Beta-blocker monotherapy may be preferred for primary prophylaxis of esophageal variceal bleeding

Guidelines currently recommend nonselective beta-blockers or variceal band ligation for primary prevention of variceal bleeding based on similar efficacy, but survival benefit may be better with the former treatment.


Monotherapy with nonselective beta-blockers may be the best initial choice of therapy for primary prophylaxis of esophageal variceal bleeding in patients with cirrhosis and large esophageal varices, according to a recent systematic review and network meta-analysis.

Researchers examined randomized clinical trials that involved at least 12 months of follow-up and compared different therapies alone or in combination in adults with cirrhosis, large esophageal varices, and no history of bleeding. Reduction in all-cause mortality and prevention of esophageal variceal bleeding were primary outcomes. The goal of the current study was to compare the efficacy of different therapies for primary prevention of death and first esophageal variceal bleeding. Results were published online Aug. 19 by Hepatology.

Overall, 32 trials involving 3,362 adults with cirrhosis were included, comparing nonselective beta-blockers, isosorbide-mononitrate, carvedilol, and variceal band ligation. Median follow-up among the trials was 19 months. The authors found moderate-quality evidence to support a decrease in mortality with nonselective beta-blockers as monotherapy (odds ratio [OR], 0.70; 95% CI, 0.49 to 1.00) or combined with variceal band ligation (OR, 0.49; 95% CI, 0.23 to 1.02) or isosorbide-mononitrate (OR, 0.44; 95% CI, 0.21 to 0.93).

For primary prevention of variceal bleeding, moderate-quality evidence supported carvedilol (OR, 0.21; 95% CI, 0.08 to 0.56) and variceal band ligation (OR, 0.33; 95% CI, 0.19 to 0.55) each as monotherapy or in combination with nonselective beta-blockers (OR, 0.34; 95% CI, 0.14 to 0.86). Low-quality evidence supported monotherapy with nonselective beta-blockers for primary prevention of variceal bleeding (OR, 0.64; 95% CI, 0.38 to 1.07). Serious adverse events were reported more frequently with variceal band ligation than with nonselective beta-blocker monotherapy, although adverse events were not analyzed because definitions differed among studies.

The authors noted that the included studies were heterogeneous and that few studies looked at direct and indirect treatment comparisons, among other limitations. However, they concluded that while guidelines currently recommend nonselective beta-blockers or variceal band ligation for primary prevention of variceal bleeding based on similar efficacy, their results indicate that survival benefit may be better with the former treatment.

“Based on these findings, [nonselective beta-blockers] may be considered as the preferred initial approach for primary prevention of variceal bleeding, particularly in patients with early or compensated liver disease,” the authors wrote. “Future studies on predictive factors for response to therapy may help further individualize the management of esophageal varices.”