What are the effects of Nadolol (beta blocker) on patients with liver failure?

From the Guidelines

Nadolol should be used with caution in patients with liver failure, and dose reduction is recommended, as its use can lower arterial pressure, decrease survival time, and increase the risk of paracentesis-induced circulatory dysfunction in patients with refractory ascites, as noted in the 2020 guidelines for liver cirrhosis 1. When using nadolol in patients with liver failure, it is essential to consider the potential risks and benefits, as the medication can have adverse effects such as bradycardia, hypotension, and bronchospasm.

• The initial dose should be reduced by 30-50% of the normal starting dose (typically 20-40 mg daily instead of 40-80 mg), with careful titration based on clinical response.
• Regular monitoring of heart rate, blood pressure, and clinical status is crucial when using nadolol in these patients.
• If signs of beta-blocker toxicity develop (severe bradycardia, hypotension, bronchospasm), the dose should be reduced or the medication discontinued.
• Alternative beta-blockers with minimal hepatic metabolism, such as atenolol, might be considered in severe liver failure cases. The use of nonselective beta-blockers (NSBBs) in patients with liver failure is still a topic of controversy, with some studies suggesting that they may be associated with a higher likelihood of poor outcomes, as noted in the 2021 practice guidance by the American Association for the Study of Liver Diseases 1.
• However, it is essential to weigh the potential benefits of NSBBs, such as reducing the risk of variceal bleeding, against the potential risks, and to carefully monitor patients for any adverse effects.
• The "window period" hypothesis suggests that NSBBs may only be useful during a certain period in the natural history of cirrhosis, and that their use beyond that time may be detrimental 1. Overall, the use of nadolol in patients with liver failure requires careful consideration of the potential risks and benefits, and close monitoring of patients for any adverse effects.

From the Research

Effects of Nadolol on Patients with Liver Failure

• The effects of nadolol, a beta blocker, on patients with liver failure are not entirely clear, but some studies provide insight into its impact on liver function and patient outcomes 2.
• A study published in 1988 found that long-term treatment with nadolol did not significantly impair liver function in patients with cirrhosis, as measured by quantitative liver function tests 2.
• However, another study from 1997 notes that drugs dependent on liver metabolism, like nadolol, may accumulate in patients with liver disease, leading to excessive plasma concentrations and potential adverse effects 3.
• In contrast, carvedilol, another beta blocker, has been shown to have a more favorable profile in patients with liver disease, with improved survival and reduced risk of decompensation in patients with compensated and decompensated cirrhosis 4, 5.
• The pharmacokinetics of nadolol in patients with liver disease are not well-studied, but it is known that the drug is metabolized by the liver, and its bioavailability may be increased in patients with liver disease 6.

Comparison with Carvedilol

• Carvedilol has been compared to nadolol and other non-selective beta blockers in patients with cirrhosis, and has been found to have a more favorable efficacy and safety profile 4, 5.
• A study published in 2024 found that carvedilol reduced the risk of decompensation and mortality in patients with compensated and decompensated cirrhosis, compared to non-selective beta blockers like nadolol 4.
• Another study from 2019 found that treatment with carvedilol improved survival and reduced the risk of acute kidney injury and spontaneous bacterial peritonitis in patients with acute-on-chronic liver failure 5.

Clinical Implications

• The use of nadolol in patients with liver failure should be approached with caution, given the potential for accumulation and adverse effects 3.
• Carvedilol may be a preferred option for patients with liver disease, given its more favorable efficacy and safety profile 4, 5.
• Further studies are needed to fully understand the effects of nadolol and other beta blockers on patients with liver failure, and to determine the optimal treatment strategies for these patients 3, 4, 2, 5.