Early identification of haemodynamic response to pharmacotherapy is essential for primary prophylaxis of variceal bleeding in patients with ‘high‐risk’ varices

Abstract

Background A beta‐blocker is recommended for primary prophylaxis of variceal bleeding; however, only one‐third have hepatic venous pressure gradient (HVPG) response. The role of addition of isosorbide‐5‐mononitrate (ISMN) to beta‐blocker and benefits of HVPG‐guided ‘a la carte’ approach remain unclear. Aim To determine the benefits of HVPG‐guided pharmacotherapy in primary prophylaxis of variceal bleeding using beta‐blocker and ISMN. Patients and methods Consecutive patients of cirrhosis, with high‐risk varices, with no previous variceal bleeding were included. After baseline HVPG, patients received incremental propranolol to achieve HR of 55/min. After one‐month, HVPG was repeated to determine response (P = N.S.]. The actuarial probability of variceal bleeding at median 24 months was 4% in responders and 22% in nonresponders (P < 0.05). Ten (18%) patients developed adverse effects to propranolol and six of 35 (17%) to nitrates requiring dose reduction. Risk factors of variceal bleed were grade IV varices and haemodynamic nonresponse. Conclusions For primary prophylaxis, a beta‐blocker is effective in 38% and addition of ISMN raises the response rate to about half of patients. The HVPG‐guided ‘a la carte’ approach may be considered for these patients.