The Use of Beta-Blockers in Hereditary Hemorrhagic Telangiectasia-Related Epistaxis: A Systematic Review

Abstract

Background Hereditary hemorrhagic telangiectasia (HHT) is an autosomal dominant disease affecting 1 in 5000 individuals. Epistaxis is seen in more than 90% of patients with HHT. Severe recurrent epistaxis can significantly decrease quality of life and may be resistant to standard treatment measures. Dysregulation of angiogenesis has been shown to cause the proliferation of abnormal blood vessels. As such, antiangiogenic treatments have been investigated including beta-blockers. Objective A systematic review of the efficacy of beta-blockers in topical treatment of epistaxis in patients with HHT based on epistaxis duration, frequency, and severity. Methods A systematic search was performed using the PubMed, Embase via Ovid, and Cochrane databases. The Preferred Items for Systematic Reviews and Meta-Analyses guidelines were followed. Studies that measured the efficacy of beta-blocker treatment of epistaxis in patients with HHT were included for qualitative analysis. Results Five studies (3 randomized controlled trials and 2 case series) with a total of 132 patients were included. Administration (systemically or topically via a spray or gel) of timolol and propranolol showed mixed evidence of improvement in epistaxis frequency, severity, and duration when compared with control groups. The evidence for propranolol appears more promising than timolol. Conclusion There are significant limitations in the included studies, and further investigation with larger longitudinal or randomized prospective trials is recommended. The available evidence suggests that beta-blocker treatment may have a positive effect on HHT-related epistaxis.

Hereditary hemorrhagic telangiectasia: from signaling insights to therapeutic advances

“…For instance, four randomized studies using topical timolol in the form of a nasal spray or gel for epistaxis and an ophthalmic solution for cutaneous telangiectases reported discordant results in cohorts ranging from 6 to 58 patients ( 148 – 151 ). This is consistent with a systematic review from 2022 ( 152 ) on topical beta blockers suggesting that propranolol is more promising than timolol. Topical propranolol was reported to increase hemoglobin levels ( 153 , 154 ), but its use warrants monitoring for bradycardia occurrence, even when administered locally.…”

Finding Professional Engagement and Connection Through Scholarly Activity

“…In a systematic review, both topical and systemic beta blockers were found to have mixed benefits on epistaxis duration, frequency, and severity in HHT patients, although evidence for benefit with propranolol seemed most promising and deserving of future study. 19 In another systematic review, equivalent efficacy of endoscopic vidian neurectomy (EVN), surgical posterior nasal neurectomy (SPNN), and cryoablative posterior nasal neurectomy (CPNN) was found for nonallergic rhinitis patients, with EVN having higher rates of dry eye and palate/cheek numbness. 20 The use of temperature-controlled radiofrequency neurolysis of the posterior nasal nerve was found by Lee et al in a multisite prospective single-arm study to have sustained improvement in rhinitis symptoms based on 24h reflective total nasal symptom scores at 3- and 6-month follow-ups.…”