Non-selective Beta-Blockers in Decompensated Cirrhosis
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PORTAL HYPERTENSION (J GONZALEZ-ABRALDES AND E TSOCHATZIS, SECTION EDITORS)
Non-selective Beta-Blockers in Decompensated Cirrhosis Annsa C. Huang 1 & James M. Gardner 2 & Bilal Hameed 1
# Springer Science+Business Media, LLC, part of Springer Nature 2020
Abstract Purpose of Review The safety of non-selective beta-blockers (NSBB) in decompensated cirrhosis, particularly in patients with refractory ascites, has recently been called int question. This review summarizes recent evidence on the role of NSBBs in decompensated cirrhosis and provides recommendations for their appropriate use. Recent Findings Current evidence on the use of NSBBs in decompensated cirrhosis is mixed and is based on observational data. An initial study in 2010 demonstrated decreased survival in patients with refractory ascites who received propranolol compared to those who did not. Since then, multiple subsequent studies have not demonstrated a harmful effect of NSBBs in this setting. The safety of NSBB use is mediated by its dose, the type of NSBB, and the presence of underlying hemodynamic derangements related to end-stage cirrhosis. Summary Refractory ascites per se is not a contraindication to NSBB use. NSBBs can be safely used in decompensated cirrhosis, though the decision to do so requires careful decision making on the risk and benefit profile of NSBBs for each individual patient. Keywords Beta-blockers . Decompensated cirrhosis . Refractory ascites . Mortality . Complications . Portal hypertension
Introduction
Pathophysiology of Portal Hypertension
Non-selective beta blockers (NSBB) have been the mainstay of therapy for portal hypertension in patients with cirrhosis. By decreasing portal hypertension, they are used to reduce the risk of variceal bleeding and to prevent both initial and recurrent episodes of hemorrhage. The role of NSBBs in decompensated cirrhosis, particularly in patients with refractory ascites, has recently been called into question. The purpose of this review is to describe the role of NSBBs in decompensated cirrhosis and to provide recommendations for their appropriate use based on current evidence.
Cirrhosis is defined by progressive liver injury and ultimately irreversible fibrosis, leading to complications of portal hypertension. Clinical decompensation, including ascites, esophageal variceal hemorrhage, and hepatic encephalopathy, is associated with increased mortality in cirrhosis [1•]. Decompensated cirrhosis portends poor prognosis, with median survival times of around 2 years compared to > 12 years in compensated cirrhosis [2]. Portal hypertension occurs in cirrhosis as a result of increased vascular resistance to portal flow through the liver. Clinically significant portal hypertension is defined as a hepatic venous pressure gradient ≥ 10 mmHg, a threshold associated with increased risk of developing esophageal varices, overt clinical decompensation, and hepatocellular carcinoma [1•, 3]. Portal hypertension leads to development of portosystemic collateral vessels, in addition to splanchnic and perip
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