Do you use immediate or extended propranolol (beta-blocker) for esophageal varices management?

From the Guidelines

For esophageal varices management, extended propranolol is recommended over immediate propranolol due to its ability to provide consistent blood levels throughout the day, improving adherence and reducing side effect fluctuations, as stated in the 2020 guidelines for liver cirrhosis management 1. The advantages of using non-selective beta-blockers (NSBBs) like propranolol include low cost, ease of administration, and not requiring follow-up endoscopies 1.

• The recommended starting dose for propranolol is 20–40 mg twice a day, which can be adjusted every 2–3 days until the treatment goal, a resting heart rate of 55–60 beats per minute, is achieved 1.
• The maximum dose is 320 mg daily in patients without ascites and 160 mg daily in patients with ascites, with the caveat that systolic blood pressure should not decrease below 90 mmHg 1. Key considerations for the use of propranolol in esophageal varices management include:
• Contraindications such as sinus bradycardia, insulin-dependent diabetes mellitus, obstructive pulmonary disease, heart failure, aortic valve disease, second- or third-degree atrioventricular heart block, and peripheral arterial insufficiency 1.
• Potential side effects like dizziness, fatigue, general weakness, dyspnea, headache, hypotension, bradycardia, and erectile dysfunction, which may necessitate dose reduction or discontinuation 1. It is crucial to continue treatment with NSBBs indefinitely to prevent variceal bleeding and mortality, unless contraindications or severe side effects develop, in which case endoscopic variceal ligation (EVL) is recommended 1.

From the Research

Esophageal Varices Management

For the management of esophageal varices, the use of beta-blockers, specifically propranolol, is a common approach. The decision to use immediate or extended propranolol depends on various factors, including the patient's condition and the presence of variceal bleeding.

Prevention of First Variceal Hemorrhage

• The study by 2 found that propranolol effectively prevents the first variceal hemorrhage in patients with alcoholic cirrhosis and large esophageal varices.
• Another study by 3 recommends that cirrhotic patients with large varices should be started on beta-blocker therapy to reduce the risk of bleeding by 50%.
• The study by 4 also supports the use of nonselective β-blockers, such as propranolol, for primary prevention of variceal bleeding in high-risk patients.

Management of Acute Variceal Hemorrhage

• The study by 5 suggests that vasoactive drugs, such as terlipressin or somatostatin, should be started as soon as possible in cases of acute oesophageal variceal bleeding, and maintained for 2-5 days.
• The study by 3 recommends that patients with acute variceal hemorrhage should be started on prophylactic intravenous antibiotics and intravenous octreotide, and that endoscopy should be performed to diagnose and treat variceal hemorrhage.

Prevention of Rebleeding

• The study by 5 found that the combination of beta-blockers and isosorbide mononitrate may be a valid first-line choice for preventing rebleeding.
• The study by 3 recommends that variceal eradication is best accomplished with repeat band ligation every 10 to 14 days until varices are obliterated, and that beta-blocker therapy can be used to prevent recurrent bleeding.
• The study by 6 found that HVPG-guided treatment is feasible and effective in preventing esophageal varices rebleeding, and that the use of beta-blockers and endoscopic variceal ligation can be guided by HVPG measurements.