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To block, or not to block in advanced cirrhosis and ascites: that is the question; Whether 'tis nobler in the mind to suffer the slings and arrows of outrageous non-selective β-blockers (NSBB), or to take arms against a sea of criticism. These words rephrase Prince Hamlet's contemplation of death and suicide in William Shakespeare's tragedy Hamlet. He bemoans the pains and unfairness of life but acknowledges that the alternative may still be worse.
NSBBs have been studied since the early 1960s and have been a cornerstone in clinical hepatology where they have benefitted more patients and saved more lives than any other drug in this field over the past three decades (table 1).1 ,2 In addition, NSBBs continue to be intensively studied and have become the Holy Grail in portal hypertension.
In 2010, the scientific community was shocked as data came out suggesting that NSBBs were associated with poor survival in patients with refractory ascites.3 That study led to subsequent debates and a number of additional observational studies with conflicting results (table 2). Nevertheless, a serious concern regarding the safety of NSBB in advanced cirrhosis has been raised3 ,4 which should be weighed against the potential benefit of NSBBs and alternative treatment options (table 1, figure 1). None of the randomised controlled trials (RCTs) on NSBB to date have specifically assessed safety and efficacy in advanced stage disease and consequently no strong recommendations can be made. Previous RCTs on NSBB excluded patients with advanced liver disease or only included a small number of these patients.5 ,6 Until we have specific RCTs evaluating NSBB in late stage cirrhosis, large observational studies are needed and may …
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