What is the next best step for variceal prophylaxis in a patient with hepatitis C-related cirrhosis, ascites, and hepatic encephalopathy, who is currently taking Lactulose (Lactulose) and Rifaximin (Rifaximin) for encephalopathy, and diuretics and large-volume paracenteses for ascites, with laboratory results indicating thrombocytopenia, coagulopathy, mild impaired renal function, and hypoalbuminemia?

From the Guidelines

The next best step for this patient for variceal prophylaxis is non-selective beta blocker therapy. This 42-year-old woman with hepatitis C-related cirrhosis has decompensated liver disease as evidenced by her history of hepatic encephalopathy and ascites, along with laboratory findings consistent with advanced liver disease (MELD score of 20). For primary prophylaxis of variceal bleeding in patients with cirrhosis, non-selective beta blockers such as propranolol or nadolol are the first-line therapy, as recommended by the American Association for the Study of Liver Diseases (AASLD) guidelines 1. These medications reduce portal pressure by decreasing cardiac output and causing splanchnic vasoconstriction, thereby reducing the risk of variceal bleeding. The patient has not had previous variceal bleeding, making this primary prophylaxis.

While band ligation is also effective for primary prophylaxis, it is typically reserved for patients who cannot tolerate or have contraindications to beta blockers. Combination therapy with band ligation followed by beta blockers is generally used for secondary prophylaxis after a bleeding episode. TIPS (transjugular intrahepatic portosystemic shunt) is too invasive for primary prophylaxis and is reserved for patients with refractory bleeding or other specific indications, as stated in the EASL clinical practice guidelines for the management of patients with decompensated cirrhosis 1.

The patient should be started on a non-selective beta blocker with careful monitoring of blood pressure, as she already has relatively low blood pressure. It is essential to consider the potential risks and benefits of non-selective beta blockers in patients with advanced cirrhosis, particularly those with refractory ascites, as discussed in the EASL guidelines 1. However, the most recent and highest quality study, the 2018 EASL clinical practice guidelines, recommends non-selective beta blockers as the first-line therapy for primary prophylaxis of variceal bleeding in patients with cirrhosis, including those with decompensated liver disease 1.

Key points to consider in the management of this patient include:

• Non-selective beta blockers are the first-line therapy for primary prophylaxis of variceal bleeding in patients with cirrhosis.
• The patient's low blood pressure should be carefully monitored while initiating non-selective beta blocker therapy.
• Band ligation and TIPS are reserved for specific indications, such as secondary prophylaxis or refractory bleeding.
• The patient's advanced liver disease and decompensated cirrhosis require careful consideration of the potential risks and benefits of non-selective beta blockers.