Nonselective β-Blockers and Survival in Patients With Cirrhosis and Ascites: A Systematic Review and Meta-analysis

Chirapongsathorn, Sakkarin; Valentin, Nelson; Alahdab, Fares; Krittanawong, Chayakrit; Erwin, Patricia J.; Murad, M. Hassan; Kamath, Patrick S.

doi:10.1016/j.cgh.2016.01.012

Cited by 63 publications

(54 citation statements)

References 30 publications

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“…This study did not show a negative effect of NSBB on survival, though there was significant heterogeneity. A subanalysis of the 3 RCTs showed similar results, with no heterogeneity …”

Section: Use Of Nsbbs In Advanced Cirrhosis: Clinical Evidencementioning

confidence: 67%

Beta‐blockers in patients with advanced liver disease: Has the dust settled?

2017

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Nonselective beta-blockers (NSBBs) have been the backbone for the treatment of portal hypertension in cirrhosis for the last 3 decades. A publication in 2010 of a prospective observational study suggested that NSBBs could increase mortality in patients with refractory ascites. This opened a controversy about the safety and efficacy of NSBBs in patients with advanced liver disease and led to the publication of a large corpus of observational data assessing the safety of NSBBs in patients with advanced cirrhosis. In this article, we briefly review the clinical pharmacology of NSBBs, the pathophysiological basis for the underlying benefits and harms of NSBBs in advanced cirrhosis, and the evidence in favor and against the use of NSBBs in specific scenarios. Finally, we summarize the current recommendations and propose areas of opportunity for future research. Liver Transplantation 23 1058-1069 2017 AASLD.

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“…This study did not show a negative effect of NSBB on survival, though there was significant heterogeneity. A subanalysis of the 3 RCTs showed similar results, with no heterogeneity …”

Section: Use Of Nsbbs In Advanced Cirrhosis: Clinical Evidencementioning

confidence: 67%

Beta‐blockers in patients with advanced liver disease: Has the dust settled?

2017

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“…Other retrospective studies and meta analyses could not confirm this [24][25][26], but it is nevertheless possible that in a subset of patients with refractory ascites in whom the cardiac response to hypotension may be inadequate, NSBB may lead to a disturbance in the circulatory status, and therefore the Baveno consensus meeting recommended that for the given time, NSBB should be used cautiously in case of a systolic blood pressure <90 mm Hg, serum sodium <130 mEq/L or acute kidney injury [5] . In this regard, a recent study demonstrated that there was no clinical or hemodynamic rebound after abrupt interruption of NSBB in patients with cirrhosis [27] .…”

Section: Old Strategies With New Insightsmentioning

confidence: 79%

Novel Approaches to Reducing the Risk of Variceal Hemorrhage

Nevens

2017

Dig Dis

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Background: Complications of advanced liver disease occur at the moment of clinical significant portal hypertension. Nitric oxide (NO) dysfunction and fibrosis play an important role in the pathophysiology of PH, but other mechanisms are also involved. Non-selective beta blockers (NSBB) stay the cornerstone in the primary and secondary prevention of variceal bleeding, but their safety in advanced cirrhosis has been recently debated and new drugs are under investigation. Transjugular intrahepatic portosystemic shunt and balloon tamponade are the standard therapy in case of refractory variceal bleeding, but both interventions have drawbacks. Key Message: Transelastography under certain conditions and the presence of collateral circulation on imaging allow to rule-in CSPH, which makes patients open at risk for variceal hemorrhage. FXR agonists are intrahepatic NO donors; they reduce fibrosis and prevent bacterial translocation, which make them promising drugs for the treatment of PH. NSBB should be used with caution in patients with refractory ascites and certainly in those with hepatorenal syndrome. Preliminary clinical data suggest that simvastatin and enoxaparin improve the prognosis of patients with cirrhosis. Finally, covered esophageal metallic stents are safer and more effective than balloon tamponade in the case of refactory variceal bleeding. Conclusions: Liver stiffness measurements enable the selection of patients for endoscopic screening for esophageal varices. In the case of tense ascites, the dose of NSBB should be adapted to the hemodynamic condition of the patient. Self-expanding, covered esophageal metallic stents replace balloon tamponade in the treatment of massive variceal hemorrhage.

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“…Full-text manuscripts published over more than 35 years, from 1980 to April 2016, were reviewed for relevance and reference lists were cross-checked for additional pertinent studies regarding potential NSBB effects (including non-haemodynamic ones), but especially focused on those concerned with survival and/or acute kidney injury (AKI) 22. Since the previous meta-analysis by Chirapongsathorn et al 23 included a thorough review up until January 2015, we particularly focused on those articles published or indexed after that date. This consisted of peer-reviewed journal articles, retrospectives studies, post hoc analysis and expert opinions.…”

Section: Introductionmentioning

confidence: 99%

“…Recently, Chirapongsathorn et al 23 conducted a systematic review and meta-analysis to evaluate the effect of NSBBs on all-cause mortality in patients with cirrhosis and RA. The meta-analysis included 3145 patients from three RCTs and eight observational studies of propranolol, carvedilol, nadolol and metoprolol up until January 2015, reporting 1206 deaths.…”

Section: Introductionmentioning

confidence: 99%

Non-selective β-blockers in advanced cirrhosis: a critical review of the effects on overall survival and renal function

Blasco-Algora

Masegosa-Ataz

Alonso

et al. 2016

BMJ Open Gastroenterol

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IntroductionNon-selective β-blockers (NSBBs) are widely prescribed in patients with cirrhosis for primary and secondary prophylaxis of bleeding oesophageal varices. Furthermore, it has been suggested that the clinical benefits of NSBBs may extend beyond their haemodynamic effects. Recently, a potentially harmful effect has been described in patients with refractory ascites or spontaneous bacterial peritonitis.MethodologyA comprehensive literature search on β-blockers and cirrhosis survival using the electronic databases PubMed/MEDLINE, AMED, CINAHL and the Cochrane Central Register of Controlled Trials. Full-text manuscripts published over more than 35 years, from 1980 to April 2016 were reviewed for relevance and reference lists were cross-checked for additional pertinent studies regarding potential NSBB effects, especially focused on those concerned with survival and/or acute kidney injury (AKI).DiscussionThe proposed review will be able to provide valuable evidence to help decision making in the use of NSBB for the treatment of advanced cirrhosis and highlights some limitations in existing evidence to direct future research.

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Nonselective β-Blockers and Survival in Patients With Cirrhosis and Ascites: A Systematic Review and Meta-analysis

Cited by 63 publications

References 30 publications

Beta‐blockers in patients with advanced liver disease: Has the dust settled?

Beta‐blockers in patients with advanced liver disease: Has the dust settled?

Novel Approaches to Reducing the Risk of Variceal Hemorrhage

Non-selective β-blockers in advanced cirrhosis: a critical review of the effects on overall survival and renal function

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