Use of Nonselective β-Blockers in Patients With End-Stage Liver Disease and Select Complications

Abstract

Objective: To review the literature and recommendations for nonselective β-blockers (NSBBs) in the setting of variceal bleeding prophylaxis and decompensated liver disease. Data Sources: Literature search of MEDLINE was performed (1988 to October 2019) using the following search terms: cirrhosis, advanced cirrhosis, β-blocker, decompensation, prophylaxis. Abstracts, peer-reviewed publications, clinical practice guidelines, and product monographs were reviewed. Study Selection and Data Extraction: Relevant English language studies and those conducted in humans were considered for analysis and inclusion. Data Synthesis: Evidence that suggests that NSBBs are harmful in advanced cirrhosis is overshadowed by confounding variables and small patient populations. The majority of the available evidence suggests neutral or beneficial effects on mortality with continuation of NSBBs despite liver disease progression. Based on the available literature, guidelines, and expert consensuses, NSBBs can be considered within this patient population and may have a positive impact on the majority of these patients. Relevance to Patient Care and Clinical Practice: This review summarizes current place in therapy for NSBBs in the setting of cirrhosis and variceal bleeding prophylaxis. It also includes a discussion of the literature for use of NSBBs within the setting of different acute decompensations in which the data and recommendations for use are less clear. Conclusions: Recent evidence shows neutral or positive results for NSBB use in particular decompensation subgroups, which suggests that NSBBs can be used cautiously with close monitoring in patients with advanced cirrhosis. Questions still remain regarding optimal agent and dose and whether agents can be safely restarted after an acute decompensation episode.

Beta-blockers in patients with liver cirrhosis: Pragmatism or perfection?

“…There is now a number of reviews that carefully analyze the existing literature, as to whether NSBBs are appropriate in severely decompensated liver cirrhosis (14,139). Some evidence suggests that ß-blockers can/should also be given in patients with ascites and decompensated liver cirrhosis (140)(141)(142) under strict control of pulse, blood pressure and renal function using an adjusted lower dosage (143). Further reduction of the cardiac index (CI) in the presence of primarily already reduced cardiac function in the sense of cirrhotic cardiomyopathy is certainly unfavorable (144,145).…”

Evaluation of the Effectiveness of Various Methods of Primary Prevention of Varicose Bleeding in Patients With Liver Cirrhose

“…Метаанализ восьми рандомизированных клинических исследований (РКИ) [12], сравнивающих ЭВП с отсутствием лечения (ОЛ), показал, что ЭВП снижает как риск первого портального гипертонического кровотечения (OR = 0,3, 95 % CI: 0,17-0,53), так и летальность (OR = 0,42, 95 % CI: 0,3-0,6) (таблица) без статистической гетерогенности для кровотечения или летальности. В проспективном когортном исследовании пациенты с противопоказаниями, непереносимостью или отсутствием ответа на бета-блокаторы, получавшие лечение ЭВП, достигли профилактики от повторного варикозного кровотечения, сравнимой с таковой у пациентов с хорошим ответом на бета-блокаторы.…”

Beta-blockers and Statins: Role in Portal Hypertension and Beyond

“…It should be noted that the association of EVL with carvedilol in secondary prophylaxis may be harmful in a subgroup of patients with more advanced disease, renal dysfunction, and arterial hypotension [16] . Studies are still controversial regarding beta-blockers' effect on renal function in patients with refractory ascites, spontaneous bacterial peritonitis, and other infectious complications.…”