Is propranolol (beta blocker) prescribed for esophageal varices?

Propranolol for Esophageal Varices

Yes, propranolol (a nonselective beta-blocker) is prescribed for esophageal varices and is a cornerstone of both primary and secondary prophylaxis to prevent variceal bleeding. 1, 2

Primary Prophylaxis (Preventing First Bleed)

For Medium/Large Varices

Nonselective beta-blockers like propranolol are strongly recommended for patients with medium or large esophageal varices who have never bled. 1 The evidence is compelling:

• Propranolol reduces the risk of first variceal bleeding from 30% to 14%, preventing one bleeding episode for every 10 patients treated 1, 2
• Mortality is also significantly reduced in the beta-blocker group compared to controls 1
• Both propranolol and nadolol are equally effective nonselective beta-blockers for this indication 1

For Small Varices

The indication is more nuanced for small varices:

• Propranolol should be used in patients with small varices who have high bleeding risk: specifically those with Child B/C cirrhosis or red wale marks on the varices 1, 2
• For other patients with small varices, propranolol can slow progression to large varices (reducing progression from 37% to 11% at 3 years), though long-term benefit is not definitively established 1, 2
• Propranolol should NOT be started in patients with cirrhosis but no varices, as it does not prevent varix formation and increases adverse events 3

Mechanism and Dosing

How It Works

Propranolol reduces portal pressure through two mechanisms 1, 2:

• β1-blockade: Decreases cardiac output
• β2-blockade: Produces splanchnic vasoconstriction, reducing portal blood flow

The goal is to reduce hepatic venous pressure gradient (HVPG) to <12 mmHg or by ≥20% from baseline, which essentially eliminates bleeding risk 1, 2

Practical Dosing

• Start propranolol at 40 mg once daily 1
• Titrate to the maximal tolerated dose, not to heart rate reduction (heart rate does not correlate with HVPG reduction) 1
• Typical maintenance doses range from 80-160 mg daily 1, 2
• Long-acting formulations can be used to improve compliance 1, 2

Secondary Prophylaxis (Preventing Rebleeding)

For patients who have already bled from varices, the combination of nonselective beta-blockers PLUS endoscopic variceal ligation is superior to either therapy alone and is the recommended approach 2, 4

Critical Contraindications and Cautions

Do NOT use propranolol in the following situations:

• During acute variceal bleeding with hypotension (systolic BP <90 mmHg or MAP <65 mmHg) - beta-blockers should be temporarily suspended 3
• Asthma or severe COPD 2, 4
• High-degree heart block or severe bradycardia 2, 4
• Decompensated heart failure 2

Important adverse event consideration: More patients on beta-blockers experience side effects requiring withdrawal (11-23%) compared to placebo (1-6%) 1, 5, 6

Duration of Therapy

Once started, propranolol should be continued indefinitely, as discontinuation increases bleeding risk 1, 2

Monitoring

• Patients on propranolol do not need surveillance endoscopy 1
• Patients with small varices NOT on propranolol should have endoscopy every 2 years, or annually if decompensated 1, 2
• Monitor heart rate, blood pressure, and renal function regularly 2

Why Nonselective Beta-Blockers?

Selective beta-blockers (like atenolol or metoprolol) are less effective and suboptimal for variceal prophylaxis because they lack the β2-mediated splanchnic vasoconstriction effect 1, 4