From the Guidelines
No, non-selective beta-blockers (NSBBs) are not used exclusively for portal hypertension. While NSBBs like propranolol and nadolol are cornerstone treatments for preventing variceal bleeding in portal hypertension, they have numerous other clinical applications, as noted in the 2020 guidelines for liver cirrhosis 1. NSBBs are widely used to treat hypertension, angina, arrhythmias, heart failure, migraine prophylaxis, essential tremor, and anxiety disorders. In portal hypertension specifically, NSBBs work by reducing portal pressure through decreasing cardiac output (beta-1 effect) and causing splanchnic vasoconstriction (beta-2 blockade), typically starting at doses like propranolol 20mg twice daily and titrating based on heart rate response (target 55-60 bpm) 1.
Key Considerations
- The use of NSBBs in patients with decompensated cirrhosis, especially those with refractory ascites, spontaneous bacterial peritonitis, or hepatorenal syndrome, requires careful consideration due to potential worsening of outcomes, as discussed in the 2018 EASL guidelines for the management of patients with decompensated cirrhosis 1.
- The mechanism of NSBBs differs by indication - for cardiovascular conditions, they primarily reduce sympathetic drive to the heart, while for portal hypertension, the splanchnic vasoconstriction effect is particularly important.
- Recent guidelines, such as the 2024 EASL position paper on clinical follow-up after HCV cure, suggest that NSBBs can be discontinued in patients with resolved cirrhosis after SVR, but this decision should be made on a case-by-case basis considering the risk of variceal bleeding and other complications 1.
Clinical Application
- NSBBs should be used with caution in patients with severe or refractory ascites, and their use should be based on a critical risk/benefit evaluation, as suggested by the 2018 EASL guidelines 1.
- The dose of NSBBs should be reduced or temporarily discontinued in patients with refractory ascites and signs of systemic circulatory dysfunction, such as severe hyponatraemia, low mean arterial pressure, or increasing serum creatinine, as proposed by the BAVENO VI consensus.
- In patients with refractory ascites and secondary prophylaxis, covered TIPS placement may be considered if the patient is an appropriate candidate, as discussed in the 2018 EASL guidelines 1.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Use of Non-Selective Beta Blockers (NSBBs) in Portal Hypertension
- NSBBs are the cornerstone of primary and secondary prophylaxis of variceal bleeding in cirrhotic patients 2, 3, 4, 5, 6.
- They are used to reduce portal pressure and prevent ascites development and death in compensated patients with clinically significant portal hypertension 2, 3, 6.
- Carvedilol is a more potent NSBB than propranolol and nadolol in reducing portal pressure, and its use has expanded to reduce the risk of hepatic decompensation among patients with clinically significant portal hypertension 2, 4, 6.
- NSBBs can be beneficial in preventing further decompensations after ascites onset, but their use should be carefully monitored or avoided in patients with refractory ascites due to the risk of impairing cardiac reserve and facilitating hemodynamic breakdown 3, 4.
Indications for NSBBs
- Primary prophylaxis of variceal bleeding in patients with cirrhosis and portal hypertension 2, 5, 6.
- Secondary prophylaxis of variceal bleeding in patients with cirrhosis and portal hypertension 2, 5, 6.
- Reduction of risk of hepatic decompensation in patients with compensated cirrhosis and clinically significant portal hypertension 2, 6.
- Prevention of ascites development and death in compensated patients with clinically significant portal hypertension 2, 3.
Monitoring and Safety
- Monitoring of NSBB treatment is crucial, especially in patients with ascites, to avoid impairing cardiac reserve and facilitating hemodynamic breakdown 3, 4.
- The target dose of carvedilol to treat portal hypertension should be 12.5 mg/day, with maintained arterial blood pressure as a suitable safety surrogate 6.