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Early identification of haemodynamic response to pharmacotherapy is essential for primary prophylaxis of variceal bleeding in patients with ‘high-risk’ varices

  1. P. SHARMA1,2,
  2. A. KUMAR1,2,
  3. B. C. SHARMA1,
  4. S. K. SARIN1,2

Article first published online: 8 APR 2009

DOI: 10.1111/j.1365-2036.2009.04015.x

Issue

Alimentary Pharmacology & Therapeutics

Alimentary Pharmacology & Therapeutics

Volume 30, Issue 1, pages 48–60, July 2009

Additional Information

How to Cite

SHARMA, P., KUMAR, A., SHARMA, B. C. and SARIN, S. K. (2009), Early identification of haemodynamic response to pharmacotherapy is essential for primary prophylaxis of variceal bleeding in patients with ‘high-risk’ varices. Alimentary Pharmacology & Therapeutics, 30: 48–60. doi: 10.1111/j.1365-2036.2009.04015.x

Author Information

  1. 1

    Department of Gastroenterology, GB Pant Hospital, New Delhi, India

  2. 2

    Department of Hepatology, Institute of Liver & Biliary Sciences (ILBS), New Delhi, India

*Dr S. K. Sarin, Room 201, Academic Block, Department of Gastroenterology, G B Pant Hospital, Affiliated to University of Delhi, New Delhi – 110 002, India. E-mail: sksarin@nda.vsnl.net.in

Publication History

  1. Issue published online: 15 JUN 2009
  2. Article first published online: 8 APR 2009
  3. Publication data Submitted 28 February 2009 First decision 10 March 2009 Resubmitted 16 March 2009 Resubmitted 23 March 2009 Accepted 2 April 2009 Epub Accepted Article 8 April 2009

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Summary

Background  A beta-blocker is recommended for primary prophylaxis of variceal bleeding; however, only one-third have hepatic venous pressure gradient (HVPG) response. The role of addition of isosorbide-5-mononitrate (ISMN) to beta-blocker and benefits of HVPG-guided ‘a la carte’ approach remain unclear.

Aim  To determine the benefits of HVPG-guided pharmacotherapy in primary prophylaxis of variceal bleeding using beta-blocker and ISMN.

Patients and methods  Consecutive patients of cirrhosis, with high-risk varices, with no previous variceal bleeding were included. After baseline HVPG, patients received incremental propranolol to achieve HR of 55/min. After one-month, HVPG was repeated to determine response (<12 mmHg or ≥20% reduction). ISMN was added in nonresponders and HVPG repeated. Patients were followed up for 24 months.

Results  Of 56 patients (age 47 ± 13, males 79%) from 89 eligible patients, 21 (38%) responded to beta-blocker alone. Six additional patients responded to combination. Thus, overall 48% (27/56) patients responded. Variceal bleeding occurred in seven of 56 (13%) patients [one of 27 (4%) responder, five of 23 (22%) nonresponders and one of six (17%) with unknown response; P = N.S.]. The actuarial probability of variceal bleeding at median 24 months was 4% in responders and 22% in nonresponders (P < 0.05). Ten (18%) patients developed adverse effects to propranolol and six of 35 (17%) to nitrates requiring dose reduction. Risk factors of variceal bleed were grade IV varices and haemodynamic nonresponse.

Conclusions  For primary prophylaxis, a beta-blocker is effective in 38% and addition of ISMN raises the response rate to about half of patients. The HVPG-guided ‘a la carte’ approach may be considered for these patients.

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