aGeneral Hospital of Shenyang Military Area, Shenyang;
bXijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi’an, China
Non-selective β-blockers (NSBBs) could effectively prevent the development of first variceal bleeding in cirrhotic patients with medium/large varices. However, as recently reviewed by Giannelli et al , the clinical benefit of NSBBs remains controversial in cirrhotic patients with small varices. In line with their considerations, we would like to further comment on the controversy.
A previous meta-analysis demonstrated that the incidence of first variceal bleeding was not different between patients with small varices who received NSBBs and those who did not . On the other hand, two randomized controlled trials (RCT) demonstrated that NSBBs could not prevent the development of large varices in patients with small varices. In a previous study by Cales et al, the NSBB group had a higher proportion of development of large varices than the placebo group (52/60 versus 30/67, P<0.0001, Chi-square test) . In a recent study by Sarin et al, the cumulative incidence of growth of varices was similar between NSBB and placebo groups (11% versus 16%, P=0.786, log-rank test) . By contrast, another RCT by Merkel et al achieved a positive result, suggesting that the cumulative risk of growth of varices was significantly lower in the NSBB group than in the placebo group (20% versus 51%, P<0.001, log-rank test) . But it should be noted that NSBB did not improve the survival and increase the rate of adverse events.
Taken together, we should acknowledge the inconsistency of evidence regarding the benefit of NSBBs for the management of small varices in liver cirrhosis. Additionally, given the potential drug-related adverse events, the use of NSBBs might be unnecessary in such patients.
1. Giannelli V, Lattanzi B, Thalheimer U, Merli M. Beta-blockers in liver cirrhosis. Ann Gastroenterol 2014;27:20-26.
2. D’Amico G, Pagliaro L, Bosch J. The treatment of portal hypertension: a meta-analytic review. Hepatology 1995;22:332-354.
3. Cales P, Oberti F, Payen JL, et al. Lack of effect of propranolol in the prevention of large oesophageal varices in patients with cirrhosis: a randomized trial. French-Speaking Club for the Study of Portal Hypertension. Eur J Gastroenterol Hepatol 1999;11:741-745.
4. Sarin SK, Mishra SR, Sharma P, Sharma BC, Kumar A. Early primary prophylaxis with beta-blockers does not prevent the growth of small esophageal varices in cirrhosis: a randomized controlled trial. Hepatol Int 2013;7:248-256.
5. Merkel C, Marin R, Angeli P, et al. A placebo-controlled clinical trial of nadolol in the prophylaxis of growth of small esophageal varices in cirrhosis. Gastroenterology 2004;127:476-484.