Lack of effect of propranolol in the prevention of large oesophageal varices in patients with cirrhosis

Calès, Paul; Oberti, Frédéric; Payen, Jean‐Louis; Naveau, S.; Guyader, Dominique; Blanc, P; Abergel, A.; Bichard, Philippe; Raymond, J M; Canva-Delcambre, V.; Vetter, D; Valla, Dominique; Beauchant, Michel; Hadengue, Antoine; Champigneulle, B; Pascal, Jean‐Pierre; Poynard, Thierry; Lebrec, Didier

doi:10.1097/00042737-199907000-00011

Cited by 136 publications

(71 citation statements)

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“…The only two available studies, specifically addressing the issue of the efficacy of nonselective b-blockers in preventing the enlargement of small varices, have contradictory results. In the first study by Cales et al [25], the 2-year proportion of patients with large varices was unexpectedly larger in the propranolol group than in the placebo group (31% vs. 14%, P \ 0.05). However, the study enrolled patients with no and small varices, and a large number of the patients failed to have a regular follow-up.…”

Section: Recommendationsmentioning

confidence: 88%

“…Previous trials reporting on the pharmacologic prophylaxis of small esophageal varices have included a total of 179 patients. Heterogeneity in both the classification of varices and the number of bleeding episodes in this subgroup is small [20][21][22][23][24][25][26]. The only two available studies, specifically addressing the issue of the efficacy of nonselective b-blockers in preventing the enlargement of small varices, have contradictory results.…”

Section: Recommendationsmentioning

confidence: 99%

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Primary prophylaxis of gastroesophageal variceal bleeding: consensus recommendations of the Asian Pacific Association for the Study of the Liver

et al. 2008

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The Asian Pacific Association for the Study of the Liver (APASL) set up a Working Party on Portal Hypertension in 2002, with a mandate to develop consensus guidelines on various clinical aspects of portal hypertension relevant to disease patterns and clinical practice in the Asia-Pacific region. Variceal bleeding is a consequence of portal hypertension, which, in turn, is the major complication of liver cirrhosis. Primary prophylaxis to prevent the first bleed from varices is one of the most important strategies for reducing the mortality in cirrhotic patients. Experts predominantly from the Asia-Pacific region were requested to identify the different aspects of primary prophylaxis and develop the consensus guidelines. The APASL Working Party on Portal Hypertension evaluated the various therapies that have been used for the prevention of first variceal bleeding. A 2-day meeting was held on January 12 and 13, 2007, at New Delhi, India, to discuss and finalize the consensus statements. Only those statements that were unanimously approved by the experts were accepted. These statements were circulated to all the experts and were subsequently presented at the annual conference of the APASL at Kyoto, Japan, in March 2007.

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Section: Recommendationsmentioning

confidence: 88%

Section: Recommendationsmentioning

confidence: 99%

Primary prophylaxis of gastroesophageal variceal bleeding: consensus recommendations of the Asian Pacific Association for the Study of the Liver

et al. 2008

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“…Estos hallazgos han constituido la base racional para el diseño de estudios clínicos destinados a testar la hipótesis de que la administración precoz de betabloqueantes puede prevenir la formación de varices esofágicas. Hasta el momento hay publicados en la literatura 3 estudios multicéntricos, controlados y aleatorizados, con betabloqueantes para prevenir la formación, desarrollo y/o crecimiento de las varices esofágicas en enfermos con cirrosis e hipertensión portal (36,61,62) (Tabla II). Todos ellos utilizan un beta bloqueante frente a placebo, pero el tipo de betabloqueante es diferente en cada uno de los estudios.…”

Section: Profilaxis Preprimaria De Las Varices Esofágicasunclassified

Profilaxis preprimaria de la hemorragia por varices

González-Alonso

Gómez

Martínez

2007

Rev. esp. enferm. dig.

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INTRODUCCIÓNLas varices esofágicas son una manifestación clínica de la hipertensión portal, cuya causa más frecuente en nuestro medio es la cirrosis. La hemorragia digestiva alta por rotura de varices esofágicas es su complicación más grave, con una mortalidad elevada y una reducción de la supervivencia del 50% al año (1). El tratamiento actual de la hipertensión portal consiste en identificar a los pacientes que presentan varices, para administrar fármacos que al reducir la presión portal, también disminuyan la presión y la tensión variceal y con ello el riesgo de rotura y hemorragia. Otra estrategia que se ha planteado es identificar a los enfermos con presión portal elevada, pero que aún no han desarrollado varices, con objeto de tratarlos con fármacos reductores de la presión portal y así evitar que las varices lleguen a formarse. Este artículo describe las bases fisiopatológicas en las que se fundamenta REV ESP ENFERM DIG (Madrid) Vol. 99. N.°12, pp. 714-721, 2007 Correspondencia: Agustín Albillos Martínez. Servicio de Gastroenterología. Hospital Universitario Ramón y Cajal. Ctra. de Colmenar km 9,600. 28034 Madrid: e-mail: aalbillosm@meditex.es 2007; 99: 714-721. González-Alonso R, Garrido Gómez E, Albillos Martínez A. Profilaxis preprimaria de la hemorragia por varices. Rev Esp Enferm Dig RESUMENLa formación de colaterales portosistémicas, en especial en la unión esofagogástrica, es una de las consecuencias más graves de la hipertensión portal. El aumento de la presión portal es la fuerza más importante que dirige la formación de varices esofagogástri-cas, siendo necesario para que esto ocurra que la presión portal (estimada por el gradiente de presión venosa hepática) alcance un valor mínimo de 10 mmHg. Posteriormente, la hiperemia esplác-nica también contribuye al desarrollo de las varices. Las colaterales portosistémicas se forman por repermeabilización de vasos preexistentes, remodelado vascular y angiogénesis. El objetivo de la profilaxis preprimaria es evitar o retrasar la formación de varices esofagogástricas. En modelos experimentales de hipertensión portal, la administración precoz de vasoconstrictores esplácnicos como los beta-bloqueantes, de inhibidores de la síntesis de óxido nítrico o de sustancias anti-angiogénicas, inhibe la formación de colaterales portosistémicas. Sin embargo, los ensayos clínicos con beta-bloqueantes realizados en pacientes con cirrosis sin varices con objeto de retrasar su formación no han alcanzado los resultados esperados.Palabras clave: Hipertensión portal. Varices esofágicas. Hemorragia digestiva alta. Profilaxis. Cirrosis hepática. ABSTRACTPortosystemic collateral formation, particularly at the gastroesophageal junction, is a most serious consequence of portal hypertension. Increased portal pressure is the most significant force underlying gastroesophageal variceal formation, to which end portal pressure (estimated from the hepatic venous pressure gradient) must reach at least 10 mmHg. Subsequently, splanchnic hyperemia also contributes to variceal development. ...

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“…The average probability of patient dropout in the BB arms of 11 primary prophylaxis studies is 10%, and we adopted this as our base case estimate. [23][24][25][26][27][28][29][30][31][32][33] We assumed that these patients had a risk of bleeding equal to untreated controls. The average probability of reported noncompliance because of intolerable side effects is 15%.…”

Section: Appendix B: Rationale For Probability Estimates Of Compliancmentioning

confidence: 99%

“…The average probability of reported noncompliance because of intolerable side effects is 15%. [22][23][24][25][26][27][28][29][30][31][32] We assumed that these patients were referred for EBL, because the clinician was aware of the noncompliance. The probability of unreported noncompliance is difficult to discern, although it may play an important role in determining the effectiveness of BB therapy because unreported noncompliance will not prompt referral for alternative treatment.…”

Section: Appendix B: Rationale For Probability Estimates Of Compliancmentioning

confidence: 99%

Endoscopic screening for esophageal varices in cirrhosis: Is it ever cost effective?

Spiegel

Targownik²,

Dulai³

et al. 2003

Hepatology

141

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Current guidelines for the management of patients with compensated cirrhosis recommend universal screening endoscopy followed by prophylactic ␤-blocker therapy to prevent initial hemorrhage in those found to have esophageal varices. However, the cost-effectiveness of this recommendation has not been established. Our objective was to determine whether screening endoscopy is cost-effective compared with empiric medical management in patients with compensated cirrhosis. Decision analysis with Markov modeling was used to calculate the costeffectiveness of 6 competing strategies: (1) universal screening endoscopy (EGD) followed by ␤-blocker (BB) therapy (EGD3 BB) if varices are present, (2) EGD followed by endoscopic band ligation (EBL) (EGD3 EBL) if varices are present, (3) selective screening endoscopy (sEGD) in high risk patients followed by BB therapy if varices are present (sEGD3 BB), (4) selective screening endoscopy followed by EBL (sEGD3 EBL) if varices are present, (5) empiric ␤-blocker therapy in all patients, and (6) no prophylactic therapy ("Do Nothing"). Cost estimates were from a third-party payer perspective. The main outcome measure was the cost per initial variceal hemorrhage prevented. The "Do Nothing" strategy was the least expensive yet least effective approach. Compared with the "Do Nothing" strategy, the empiric ␤-blocker strategy cost an incremental $12,408 per additional variceal bleed prevented. Compared with the empiric ␤-blocker strategy, in turn, both the EGD3 BB and the EGD3 EBL strategies cost over $175,000 more per additional bleed prevented. The sEGD3 BB and sEGD3 EBL strategies were more expensive and less effective than the empiric ␤-blocker strategy. In conclusion, empiric ␤-blocker therapy for the primary prophylaxis of variceal hemorrhage is a cost-effective measure, as the use of screening endoscopy to guide therapy adds significant cost with only marginal increase in effectiveness. (HEPATOLOGY 2003;37:366-377.)

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Lack of effect of propranolol in the prevention of large oesophageal varices in patients with cirrhosis

Cited by 136 publications

References 0 publications

Primary prophylaxis of gastroesophageal variceal bleeding: consensus recommendations of the Asian Pacific Association for the Study of the Liver

Primary prophylaxis of gastroesophageal variceal bleeding: consensus recommendations of the Asian Pacific Association for the Study of the Liver

Profilaxis preprimaria de la hemorragia por varices

Endoscopic screening for esophageal varices in cirrhosis: Is it ever cost effective?

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