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Carvedilol for primary prophylaxis of variceal bleeding in cirrhotic patients with haemodynamic non-response to propranolol.
Gut 2013; 62(11):1634-41Gut

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.

Authors+Show Affiliations

Division of Gastroenterology & Hepatology, Department of Internal Medicine III, Medical University of Vienna, , Vienna, Austria.No affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info available

Pub Type(s)

Clinical Trial
Journal Article

Language

eng

PubMed ID

23250049

Citation

Reiberger, Thomas, et al. "Carvedilol for Primary Prophylaxis of Variceal Bleeding in Cirrhotic Patients With Haemodynamic Non-response to Propranolol." Gut, vol. 62, no. 11, 2013, pp. 1634-41.
Reiberger T, Ulbrich G, Ferlitsch A, et al. Carvedilol for primary prophylaxis of variceal bleeding in cirrhotic patients with haemodynamic non-response to propranolol. Gut. 2013;62(11):1634-41.
Reiberger, T., Ulbrich, G., Ferlitsch, A., Payer, B. A., Schwabl, P., Pinter, M., ... Peck-Radosavljevic, M. (2013). Carvedilol for primary prophylaxis of variceal bleeding in cirrhotic patients with haemodynamic non-response to propranolol. Gut, 62(11), pp. 1634-41. doi:10.1136/gutjnl-2012-304038.
Reiberger T, et al. Carvedilol for Primary Prophylaxis of Variceal Bleeding in Cirrhotic Patients With Haemodynamic Non-response to Propranolol. Gut. 2013;62(11):1634-41. PubMed PMID: 23250049.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Carvedilol for primary prophylaxis of variceal bleeding in cirrhotic patients with haemodynamic non-response to propranolol. AU - Reiberger,Thomas, AU - Ulbrich,Gregor, AU - Ferlitsch,Arnulf, AU - Payer,Berit Anna, AU - Schwabl,Philipp, AU - Pinter,Matthias, AU - Heinisch,Birgit B, AU - Trauner,Michael, AU - Kramer,Ludwig, AU - Peck-Radosavljevic,Markus, AU - ,, Y1 - 2012/12/18/ PY - 2012/12/20/entrez PY - 2012/12/20/pubmed PY - 2013/12/18/medline KW - Bleeding KW - Cirrhosis KW - Portal Hypertension SP - 1634 EP - 41 JF - Gut JO - Gut VL - 62 IS - 11 N2 - 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. SN - 1468-3288 UR - https://www.unboundmedicine.com/medline/citation/23250049/Carvedilol_for_primary_prophylaxis_of_variceal_bleeding_in_cirrhotic_patients_with_haemodynamic_non_response_to_propranolol_ L2 - http://gut.bmj.com/cgi/pmidlookup?view=long&amp;pmid=23250049 DB - PRIME DP - Unbound Medicine ER -