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Alsaeid M, Sung S, Bai W, Tam M, Wong YJ, Cortes J, Cobo E, Gonzalez JA, Abraldes JG. Heterogeneity of treatment response to beta-blockers in the treatment of portal hypertension: A systematic review. Hepatol Commun 2024; 8:e0321. [PMID: 38285880 PMCID: PMC10830085 DOI: 10.1097/hc9.0000000000000321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 09/28/2023] [Indexed: 01/31/2024] Open
Abstract
BACKGROUND It has been suggested that a relevant proportion of patients do not respond to nonselective beta-blockers (NSBB)s, which raises questions regarding the need for individualized therapy. The existence of potential heterogeneity in the treatment response can be assessed using the variability ratio (VR) of the outcome measurement (in this case, HVPG) between the treated and placebo groups. We conducted a systematic review and meta-analysis of randomized controlled trials to assess the potential heterogeneity in the portal pressure response to NSBBs. METHODS After a systematic search, we quantified the heterogeneity of treatment response with the VR between the treatment and control groups, with VR > 1 indicating potential heterogeneity. We used a similar approach to compare carvedilol with propranolol and statins with placebo. RESULTS We identified 18 studies that included 965 patients. A comparison between beta-blockers and placebo showed a pooled VR of 0.99 (95% CI:0.87-1.14), which suggests a homogeneous HVPG response to NSBB at the individual patient level (ie, no evidence to support that some patients responded to beta-blockers and others did not). For the comparison between carvedilol and propranolol, pooled VR was 0.97 (95% CI 0.82-1.14), suggesting that carvedilol achieves a greater average response (rather than an increase in the proportion of responders). There was no evidence of a heterogeneous response to statins. CONCLUSION Our analysis did not support the existence of a heterogeneous patient-by-patient response to NSBBs in cirrhosis. These findings challenge the concept of personalized therapy based on portal pressure response and indicate that routine portal pressure measurement may not be necessary to guide NSBB therapy.
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Affiliation(s)
- Mohammad Alsaeid
- Liver Unit, Division of Gastroenterology, University of Alberta, Alberta, Canada
| | - Shuen Sung
- Liver Unit, Division of Gastroenterology, University of Alberta, Alberta, Canada
| | - Wayne Bai
- Waikato District Health Board, University of Auckland, Auckland, New Zealand
| | - Matthew Tam
- Liver Unit, Division of Gastroenterology, University of Alberta, Alberta, Canada
| | - Yu Jun Wong
- Liver Unit, Division of Gastroenterology, University of Alberta, Alberta, Canada
| | - Jordi Cortes
- Department of Statistics and Operations Research, Universitat Politècnica de Catalunya, Barcelona-Tech (UPC), Barcelona-Tech, Spain
| | - Erik Cobo
- Department of Statistics and Operations Research, Universitat Politècnica de Catalunya, Barcelona-Tech (UPC), Barcelona-Tech, Spain
| | - Jose Antonio Gonzalez
- Department of Statistics and Operations Research, Universitat Politècnica de Catalunya, Barcelona-Tech (UPC), Barcelona-Tech, Spain
| | - Juan G. Abraldes
- Liver Unit, Division of Gastroenterology, University of Alberta, Alberta, Canada
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Xu X, Guo X, De Stefano V, Silva-Junior G, Goyal H, Bai Z, Zhao Q, Qi X. Nonselective beta-blockers and development of portal vein thrombosis in liver cirrhosis: a systematic review and meta-analysis. Hepatol Int 2019; 13:468-481. [PMID: 31175581 DOI: 10.1007/s12072-019-09951-6] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Accepted: 05/11/2019] [Indexed: 02/07/2023]
Abstract
Portal vein thrombosis (PVT), which is associated with reduced portal vein velocity, is considered to be an indicator for worse outcomes in liver cirrhosis. Nonselective beta-blockers (NSBBs), which are widely used for primary and secondary prophylaxis of esophageal variceal bleeding in liver cirrhosis, can significantly decrease the portal vein velocity. We proposed a hypothesis that the use of NSBBs might facilitate the development of PVT in cirrhotic patients. The PubMed, EMBASE, and Cochrane Library databases were searched. Major meeting abstracts and randomized-controlled trials regarding the use of NSBBs in liver cirrhosis were also hand-searched. The number of patients who developed PVT in groups treated with or without NSBBs was pooled. Odds ratios (ORs) or risk ratios (RRs) with 95% confidence intervals (CIs) were calculated. Subgroup meta-analyses were performed according to the type of studies, region, and study quality. Meta-regression and sensitivity analyses were performed to explore the source of heterogeneity. Nine of the 6416 retrieved papers were finally included. Overall, meta-analysis demonstrated that NSBBs were significantly associated with the development of PVT (OR 4.62, 95% CI 2.50-8.53; p < 0.00001). The heterogeneity was statistically significant (I2 = 80%; p < 0.00001). Subgroup meta-analyses still demonstrated a significantly positive association of NSBBs with the development of PVT in cohort studies (RR 2.57, 95% CI 1.46-4.51; p = 0.001) and case-control studies (OR 8.17, 95% CI 2.46-27.06; p = 0.0006). Sensitivity analyses based on subgroups find the source of heterogeneity. Based on the systematic review and meta-analysis, we found that the use of NSBBs increased a 4.62-fold risk of PVT in cirrhotic patients.
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Affiliation(s)
- Xiangbo Xu
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command (Formerly Called General Hospital of Shenyang Military Area), No. 83 Wenhua Road, Shenyang, 110840, Liaoning, China
- Postgraduate College, Shenyang Pharmaceutical University, Shenyang, China
| | - Xiaozhong Guo
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command (Formerly Called General Hospital of Shenyang Military Area), No. 83 Wenhua Road, Shenyang, 110840, Liaoning, China
| | - Valerio De Stefano
- Fondazione Policlinico A. Gemelli IRCCS, Istituto Di Ematologia, Università Cattolica, Rome, Italy
| | - Gilberto Silva-Junior
- Department of General Medicine and Hepatology, Quinta D'Or Hospital, Rio de Janeiro, Brazil
| | - Hemant Goyal
- Department of Internal Medicine, School of Medicine, Mercer University, Macon, GA, USA
| | - Zhaohui Bai
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command (Formerly Called General Hospital of Shenyang Military Area), No. 83 Wenhua Road, Shenyang, 110840, Liaoning, China
- Postgraduate College, Shenyang Pharmaceutical University, Shenyang, China
| | - Qingchun Zhao
- Postgraduate College, Shenyang Pharmaceutical University, Shenyang, China
| | - Xingshun Qi
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command (Formerly Called General Hospital of Shenyang Military Area), No. 83 Wenhua Road, Shenyang, 110840, Liaoning, China.
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Acute and chronic hemodynamic changes after propranolol in patients with cirrhosis under primary and secondary prophylaxis of variceal bleeding: a pilot study. Eur J Gastroenterol Hepatol 2010; 22:507-12. [PMID: 20150817 DOI: 10.1097/meg.0b013e32832ca06b] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND AIM Prophylactic treatment of variceal bleeding in cirrhotic patients with beta-blockers is effective in only some patients. Our aim was to determine whether the response of the hepatic venous pressure gradient (HVPG) to the intravenous administration of propranolol predicts the response after chronic oral propranolol treatment. PATIENTS AND METHODS We included prospectively cirrhotic patients with esophageal varices under primary prophylaxis (PP) and secondary prophylaxis (SP). The HVPG was measured at baseline and after a propranolol bolus (0.15 mg/kg intravenous). A patient was considered a good-responder if HVPG decreased to 12 mmHg or 20% from baseline. Patients then received oral propranolol (heart rate titrated). Poor-responders under SP were also included in a variceal band ligation program. After at least 3 months, a second hemodynamic study was conducted. RESULTS Fifty-six patients were included (36 SP and 20 PP). Response rate was similar (32.1 and 41.9%, P=0.7) and the Pearson's correlation coefficient was 0.61 (P=0.001). In 81.4% patients, the first study predicted the response status of the second. Six patients rebled on follow-up between the studies, all of them were poor responders to intravenous propranolol. CONCLUSION A single hemodynamic study using intravenous propranolol seems to predict chronic response to propranolol.
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Sgouros SN, Vasiliadis KV, Pereira SP. Systematic review: endoscopic and imaging-based techniques in the assessment of portal haemodynamics and the risk of variceal bleeding. Aliment Pharmacol Ther 2009; 30:965-76. [PMID: 19735231 DOI: 10.1111/j.1365-2036.2009.04135.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Invasive measurement of the hepatic venous pressure gradient (HVPG) is regarded as the gold standard for risk stratification and the evaluation of pharmaceutical agents in patients with portal hypertension. AIM To review the techniques for endoscopic and imaging-based assessment of portal haemodynamics, with particular emphasis on trials where the results were compared with HVPG or direct portal pressure measurement. METHODS Systematic search of the MEDLINE electronic database with keywords: portal hypertension, variceal bleeding, variceal pressure, endoscopic ultrasound, Doppler ultrasonography, magnetic resonance angiography, CT angiography, hepatic venous pressure gradient. RESULTS Computed tomography angiography and endoscopic ultrasound (EUS) have been both employed for the diagnosis of complications of portal hypertension and for the evaluation of the efficacy of endoscopic therapy. Colour Doppler ultrasonography and magnetic resonance angiography has given discrepant results. Endoscopic variceal pressure measurements either alone or combined with simultaneous EUS, correlate well with HVPG and risk of variceal bleeding and have a low interobserver variability. CONCLUSIONS Endoscopic and imaging-based measurements of portal haemodynamics provide an alternate means for the assessment of complications of portal hypertension. Further studies are required to validate their use in risk stratification and the evaluation of drug therapies in patients with portal hypertension.
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Affiliation(s)
- S N Sgouros
- Department of Gastroenterology, University College London Hospitals NHS Foundation Trust, UK
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Abstract
Variceal bleeding is still a life-threatening complication of portal hypertension responsible for an appreciable rate of morbidity and mortality. The most appropriate treatment approach, whether drugs (nonselective beta-blockers) or endoscopic (variceal band ligation) therapy, to prevent the initial bleed, or primary prophylaxis, is an issue of controversy. Meta-analysis of randomized controlled trials indicates that banding seems to be somehow slightly more effective than beta-blockers at preventing a first bleeding episode, but this does not translate to improved survival. The firmness of this conclusion is, in addition, diminished by the small sample size and short follow-up of most studies. Moreover, adverse events due to banding are more severe than those associated with beta-blockers. Thus, beta-blockers remain as first-line therapy in patients with cirrhosis and large esophageal varices. Prophylactic therapy with beta-blockers can be considered in patients with small varices, especially in those with red signs or Child class C liver disease. The available evidence does not support the idea that organic nitrates improve the efficacy of beta-blockers in primary prophylaxis. The method used to establish the dose of beta-blockers and check its effect on hepatic venous pressure gradient (HVPG) has also been disputed. An attractive strategy is to measure the HVPG response to beta-blockers as a guide to primary prophylaxis, with the aim of switching to another therapy, that is, band ligation, in HVPG nonresponders. However, no study has yet demonstrated that banding as rescue therapy in nonresponders lowers the risk of first bleeding and improves survival.
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Kalambokis G, Economou M, Kosta P, Papadimitriou K, Tsianos EV. The effects of treatment with octreotide, diuretics, or both on portal hemodynamics in nonazotemic cirrhotic patients with ascites. J Clin Gastroenterol 2006; 40:342-6. [PMID: 16633107 DOI: 10.1097/01.mcg.0000210101.74618.61] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
GOALS To evaluate the effects of diuretic treatment, octreotide, or both on portal hemodynamics in nonazotemic cirrhotic patients with ascites. BACKGROUND Diuretics and octreotide have been associated with a decrease in portal pressure in cirrhotic patients, suggested to be mediated by plasma volume depletion and splanchnic vasoconstriction, respectively. However, liver cirrhosis is characterized by activation of the renin-angiotensin-aldosterone axis, which increases hepatic vascular resistance and is augmented or suppressed by diuretics or octreotide, respectively. STUDY Twenty nonazotemic cirrhotic patients with ascites were treated with furosemide and spironolactone. Of them, 10 (group 1) discontinued diuretic treatment for 7 days. Thereafter for 5 days, each patient received subcutaneous octreotide, 300 microg twice per day; ten of them (group 2) received the octreotide in addition to their usual diuretic treatment. Portal and systemic hemodynamics with Doppler ultrasound and endogenous vasoactive systems were evaluated while the patients received diuretics (both groups), after discontinuation of diuretics (group 1), and after octreotide administration (both groups). RESULTS The withdrawal of diuretics did not alter portal hemodynamics, but it impaired systemic hemodynamics and suppressed the renin-aldosterone axis. The addition of octreotide to diuretic treatment but not octreotide alone improved portal and systemic hemodynamics. In both groups the initiation of octreotide administration suppressed the renin-aldosterone axis and plasma glucagon levels. CONCLUSIONS In nonazotemic cirrhotic patients with ascites, the combination of diuretics and octreotide improves systemic hemodynamics and inhibits the diuretic-related component of the activated renin-aldosterone axis, which in turn augments the portal hypotensive effect of diuretic-induced plasma volume depletion.
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Affiliation(s)
- Georgios Kalambokis
- Department of Internal Medicine, Medical School of Ioannina, 45110 Ioannina, Greece
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7
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Berzigotti A, Rinaldi MF, Magalotti D, Morelli MC, Zappoli P, Andreone P, Rossi C, Zoli M. Primary prophylaxis with nadolol in cirrhotic patients: Doppler patterns of splanchnic hemodynamics in good and poor responders. J Hepatol 2006; 44:310-6. [PMID: 16343679 DOI: 10.1016/j.jhep.2005.10.015] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2005] [Revised: 10/13/2005] [Accepted: 10/16/2005] [Indexed: 12/18/2022]
Abstract
BACKGROUND/AIMS We aimed to characterize by echo-color-Doppler the splanchnic hemodynamics of patients good and poor responders to primary prophylaxis with nadolol. METHODS Thirty cirrhotic patients (Child-score 7.0+/-1.8) with medium/large esophageal varices without previous bleedings were consecutively enrolled. At inclusion and after 3 months of treatment with nadolol, they underwent a splanchnic echo-color-Doppler study and a measurement of hepatic venous pressure gradient (HVPG). RESULTS Nadolol (60+/-36 mg/day; range 20-160) induced a significant reduction of HVPG (16.6+/-6.1 vs. 19.4+/-4.6 mmHg, P < 0.0001). 13 patients (43.3%) were hemodynamic responders. Responders and Poor-responders had similar baseline clinical characteristics. Poor-responders at baseline were characterized by lower impedance indexes in superior mesenteric artery (SMA) (PI 2.29+/-0.45 vs. 2.74+/-0.46; P = 0.01; RI 0.83+/-0.04 vs. 0.86+/-0.03; P = 0.02), hepatic artery (HA) (PI 1.41+/-0.19 vs. 1.79+/-0.48; P = 0.03; RI 0.71+/-0.05 vs. 0.80+/-0.07; P = 0.02), and splenic artery (SA) (PI 1.18+/-0.27 vs. 1.73+/-0.40; P = 0.01; RI 0.66+/-0.07 vs. 0.73+/-0.09; P = 0.02), and by higher mean flow velocity of HA (52.6+/-21.6 vs. 26.5+/-9.5 cm/s; P = 0.02) and SMA (49.7+/-14.5 vs. 33.9+/-13.1 cm/s; P = 0.06). CONCLUSIONS Cirrhotic patients poor-responders to nadolol show a pronounced arterial splanchnic vasodilatation at a baseline echo-color-Doppler study. This can be considered a non-invasive clue for the a priori identification of this subgroup of patients.
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Affiliation(s)
- Annalisa Berzigotti
- Dipartimento di Medicina Interna, Cardioangiologia, Epatologia, Policlinico S. Orsola-Malpighi, Via Albertoni 15, 40138 Bologna, Italy
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8
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Deibert P, Schumacher YO, Ruecker G, Opitz OG, Blum HE, Rössle M, Kreisel W. Effect of vardenafil, an inhibitor of phosphodiesterase-5, on portal haemodynamics in normal and cirrhotic liver -- results of a pilot study. Aliment Pharmacol Ther 2006; 23:121-8. [PMID: 16393289 DOI: 10.1111/j.1365-2036.2006.02735.x] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Dysregulation of the cyclic guanosine 3',5' monophosphate-nitric oxide system is in part responsible for portal hypertension in cirrhosis. AIM To test the effects of inhibitors of phosphodiesterase-5 on portal haemodynamics. METHODS To 18 healthy subjects and 18 patients with Child A liver cirrhosis, 10 mg of vardenafil, an inhibitor of phosphodiesterase-5, were administered orally. Doppler sonographic measurements of hepatic and splanchnic blood flow, systemic blood pressure and heart rate were recorded before, 1 h after, and 48 h after the application. Vardenafil plasma levels were determined after 1 h. In five patients, invasive registration of free and wedged hepatic vein pressure was performed. RESULTS Portal venous flow increased in patients from 0.82 +/- 0.30 L/min (mean +/- s.d.) by 26% (CI: 16-37%, P = 0.0004) and in healthy subjects from 0.75 +/- 0.20 L/min (mean +/- s.d.) by 19% (CI: 9-28%; P = 0.0010). Celiac and hepatic artery resistivity indices rose significantly. Systemic blood pressure decreased slightly in patients. The wedged hepatic venous pressure gradient decreased in four of five patients with liver cirrhosis. Vardenafil plasma levels were higher in patients (14 +/- 10 microg/L) than in healthy subjects (9 +/- 6 microg/L; n.s.). CONCLUSIONS Inhibition of phosphodiesterase-5 increases portal flow and lowers portal pressure by a decrease in sinusoidal resistance and may be a novel therapeutic strategy for portal hypertension.
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Affiliation(s)
- P Deibert
- Department of Preventive and Rehabilitative Sports Medicine, University Hospital Freiburg, Freiburg, Germany
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Péron JM. [First episode of gastrointestinal bleeding, risk evaluation: when and how?]. GASTROENTEROLOGIE CLINIQUE ET BIOLOGIQUE 2004; 28 Spec No 2:B35-43. [PMID: 15150496 DOI: 10.1016/s0399-8320(04)95239-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
Affiliation(s)
- Jean-Marie Péron
- Service d'Hépato-Gastroentérologie, Fédération Digestive, CHU Purpan, Toulouse
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Pilette C. [Gastrointestinal hemorrhage. Does drug efficacy have to be checked? If so, how?]. GASTROENTEROLOGIE CLINIQUE ET BIOLOGIQUE 2004; 28 Spec No 2:B98-103. [PMID: 15150501 DOI: 10.1016/s0399-8320(04)95244-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
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Valla DC. Faut-il surveiller l’efficacité des traitements pharmacologiques et si oui, comment ? GASTROENTÉROLOGIE CLINIQUE ET BIOLOGIQUE 2004; 28 Spec No 2:B242-55. [PMID: 15150520 DOI: 10.1016/s0399-8320(04)95263-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Affiliation(s)
- Dominique-Charles Valla
- Service d'Hépatologie, Fédération Médico-chirurgicale d'Hépatogastroentérologie, AP-HP, Clichy
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Schiedermaier P, Koch L, Stoffel-Wagner B, Layer G, Sauerbruch T. Effect of propranolol and depot lanreotide SR on postprandial and circadian portal haemodynamics in cirrhosis. Aliment Pharmacol Ther 2003; 18:777-84. [PMID: 14535870 DOI: 10.1046/j.1365-2036.2003.01682.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND Long-acting somatostatin analogues have been suggested as an alternative to propranolol for the prevention of variceal rebleeding. AIM To compare the effectiveness of lanreotide SR, a new depot formulation injected once-weekly, and propranolol in reducing circadian portal blood flow (PVF) and meal-stimulated hepatic venous pressure gradient (HVPG) in patients with liver cirrhosis. METHODS Patients were randomized to receive either lanreotide SR intramuscularly (30 mg once weekly, n=12) or propranolol (n=12) orally. Hemodynamic measurements were performed on day 0 and on day 21 after a 3-week period of drug administration, while patients received three standard oral liquid test meals. On each study day 27 PVF measurements were performed over 24 h and eight measurements of HVPG during the first postprandial period. RESULTS Propranolol was more effective than lanreotide SR in reducing baseline HVPG (-21.9 vs. -13.6%, P=0.04) and meal-stimulated HVPG (-16.6 vs. -3.8%, P=0.04). Propranolol reduced circadian PVF significantly by 9.3% (P=0.03) but not lanreotide SR. CONCLUSIONS Long-term treatment with propranolol reduced baseline and postprandial HVPG and circadian PVF, while lanreotide SR did not. The results of our study do not encourage clinical testing of lanreotide SR 30 mg for the prevention of variceal haemorrhage.
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Affiliation(s)
- P Schiedermaier
- Department of Internal Medicine I, University of Bonn, Germany
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Cheng JW, Zhu L, Gu MJ, Song ZM. Meta analysis of propranolol effects on gastrointestinal hemorrhage in cirrhotic patients. World J Gastroenterol 2003; 9:1836-9. [PMID: 12918133 PMCID: PMC4611556 DOI: 10.3748/wjg.v9.i8.1836] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To assess the effects of propranolol as compared with placebo on gastrointestinal hemorrhage and total mortality in cirrhotic patients by using meta analysis of 20 published randomized clinical trials.
METHODS: A meta analysis of published randomized clinical trials was designed. Published articles were selected for study based on a computerized MEDLINE and a manual search of the bibliographies of relevant articles. Data from 20 relevant studies fulfilling the inclusion criteria were retrieved by means of computerized and manual search. The reported data were extracted on the basis of the intention-to-treat principle, and treatment effects were measured as risk differences between propranolol and placebo. Pooled estimates were computed according to a random-effects model. We evaluated the pooled efficacy of propranolol on the risk of gastrointestinal hemorrhage and the total mortality.
RESULTS: A total of 1859 patients were included in 20 trials, 931 in the propranolol groups and 928 as controls. Among the 652 patients with upper gastrointestinal tract hemorrhage, 261 patients were treated with propranolol, and 396 patients were treated with placebo or non-treated. Pooled risk differences of gastrointestinal hemorrhage were -18% [95%CI, -25%, -10%] in all trials, -11% [95%CI, -21%, -1%] in primary prevention trials, and -25% [95%CI, -39%, -10%] in secondary prevention trials. A total of 440 patients died, 188 in propranolol groups and 252 in control groups. Pooled risk differences of total death were -7% [95%CI, -12%, -3%] in all trials, -9% [95%CI, -18%, -1%] in primary prevention trials, and -5% [95%CI, -9%, -1%] in secondary prevention trials.
CONCLUSION: Propranolol can markedly reduce the risks of both primary and recurrent gastrointestinal hemorrhage, and also the total mortality.
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Affiliation(s)
- Jin-Wei Cheng
- Department of Gastroenterology, Changzheng Hospital, Second Military Medical University, Shanghai 200003, China.
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Affiliation(s)
- A Albillos Martínez
- Servicio de Gastroenterología, Hospital Ramón y Cajal, Departamento de Medicina, Universidad de Alcalá, Madrid
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Schepke M, Raab P, Hoppe A, Schiedermaier P, Brensing KA, Sauerbruch T. Comparison of portal vein velocity and the hepatic venous pressure gradient in assessing the acute portal hemodynamic response to propranolol in patients with cirrhosis. Am J Gastroenterol 2000; 95:2905-9. [PMID: 11051366 DOI: 10.1111/j.1572-0241.2000.03202.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE The aim of this prospective study was to compare noninvasive Doppler sonography and invasive measurement of the hepatic venous pressure gradient (HVPG) to determine the acute portal hemodynamic response to propranolol in patients with liver cirrhosis. METHODS In a blinded study design, portal vein velocity (PVV) and HVPG were simultaneously assessed in 11 cirrhotic patients for 4 h after oral ingestion of 40 mg propranolol. RESULTS Both HVPG (17.2% +/- 4.3%, p < 0.0001) and PVV (15.6% +/- 2.1%, p < 0.0002) showed a highly significant reduction during the study period versus baseline. Based on HVPG measurements, four patients (36%) were classified as nonresponders. These patients had a significantly lower PVV reduction compared to the responders (responders: 18.8% +/- 2.0% vs nonresponders: 10.0% +/- 2.1%, p < 0.05). Nonresponders were identified by Doppler sonography with a sensitivity of 1.0, specificity of 0.86, and positive predictive value of 0.9 when a threshold of 20% PVV reduction 120 min after drug intake was applied. CONCLUSIONS Doppler sonography is a useful tool for assessment of the acute portal hemodynamic effect of propranolol. To distinguish portal hemodynamic nonresponders from responders to propranolol, PVV measurements should be carried out 2 h after drug administration, and PVV reduction should be not <20% in propranolol responders.
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Affiliation(s)
- M Schepke
- Department of Internal Medicine I, University of Bonn, Germany
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Abstract
Increased resistance to portal blood flow is the primary factor in the pathophysiology of portal hypertension, and is mainly determined by the morphological changes occurring in chronic liver diseases. This is aggravated by a dynamic component, due to the active-reversible- contraction of different elements of the porto-hepatic bed. A decreased synthesis of NO in the intrahepatic circulation is the main determinant of this dynamic component. This provides a rationale for the use of vasodilators to reduce intrahepatic resistance and portal pressure. Another factor contributing to aggravate the portal hypertension is a significant increase in portal blood flow, caused by arteriolar splanchnic vasodilation and hyperkinetic circulation. Splanchnic arteriolar vasodilation is a multifactorial phenomenon, which may involve local (endothelial) mechanisms as well as neurogenic and humoral pathways. Most pharmacological treatments have been aimed at correcting the increased portal blood inflow by the use of splanchnic vasoconstrictors, such as beta-blockers, vasopressin derivatives and somatostatin. Several studies have demonstrated that changes in the hepatic venous pressure gradient (HVPG) during maintenance therapy are useful to identify those patients who are going to have a variceal bleeding or rebleeding. The wide individual variation in the HVPG response to pharmacological treatment makes it desirable to schedule follow-up measurements of HVPG during pharmacological therapy. A priority for research in the forthcoming years is to develop accurate non-invasive methods to assess prognosis, which can be used to substitute or as surrogate indicators of the HVPG response. In the clinical management of portal hypertension, beta-blockers are at present the only accepted treatment for the prevention of variceal bleeding. Whether the association of isosorbide-5-mononitrate will improve the high efficacy of beta-blockers is questionable. The efficacy of more aggressive techniques, such as endoscopic band ligation, should be further tested against beta-blockers in patients with a high risk of bleeding. In the treatment of acute variceal bleeding, administration of somatostatin or terlipressin is an established therapy. It may be used alone or, preferably, as an initial treatment before sclerotherapy or endoscopic band ligation. No more than two sessions of endoscopic treatment should be used to control the bleeding. If the bleeding is not easily controlled, other alternatives such as transjugular intrahepatic portosystemic shunts (TIPS) or derivative surgery should be considered, the former being the best in patients with poor liver function. Recent studies suggest that early measurement of HVPG during variceal bleeding may be used as a guide for therapeutic decisions in the treatment of patients with acute variceal bleeding. Those patients with a high HVPG have a high risk of poor evolution, and may be candidates for more intensive and aggressive therapy, such as surgery or TIPS. Those with lower HVPG have a very high probability of an uneventful evolution, and may thus be managed more conservatively using medical and endoscopic treatments. Pharmacological agents (propranolol or nadolol), endoscopic treatment (preferably banding ligation) or surgery can be used to prevent rebleeding. A pending task for the new millennium is to assess whether the early treatment of asymptomatic, compensated cirrhotic patients with portal pressure reducing agents can prevent the development of esophageal varices and of other complications of portal hypertension.
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Affiliation(s)
- J Bosch
- Hepatic Hemodynamic Laboratory, IMD, Hospital Clinic, IDIBAPS, University of Barcelona, Spain
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17
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Schepke M, Raab P, Hoppe A, Brensing K, Paar D, Potyka U, Sauerbruch T. Propranolol stereoisomer plasma concentrations and portal haemodynamic response in patients with liver cirrhosis. Aliment Pharmacol Ther 1999; 13:1451-8. [PMID: 10571601 DOI: 10.1046/j.1365-2036.1999.00622.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/08/2022]
Abstract
BACKGROUND The haemodynamic effect of propranolol on portal pressure in patients with portal hypertension is highly variable and does not correlate with propranolol racemate plasma concentrations. AIM To investigate the stereoselective metabolism of the propranolol enantiomers and its impact on portal haemodynamics in patients with liver cirrhosis since only S-propranolol is haemodynamically active. METHODS Twenty patients with liver cirrhosis and portal hypertension received 40 mg propranolol orally. Portal blood velocity (PBV) and propranolol stereoisomer plasma concentrations were determined. RESULTS During the 4 h examination period we observed a significant reduction in PBV (18.3 +/- 2.2%, P < 0.0001) vs. baseline. The area under the curve (AUC) during the study period was significantly different for the two isomers (S-propranolol 1217.0 +/- 118.5 nmol.h/L; R-propranolol 728.8 +/- 103.8 nmol.h/L, P < 0.0001). Seven patients (35%) were portal haemodynamic non-responders to propranolol. Propranolol stereoisomer AUC values were no different between responders (S-propranolol 1133. 3 +/- 132.0 nmol.h/L; R-propranolol 718.0 +/- 129.7 nmol.h/L) and non-responders (S-propranolol 1371.8 +/- 250.5 nmol.h/L; R-propranolol 746.9 +/- 200.3 nmol.h/L); neither was there a correlation between propranolol enantiomer plasma concentrations and the portal haemodynamic effect. CONCLUSIONS Our data demonstrate a stereoselective metabolism of propranolol enantiomers in liver cirrhosis. However, following oral propranolol administration, stereoisomer plasma concentrations do not predict the portal haemodynamic effect.
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Affiliation(s)
- M Schepke
- Department of Internal Medicine I, University of Bonn, Bonn, Germany.
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18
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Clemmesen JO, Galatius S, Skak C, Dalgaard P, Larsen FS, Ott P. The effect of increasing blood pressure with dopamine on systemic, splanchnic, and lower extremity hemodynamics in patients with acute liver failure. Scand J Gastroenterol 1999; 34:921-7. [PMID: 10522613 DOI: 10.1080/003655299750025417] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Arterial hypotension occurs frequently in patients with acute liver failure (ALF). Treatment with epinephrine and norepinephrine in patients with ALF has been associated with a decrease in whole-body (systemic) oxygen consumption. We aimed to investigate the effect of increasing blood pressure with dopamine on whole-body (systemic), splanchnic, and lower extremity hemodynamics and oxygen consumption in patients with acute liver failure and hepatic encephalopathy grade III or IV. METHODS In seven patients with ALF cardiac output (CO) was measured with the thermodilution technique, and hepatic blood flow (HBF) was estimated with infusion of sorbitol as test compound, liver vein catheterization, and calculations on the basis of Fick's principle. Lower-extremity blood flow was measured with strain-gauge plethysmography. RESULTS During infusion of dopamine (5 +/- 2 microg kg(-1) min(-1)) mean arterial pressure (MAP) increased from 68 +/- 5 to 85 +/- 8 mmHg. CO increased from 6.8 +/- 0.8 to 9.0 +/- 2.4 l/min (P < 0.05), systemic oxygen delivery from 45 +/- 7 to 63 +/- 19 mmol/min (P < 0.05), systemic oxygen consumption from 10.2 +/- 2.0 to 11.5 +/- 3.3 mmol/min (NS). HBF increased from 2.2 +/- 0.7 to 2.7 +/- 1.0 l/ min (P < 0.05), splanchnic oxygen delivery from 14.4 +/- 5.3 to 18.5 +/- 7.2 mmol/min (P < 0.01), and splanchnic oxygen consumption decreased from 3.9 +/- 1.1 to 2.9 +/- 0.6 mmol/min (P < 0.05). No significant changes in lower extremity flow and oxygenation variables were found. CONCLUSIONS The use of dopamine in patients with ALF to increase MAP was associated with increases in systemic and splanchnic oxygen delivery. A concomitant decrease in splanchnic oxygen consumption was observed.
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Affiliation(s)
- J O Clemmesen
- Dept of Hepatology, Cardiology, and Anesthesiology, Rigshospitalet, University of Copenhagen, Denmark
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19
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Piscaglia F, Gaiani S, Donati G, Masi L, Bolondi L. Doppler evaluation of the effects of pharmacological treatment of portal hypertension. ULTRASOUND IN MEDICINE & BIOLOGY 1999; 25:923-932. [PMID: 10461720 DOI: 10.1016/s0301-5629(99)00035-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
The splanchnic pharmacodynamic effects of the drugs used for the treatment of hemorrhagic complications of portal hypertension were poorly clarified until some years ago. The introduction of Doppler ultrasound provided a powerful tool to investigate such hemodynamic effects and brought new insights in this field. The present article reviews the pharmacodynamics of the substances used in the treatment of portal hypertension, with particular regard to the effects assessable by duplex Doppler ultrasonography.
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Affiliation(s)
- F Piscaglia
- Divisione di Medicina Interna, University of Bologna, Italy
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20
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Müller MJ, Böttcher J, Selberg O, Weselmann S, Böker KH, Schwarze M, von zur Mühlen A, Manns MP. Hypermetabolism in clinically stable patients with liver cirrhosis. Am J Clin Nutr 1999; 69:1194-201. [PMID: 10357739 DOI: 10.1093/ajcn/69.6.1194] [Citation(s) in RCA: 148] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Hypermetabolism has a negative effect on prognosis in patients with liver cirrhosis. Its exact prevalence and associations with clinical data, the nutritional state, and beta-adrenergic activity are unclear. OBJECTIVE We investigated resting energy expenditure (REE) in 473 patients with biopsy-proven liver cirrhosis. DESIGN This was a cross-sectional study with a controlled intervention (beta-blockade) in a subgroup of patients. RESULTS Mean REE was 7.12 +/- 1.34 MJ/d and correlated closely with predicted values (r = 0.70, P < 0.0001). Hypermetabolism was seen in 160 patients with cirrhosis (33.8% of the study population). REE was > 30% above the predicted value in 41% of the hypermetabolic patients with cirrhosis. Hypermetabolism had no association with clinical or biochemical data on liver function. REE correlated with total body potassium content (TBP; r = 0.49, P < 0.0001). Hypermetabolic patients had lower than normal body weight and TBP (P < 0.05). About 47% of the variance in REE could be explained by body composition whereas clinical state could maximally explain 3%. Plasma epinephrine and norepinephrine concentrations were elevated in hypermetabolic cirrhotic patients (by 56% and 41%, respectively; P < 0.001 and 0.01). Differences in REE from predicted values were positively correlated with epinephrine concentration (r = 0.462, P < 0.001). Propranolol infusion resulted in a decrease in energy expenditure (by 5 +/- 3%; P < 0.05), heart rate (by 13 +/- 4%; P < 0.01), and plasma lactate concentrations (by 32 +/- 12%; P < 0.01); these effects were more pronounced in hypermetabolic patients (by 50%, 33%, and 68%, respectively; each P < 0.05). CONCLUSIONS Hypermetabolism has no association with clinical data and thus is an extrahepatic manifestation of liver disease. Increased beta-adrenergic activity may explain approximately 25% of hypermetabolism.
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Affiliation(s)
- M J Müller
- Medizinische Hochschule Hannover, Germany.
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21
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Albillos A, García-Pagán JC, Iborra J, Bandi JC, Cacho G, Pérez-Paramo M, Escorsell A, Calleja JL, Escartín P, Bosch J. Propranolol plus prazosin compared with propranolol plus isosorbide-5-mononitrate in the treatment of portal hypertension. Gastroenterology 1998; 115:116-23. [PMID: 9649466 DOI: 10.1016/s0016-5085(98)70372-5] [Citation(s) in RCA: 79] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND & AIMS The association of prazosin to propranolol enhances the decrease in portal pressure but may cause hypotension and sodium retention. The aim of this study was to compare the portal pressure reduction and safety of the combination of propranolol plus prazosin with that of propranolol plus isosorbide-5-mononitrate (ISMN). METHODS Fifty-six portal-hypertensive cirrhotics received randomly propranolol plus prazosin (n = 28) or propranolol plus ISMN (n = 28) orally for 3 months. Hemodynamics and liver and renal function were assessed at baseline and after 3 months. RESULTS Propranolol plus prazosin caused a greater reduction in hepatic venous pressure gradient (HVPG) than propranolol plus ISMN (-24.2% +/- 11% vs. -16.1% +/- 11%; P < 0.01). A reduction in HVPG of > 20% was significantly more frequent in the propranolol plus prazosin group than in the propranolol plus ISMN group (85% vs. 53%; P < 0.05). Neither treatment modified hepatic blood flow, quantitative liver function test results, glomerular filtration rate, plasma renin activity, or plasma aldosterone level. Side effects occurred in 13 patients receiving propranolol plus prazosin compared with 7 receiving propranolol plus ISMN (P = 0.16). CONCLUSIONS Propranolol plus prazosin has a greater portal pressure-lowering effect than propranolol plus ISMN. Both therapies were safe for liver and renal function. However, the combination of propranolol plus prazosin caused a greater decrease in arterial pressure and was less well tolerated than propranolol plus ISMN.
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Affiliation(s)
- A Albillos
- Division of Gastroenterology, Clínica Puerta de Hierro, Madrid, Spain
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22
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Merkel C, Sacerdoti D, Bolognesi M, Bombonato G, Gatta A. Doppler sonography and hepatic vein catheterization in portal hypertension: assessment of agreement in evaluating severity and response to treatment. J Hepatol 1998; 28:622-30. [PMID: 9566831 DOI: 10.1016/s0168-8278(98)80286-9] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND/AIM The study was designed to assess to what extent portal hemodynamic parameters obtained by duplex Doppler ultrasonography may be substituted for the measurement of hepatic venous pressure gradient in evaluating the severity of portal hypertension and the response to medical treatment with beta-blockers or beta-blockers plus nitrates in patients with cirrhosis and portal hypertension. METHODS In 39 of these patients hepatic venous pressure gradient was determined by hepatic vein catheterization, and portal blood flow velocity and the congestion index of the portal vein were measured by duplex Doppler ultrasonography. In 19 of these patients the changes in hepatic venous pressure gradient and in Doppler parameters were also assessed after chronic administration of nadolol. In 11 of the 19 patients the changes after chronic administration of nadolol plus isosorbide-5-mononitrate were also measured. RESULTS In the whole series, no significant correlation was found between hepatic venous pressure gradient and duplex Doppler parameters, but, when the 12 patients with a patent para-umbilical vein were excluded, significant linear correlations were found between hepatic venous pressure gradient and portal blood velocity (r=-0.39; p=0.05) or congestion index (r=0.37; p=0.05). Considering together the changes induced by nadolol and nadolol plus isosorbide-5-mononitrate, no correlation was apparent between changes in duplex Doppler parameters and in hepatic venous pressure gradient. Agreement between hepatic venous pressure gradient and duplex Doppler parameters in defining good and poor responders was insufficient. CONCLUSIONS These data suggest that portal blood velocity and the congestion index of the portal vein are related to portal hypertension in patients without a patent para-umbilical vein, but are of limited value in discriminating good responders from poor responders to medical treatment for portal hypertension.
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Affiliation(s)
- C Merkel
- Department of Clinical and Experimental Medicine, University of Padua, Padova, Italy
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