What is the indication for beta blockers (beta-adrenergic blocking agents) in the management of esophageal varices?

Beta Blocker Indications for Esophageal Varices

Beta blockers are indicated for both primary and secondary prophylaxis of esophageal variceal bleeding in patients with cirrhosis, with nonselective beta blockers being the gold standard for prevention of first variceal hemorrhage in patients with medium/large varices and for secondary prophylaxis when combined with endoscopic variceal ligation. 1

Primary Prophylaxis

Patients with Small Varices

• Beta blockers are indicated in patients with small varices who have high risk of bleeding (Child B/C cirrhosis or presence of red wale marks on varices) 1
• Beta blockers can be used in patients with small varices without high-risk features, although long-term benefit is less established 1
• Beta blockers have been shown to slow progression from small to large varices (11% vs 37% at 3 years) 1

Patients with Medium/Large Varices

• Nonselective beta blockers are strongly indicated for primary prophylaxis in patients with medium/large varices who have not bled 1
• Beta blockers significantly reduce the risk of first variceal bleeding from 30% to 14%, with one bleeding episode avoided for every 10 patients treated 1
• Beta blockers also reduce mortality in these patients 1

Secondary Prophylaxis

• Combination of nonselective beta blockers plus endoscopic variceal ligation (EVL) is the best option for secondary prophylaxis of variceal hemorrhage 1
• The nonselective beta blocker should be adjusted to the maximal tolerated dose 1
• Beta blocker therapy should be continued indefinitely once started, as discontinuation increases bleeding risk 2

Mechanism of Action

• Nonselective beta blockers (propranolol, nadolol) reduce portal pressure by:
  • Decreasing cardiac output (β1 effect)
  • Producing splanchnic vasoconstriction (β2 effect), reducing portal blood flow 1, 3
• A reduction in hepatic venous pressure gradient (HVPG) of ≥20% from baseline or to <12 mmHg significantly decreases bleeding risk 1, 3

Dosing and Administration

• Propranolol is typically started at 40 mg once daily and titrated up 1, 2
• The dose should be adjusted to the maximal tolerated dose rather than targeting heart rate reduction 1, 2
• Long-acting propranolol can be used at doses of 80-160 mg daily to improve compliance 2
• In patients with ascites, maximum recommended dose should be reduced to 160 mg daily 2

Important Clinical Considerations

• Selective beta blockers (atenolol, metoprolol) are less effective and suboptimal for variceal prophylaxis 1, 3
• Contraindications include asthma, severe COPD, heart block, significant bradycardia, hypotension, and decompensated heart failure 3, 2
• Beta blockers should not be used during acute variceal bleeding episodes 3
• For patients who cannot tolerate beta blockers, endoscopic variceal ligation is the alternative treatment of choice 2, 4

Monitoring and Follow-up

• In patients with small varices not receiving beta blockers, endoscopy should be repeated every 2 years, or annually if there is evidence of hepatic decompensation 1
• In patients with small varices who receive beta blockers, follow-up endoscopy may not be necessary 3
• Regular monitoring of heart rate, blood pressure, and renal function is essential, particularly in patients with end-stage liver disease 2

Combination Therapies

• Combination of nonselective beta blockers plus EVL is recommended for secondary prophylaxis 1
• The combination of beta blockers and isosorbide mononitrate is not currently recommended for primary prophylaxis 1