The PRECIOSA trial and PREDESCI trial both studied non-selective beta-blockers (NSBB) in cirrhosis. The current recommendation regarding NSBBs in cirrhotic patients with refractory ascites is:
- A NSBBs (propranolol/nadolol) should be used cautiously or avoided in severe cirrhosis with refractory ascites, SBP, or severe hyponatraemia due to risk of haemodynamic decompensation; carvedilol is preferred where tolerated ✓
- B NSBBs should be continued at full dose as they always reduce portal hypertension
- C NSBBs are absolutely contraindicated in any patient with ascites
- D NSBBs have no mortality benefit in primary prophylaxis of variceal bleeding
Explanation
The PREDESCI trial showed carvedilol reduced decompensation events in compensated cirrhosis with high HVPG. However, in decompensated cirrhosis with refractory ascites, NSBBs (especially propranolol and nadolol) can reduce cardiac output and renal perfusion, precipitating hepatorenal syndrome in haemodynamically fragile patients. Current EASL guidelines recommend caution with NSBBs in patients with refractory ascites or SBP; they should be reduced or withheld if systolic BP < 90 mmHg, serum Na < 130 mEq/L, or AKI develops. Carvedilol (combined alpha-1/non-selective beta-blocker) has additional haemodynamic advantages and is preferred by many experts.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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