Aa
Are you taking a Beta Blocker?
I recently had an internal bleed - not serious but now I am taking Nadolol (Corgard). Is this a for the rest of my life thing? My blood pressure is normal but I have Portal Hypertension and varcies
Hi since no one has commented I thought to do a little research. Have you asked your doctor? I am thinking this would be for life kind of thing unless you have banding done
I found this at GI.org
E. Patients with Cirrhosis Who Have Recovered From Acute Variceal Hemorrhage
Patients who survive an episode of acute variceal hemorrhage have a very high risk of rebleeding and death. The median rebleeding rate in untreated individuals is around 60% within 1–2 years of the index hemorrhage, with a mortality of 33% (35, 36). It is therefore essential that patients who have recovered from an episode of variceal hemorrhage and have had no evidence of hemorrhage for at least 24 hours be started on therapy to prevent recurrence prior to discharge from the hospital. Patients who required shunt surgery/TIPS to control the acute episode do not require further preventive measures. All these patients should be referred to a transplant center if they are otherwise a candidate (i.e., Child-Pugh score ≥7or a MELD score ≥15).
Nonselective β-blockers or sclerotherapy reduce rates of variceal rebleeding to around 42–43% (35, 36, 82, 115), although patients treated with sclerotherapy have a higher rate of side effects. However, there are better pharmacological and endoscopic therapeutic options.
Regarding pharmacological therapy, the combination of a nonselective β-blocker and ISMN has a synergistic portal pressure-reducing effect and could theoretically be more effective than β-blockers alone. Only one study has performed a direct comparison between the combination of propranolol plus ISMN and propranolol alone in patients with prior variceal hemorrhage (116). This study showed a benefit of combination therapy (33% vs. 41% rebleeding rate), but it was not statistically significant. Data collected from different randomized clinical trials show that the median rebleeding rate in patients treated with combined pharmacological therapy is around 33–35% (35, 36), lower than that obtained with β-blockers alone. Therefore, the pharmacological therapy of choice in the prevention of variceal rebleeding is probably the combination of a nonselective β-blocker and a nitrate. However, this combination has significantly greater side effects compared to β-blockers alone (35, 116) and is poorly tolerated in clinical practice so that most patients end up taking β-blockers alone.
Regarding endoscopic therapy, EVL is the endoscopic method of choice for preventing variceal rebleeding since it has been shown to be superior to sclerotherapy (115, 117). Data collected from different randomized clinical trials show a median rebleeding rate in patients treated with EVL of around 32% (36). EVL sessions are repeated at 7- to 14-day intervals until variceal obliteration, which usually requires 2 to 4 sessions (118). Once eradicated, EGD is usually repeated every 3 to 6 months to evaluate for variceal recurrence and need for repeat EVL. Complications of EVL occur in about 14% of cases but are usually minor. The most common complication is transient dysphagia and chest discomfort. Shallow ulcers at the site of each ligation are the rule, and they may bleed. In a small (n = 43) randomized placebo-controlled trial of pantoprazole (40 mg IV after EVL followed by 40 mg oral every day for 9 days), the number of post-EVL ulcers at day 10 after EVL was the same in both groups; however, ulcers were significantly smaller in the pantoprazole group and, although not statistically significant, all 3 post-EVL bleeding episodes occurred in the placebo group (119). These results would favor the use of proton pump inhibitors in patients treated with EVL.
Optimal pharmacological therapy (β-blockers plus nitrates) versus optimal endoscopic therapy (EVL) has been compared in 3 randomized studies showing different results. One study showed a benefit of combination pharmacological therapy (23), another showed a benefit of EVL (120), and a third showed no difference between treatment groups, despite a clear tendency in favor of pharmacological therapy (121). These differences probably reflect the dosage of medications used, patient population and, ultimately, center expertise (122). Both therapies would appear to be at least equivalent in the prevention of variceal rebleeding with rebleeding rates of 32–35%.
Combination endoscopic plus pharmacological therapy is the most rational approach because nonselective β-blockers theoretically will protect against rebleeding prior to variceal obliteration and would prevent variceal recurrence. Two randomized trials demonstrate the superiority of combined therapy versus EVL alone (123, 124). Rebleeding rates in these 2 trials were 23% and 14%, respectively, for EVL plus nadolol compared to 47% and 38% for EVL alone. These results support the use of combination therapy to prevent rebleeding, even though a recent consensus conference recommended EVL or β-blocker + nitrates as first-line therapy in treatment naïve patients (7). The combination EVL plus a nonselective β-blocker is clearly recommended in patients who develop variceal hemorrhage (first or recurrent) while on EVL or a β-blocker alone.
The lowest rate of variceal rebleeding (~10%) is obtained in patients who are HVPG responders; that is, patients in whom pharmacological therapy (either β-blockers alone or β-blockers + nitrates) leads to a reduction in HVPG to 20% from baseline (19, 36). In patients who are HVPG responders, it would not be rational to use endoscopic therapy. As suggested recently, perhaps the most rational therapy would be to adapt the different therapies to prevent variceal rebleeding in the context of HVPG response (125, 126); however, this would require standardization of the HVPG technique, including the best timing to perform the repeat HVPG measurement. Existing studies have performed the second HVPG measurement a median of 90 days after the first measurement (range 19–159 days), and there is evidence suggesting that the predictive value of the change in HVPG is reduced with increasing time between measurements (19).
I found this at GI.org
E. Patients with Cirrhosis Who Have Recovered From Acute Variceal Hemorrhage
Patients who survive an episode of acute variceal hemorrhage have a very high risk of rebleeding and death. The median rebleeding rate in untreated individuals is around 60% within 1–2 years of the index hemorrhage, with a mortality of 33% (35, 36). It is therefore essential that patients who have recovered from an episode of variceal hemorrhage and have had no evidence of hemorrhage for at least 24 hours be started on therapy to prevent recurrence prior to discharge from the hospital. Patients who required shunt surgery/TIPS to control the acute episode do not require further preventive measures. All these patients should be referred to a transplant center if they are otherwise a candidate (i.e., Child-Pugh score ≥7or a MELD score ≥15).
Nonselective β-blockers or sclerotherapy reduce rates of variceal rebleeding to around 42–43% (35, 36, 82, 115), although patients treated with sclerotherapy have a higher rate of side effects. However, there are better pharmacological and endoscopic therapeutic options.
Regarding pharmacological therapy, the combination of a nonselective β-blocker and ISMN has a synergistic portal pressure-reducing effect and could theoretically be more effective than β-blockers alone. Only one study has performed a direct comparison between the combination of propranolol plus ISMN and propranolol alone in patients with prior variceal hemorrhage (116). This study showed a benefit of combination therapy (33% vs. 41% rebleeding rate), but it was not statistically significant. Data collected from different randomized clinical trials show that the median rebleeding rate in patients treated with combined pharmacological therapy is around 33–35% (35, 36), lower than that obtained with β-blockers alone. Therefore, the pharmacological therapy of choice in the prevention of variceal rebleeding is probably the combination of a nonselective β-blocker and a nitrate. However, this combination has significantly greater side effects compared to β-blockers alone (35, 116) and is poorly tolerated in clinical practice so that most patients end up taking β-blockers alone.
Regarding endoscopic therapy, EVL is the endoscopic method of choice for preventing variceal rebleeding since it has been shown to be superior to sclerotherapy (115, 117). Data collected from different randomized clinical trials show a median rebleeding rate in patients treated with EVL of around 32% (36). EVL sessions are repeated at 7- to 14-day intervals until variceal obliteration, which usually requires 2 to 4 sessions (118). Once eradicated, EGD is usually repeated every 3 to 6 months to evaluate for variceal recurrence and need for repeat EVL. Complications of EVL occur in about 14% of cases but are usually minor. The most common complication is transient dysphagia and chest discomfort. Shallow ulcers at the site of each ligation are the rule, and they may bleed. In a small (n = 43) randomized placebo-controlled trial of pantoprazole (40 mg IV after EVL followed by 40 mg oral every day for 9 days), the number of post-EVL ulcers at day 10 after EVL was the same in both groups; however, ulcers were significantly smaller in the pantoprazole group and, although not statistically significant, all 3 post-EVL bleeding episodes occurred in the placebo group (119). These results would favor the use of proton pump inhibitors in patients treated with EVL.
Optimal pharmacological therapy (β-blockers plus nitrates) versus optimal endoscopic therapy (EVL) has been compared in 3 randomized studies showing different results. One study showed a benefit of combination pharmacological therapy (23), another showed a benefit of EVL (120), and a third showed no difference between treatment groups, despite a clear tendency in favor of pharmacological therapy (121). These differences probably reflect the dosage of medications used, patient population and, ultimately, center expertise (122). Both therapies would appear to be at least equivalent in the prevention of variceal rebleeding with rebleeding rates of 32–35%.
Combination endoscopic plus pharmacological therapy is the most rational approach because nonselective β-blockers theoretically will protect against rebleeding prior to variceal obliteration and would prevent variceal recurrence. Two randomized trials demonstrate the superiority of combined therapy versus EVL alone (123, 124). Rebleeding rates in these 2 trials were 23% and 14%, respectively, for EVL plus nadolol compared to 47% and 38% for EVL alone. These results support the use of combination therapy to prevent rebleeding, even though a recent consensus conference recommended EVL or β-blocker + nitrates as first-line therapy in treatment naïve patients (7). The combination EVL plus a nonselective β-blocker is clearly recommended in patients who develop variceal hemorrhage (first or recurrent) while on EVL or a β-blocker alone.
The lowest rate of variceal rebleeding (~10%) is obtained in patients who are HVPG responders; that is, patients in whom pharmacological therapy (either β-blockers alone or β-blockers + nitrates) leads to a reduction in HVPG to 20% from baseline (19, 36). In patients who are HVPG responders, it would not be rational to use endoscopic therapy. As suggested recently, perhaps the most rational therapy would be to adapt the different therapies to prevent variceal rebleeding in the context of HVPG response (125, 126); however, this would require standardization of the HVPG technique, including the best timing to perform the repeat HVPG measurement. Existing studies have performed the second HVPG measurement a median of 90 days after the first measurement (range 19–159 days), and there is evidence suggesting that the predictive value of the change in HVPG is reduced with increasing time between measurements (19).
2 Comments
yes, pretty quiet around here but thank you for doing my homework for me FlyinLynn! This is great. So basically, one can now utilize endoscopy as a find it and fix it kind of deal while taking the Beta Blocker (Nadonol) with the Propanol - both of which I have been taking. This is probably only true for those like me who had a minor bleed, whose liver labs fall within normal limits - except for platelets, dammit, that were 67 during this adventure, and who are not recommended for banding or any other invasive surgery. How far we have come! Thanks again Lynn and I hereby bestow you the Howie Crown for being such a wonderful activist and intelligent voice in the world of Hep C and it's ongoing consequences
I cannot begin to represent for our dear friend Howie I just try my best.
I had bandings done because the goal of Beta blocker blocker use is to lower resting HR below 60 which is what my resting HR already is 60 BPM and less. So I could not use a Beta blocker even if I had wanted.
I have an upper EGD every year since my grade 3 varicies were discovered in 20012. Never had a bleed or even red wale marks only worrisomely enlarged.
So far so good no re-occurrence.
Take care ;-)
I had bandings done because the goal of Beta blocker blocker use is to lower resting HR below 60 which is what my resting HR already is 60 BPM and less. So I could not use a Beta blocker even if I had wanted.
I have an upper EGD every year since my grade 3 varicies were discovered in 20012. Never had a bleed or even red wale marks only worrisomely enlarged.
So far so good no re-occurrence.
Take care ;-)
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