/day.
- Titrate the dose to achieve a 25% reduction in heart rate or a resting heart rate of 55-60 beats per minute, while monitoring for signs of systemic circulatory dysfunction, such as severe hyponatraemia, low mean arterial pressure, or cardiac output 1.
Special Considerations
- In patients with refractory ascites, the use of NSBBs should be based on a critical risk/benefit evaluation, and the dose should be reduced or temporarily discontinued if necessary, according to the BAVENO VI consensus 1.
- For patients who cannot tolerate beta-blockers, isosorbide mononitrate (starting at 20 mg twice daily) can be used as an alternative, but its effectiveness in reducing portal pressure is still debated 1.
Additional Recommendations
- Patients should be advised to avoid alcohol, maintain a low-sodium diet, and undergo regular endoscopic screening for esophageal varices 1.
- If large varices are present, endoscopic band ligation may be recommended in conjunction with medical therapy, as combination therapy with NSBBs and endoscopic band ligation has been shown to significantly decrease the probability of rebleeding compared to monotherapy 1.
- Recent guidelines suggest that all patients with clinically significant portal hypertension (CSPH) should be treated with beta-blockers to prevent variceal bleeding and non-bleeding-related decompensation, regardless of the presence of varices 1.
From the Research
Medications for Managing Portal Hypertension
The primary medications used for managing portal hypertension include:
- Non-selective beta blockers, such as propranolol and nadolol, which are considered the pharmacotherapy of choice for prevention of first episode of variceal bleeding and for prevention of its recurrence after initial hemostasis 2, 3, 4, 5
- Carvedilol, which has been shown to be more effective in reducing portal pressure compared to nadolol or propranolol and is considered a first-line treatment until the decompensated stage 2, 3, 5
- Nitrates, such as isosorbide dinitrate, which can reduce portal pressure by decreasing resistance to portal and collateral blood flow and by promoting reflex splanchnic vasoconstriction 6
- Spironolactone, which has been shown to lower hepatic venous pressure gradient (HVPG) in patients with cirrhosis and may be used in combination with beta blockers and nitrates 6
Combination Therapies
Combination therapies, such as beta blockers with nitrates or spironolactone, may be more effective in reducing portal pressure than monotherapy 3, 6, 4 Combining beta blockers with band ligation may also be effective in preventing variceal bleeding, although the evidence is limited 3, 4
Patient Selection and Monitoring
Patient selection and monitoring are crucial in the management of portal hypertension with medications 2, 3, 4, 5 Non-invasive tests, such as liver stiffness measurement and platelet count, may be used to identify patients with clinically significant portal hypertension 2, 5 Hemodynamic monitoring, such as measurement of HVPG, may be used to assess the response to treatment and identify non-responders 3, 4, 5