We read with great interest the recent guideline1 titled “Prevention and Management of Gastroesophageal Varices and Variceal Hemorrhage in Cirrhosis”.This guideline provided a comprehensive in-depth review on the issues of prophylaxis and treatment of variceal bleeding in patients with cirrhosis. However, there are some comments we would like to raise.
In the section of “Specific measures to control acute hemorrhage and prevent early recurrence”, the authors clearly stated that results of meta-analyses of trials of octreotide are controversial and a more recent meta-analysis of trials of somatostatin analogs showed a negligible beneficial effect. However, Recommendation 14 classified the evidence of pharmacological therapy (somatostatin or its analogs octreotide and vapreotide; terlipressin) as Class I, Level A. This may cause some confusion, because table 1 (“Grading System for Recommendations”) in the article states that Class I means conditions for which there is evidence and/or general agreement that a treatment is beneficial, useful, and effective. In the case of somatostatin and its analogs, it can only be stated this pharmacological therapy is safe, but not definitely beneficial, useful, and effective. In view of this, the recommendation of somatostatin and its analogs shall be categorized as Class IIa, Level A. On the contrary, terlipressin is the only vasoactive agent that has been shown to reduce mortality in single studies and meta-analyses,2 and the recommendation on the use of terlipressin shall be categorized as Class I, Level A. However, this recent excellent Cochrane systematic review was not included in the references list.
Thus, we suggest that distinguishing the recommendations between somatostatin and/or its analogs and terlipressin would be more appropriate.