From the Guidelines
Beta blockers should be started in cirrhosis patients with grade 1 esophageal varices if they have high-risk features such as red wale marks on endoscopy or Child-Pugh class B or C cirrhosis, as recommended by the most recent guidelines 1. For patients with low-risk grade 1 varices (no red signs, Child-Pugh class A), beta blockers are optional but can be considered. The preferred medications are non-selective beta blockers such as propranolol or nadolol, which work by reducing portal pressure through decreasing cardiac output and causing splanchnic vasoconstriction, thereby reducing the risk of variceal bleeding 1. The goal is to reduce the heart rate by 25% from baseline or to 55-60 beats per minute, while maintaining systolic blood pressure above 90mmHg, as suggested by previous studies 1. Common side effects include fatigue, dizziness, and sexual dysfunction, and beta blockers are contraindicated in patients with asthma, severe bradycardia, heart block, or decompensated heart failure. Regular follow-up is essential to monitor for side effects and ensure adequate dosing, and high doses of NSBB should be avoided 1. It is also important to note that the use of carvedilol cannot be recommended at present, and in patients with progressive hypotension or acute intercurrent conditions, NSBBs should be discontinued 1.
Some key points to consider when starting beta blockers in cirrhosis patients with grade 1 esophageal varices include:
- The presence of high-risk features such as red wale marks on endoscopy or Child-Pugh class B or C cirrhosis
- The use of non-selective beta blockers such as propranolol or nadolol
- The goal of reducing heart rate by 25% from baseline or to 55-60 beats per minute
- The importance of regular follow-up to monitor for side effects and ensure adequate dosing
- The contraindications for beta blockers, including asthma, severe bradycardia, heart block, or decompensated heart failure. The most recent and highest quality study 1 provides the best guidance for the management of cirrhosis patients with grade 1 esophageal varices, and should be consulted for further information.
From the Research
Timing of Beta Blockers in Cirrhosis Patients with Grade 1 Esophageal Varices
- The decision on when to start beta blockers in cirrhosis patients with grade 1 esophageal varices is based on the risk of variceal bleeding and the potential benefits of beta blocker therapy.
- A study published in 2004 2 suggests that beta-blocker prophylaxis of variceal bleeding in patients with compensated cirrhosis should be started when small esophageal varices are present, as it can delay the growth of varices and reduce the risk of bleeding.
- Another study from 1990 3 found that patients with grade 1 oesophageal varices at entry had a higher risk of developing large oesophageal varices, and suggests that these patients may benefit from annual upper gastrointestinal endoscopy and consideration of beta blocker therapy.
- The use of beta-adrenergic antagonists for primary prevention of gastrointestinal hemorrhage in patients with cirrhosis and esophageal varices is supported by several studies 4, 5, which show that beta blockers can reduce the frequency of initial bleeding in patients with esophageal varices.
Factors to Consider
- The size of the esophageal varices, with larger varices being at higher risk of bleeding 3
- The presence of other risk factors, such as a high Child-Pugh score 3
- The potential benefits and risks of beta blocker therapy, including the risk of adverse effects 6, 4
- The need for regular endoscopic monitoring to assess the size of the varices and the risk of bleeding 3
Beta Blocker Therapy
- Beta blockers, such as propranolol and nadolol, are commonly used for the primary prevention of variceal bleeding in patients with cirrhosis and esophageal varices 6, 2, 4, 5
- The dose of beta blockers should be adjusted to reduce the heart rate by 20-25% or to decrease hepatic vein pressure by 25% of basal levels or to a level of less than 12 mm Hg 4