What beta blocker (beta-adrenergic blocking agent) is used to treat portal hypertension?

From the Guidelines

Beta blockers are the first-line treatment for portal hypertension, and all patients with clinically significant portal hypertension (CSPH) should be treated with beta-blockers to prevent variceal bleeding and non-bleeding-related decompensation. According to the most recent guidelines, as stated in the EASL position paper on clinical follow-up after HCV cure 1, patients with post-SVR VCTE-LSM >25 kPa have a high likelihood of CSPH and should continue treatment with non-selective beta blockers (NSBB) or carvedilol if already on it.

Key Considerations for Beta Blocker Use

• Non-selective beta blockers like propranolol and nadolol are preferred, with propranolol typically starting at 20mg twice daily and nadolol at 20-40mg once daily.
• Carvedilol, with its additional alpha-1 blocking properties, may be more effective and is started at 6.25mg daily, increasing to 12.5mg daily as needed and tolerated.
• The goal of beta blocker therapy is to reduce portal pressure by decreasing cardiac output and causing splanchnic vasoconstriction, which is effective in the presence of hyperdynamic circulation, usually seen in patients with HVPG >10 mmHg.
• Treatment with beta blockers should be lifelong unless contraindications develop, such as asthma, severe bradycardia, heart block, or decompensated heart failure.
• Regular monitoring of heart rate, blood pressure, and signs of hepatic decompensation is crucial during treatment, as side effects can include fatigue, dizziness, and sexual dysfunction.

Decision to Discontinue Beta Blockers

The decision to discontinue beta blockers can be considered if CSPH has been resolved after SVR, as indicated by post-SVR VCTE-LSM <12 kPa and PLT >150 G/L 1. However, patients with a history of variceal bleeding should continue secondary prophylaxis, including endoscopic band ligation plus NSBB/carvedilol, unless these criteria are met.

Screening Priority

Screening for CSPH rather than for varices has become a diagnostic priority, emphasizing the importance of early detection and treatment of portal hypertension to prevent both bleeding and non-bleeding complications, as supported by the PREDESCI study and the Baveno VII recommendations, although not directly cited here, their impact is reflected in the current practice guidelines 1.

From the Research

Beta Blockers for Portal Hypertension

• Non-selective beta blockers are the mainstay of medical therapy in preventing variceal bleeding and rebleeding in patients with portal hypertension 2, 3, 4, 5.
• These drugs work by reducing cardiac output and producing splanchnic vasoconstriction, which reduces portal flow and pressure 5.
• Examples of non-selective beta blockers used in portal hypertension include propranolol, nadolol, and carvedilol 3, 4, 6.
• Carvedilol is a more potent agent than propranolol in reducing portal pressure and is better tolerated 3, 4.
• The use of beta blockers has been shown to reduce the risk of variceal bleeding and rebleeding, with a reduction in bleeding risk from 30 to 15% in primary prophylaxis and from 60 to 42% in secondary prophylaxis 5.

Efficacy and Safety

• The efficacy of beta blockers in reducing portal pressure has been demonstrated by numerous trials, with a satisfactory reduction in portal pressure possible in a third to half of patients with propranolol and nadolol 3.
• However, there are safety concerns in advanced disease, such as in patients with refractory ascites, and beta blockers should be used with caution in these patients 2, 3.
• Hemodynamic monitoring can help select non-responders who may benefit from additional therapies such as band ligation 3, 5.

Current Status and Expanding Indications

• Non-selective beta blockers remain the pharmacotherapy of choice for primary and secondary prophylaxis of variceal bleeding 4.
• Data have emerged on the use of carvedilol in preventing hepatic decompensation and improving patient survival among patients with clinically significant portal hypertension 4.
• Non-invasive tests with liver stiffness measurement in combination with platelet count may be accurate in identifying clinically significant portal hypertension and guiding treatment 4.