Which beta blocker (BB) to use in portal hypertension?

From the Guidelines

Non-selective beta-blockers (NSBBs), specifically propranolol and nadolol, are the preferred choice for managing portal hypertension, as they have been shown to reduce the risk of variceal bleeding and improve survival in patients with cirrhosis 1. When selecting a beta blocker for portal hypertension, it is essential to consider the patient's individual characteristics, such as the presence of refractory ascites, systemic circulatory dysfunction, and signs of advanced liver disease.

• The dosing of NSBBs should be carefully considered, with low doses (<160 mg/day) of propranolol potentially being associated with reduced mortality after experiencing an SBP 1.
• Carvedilol, an NSBB with additional alpha-1 blocking properties, may be deleterious in decompensated patients due to its potential to cause a systemic haemodynamic depressive effect and should be avoided or closely monitored 1.
• The concept of titrating NSBBs to a target heart rate of 50–55 bpm may need to be re-evaluated in decompensated patients, as higher doses may be hazardous in this population 1.
• Parameters such as severe hyponatraemia, low mean arterial pressure or cardiac output, and increasing SCr can identify vulnerable patients who may require dose reduction or temporary discontinuation of NSBB treatment 1.
• The BAVENO VI consensus recommends reducing or temporarily discontinuing NSBBs in patients with refractory ascites and systolic blood pressure <90 mmHg, SCr >1.5 mg/dl, or hyponatraemia <130 mmol/L 1.
• In patients who cannot tolerate NSBBs, alternative options such as endoscopic band ligation (EBL) or covered TIPS placement may be considered 1.

From the Research

Beta Blockers for Portal Hypertension

• Non-selective beta blockers, such as propranolol and nadolol, are commonly used for primary and secondary prevention of variceal bleeding in patients with portal hypertension 2, 3, 4.
• Carvedilol has been shown to be more effective in reducing portal pressure compared to propranolol and nadolol, and its use has expanded to reduce the risk of hepatic decompensation in patients with clinically significant portal hypertension 2, 3, 5.
• The choice of beta blocker may depend on individual patient characteristics, such as the presence of refractory ascites or low blood pressure, which may affect the therapeutic window of non-selective beta blockers 5.
• A randomized controlled trial (PREDESCI) found that long-term treatment with beta blockers, including propranolol and carvedilol, could increase decompensation-free survival in patients with compensated cirrhosis and clinically significant portal hypertension, mainly by reducing the incidence of ascites 6.

Comparison of Beta Blockers

• Carvedilol is considered a more potent agent than propranolol in reducing portal pressure, particularly in non-responders, and is better tolerated 3.
• Propranolol should be used with caution in patients with refractory ascites, although the current evidence is not of sufficient quality to justify not using these drugs in such situations 3.
• The clinical risk-to-benefit ratio of non-selective beta blockers appears to deteriorate in advanced decompensated stages, and the risk of harm is high in patients with refractory ascites, low blood pressure, and renal impairment 5.