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Carvedilol for primary prophylaxis of variceal bleeding in cirrhotic patients with haemodynamic non-response to propranolol
  1. Thomas Reiberger1,
  2. Gregor Ulbrich2,
  3. Arnulf Ferlitsch1,
  4. Berit Anna Payer1,
  5. Philipp Schwabl1,
  6. Matthias Pinter1,
  7. Birgit B Heinisch1,
  8. Michael Trauner1,
  9. Ludwig Kramer2,
  10. Markus Peck-Radosavljevic1,
  11. Vienna Hepatic Hemodynamic Lab
  1. 1Division of Gastroenterology & Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
  2. 2Division of Gastroenterology & Hepatology, Department of Internal Medicine I, Hospital Hietzing, Vienna, Austria
  1. Correspondence to Professor Dr Markus Peck-Radosavljevic, Department of Internal Medicine III, Division of Gastroenterology & Hepatology, Vienna Hepatic Hemodynamic Laboratory, Medical University Vienna, Waehringer Guertel 18-20, A-1090 Vienna, Austria; markus.peck{at}meduniwien.ac.at

Abstract

Objective Non-selective β-blockers or endoscopic band ligation (EBL) are recommended for primary prophylaxis of variceal bleeding in patients with oesophageal varices. Additional α-adrenergic blockade (as by carvedilol) may increase the number of patients with haemodynamic response (reduction in hepatic venous pressure gradient (HVPG) of ≥20% or to values <12 mm Hg).

Design Patients with oesophageal varices undergoing measurement of HVPG before and under propranolol treatment (80–160 mg/day) were included. HVPG responders were kept on propranolol (PROP group), while non-responders were placed on carvedilol (6.25–50 mg/day). Carvedilol responders continued treatment (CARV group), while non-responders to carvedilol underwent EBL. The primary aim was to assess haemodynamic response rates to carvedilol in propranolol non-responders.

Results 36% (37/104) of patients showed a HVPG response to propranolol. Among the propranolol non-responders 56% (38/67) eventually achieved a haemodynamic response with carvedilol, while 44% (29/67) patients were finally treated with EBL. The decrease in HVPG was significantly greater with carvedilol (median 12.5 mg/day) than with propranolol (median 100 mg/day): −19±10% versus −12±11% (p<0.001). During a 2 year follow-up bleeding rates for PROP were 11% versus CARV 5% versus EBL 25% (p=0.0429). Fewer episodes of hepatic decompensation (PROP 38%/CARV 26% vs EBL 55%; p=0.0789) and significantly lower mortality (PROP 14%/CARV 11% vs EBL 31%; p=0.0455) were observed in haemodynamic responders compared to the EBL group.

Conclusions Carvedilol leads to a significantly greater decrease in HVPG than propranolol. Using carvedilol for primary prophylaxis a substantial proportion of non-responders to propranolol can achieve a haemodynamic response, which is associated with improved outcome with regard to prevention of variceal bleeding, hepatic decompensation and death.

  • Portal Hypertension
  • Cirrhosis
  • Bleeding

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