Liver and Bile
Clin Gastroenterol Hepatol. 2023;21(9):2318–26.e7
Carvedilol achieves higher hemodynamic response and lower rebleeding rates than propranolol in secondary prophylaxis
Background and aims: Carvedilol induces stronger decreases in hepatic venous pressure gradient (HVPG) than conventional non-selective beta-blockers (NSBB, i.e., propranolol). Limited data exist on the efficacy of carvedilol in secondary prophylaxis of variceal bleeding.
Methods: Patients undergoing paired HVPG measurements for guiding secondary prophylaxis with either carvedilol or propranolol were included in this retrospective analysis. All patients also underwent band ligation. Changes in HVPG and systemic hemodynamics were compared between the 2 groups. Long-term follow-up data on rebleeding, acute kidney injury, non-bleeding decompensation, and liver-related death were analyzed applying competing risk regression.
Results: 87 patients (carvedilol/propranolol, n = 45/42) were included in the study. The median baseline HVPG was 21 mmHg (interquartile range [IQR], 18–24 mmHg), and 39.1%/48.3%/12.6% had Child-Turcotte-Pugh A/B/C cirrhosis, respectively. Upon NSBB initiation, HVPG decreased more strongly in carvedilol users (median relative decrease, -20% [IQR, -29% to -10%] vs. -11% [IQR, -22% to -5%] for propranolol; p = 0.027), who also achieved chronic HVPG response more often (53.3% vs. 28.6%; p = 0.034). Cumulative incidences for rebleeding (Gray test, p = 0.027) and liver-related death (p = 0.036) were significantly lower in patients taking carvedilol compared with propranolol. Notably, ascites development/worsening also was observed less commonly in carvedilol patients (p = 0.012). Meanwhile, acute kidney injury rates did not differ between the 2 groups (p = 0.255). Stratifying patients by HVPG response status yielded similar results. The prognostic value of carvedilol intake was confirmed in competing risk regression models.
Conclusions: Carvedilol induces more marked reductions in hepatic venous pressure gradient than propranolol in secondary prophylaxis of variceal bleeding, and thus is associated with lower rates of rebleeding, liver-related death, and further non-bleeding decompensation.