What medication is given for primary prevention of esophageal varices, in a patient who has undergone endoscopy, with options including esmolol, metoprolol, nadolol, propranolol (a non-selective beta blocker), or pindolol?

From the Guidelines

For primary prevention of bleeding from esophageal varices after endoscopic diagnosis, the correct option is C, nadolol (or propranolol). Non-selective beta-blockers like nadolol and propranolol are the standard medications used for primary prevention of variceal bleeding, as they reduce portal pressure through decreasing cardiac output and causing splanchnic vasoconstriction, which reduces the risk of variceal rupture and bleeding 1.

Key Points

• Nadolol is typically dosed once daily starting at 20-40 mg and titrated to achieve a 25% reduction in heart rate or a target heart rate of 55-60 beats per minute, as tolerated.
• Propranolol is usually started at 20 mg twice daily and similarly titrated.
• Esmolol is an ultra-short-acting beta-blocker used in acute settings, not for long-term prevention.
• Metoprolol and pindolol are cardioselective beta-blockers that don't provide the necessary splanchnic vasoconstriction effect needed to reduce portal pressure effectively.

Evidence Support

The most recent and highest quality study, published in 2020, recommends the use of non-selective beta-blockers (NSBBs) such as propranolol or nadolol for primary prevention of variceal bleeding in cirrhotic patients with small esophageal varices (EVs) that have a high risk of bleeding, and in those with large EVs 1. This is further supported by earlier studies that demonstrate the efficacy of NSBBs in reducing the risk of first variceal hemorrhage and improving survival 1.

From the Research

Primary Prevention of Esophageal Variceal Bleeding

The primary prevention of esophageal variceal bleeding in patients with liver cirrhosis involves the use of nonselective beta-blockers (NSBBs) or endoscopic band ligation.

• NSBBs, such as propranolol, are commonly used for primary prevention of variceal bleeding in patients with medium to large-sized esophageal varices 2, 3, 4, 5, 6.
• The choice of treatment should be based on local resources and expertise, patient preference and characteristics, side-effects, and contra-indications 6.

Nonselective Beta-Blockers

Nonselective beta-blockers, such as:

• Propranolol
• Nadolol are effective in reducing the risk of first variceal bleeding in patients with cirrhosis and large esophageal varices 2, 3, 4, 5, 6.

Correct Option

Based on the available evidence, the correct option for primary prevention of esophageal variceal bleeding is:

• C, nadolol, e.propranolol 2, 3, 4, 5, 6.