From the Research
Non-selective beta blockers (NSBBs) are not recommended for patients with severe alcoholic hepatitis who have esophageal varices due to their potential to worsen outcomes in this specific population. NSBBs such as propranolol, nadolol, and carvedilol can reduce portal pressure and are typically used for primary and secondary prevention of variceal bleeding in cirrhosis. However, in severe alcoholic hepatitis, these medications may exacerbate systemic hemodynamic derangements by decreasing cardiac output and mean arterial pressure in patients who already have impaired hemodynamics, as suggested by a study published in 2021 1. Patients with severe alcoholic hepatitis often have systemic inflammatory response syndrome with hyperdynamic circulation, and NSBBs can precipitate or worsen hepatorenal syndrome by reducing renal perfusion. Additionally, these patients frequently have relative adrenal insufficiency, making them particularly vulnerable to the hemodynamic effects of beta blockade. A more recent study from 2022 2 highlights the complex interplay among the liver, kidney, and heart in patients with ascites, suggesting that NSBBs can critically impair the cardiac reserve and facilitate a hemodynamic breakdown, imperiling renal perfusion. Alternative management strategies for esophageal varices in these patients include endoscopic band ligation for primary prophylaxis and delaying NSBB therapy until resolution of the acute alcoholic hepatitis. Once the patient has recovered from severe alcoholic hepatitis, NSBBs can be reconsidered as part of the standard management approach for portal hypertension. It's also worth noting that the use of NSBBs in patients with decompensated liver cirrhosis may be associated with a higher risk of mortality or need for liver transplantation, as shown in a study from 2020 3. Therefore, the decision to use NSBBs in patients with severe alcoholic hepatitis should be made with caution, taking into account the potential risks and benefits, and considering alternative management strategies. The most recent and highest quality study 1 supports the notion that NSBBs may increase overall and liver mortality in alcoholic cirrhosis with MELD ≥ 12 over 5 years of follow-up, which further emphasizes the need for careful consideration of NSBB use in this population.