From the Guidelines
Propranolol is recommended for the management of esophageal varices to reduce the risk of bleeding, with a typical dosage of 40 mg twice daily, increasing to 80 mg twice daily if necessary, as per the guidelines 1. The goal of therapy with propranolol is to reduce the hepatic venous pressure gradient to less than 12 mm Hg, which can be achieved through its mechanism of blocking beta-adrenergic receptors, reducing portal pressure by decreasing cardiac output and causing splanchnic vasoconstriction 1. Some key points to consider when using propranolol for esophageal varices include:
- Starting dose: 40 mg twice daily, with potential increase to 80 mg twice daily if necessary 1
- Aim of therapy: Reduction in hepatic venous pressure gradient to less than 12 mm Hg 1
- Contraindications or intolerance: Variceal band ligation is the treatment of choice in such cases 1
- Monitoring: Patients should be monitored for side effects including fatigue, dizziness, and bradycardia, and propranolol should be used cautiously in patients with asthma, diabetes, or heart failure 1
- Combination therapy: The combination of propranolol and variceal band ligation may have a synergistic effect, but current evidence does not support its use for primary prophylaxis 1 It is essential to prioritize the most recent and highest quality study, which in this case is the 2020 guidelines from the Clinical and Molecular Hepatology journal 1, while also considering the recommendations from other studies 1.
From the Research
Propranolol and Esophageal Varices
- Propranolol is a medication used to prevent bleeding from esophageal varices in patients with cirrhosis and portal hypertension 2, 3.
- Studies have shown that propranolol can reduce the risk of first variceal bleeding in patients with high-risk esophageal varices 3, 4.
- However, the effect of propranolol on mortality is marginal, and primary prophylaxis is not generally recommended for all patients with esophageal varices 4.
Comparison with Endoscopic Variceal Ligation (EVL)
- EVL is a procedure used to treat esophageal varices by placing bands around the varices to stop bleeding 2, 5.
- Studies have compared the effectiveness of propranolol and EVL in preventing variceal bleeding, with some showing that EVL may be more effective in certain patient populations 2, 5.
- However, propranolol may have a lower rate of severe adverse events compared to EVL 2.
Patient Subgroups
- Patients with non-cirrhotic portal hypertension (NCPH) may benefit more from EVL than propranolol in preventing variceal rebleeding 5.
- Patients with Child's C cirrhosis may have a higher risk of bleeding and may benefit from combination therapy with propranolol and EVL 5.