Nonselective beta blockers
Nonselective beta blockers are first-line therapy for primary prevention of variceal bleeding because they have additional benefits, including prevention of decompensation events (eg ascites) in patients with cirrhosis. UseGarcia-Tsao 2017Tripathi 2015:
1 carvedilol 6.25 mg orally, daily initially, then increase to a target dosage of 12.5 mg daily. Doses may be given in a single dose or two divided doses daily1 gastro-oesophageal varices carvedilol
OR
2 propranolol 20 mg orally, twice daily initially, then increase gradually to a target dosage of 80 mg twice daily. gastro-oesophageal varices propranolol
Carvedilol and propranolol are both effective in reducing the risk of bleeding gastro-oesophageal varices. However, carvedilol has additional vasodilator activity (as it blocks both alpha and beta receptors), producing a greater reduction in portal pressure compared with propranolol, and less systemic hypotension for an equivalent effect on portal pressure. Villanueva 2019Weersink 2018Jachs 2022
Titrate the dose against clinical tolerance; maintain resting heart rate above 60 beats per minute and systolic blood pressure above 90 mmHgGarcia-Tsao 2017.
In patients with refractory ascites, beta blockers should be withheld acutely if serum sodium concentration is less than 130 mmol/L or the patient has acute kidney injury.
Once the target dose is achieved with beta blocker therapy, endoscopic surveillance is not required, unless the patient develops clinical decompensation, as this will not change management.