Should propranolol (a non-selective beta-blocker) be discontinued in a patient with hepatic encephalopathy?

From the Guidelines

Propranolol should be discontinued in a patient with hepatic encephalopathy, as it can potentially worsen the condition by reducing cerebral blood flow and decreasing cardiac output, and its metabolism may be impaired in severe liver dysfunction, leading to increased plasma concentrations and potential toxicity. The decision to discontinue propranolol is supported by the need to prioritize the management of hepatic encephalopathy, a life-threatening complication of cirrhosis, over the prevention of variceal bleeding, which can be managed with alternative strategies such as endoscopic band ligation 1.

When discontinuing propranolol, it is essential to taper the dose rather than stopping it abruptly to avoid rebound effects such as tachycardia or hypertension. The patient's hemodynamic status should be closely monitored during this transition, as cirrhotic patients often have altered cardiovascular function. Alternative strategies for variceal bleeding prophylaxis, such as endoscopic band ligation, may need to be considered during this period.

The recent BAVENO VI consensus proposed that in patients with refractory ascites and signs of systemic circulatory dysfunction, such as severe hyponatraemia, low mean arterial pressure, or cardiac output, and increasing serum creatinine, the NSBB dose should be reduced or even temporarily discontinued 1. This approach is supported by the concept of "the window hypothesis," which suggests that the protective effects of NSBBs may cease and a detrimental impact may begin in patients with advanced cirrhosis and refractory ascites.

In patients with hepatic encephalopathy, the risk-benefit ratio of continuing propranolol should be carefully evaluated, and the decision to restart the medication should be made after the encephalopathy resolves, potentially using a lower dose and close monitoring. The latest evidence from the EASL position paper on clinical follow-up after HCV cure suggests that CSPH can be ruled out in patients with post-SVR VCTE-LSM <12 kPa and PLT >150 G/L, and discontinuation of NSBB/carvedilol therapy can be considered 1.

Key considerations in the management of patients with hepatic encephalopathy and cirrhosis include:

• Close monitoring of hemodynamic status
• Alternative strategies for variceal bleeding prophylaxis, such as endoscopic band ligation
• Tapering of propranolol dose to avoid rebound effects
• Evaluation of the risk-benefit ratio of continuing propranolol
• Consideration of the latest evidence from the EASL position paper on clinical follow-up after HCV cure.

Overall, the management of patients with hepatic encephalopathy and cirrhosis requires a careful and individualized approach, taking into account the latest evidence and guidelines, as well as the patient's specific clinical characteristics and needs.

From the FDA Drug Label

Propranolol should be used with caution in patients with impaired hepatic or renal function. The patient with hepatic encephalopathy should exercise caution when using propranolol, as it may be affected by impaired hepatic function.

• The FDA label does not provide explicit guidance on discontinuing propranolol in patients with hepatic encephalopathy.
• However, given the caution advised for patients with impaired hepatic function, a conservative clinical decision would be to monitor the patient closely and consider alternative treatments if necessary 2.

From the Research

Discontinuation of Propranolol in Hepatic Encephalopathy

• The decision to discontinue propranolol in a patient with hepatic encephalopathy should be based on the individual patient's condition and the potential benefits and risks of continuing or stopping the medication.
• According to the study 3, propranolol did not have a significant effect on hepatic encephalopathy in patients with cirrhosis and portal hypertension.
• However, another study 4 suggests that carvedilol may be more effective than propranolol in preventing decompensation and mortality in patients with compensated and decompensated cirrhosis.
• The study 5 also recommends carvedilol as the non-selective beta-blocker of choice in patients with cirrhosis and portal hypertension, due to its superior efficacy in lowering portal hypertension.

Considerations for Discontinuation

• Before discontinuing propranolol, it is essential to consider the potential consequences of stopping the medication, including the risk of variceal bleeding and other complications of portal hypertension.
• The study 6 emphasizes the importance of timely recognition and treatment of hepatic encephalopathy, including identifying precipitating factors and providing appropriate therapy.
• The study 7 discusses the management of hepatic encephalopathy, including the use of nonabsorbable disaccharides and antibiotics, and highlights the need for novel therapeutic agents.

Clinical Implications

• The choice of beta-blocker and the decision to discontinue propranolol should be individualized based on the patient's specific condition and response to treatment.
• Clinicians should carefully weigh the potential benefits and risks of continuing or stopping propranolol in patients with hepatic encephalopathy, taking into account the latest evidence and guidelines 5, 4.