Nonselective beta-blockers (NSBBs) are the recommended class of drugs for the management of esophageal varices, with propranolol and nadolol being the primary agents used.
Primary prevention of variceal hemorrhage
- Propranolol or carvedilol: For primary prevention of variceal hemorrhage, the ESGE 2022 guidelines recommend initiating NSBBs, preferably carvedilol, in patients with compensated advanced chronic liver disease and clinically significant portal hypertension
- Propranolol or nadolol: The ASGE 2014 guidelines recommend initiating NSBBs or performing endoscopic variceal ligation for primary prophylaxis in patients with large esophageal varices with high-risk stigmata or Child-Pugh class B/C cirrhosis
- Propranolol or endoscopic band ligation: The EASL 2018 guidelines recommend initiating NSBBs or performing endoscopic band ligation in patients with medium-large varices. The choice of treatment should be based on local resources and expertise, patient preference, contraindications, and adverse events
Secondary prevention of variceal hemorrhage
- Propranolol or carvedilol: For secondary prevention of variceal hemorrhage, the ESGE 2022 guidelines recommend initiating NSBBs, either propranolol or carvedilol, in combination with endoscopic therapy in patients with advanced chronic liver disease
Management of beta-blockers
- Dose adjustment: The AASLD 2017 guidelines recommend avoiding high doses of NSBBs in patients with refractory ascites and SBP (e.g., >160 mg/day of propranolol or >80 mg/day of nadolol), as they might be associated with worse outcomes . In patients with refractory ascites and severe circulatory dysfunction (SBP < 90 mmHg, serum sodium < 130 meq/L, or hepatorenal syndrome), the dose of NSBBs should be decreased or the drug should be temporarily held. NSBBs can be reintroduced after circulatory dysfunction improves
Contraindications and cautions
- Severe or refractory ascites: Caution is advised when using NSBBs in patients with severe or refractory ascites. High doses of NSBBs should be avoided, and carvedilol should not be used in this context
- SBP, renal impairment, and hypotension: NSBBs should be discontinued at the time of SBP, renal impairment, and hypotension
In conclusion, the choice of beta-blocker for esophageal varices depends on the specific clinical context, including the stage of liver disease, presence of complications, and patient-specific factors. Propranolol and nadolol are commonly used, with carvedilol being an option in certain cases. However, caution is needed in patients with severe or refractory ascites, and dose adjustments may be necessary in patients with severe circulatory dysfunction.