From the Guidelines
For the treatment of esophageal varices, the recommended dose of beta blockers is propranolol 20–40 mg twice a day, adjusted every 2–3 days until a resting heart rate of 55–60 beats per minute is achieved, with a maximum dose of 320 mg daily in patients without ascites and 160 mg daily in patients with ascites. The treatment of esophageal varices with beta blockers, such as propranolol and nadolol, is a well-established practice, as outlined in the 2020 clinical practice guidelines for liver cirrhosis 1. Key considerations for dosing include:
- Propranolol: starting dose of 20–40 mg twice a day, with adjustments every 2–3 days to achieve the target heart rate, and a maximum dose of 320 mg daily in patients without ascites and 160 mg daily in patients with ascites.
- Nadolol: starting dose of 20–40 mg once a day, with adjustments every 2–3 days to achieve the target heart rate, and a maximum dose of 160 mg daily in patients without ascites and 80 mg daily in patients with ascites. It is crucial to monitor patients for potential side effects, such as dizziness, fatigue, and hypotension, and to adjust the dose accordingly, as discontinuing beta blockers can increase the risk of variceal bleeding and mortality, as noted in the guidelines 1. Additionally, the guidelines highlight the importance of careful consideration of the risks and benefits of beta blocker use in patients with refractory ascites or spontaneous bacterial peritonitis, and the need for thorough monitoring of blood pressure and renal function in these patients 1.
From the Research
Treatment Dose of Beta Blocker for Esophageal Varices
- The optimal dose of beta blockers for esophageal varices is not explicitly stated in the provided studies, but it is mentioned that the dose should be optimized to the highest acceptable dosage to reach the therapeutic goal 2.
- A study found that only 30.7% of patients took optimal doses of non-selective beta blockers, and poor drug adherence and previous hospital admission were significantly associated with sub-optimal dosing 2.
- Another study compared endoscopic variceal ligation with propranolol for primary prophylaxis of variceal bleeding and found that propranolol should be considered the first choice in primary prophylaxis of variceal bleeding, offering similar effects and lower severe adverse events compared with endoscopic variceal ligation 3.
- The use of beta blockers, such as propranolol and nadolol, in combination with endoscopic variceal ligation and sucralfate, has been shown to be effective in preventing variceal rebleeding 4.
- A study found that treating patients with esophageal varices with propranolol significantly reduces the incidence of first variceal bleeding, but the effect on mortality is marginal 5.
Factors Affecting Treatment Dose
- Poor drug adherence is a significant factor associated with sub-optimal dosing of non-selective beta blockers 2.
- Previous hospital admission in the last year is also a significant factor associated with sub-optimal dosing of non-selective beta blockers 2.
- The presence of high-risk esophageal varices, such as large varices with red spots, may require a higher dose of beta blockers to prevent bleeding 5.
Combination Therapy
- The combination of beta blockers, endoscopic variceal ligation, and sucralfate has been shown to be effective in preventing variceal rebleeding 4.
- The use of beta blockers in combination with endoscopic variceal ligation may further reduce the risk of rebleeding, especially in patients with a high risk of rebleeding 5, 6.