Interesting article on variceal bleeding treatment from MedScape

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Propranolol Better First-Line Prophylaxis Than Ligation for Variceal Bleeding

NEW YORK (Reuters Health) Oct 03 - Although propranolol and ligation are both effective prophylaxis treatments for variceal bleeding in patients awaiting liver transplantation, the cost and the potentially fatal bleeding associated with ligation make propranolol the choice for first-line therapy.

Several trials have compared beta-blockers and endoscopic variceal ligation for primary prophylaxis of variceal bleeding, the authors explain, but which is the better therapy has remained unclear.

Dr. Lorenzo Norberto from University of Padova, Italy and associates compared the safety and benefits of endoscopic variceal ligation versus propranolol in the prevention of first variceal bleeding in 62 candidates for liver transplantation.

There were no significant differences in the rates of first esophageal variceal hemorrhage, overall mortality, or bleeding-related mortality between the groups, the authors report in the September issue of Liver Transplantation.

Two patients in the endoscopic variceal ligation group and 5 in the propranolol group had adverse events requiring interruption of treatment, the investigators say, but only variceal ligation was associated with fatal complications.

The study was terminated after the interim analysis, when it became clear that a much larger sample size would be required to demonstrate significant differences between the treatments.

"Both propranolol and endoscopic banding are similarly effective in reducing the incidence of variceal bleeding in cirrhotic patients with high-risk varices, candidates for liver transplantation," the researchers write, "but ligation can be complicated by severe and fatal bleeding and is significantly more expensive."

"Our results suggest that banding should not be utilized as the primary prophylaxis in candidates for liver transplantation who can be treated with beta-blockers," the authors conclude.

"The use of pharmacologic therapy for preprimary prophylaxis is clearly an area that requires further study," writes Dr. D. Boyer from University of Arizona, Tucson, in a related editorial.

"Identification of new drugs that lower portal pressure to the same or greater degree than beta-blockers with fewer side effects are being sought and if found will further improve the management of the patient with varices."

Liver Transpl 2007;13:1212-1213,1272-1278.