When should a non‑selective beta‑blocker (propranolol, nadolol, carvedilol) be discontinued in a patient with chronic liver disease?

When to Discontinue Beta-Blockers in Liver Disease

Beta-blockers should be temporarily suspended during acute variceal bleeding with hypotension (systolic BP <90 mmHg or MAP <65 mmHg), and permanently discontinued in patients with refractory ascites who develop persistent hypotension, severe circulatory dysfunction, or hepatorenal syndrome. 1, 2

Temporary Discontinuation Scenarios

Acute Variceal Bleeding with Hemodynamic Instability

• Immediately suspend all beta-blockers if systolic blood pressure drops below 90 mmHg or mean arterial pressure falls below 65 mmHg during active bleeding 1, 2, 3
• Beta-blockers play no role in acute bleeding management and are contraindicated in this hemodynamically unstable setting 3
• Once hemodynamic stability is restored after the acute episode, beta-blockers should be restarted as they become the cornerstone of secondary prophylaxis 3

Permanent Discontinuation or Avoidance Scenarios

Refractory Ascites with Circulatory Dysfunction

• Permanently discontinue or avoid beta-blockers in patients with refractory ascites who have:

  • Systolic blood pressure <90 mmHg persistently 1, 2
  • Serum sodium <130 mEq/L 2
  • Hepatorenal syndrome 2
  • Severe circulatory dysfunction 2

• The rationale is that as cirrhosis progresses with worsening systemic vasodilation and refractory ascites, beta-blockers can critically impair cardiac reserve and facilitate hemodynamic breakdown, imperiling renal perfusion 4

Other Absolute Contraindications

• Severe asthma or reactive airway disease 1
• Advanced atrioventricular heart block 1
• Decompensated heart failure 1

Critical Monitoring Parameters

When to Consider Stopping in Ascites Patients

• Monitor systolic blood pressure at every visit—maintain ≥90 mmHg 2, 3
• Check serum sodium levels—discontinue if <130 mEq/L 2
• Assess for signs of hepatorenal syndrome (rising creatinine, oliguria) 2
• Evaluate for worsening circulatory dysfunction (worsening hypotension despite fluid management) 2

Nuanced Approach Based on Ascites Severity

• Mild ascites: Beta-blockers (particularly carvedilol) are safe and associated with reduced mortality risk 5
• Moderate ascites: Beta-blockers can be continued with careful monitoring—not associated with increased mortality risk 5
• Refractory ascites: Use extreme caution; discontinue if any of the above hemodynamic or renal parameters deteriorate 2, 4

Important Caveats

The "Window Hypothesis"

• Beta-blockers remain beneficial for preventing further decompensations after ascites onset, but only until the cirrhosis progresses to a point where inflammation increases dramatically and cardiodynamic equilibrium becomes extremely fragile 4
• This creates a therapeutic "window" where beta-blockers transition from beneficial to potentially harmful 4

Carvedilol vs. Traditional NSBBs

• Carvedilol may be safer than propranolol/nadolol in patients with ascites due to its additional alpha-1 blocking effect, which reduces intrahepatic resistance 6, 5
• However, the same discontinuation criteria apply regardless of which beta-blocker is used 2

Evidence of Benefit in Acute-on-Chronic Liver Failure

• Contrary to older teaching, recent evidence suggests that ongoing beta-blocker treatment in patients who develop acute-on-chronic liver failure (ACLF) is safe and reduces 28-day mortality (24.4% vs 34.1%, p=0.048) 7
• Careful consideration should be given before stopping beta-blockers in cirrhotic patients, even during acute decompensation, unless specific contraindications exist 7

Practical Algorithm

1. During acute variceal bleeding: Check blood pressure immediately

   • If SBP <90 mmHg or MAP <65 mmHg → temporarily suspend beta-blocker 1, 2
   • Once hemodynamically stable → restart beta-blocker 3

2. In patients with ascites: Assess severity and hemodynamic status

   • Mild ascites + SBP ≥90 mmHg → continue beta-blocker 5
   • Moderate ascites + SBP ≥90 mmHg → continue with close monitoring 5
   • Refractory ascites + any of the following → discontinue permanently:
     • SBP <90 mmHg persistently 2
     • Serum sodium <130 mEq/L 2
     • Hepatorenal syndrome 2
     • Severe circulatory dysfunction 2

3. In ACLF: Do not automatically discontinue—assess hemodynamics first 7

   • If blood pressure maintained → continue beta-blocker 7
   • If hypotensive → temporarily suspend 1

The key principle is that beta-blockers should be continued indefinitely once started for variceal prophylaxis, as bleeding risk recurs when stopped, but they must be suspended or discontinued when specific hemodynamic or renal contraindications develop. 8, 2