From the Guidelines
The recommended dose of propranolol for varices in cirrhosis is typically started at 20-40 mg orally twice daily, with gradual titration based on heart rate response, as stated in the most recent and highest quality study 1. The goal is to reduce the resting heart rate by 25% from baseline or to 55-60 beats per minute, whichever comes first, while maintaining systolic blood pressure above 90 mmHg. Maximum doses generally range from 160-320 mg daily, divided into two or three doses, in patients without ascites, and 160 mg daily in patients with ascites, as recommended by 1 and 1. Some key points to consider when using propranolol for varices in cirrhosis include:
- Patients should be monitored for side effects including hypotension, bradycardia, fatigue, and bronchospasm.
- Long-acting formulations may be used once daily for improved compliance.
- Treatment is typically lifelong unless contraindications develop.
- Propranolol works by reducing portal pressure through decreased cardiac output (beta-1 effect) and splanchnic vasoconstriction (beta-2 blockade), thereby reducing the risk of variceal bleeding, as explained in 1 and 1. The most effective approach is to use propranolol in patients who achieve adequate hemodynamic response, defined as a reduction in hepatic venous pressure gradient to less than 12 mmHg or by more than 20% from baseline, as stated in 1 and 1. It's also important to note that the use of non-selective beta-blockers, such as propranolol, has been shown to be effective in reducing the risk of variceal bleeding and improving survival in patients with cirrhosis, as recommended by 1, 1, 1, and 1.
From the Research
Dose of Propranolol for Varices in Cirrhosis
The recommended dose of propranolol for varices in cirrhosis is typically titrated to the maximum tolerated dose to prevent gastroesophageal variceal bleeding.
- The dose of propranolol can range from 80 mg/day to 120 mg/day or more, depending on the patient's response and tolerance 2.
- A study found that there is no dose-dependent effect of 80-120 mg/day of propranolol on the hemodynamic response in cirrhotic patients with gastroesophageal varices, suggesting that low-dose propranolol may be effective and safer 2.
- Another study reported a mean dose of propranolol of 132 mg/day, with a median dose of 80 mg/day, for the prevention of first variceal hemorrhage in patients with alcoholic cirrhosis and large esophageal varices 3.
- The dose of propranolol can be adjusted based on the patient's heart rate, with a target heart rate of less than 55 beats per minute 3, 4.
Comparison with Other Treatments
Propranolol has been compared to other treatments, such as endoscopic variceal ligation (EVL) and carvedilol, for the prevention of variceal bleeding in cirrhotic patients.
- A study found that EVL was more effective than propranolol in preventing first variceal bleeding in cirrhotic patients with high-risk varices 5.
- Another study reported that carvedilol was more effective than propranolol in reducing hepatic venous pressure gradient (HVPG) and preventing variceal bleeding in cirrhotic patients who did not respond to propranolol 6.