• CIRRHOSIS
• ASCITES
• OESOPHAGEAL VARICES

The decision of ‘if and when’ to stop non-selective β-blockers (NSBB) at certain stages of end-stage cirrhosis has been debated intensively and has generated a number of studies with various outcomes.1 ,2 Some studies demonstrated deleterious effects, others improved survival.3 ,4 However, nobody has looked into how these conflicting findings influence doctors and today’s clinical practice when prescribing NSBB.

Our hypothesis is that this ongoing controversy causes an unstandardised usage of NSBB depending on the individual clinician. To test this, we performed a survey consisting of 131 branched questions regarding the usage of NSBB in advanced cirrhosis. It was structured with potential contraindications or adverse events and the respondents were asked if they considered these as contraindications or not. Furthermore, they were questioned if NSBB should be reinstituted if the condition improved. The survey was subdivided in a section regarding patients not listed for transplantation, patients listed for transplantation, patients with Child–Pugh C cirrhosis and patients suffering from hepatocellular carcinoma. The survey was web-based on the project-redcap.org platform and data were analysed with StataIC V.14. The respondents were invited by emails which were obtained from coauthors’ network and from EASL’s website. According to Danish regulations, ethics approval is not necessary to perform surveys among healthcare professionals.

In total 629 (16%) responded, the majority from Europe (69%). Seventy-nine per cent of the respondents were either specialised hepatologists or gastroenterologists, 82% were from academic centres and 69% worked in tertiary centres. Ninety-nine per cent were clinicians, of whom 51% were combined clinicians and researchers. Ninety-seven per cent of the respondents had prescribed NSBB for patients with cirrhosis within the last year, 45% more than 20 times. In primary prevention of bleeding from oesophageal varices, 89% of the respondents used NSBB and 82% in the secondary prophylaxis. Less than 24% stated that they would treat the patients differently if listed for transplantation, were Child–Pugh C or suffering from hepatocellular carcinoma.

Interestingly, there was no consensus on standard dose and titration principle of NSBB when asked to choose between six different principles (figure 1). Furthermore, there was a huge disagreement when asked if refractory ascites, spontaneous bacterial peritonitis or renal impairment is considered a contraindication or not (table 1). Surprisingly, 6% and 17% respectively considered first-time ascites and recurrent ascites as contraindications for NSBB, and additionally 28% and 33% did not consider hepatorenal syndrome type 1 or type 2 as contraindications. This finding was supported by 25% answering ‘No’, when asked if mean arterial pressure <80 mm Hg was a contraindication for NSBB.

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Figure 1

Answers to the question ‘How much β-blocker do you prescribe?’. HVPG, hepatic venous pressure gradient.

The data were collected at a single point in time. Therefore, it is not possible to quantify if these findings have changed over time or are caused by different interpretations of the observational studies on the safety of NSBB in advanced cirrhosis. Furthermore, a low response rate is a limitation. However, a large proportion of the respondents were from academic centres and subspecialised and might have a local, regional or national key opinion leader role, suggesting that the data were likely representative of current perceptions. In addition, the data were stabled across countries supporting reliability.

Overall, the survey revealed a lack of consensus among doctors regarding ‘when and if’ to discontinue NSBB in advanced cirrhosis. Thus, we still need data to shed light on this clinically important issue. Data from studies with stronger designs are needed together with mechanistic studies, that is, should patients be separated based on clinical characteristics, haemodynamics or biochemical measures as serum sodium and creatinine. In addition, the clinical benefit of NSBB in prophylaxis of bleeding has not been established in the fragile subpopulations and the effect size may be small, particularly among patients with short life expectancy.