Is additional 5-day vasoactive drug therapy necessary for acute variceal bleeding after successful endoscopic hemostasis?

Abstract

Background:Vasoactive drugs and endoscopic therapy have been widely used in the management of acute variceal bleeding of cirrhosis patients. The current standard regimen of vasoactive drugs is in combination with endoscopic therapy and continues for up to 5 days; however, the necessity of vasoactive drugs after endoscopic hemostasis was still controversial. Therefore, we conducted a systematic review and meta-analysis to evaluate the efficacy and optimal duration of adjuvant vasoactive drugs after hemorrhage control by endoscopic therapy.Methods:A search was conducted of PubMed, EMBASE, and Cochrane Library databases until June, 2018. Lan DeMets sequential monitoring boundary was constructed to assess the reliability and conclusiveness of our major results.Results:Seven studies (639 patients) and 4 studies (435 patients) were included in the analyses to evaluate the efficacy and optimal duration of adjuvant vasoactive drugs therapy, respectively. Our analyses showed that adjuvant vasoactive drugs facilitated endoscopic hemostasis and reduced very early re-bleeding rate both in sclerotherapy (risk ratio [RR] 0.51, 95% confidence interval [CI] 0.34–0.78, P = .23, I2 = 31%) and band ligation (RR 0.48, 95% CI 0.27–0.83, P = .07, I2 = 62%). However, the 3 to 5-day therapy duration was not superior to a shorter course in very early re-bleeding rate and mortality rate in 42 days (RR 1.77, 95% CI 0.64–4.89, P = .70, I2 = 0%; RR 0.95, 95% CI 0.43–2.13, P = .81, I2 = 0%, respectively).Conclusion:Additional 5-day vasoactive drug after endoscopic hemostasis may significantly ameliorate very early re-bleeding rate, However, the 3 to 5 days’ adjuvant regimen was not superior to a shorter course.

Recent Advances in the Management of Acute Variceal Hemorrhage

“…However, as vasoconstrictors may be associated with potentially serious adverse events, the feasibility of a shorter administration (i.e., 24-48 h vs. 3-5 days) has been considered. In a recent meta-analysis, although the risk of 42-day mortality was not significantly different between one to three and five days, risk stratification was missing [41]. It may be that Child A patients could receive a shorter duration of therapy, whereas all others would require five days, but further studies are required to answer this question.…”

Endoscopic diagnosis and management of esophagogastric variceal hemorrhage: European Society of Gastrointestinal Endoscopy (ESGE) Guideline

“…Several systematic reviews/meta-analyses, including numerous RCTs with thousands of patients, have evaluated the efficacy and safety of vasoactive agents in acute EGVH 52 53 54 55 56 57 . In summary, vasoactive agents are superior to no vasoactive treatment in terms of rates of in-hospital mortality, overall mortality, variceal bleeding control, variceal rebleeding, and blood transfusion requirement.…”

Precision medicine in variceal bleeding: Are we there yet?

“…Once endoscopic haemostasis is achieved, shorter regimens of vasoactive drugs have been suggested although no clear general recommendation can be given based on the available data. [57][58][59] EBL should be the treatment of choice for oesophageal varices whereas gastric varices require glue injection. Bacterial infection and renal failure are the most feared complications of AVB and should be prophylactically treated with antibiotics and careful replacement of fluids and electrolytes.…”