What are the Baveno guidelines for primary prophylaxis in patients with cirrhosis and varices at high risk of bleeding?

Baveno Guidelines for Primary Prophylaxis in Cirrhotic Patients with High-Risk Varices

According to the Baveno VII consensus, all patients with clinically significant portal hypertension (CSPH) including those with any size varices should be treated with non-selective beta-blockers (NSBBs) to prevent variceal bleeding and non-bleeding-related decompensation. 1

Risk Stratification for Primary Prophylaxis

High-Risk Varices Definition

High-risk varices include:

• Large varices (F2, F3)
• Small varices with red color signs
• Varices in patients with decompensated cirrhosis 1

Assessment of Portal Hypertension

Portal hypertension can be assessed non-invasively:

• VCTE-LSM >25 kPa rules-in CSPH in patients with cirrhosis 1
• VCTE-LSM 20-25 kPa indicates probable CSPH 1
• VCTE-LSM <20 kPa and PLT >150 G/L rules out high-risk varices 1

Primary Prophylaxis Recommendations

For Patients with High-Risk Varices:

1. First-line therapy:

   • NSBBs (propranolol or nadolol) 1, 2
   • Carvedilol (may be more effective than traditional NSBBs) 3

2. Dosing:

   • Propranolol: Start at 40mg twice daily, titrate to maximum tolerated dose 2
   • Goal: Reduce heart rate by 25% from baseline or to 55-60 bpm 2
   • Nadolol: 40 mg once daily 2
   • Carvedilol: Target dose of 12.5 mg/day 3

3. Alternative if NSBBs contraindicated:

   • Endoscopic Variceal Ligation (EVL) every 1-2 weeks until varices are obliterated 2
   • First surveillance EGD 1-3 months after obliteration 2

4. Combination therapy:

   • Combination of EVL and NSBBs is not routinely recommended for primary prophylaxis 4, 5
   • Recent evidence suggests NSBBs alone may improve survival compared to EVL in compensated cirrhosis 6

For Patients with Small Varices Without Red Signs:

• NSBBs (propranolol and nadolol) or carvedilol could be considered to prevent progression of varices 1

For Patients Without Varices:

• NSBBs are not recommended to prevent the formation of varices 1
• Appropriate treatment for the underlying liver disease is recommended 1

Special Considerations

Compensated vs. Decompensated Cirrhosis

• In compensated cirrhosis with high-risk varices, NSBBs significantly improve survival compared to EVL 6
• In decompensated cirrhosis, survival is similar with both NSBBs and EVL 6

Contraindications and Precautions for NSBBs

• Use with caution in patients with:
  • Refractory ascites
  • Systolic blood pressure <90 mmHg
  • Serum creatinine >1.5 mg/dl
  • Hyponatremia <130 mmol/L 2
• Avoid high doses of NSBBs (>160 mg/day of propranolol) in advanced cirrhosis 2
• Avoid carvedilol in decompensated patients due to vasodilatory effects 2
• Standard contraindications: asthma, heart block, insulin-dependent diabetes, peripheral vascular disease 2

Post-SVR (Sustained Virologic Response) Management

For patients who achieved SVR after HCV treatment:

• CSPH can be ruled out if post-SVR VCTE-LSM <12 kPa and PLT >150 G/L; discontinuation of NSBB/carvedilol therapy can be considered 1
• Patients with post-SVR VCTE-LSM 20-25 kPa or PLT <150 G/L may have CSPH; EGD should be performed if not already on NSBB/carvedilol 1
• Patients with post-SVR VCTE-LSM >25 kPa have high likelihood of CSPH; those not on NSBB/carvedilol may start treatment without endoscopic proof of varices 1

Ineffective or Harmful Therapies

• Selective beta-blockers (atenolol, metoprolol) are ineffective for portal hypertension 2
• Nitrates alone can increase mortality, especially in patients over 50 years 2
• Sclerotherapy for primary prophylaxis may increase mortality 2, 4
• Shunt therapy (TIPS or surgical) for primary prophylaxis increases encephalopathy and mortality 2

Follow-up

• For patients on beta-blockers, routine follow-up endoscopy is not necessary 2
• For patients treated with EVL, repeat endoscopy every 1-2 weeks until obliteration, then surveillance at 1-3 months and every 6-12 months thereafter 2
• Beta-blocker therapy should be continued indefinitely as the risk of bleeding recurs when treatment is stopped 2