scholarly journals PRO (“The Window Is Open”): In patients with cirrhosis with prior variceal hemorrhage and ascites, the clinical benefits of nonselective beta-blockers outweigh the risks and should be prescribed

2018 ◽  
Vol 11 (5) ◽  
pp. 119-122
Author(s):  
Danielle Tholey ◽  
Nitzan Roth ◽  
Thomas Schiano
Keyword(s):  
Beta Blockers ◽  
Variceal Hemorrhage ◽  
Clinical Benefits

scholarly journals Pharmacotherapy of liver cirrhosis and its complications

2021 ◽  
pp. 23-27
Author(s):  
T. M. Bentsa
Keyword(s):  
Liver Cirrhosis ◽  
Spontaneous Bacterial Peritonitis ◽  
Hepatorenal Syndrome ◽  
Beta Blockers ◽  
Bleeding Risk ◽  
Refractory Ascites ◽  
Variceal Hemorrhage ◽  
Bacterial Peritonitis ◽  
Treatment And Prevention ◽  
Increased Risk

This article provides information about the pharmacotherapy of liver cirrhosis (LC) and its complications, such as variceal hemorrhage, ascites, increased risk of bacterial infection, spontaneous bacterial peritonitis, hepatic encephalopathy, hepatorenal syndrome LC is a major healthcare problem and is associated with an increased mortality due to the development of complications. LC is currently the 11th most common cause of death globally. Prognosis of LC is highly variable and influenced by several variables, such as etiology, severity of liver disease, presence of complications and comorbidities. In advanced cirrhosis, survival decreases to one or two years. Pharmacotherapy for LC should be implemented in accordance with up-to-date guidelines and in conjunction with aetiology management, nutritional optimisation and patient education. The main treatment of uncomplicated ascites is diuretics such as spironolactone in combination with a loop diuretic. For treatment refractory ascites vasoconstrictors and albumin are recommended. Antibiotics play a well-established role in the treatment and prevention of spontaneous bacterial peritonitis. For hepatorenal syndrome, the administration of vasopressor terlipressin and albumin is recommended. Endoscopic treatment is used for variceal bleeding (for example, ligation for esophageal varices and tissue glue for gastric varices). A shunt (TIPS) is used to treat severe or repeat variceal hemorrhage or refractory ascites. Non-selective beta-blockers effectively reduce variceal re-bleeding risk in LC patients with moderate/large varices. Thus, the treatment of LC as one of the most formidable multiorgan pathologies involves a comprehensive approach aimed at the correction of the main pathology and the treatment and prevention of its complications.

scholarly journals Motion – Prophylactic Banding of Esophageal Varices Is Useful: Arguments against the Motion

2002 ◽  
Vol 16 (10) ◽  
pp. 693-695 ◽  
Author(s):  
Kris V Kowdley
Keyword(s):  
Esophageal Varices ◽  
Variceal Bleeding ◽  
Beta Blockers ◽  
Low Cost ◽  
Cost Effective ◽  
Primary Prophylaxis ◽  
Ease Of Use ◽  
Endoscopic Sclerotherapy ◽  
Variceal Hemorrhage ◽  
Band Ligation

Bleeding from esophageal varices leads to substantial morbidity and mortality. Despite advances in pharmacological and endoscopic therapy, as well as general supportive care, the mortality rate associated with acute variceal hemorrhage has not improved significantly over the past two decades. Prophylactic therapy with nonselective beta-blockers or long acting nitrates reduces the incidence of variceal bleeding in patients with cirrhosis, is cost effective and may improve survival. Surgical portosystemic shunting reduces the risk of bleeding but is associated with significant operative mortality and a high risk of portosystemic encephalopathy. Endoscopic sclerotherapy causes adverse effects in a large proportion of patients and is, therefore, not suitable for primary prophylaxis of bleeding. Although variceal band ligation is effective in reducing the rate of bleeding and is safer than sclerotherapy, it has not been shown to provide a survival advantage compared with beta-blockers. A significant reduction in the rate of variceal bleeding with band ligation, compared with beta-blockers, was shown in only one study. Beta-blockers offer several advantages, including low cost, ease of use and safety. The available data do not yet support the prophylactic use of variceal band ligation, and this procedure should be reserved for patients who are either unwilling or unable to take beta-blockers. It is hoped that additional large, multicentre trials of band ligation versus beta-blockers will examine the efficacy, cost effectiveness and impact on quality of life among patients with cirrhosis.

Novel Approaches to Reducing the Risk of Variceal Hemorrhage

2017 ◽  
Vol 35 (4) ◽  
pp. 397-401 ◽  
Author(s):  
Frederik Nevens
Keyword(s):  
Variceal Bleeding ◽  
Beta Blockers ◽  
Liver Stiffness ◽  
Metallic Stents ◽  
New Drugs ◽  
Refractory Ascites ◽  
Variceal Hemorrhage ◽  
Endoscopic Screening ◽  
Balloon Tamponade ◽  
The Moment

Background: Complications of advanced liver disease occur at the moment of clinical significant portal hypertension. Nitric oxide (NO) dysfunction and fibrosis play an important role in the pathophysiology of PH, but other mechanisms are also involved. Non-selective beta blockers (NSBB) stay the cornerstone in the primary and secondary prevention of variceal bleeding, but their safety in advanced cirrhosis has been recently debated and new drugs are under investigation. Transjugular intrahepatic portosystemic shunt and balloon tamponade are the standard therapy in case of refractory variceal bleeding, but both interventions have drawbacks. Key Message: Transelastography under certain conditions and the presence of collateral circulation on imaging allow to rule-in CSPH, which makes patients open at risk for variceal hemorrhage. FXR agonists are intrahepatic NO donors; they reduce fibrosis and prevent bacterial translocation, which make them promising drugs for the treatment of PH. NSBB should be used with caution in patients with refractory ascites and certainly in those with hepatorenal syndrome. Preliminary clinical data suggest that simvastatin and enoxaparin improve the prognosis of patients with cirrhosis. Finally, covered esophageal metallic stents are safer and more effective than balloon tamponade in the case of refactory variceal bleeding. Conclusions: Liver stiffness measurements enable the selection of patients for endoscopic screening for esophageal varices. In the case of tense ascites, the dose of NSBB should be adapted to the hemodynamic condition of the patient. Self-expanding, covered esophageal metallic stents replace balloon tamponade in the treatment of massive variceal hemorrhage.

scholarly journals Management of variceal hemorrhage: current concepts

2014 ◽  
Vol 27 (2) ◽  
pp. 138-144 ◽  
Author(s):  
Fabricio Ferreira COELHO ◽  
Marcos Vinícius PERINI ◽  
Jaime Arthur Pirola KRUGER ◽  
Gilton Marques FONSECA ◽  
Raphael Leonardo Cunha de ARAÚJO ◽  
...  
Keyword(s):  
Portal Hypertension ◽  
Surgical Treatment ◽  
Variceal Bleeding ◽  
Endoscopic Therapy ◽  
Beta Blockers ◽  
Primary Prophylaxis ◽  
Underlying Disease ◽  
Secondary Prophylaxis ◽  
Variceal Hemorrhage ◽  
Cirrhotic Patients

INTRODUCTION: The treatment of portal hypertension is complex and the the best strategy depends on the underlying disease (cirrhosis vs. schistosomiasis), patient's clinical condition and time on it is performed (during an acute episode of variceal bleeding or electively, as pre-primary, primary or secondary prophylaxis). With the advent of new pharmacological options and technical development of endoscopy and interventional radiology treatment of portal hypertension has changed in recent decades. AIM: To review the strategies employed in elective and emergency treatment of variceal bleeding in cirrhotic and schistosomotic patients. METHODS: Survey of publications in PubMed, Embase, Lilacs, SciELO and Cochrane databases through June 2013, using the headings: portal hypertension, esophageal and gastric varices, variceal bleeding, liver cirrhosis, schistosomiasis mansoni, surgical treatment, pharmacological treatment, secondary prophylaxis, primary prophylaxis, pre-primary prophylaxis. CONCLUSION: Pre-primary prophylaxis doesn't have specific treatment strategies; the best recommendation is treatment of the underlying disease. Primary prophylaxis should be performed in cirrhotic patients with beta-blockers or endoscopic variceal ligation. There is controversy regarding the effectiveness of primary prophylaxis in patients with schistosomiasis; when indicated, it is done with beta-blockers or endoscopic therapy in high-risk varices. Treatment of acute variceal bleeding is systematized in the literature, combination of vasoconstrictor drugs and endoscopic therapy, provided significant decline in mortality over the last decades. TIPS and surgical treatment are options as rescue therapy. Secondary prophylaxis plays a fundamental role in the reduction of recurrent bleeding, the best option in cirrhotic patients is the combination of pharmacological therapy with beta-blockers and endoscopic band ligation. TIPS or surgical treatment, are options for controlling rebleeding on failure of secondary prophylaxis. Despite the increasing evidence of the effectiveness of pharmacological and endoscopic treatment in schistosomotic patients, surgical therapy still plays an important role in secondary prophylaxis.

Favorable Effects of Endoscopic Ligation Combined with Drugs on Rebleeding and Mortality in Cirrhotic Patients: A Network Meta-Analysis

2017 ◽  
Vol 36 (2) ◽  
pp. 136-149 ◽  
Author(s):  
Liang Shi ◽  
Xueping Zhang ◽  
Jianye Li ◽  
Xibo Bai
Keyword(s):  
Beta Blockers ◽  
Meta Analysis ◽  
Cochrane Library ◽  
Isosorbide Mononitrate ◽  
Endoscopic Variceal Ligation ◽  
Variceal Hemorrhage ◽  
Combination Therapies ◽  
Previous Episode ◽  
Cirrhotic Patients ◽  
Endoscopic Ligation

Background: To assess the effects of combination therapies (endoscopic plus drug[s], drug combinations) on variceal/any-cause rebleeding and mortality among cirrhotic patients with one previous episode of variceal hemorrhage. Summary: We searched PubMed, Embase, Cochrane Library, and Web of Science for eligible studies. We included 26 randomized controlled trials involving 2,536 adults using OR to measure the effects. Endoscopic variceal ligation (EVL) plus nadolol ranked first for reducing recurrent bleeds. Both EVL + nadolol and EVL + drugs (nadolol, sucralfate) decreased the risk of any-cause rebleeding than EVL alone (OR 0.34, 95% CI 0.12–0.97; OR 0.40, 95% CI 0.18–0.88, respectively). Meanwhile, EVL + drugs ranked first lowering mortality rates (P-score >0.85) with a marginal superiority over EVL alone (OR 0.52, 95% CI 0.26–1.01). Beta-blockers with isosorbide mononitrate (ISMN) also reached a marginal superiority (OR 0.78, 95% CI 0.56–1.09) for improving mortality. Key Messages: Our findings indicated that EVL + nadolol might be the preferred choice to cirrhotic patients with one previous episode of variceal hemorrhage for preventing rebleeding. EVL + nadolol + sucralfate and beta-blockers + ISMN may be potential alternatives to improve mortality. Further, well-controlled studies are warranted to compare the promising combination therapies.

scholarly journals Management and Prognosis of Heart Failure in Octogenarians: Final Report from the KorAHF Registry

2020 ◽  
Vol 9 (2) ◽  
pp. 501 ◽  
Author(s):  
Gyu Chul Oh ◽  
Hyun-Jai Cho ◽  
Sang Eun Lee ◽  
Min-Seok Kim ◽  
Jae-Joong Kim ◽  
...  
Keyword(s):  
Heart Failure ◽  
Blood Pressure ◽  
Beta Blockers ◽  
Renin Angiotensin System ◽  
The Elderly ◽  
Final Report ◽  
Aldosterone Antagonists ◽  
Reduced Ejection Fraction ◽  
Increased Risk ◽  
Clinical Benefits

Treatment of heart failure (HF) in the elderly face many difficulties due to lack of robust evidence. We analyzed the outcome of HF in octogenarians using a nationwide HF registry. Among 5625 patients from the Korean Acute Heart Failure (KorAHF) registry, prognosis of octogenarian HF and the association of guideline-directed medical therapy (GDMT) with mortality and readmissions were analyzed. Octogenarian patients (1185, 22.4%) showed a higher mortality, and males were especially at increased risk (HR (hazard ratio) 1.19, 95% CI 1.01–1.40). A J-curve association between blood pressure (BP) and mortality was observed regardless of age, but the nadir value was lower in octogenarians (123.8 vs. 127.9 mmHg for systolic blood pressure (SBP); 67.1 vs. 73.9 mmHg for diastolic blood pressure (DBP), p < 0.001). Use of GDMT in octogenarian patients with HF and reduced ejection fraction (EF) were inadequate (74.3%, 47.1%, and 46.1% in octogenarians vs. 78.4%, 59.8%, and 55.2% in non-elderly for renin-angiotensin system inhibitors, beta-blockers, and aldosterone antagonists, respectively; all p < 0.05). However, those on medications had a significant reduction in 6 month mortality. For octogenarians with HF and preserved EF, angiotensin receptor blocker use reduced hospitalizations for HF in men (HR 0.19, 95% CI 0.04–0.87), but not in women (p-interaction = 0.037). HF in octogenarians were found to have different characteristics compared with the non-elderly. However, adequate use of GDMT was still associated with improved survival, and more attention should be given to prescribing medications with clinical benefits.

Premorbid, cardioselective beta-blocker exposure decreases ICU mortality in septic patients defined by sepsis-3

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
M Kuo ◽  
R.H Chou ◽  
C.H Wu ◽  
P.H Huang ◽  
S.J Lin
Keyword(s):  
Beta Blocker ◽  
Myocardial Injury ◽  
Beta Blockers ◽  
Lactate Concentration ◽  
Funding Source ◽  
Icu Mortality ◽  
Kaplan Meier ◽  
Clinical Benefits ◽  
The Difference

Abstract Introduction Beta-blockers may exert a protective effect against the catecholaminergic myocardial injury in septic patients. The difference between cardioselective and non-selective beta blockers was not fully elaborated. The aim of this study was to investigate the association between premorbid prescriptions of different class of beta-blockers and mortality rate in septic patients. Methods We retrospectively screened 2678 patients admitted to the ICU during December 2015 to July 2017. Premorbid beta-blocker exposure was defined as prescription of any beta blocker for at least 1 month. Bisoprolol, esmolol, and atenolol were classified as cardioselective beta-blockers, and others were classified as non-selective beta-blockers. Results Among 1262 septic patients, 209 (16.6%) cases were long-term beta-blockers users. Patients with premorbid beta-blocker exposure were associated with higher BP, lower HR, lactate concentration, and improved ICU mortality. However, only premorbid cardioselective beta-blocker users (adjusted HR 0.26; 95% CI 0.11–0.64; p=0.003), but not non-selective beta-blocker users (adjusted HR 0.66; 95% CI 0.29–1.51; p=0.326), were associated with reduced ICU mortality. Conclusion Only premorbid cardioselective beta-blockers, but not non-selective beta-blockers, were associated with improved mortality in septic patients. These findings supported the cardioprotective effect and clinical benefits of beta-blocker in septic patients. Kaplan-Meier Curve of ICU Mortality Funding Acknowledgement Type of funding source: None

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