BB in cirrhosis

Q: Which of the following beta blockers (BB) is recommended as first-line prophylaxis in compensated cirrhosis? - select one

A) Carvedilol

B) Propranolol

Answer: B

Clinicians often fail to understand the difference in the use of BB in cirrhosis.

• For compensated cirrhosis, carvedilol is the first-line prophylaxis. It has been found to have a survival benefit.
• For decompensated cirrhosis, a nonselective beta blocker that does not have anti-alpha 1 adrenergic activity, like nadolol or propranolol, is recommended. 

Carvedilol is not preferred in decompensated cirrhosis because, due to its anti-alpha 1 adrenergic activity, it may drop blood pressure drastically.

BB lowers the portal pressure by reducing portal blood flow, which is accomplished by vasoconstricting the splanchnic circulation. The target heart rate is 55 to 60 beats per minute, in balance with a tolerable mean arterial pressure (MAP).

#hepatology

#pharmacology

References:

1. McDowell HR, Chuah CS, Tripathi D, et al. Carvedilol is associated with improved survival in patients with cirrhosis: a long-term follow-up study. Aliment Pharmacol Ther 2021; 53:531.

2. Shah HA, Azam Z, Rauf J, et al. Carvedilol vs. esophageal variceal band ligation in the primary prophylaxis of variceal hemorrhage: a multicentre randomized controlled trial. J Hepatol 2014; 60:757.

3. Tripathi D, Handley K, Holden L, et al. Clinical Trial: A Multicentre Randomised Controlled Trial of Carvedilol Versus Variceal Band Ligation in Primary Prevention of Variceal Bleeding in Liver Cirrhosis (CALIBRE Trial). Aliment Pharmacol Ther 2025; 61:1740.