Management of Esophageal Varices with Beta Blockers

Primary Prophylaxis

The American Association for the Study of Liver Diseases (AASLD) recommends starting nonselective beta-blockers (NSBBs) immediately upon detection of medium or large esophageal varices (>5mm) that have not bled, as they reduce first bleeding risk from 30% to 14% and improve mortality 1, 2, 3
NSBBs should be started in patients with small varices (≤5mm) and high-risk features, such as Child-Pugh class B or C cirrhosis, or red wale marks on varices 1, 2, 3, 4
The AASLD guidelines note that NSBBs can be used to slow progression from small to large varices, but long-term benefit is not well established 1, 2, 3

The recommended starting dose of propranolol is 40 mg once daily, titrated to maximal tolerated dose 4, 8
The recommended starting dose of nadolol is 40 mg once daily, titrated to maximal tolerated dose 1, 2

The AASLD recommends starting NSBBs plus endoscopic variceal ligation (EVL) combination therapy after variceal bleeding, as this is superior to either modality alone for preventing rebleeding 4

In pregnancy, NSBBs (propranolol preferred) should be started for medium/large varices identified on screening EGD performed in the second trimester 6, 5
In patients with post-HCV cure, NSBBs can be discontinued if post-SVR liver stiffness <12 kPa and platelets >150 G/L, but should be continued if liver stiffness >25 kPa 9

NSBBs reduce portal pressure through β1-mediated decreased cardiac output and β2-mediated splanchnic vasoconstriction 1, 2, 3, 4
Selective beta-blockers (atenolol, metoprolol) are suboptimal and should not be used 1, 2, 3, 4

Asthma, severe COPD, heart block, significant bradycardia, hypotension, decompensated heart failure are contraindications for NSBBs 4
In acute variceal bleeding, beta-blockers should be temporarily suspended until hemodynamic stability is achieved 10