Propranolol plus placebo versus propranolol plus isosorbide-5-mononitrate in the prevention of a first variceal bleed

Oesophageal varices in cirrhotic patients: from variceal screening to primary prophylaxis of the first oesophageal variceal bleeding

“…Although it was shown previously by Garcia‐Pagan et al (73) that adding ISMN to β‐blockers leads to a higher HVPG response rate, there were divergent results as far as the clinical efficacy of a combination in primary prophylaxis is concerned. In a multicentre randomized trial on 146 patients, nadolol+ISMN demonstrated a significantly lower rate of first bleeding than nadolol alone in the long‐term (up to 7 years) use, with few side effects, but without improving survival (74).…”

Beta Blocker Prophylaxis for Patients With Variceal Hemorrhage

“…3,4 Nonselective beta blockers lower portal hypertension by decreasing cardiac output and azygous blood flow and by causing splanchnic vasoconstriction. 6,[15][16][17][18][19][20][21][22][23] Band ligation is the preferred treatment in the face of inability to administer beta blocker, but other pharmacotherapeutic therapies for lowering portal pressure have been investigated. Overall, beta blocker therapy has been demonstrated to decrease risk of recurrent bleeding (by 34%) and mortality (by 26%) in patients with history of variceal hemorrhage (secondary prophylaxis).…”

Beta‐blockers in portal hypertension: new developments and controversies

“…ISMN has been compared with propranolol or nadolol, with no effect on survival and a tendency towards worse survival in those over 50 (49,50). ISMN in combination with NSBB has yielded mixed results, and has a worse side effect profile (51,52).…”