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Carvedilol for primary prophylaxis of variceal bleeding in cirrhosis

The most recent issue of Gut investigates the use of carvedilol for primary prophylaxis of variceal bleeding in cirrhotic patients with hemodynamic non-response to propranolol.

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Non-selective β-blockers or endoscopic band ligation are recommended for primary prophylaxis of variceal bleeding in patients with esophageal varices.

Additional α-adrenergic blockade (as by carvedilol) may increase the number of patients with hemodynamic response.

Professor Markus Peck-Radosavljevic and colleagues from Austria examined patients with esophageal varices undergoing measurement of HVPG before and under propranolol treatment.

HVPG responders were kept on propranolol, while non-responders were placed on carvedilol.

Carvedilol responders continued treatment, while non-responders to carvedilol underwent endoscopic band ligation.

Bleeding rates were 11% in patients on propranolol
Gut

The research team's primary aim was hemodynamic response rates to carvedilol in propranolol non-responders.

The team found that 36% of patients showed a HVPG response to propranolol.

Among the propranolol non-responders 56% eventually achieved a hemodynamic response with carvedilol, while 44% of patients were finally treated with endoscopic band ligation.

The team found that the decrease in HVPG was significantly greater with carvedilol than with propranolol.

During a 2 year follow-up bleeding rates were 11% in patients on propanolol versus 5% in Carvedilol responders versus 25% with endoscopic band ligation.

The team observed fewer episodes of hepatic decompensation, and significantly lower mortality were observed in hemodynamic responders compared to the endoscopic band ligation group.

Professor Peck-Radosavljevic's team concludes, "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."

Gut 2013; 62: 1634-1641
21 October 2013

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