Portal hypertension medical therapy: Difference between revisions
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__NOTOC__ | __NOTOC__ | ||
{{Portal hypertension}} | {{Portal hypertension}} | ||
{{CMG}}; {{AE}} | {{CMG}}; {{AE}}{{EG}} | ||
==Overview== | ==Overview== | ||
Pharmacological medical therapy is recommended among patients with [[cirrhosis]] and portal hypertension without [[esophageal varices]], with [[esophageal varices]] but not yet [[bleeding]], with [[esophageal varices]] that is [[bleeding]], and with [[esophageal varices]] that has already bled. Pharmacological medical therapies for portal hypertension include [[Beta blockers|non-selective beta blockers (NSBB)]], analogues of [[Nitric oxide|nitric oxide (NO)]], and [[Vasoactive amine|vasoactive agents]]. | |||
==Medical Therapy== | ==Medical Therapy== | ||
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**2.1 '''Low-risk small varices'''<ref name="pmid15300580">{{cite journal |vauthors=Merkel C, Marin R, Angeli P, Zanella P, Felder M, Bernardinello E, Cavallarin G, Bolognesi M, Donada C, Bellini B, Torboli P, Gatta A |title=A placebo-controlled clinical trial of nadolol in the prophylaxis of growth of small esophageal varices in cirrhosis |journal=Gastroenterology |volume=127 |issue=2 |pages=476–84 |year=2004 |pmid=15300580 |doi= |url=}}</ref> | **2.1 '''Low-risk small varices'''<ref name="pmid15300580">{{cite journal |vauthors=Merkel C, Marin R, Angeli P, Zanella P, Felder M, Bernardinello E, Cavallarin G, Bolognesi M, Donada C, Bellini B, Torboli P, Gatta A |title=A placebo-controlled clinical trial of nadolol in the prophylaxis of growth of small esophageal varices in cirrhosis |journal=Gastroenterology |volume=127 |issue=2 |pages=476–84 |year=2004 |pmid=15300580 |doi= |url=}}</ref> | ||
***2.1.1 '''Adult''' | ***2.1.1 '''Adult''' | ||
****Preferred regimen (1): Conservative management | |||
****Alternative regimen (1): | ****Alternative regimen (1): | ||
*****Starting dose: [[Propranolol]] 20 mg [[Per os|PO]] q12h; adjust every 2-3 days to achieve final goal; not exceed 320 mg daily. | *****Starting dose: [[Propranolol]] 20 mg [[Per os|PO]] q12h; adjust every 2-3 days to achieve final goal; not exceed 320 mg daily. | ||
| Line 31: | Line 32: | ||
*****Therapeutic goals: Maximal tolerating dose; resting [[heart rate]] of 50-55 [[beats per minute]]. | *****Therapeutic goals: Maximal tolerating dose; resting [[heart rate]] of 50-55 [[beats per minute]]. | ||
*****Maintenance and follow up: Continue indefinitely without need to follow up [[endoscopy]]. | *****Maintenance and follow up: Continue indefinitely without need to follow up [[endoscopy]]. | ||
**2.2 | **2.2 '''Medium risk large varices'''<ref name="pmid18042114">{{cite journal |vauthors=Gluud LL, Klingenberg S, Nikolova D, Gluud C |title=Banding ligation versus beta-blockers as primary prophylaxis in esophageal varices: systematic review of randomized trials |journal=Am. J. Gastroenterol. |volume=102 |issue=12 |pages=2842–8; quiz 2841, 2849 |year=2007 |pmid=18042114 |doi=10.1111/j.1572-0241.2007.01564.x |url=}}</ref><ref name="pmid18293274">{{cite journal |vauthors=Bosch J, Abraldes JG, Berzigotti A, Garcia-Pagan JC |title=Portal hypertension and gastrointestinal bleeding |journal=Semin. Liver Dis. |volume=28 |issue=1 |pages=3–25 |year=2008 |pmid=18293274 |doi=10.1055/s-2008-1040318 |url=}}</ref> | ||
*** 2.2.1 '''Adult''' | *** 2.2.1 '''Adult''' | ||
****Preferred regimen (1): | ****Preferred regimen (1): | ||
| Line 42: | Line 42: | ||
*****Therapeutic goals: Maximal tolerating dose; resting [[heart rate]] of 50-55 [[beats per minute]]. | *****Therapeutic goals: Maximal tolerating dose; resting [[heart rate]] of 50-55 [[beats per minute]]. | ||
*****Maintenance and follow up: Continue indefinitely without need to follow up [[endoscopy]]. | *****Maintenance and follow up: Continue indefinitely without need to follow up [[endoscopy]]. | ||
****Preferred procedure (3): Endoscopic variceal ligation every 2-4 weeks | ****Preferred procedure (3): Endoscopic variceal ligation every 2-4 weeks. Only to used with [[Beta blockers|non-selective beta-blockers]]. | ||
****Alternative regimen (1): | ****Alternative regimen (1): | ||
*****Starting dose: [[Isosorbide mononitrate|Isosorbide-5-mononitrate]] 10 mg [[Per os|PO]] at night daily; adjust every 2-3 days by adding 10 mg to morning and then evening; not exceed 20 mg q12h. | *****Starting dose: [[Isosorbide mononitrate|Isosorbide-5-mononitrate]] 10 mg [[Per os|PO]] at night daily; adjust every 2-3 days by adding 10 mg to morning and then evening; not exceed 20 mg q12h. | ||
*****Therapeutic goals: Maximal tolerating dose; [[systolic blood pressure]] remains more than 95 mmHg. | *****Therapeutic goals: Maximal tolerating dose; [[systolic blood pressure]] remains more than 95 mmHg. | ||
*****Maintenance and follow up: Continue indefinitely. | *****Maintenance and follow up: Continue indefinitely. | ||
**2.3 '''High | **2.3 '''High risk small varices''' | ||
*** 2.3.1 '''Adult''' | *** 2.3.1 '''Adult''' | ||
****Preferred regimen (1): | ****Preferred regimen (1): | ||
| Line 57: | Line 57: | ||
*****Therapeutic goals: Maximal tolerating dose; resting [[heart rate]] of 50-55 [[beats per minute]]. | *****Therapeutic goals: Maximal tolerating dose; resting [[heart rate]] of 50-55 [[beats per minute]]. | ||
*****Maintenance and follow up: Continue indefinitely without need to follow up [[endoscopy]]. | *****Maintenance and follow up: Continue indefinitely without need to follow up [[endoscopy]]. | ||
****Alternative procedure (1): Endoscopic [[Esophageal varices|variceal]] [[ligation]] every 2-4 weeks | ****Alternative procedure (1): Endoscopic [[Esophageal varices|variceal]] [[ligation]] every 2-4 weeks. Only to used with [[Beta blockers|non-selective beta-blockers]]. | ||
****Alternative regimen (2): | ****Alternative regimen (2): | ||
*****Starting dose: [[Isosorbide mononitrate|Isosorbide-5-mononitrate]] 10 mg [[Per os|PO]] at night daily; adjust every 2-3 days by adding 10 mg to morning and then evening; not exceed 20 mg q12h. | *****Starting dose: [[Isosorbide mononitrate|Isosorbide-5-mononitrate]] 10 mg [[Per os|PO]] at night daily; adjust every 2-3 days by adding 10 mg to morning and then evening; not exceed 20 mg q12h. | ||
*****Therapeutic goals: Maximal tolerating dose; [[systolic blood pressure]] remains more than 95 mmHg. | *****Therapeutic goals: Maximal tolerating dose; [[systolic blood pressure]] remains more than 95 mmHg. | ||
| Line 64: | Line 64: | ||
* '''3 Stage 3 - With esophageal varices which is bleeding''' | * '''3 Stage 3 - With esophageal varices which is bleeding''' | ||
** 3.1 '''Basic Medical conditions''' | ** 3.1 '''Basic Medical conditions''' | ||
*** 3.1.1 [[Airway]], [[breathing]], and [[circulation]] | *** 3.1.1 [[Airway]], [[breathing]], and [[circulation]] stabilization | ||
** 3.2 '''Advance cirrhosis''' | ** 3.2 '''Advance cirrhosis''' | ||
*** 3.2.1 [[Antibiotic]] prophylaxis<ref name="pmid17030175">{{cite journal |vauthors=Fernández J, Ruiz del Arbol L, Gómez C, Durandez R, Serradilla R, Guarner C, Planas R, Arroyo V, Navasa M |title=Norfloxacin vs ceftriaxone in the prophylaxis of infections in patients with advanced cirrhosis and hemorrhage |journal=Gastroenterology |volume=131 |issue=4 |pages=1049–56; quiz 1285 |year=2006 |pmid=17030175 |doi=10.1053/j.gastro.2006.07.010 |url=}}</ref> | *** 3.2.1 [[Antibiotic]] prophylaxis<ref name="pmid17030175">{{cite journal |vauthors=Fernández J, Ruiz del Arbol L, Gómez C, Durandez R, Serradilla R, Guarner C, Planas R, Arroyo V, Navasa M |title=Norfloxacin vs ceftriaxone in the prophylaxis of infections in patients with advanced cirrhosis and hemorrhage |journal=Gastroenterology |volume=131 |issue=4 |pages=1049–56; quiz 1285 |year=2006 |pmid=17030175 |doi=10.1053/j.gastro.2006.07.010 |url=}}</ref> | ||
| Line 77: | Line 77: | ||
* '''4 Stage 4 - With esophageal varices which has already bled''' | * '''4 Stage 4 - With esophageal varices which has already bled''' | ||
** 4.1 '''Patients with transjugular intrahepatic portosystemic shunt (TIPS)''' | ** 4.1 '''Patients with transjugular intrahepatic portosystemic shunt (TIPS)''' | ||
*** No need to treat portal hypertension | *** No need to treat portal hypertension anymore | ||
*** Check the [[Shunt (medical)|shunt]] patency every 6 months | *** Check the [[Shunt (medical)|shunt]] patency every 6 months | ||
** 4.1 '''Patients without''' '''transjugular intrahepatic portosystemic shunt''' '''(TIPS)'''<ref name="pmid8985266">{{cite journal |vauthors=Bernard B, Lebrec D, Mathurin P, Opolon P, Poynard T |title=Beta-adrenergic antagonists in the prevention of gastrointestinal rebleeding in patients with cirrhosis: a meta-analysis |journal=Hepatology |volume=25 |issue=1 |pages=63–70 |year=1997 |pmid=8985266 |doi=10.1053/jhep.1997.v25.pm0008985266 |url=}}</ref> | ** 4.1 '''Patients without''' '''transjugular intrahepatic portosystemic shunt''' '''(TIPS)'''<ref name="pmid8985266">{{cite journal |vauthors=Bernard B, Lebrec D, Mathurin P, Opolon P, Poynard T |title=Beta-adrenergic antagonists in the prevention of gastrointestinal rebleeding in patients with cirrhosis: a meta-analysis |journal=Hepatology |volume=25 |issue=1 |pages=63–70 |year=1997 |pmid=8985266 |doi=10.1053/jhep.1997.v25.pm0008985266 |url=}}</ref> | ||
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*****Therapeutic goals: Maximal tolerating dose; resting [[heart rate]] of 50-55 [[beats per minute]]. | *****Therapeutic goals: Maximal tolerating dose; resting [[heart rate]] of 50-55 [[beats per minute]]. | ||
*****Maintenance and follow up: Continue indefinitely without need to follow up [[endoscopy]]. | *****Maintenance and follow up: Continue indefinitely without need to follow up [[endoscopy]]. | ||
****Alternative regimen (1): | ****Alternative regimen (1): | ||
*****Starting dose: [[Isosorbide mononitrate|Isosorbide-5-mononitrate]] 10 mg [[Per os|PO]] at night daily; adjust every 2-3 days by adding 10 mg to morning and then evening; not exceed 20 mg q12h. | *****Starting dose: [[Isosorbide mononitrate|Isosorbide-5-mononitrate]] 10 mg [[Per os|PO]] at night daily; adjust every 2-3 days by adding 10 mg to morning and then evening; not exceed 20 mg q12h. | ||
*****Therapeutic goals: Maximal tolerating dose; [[systolic blood pressure]] remains more than 95 mmHg. | *****Therapeutic goals: Maximal tolerating dose; [[systolic blood pressure]] remains more than 95 mmHg. | ||
| Line 100: | Line 100: | ||
[[Category:Hepatology]] | [[Category:Hepatology]] | ||
[[Category:Disease]] | [[Category:Disease]] | ||
[[Category: | [[Category:Emergency medicine]] | ||
[[Category:Up-To-Date]] | |||
{{WS}} | {{WS}} | ||
{{WH}} | {{WH}} | ||
Latest revision as of 14:18, 7 December 2017
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Portal Hypertension Microchapters |
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Portal hypertension medical therapy On the Web |
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Risk calculators and risk factors for Portal hypertension medical therapy |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Eiman Ghaffarpasand, M.D. [2]
Overview
Pharmacological medical therapy is recommended among patients with cirrhosis and portal hypertension without esophageal varices, with esophageal varices but not yet bleeding, with esophageal varices that is bleeding, and with esophageal varices that has already bled. Pharmacological medical therapies for portal hypertension include non-selective beta blockers (NSBB), analogues of nitric oxide (NO), and vasoactive agents.
Medical Therapy
- Pharmacological medical therapy is recommended among patients with cirrhosis and portal hypertension:
- Without esophageal varices
- With esophageal varices but not yet bleeding
- With esophageal varices which is bleeding
- With esophageal varices which has already bled
- Pharmacological medical therapies for portal hypertension include non-selective beta blockers (NSBB), analogues of nitric oxide (NO), and vasoactive agents.
Portal hypertension
- 1 Stage 1 - Without esophageal varices
- 2 Stage 2 - With esophageal varices but not yet bleeding
- 2.1 Low-risk small varices[2]
- 2.1.1 Adult
- Preferred regimen (1): Conservative management
- Alternative regimen (1):
- Starting dose: Propranolol 20 mg PO q12h; adjust every 2-3 days to achieve final goal; not exceed 320 mg daily.
- Therapeutic goals: Maximal tolerating dose; resting heart rate of 50-55 beats per minute.
- Maintenance and follow up: Continue indefinitely without need to follow up endoscopy.
- Alternative regimen (2):
- Starting dose: Nadolol 40 mg PO daily; adjust every 2-3 days to achieve final goal; not exceed 160 mg daily.
- Therapeutic goals: Maximal tolerating dose; resting heart rate of 50-55 beats per minute.
- Maintenance and follow up: Continue indefinitely without need to follow up endoscopy.
- 2.1.1 Adult
- 2.2 Medium risk large varices[3][4]
- 2.2.1 Adult
- Preferred regimen (1):
- Starting dose: Propranolol 20 mg PO q12h; adjust every 2-3 days to achieve final goal; not exceed 320 mg daily.
- Therapeutic goals: Maximal tolerating dose; resting heart rate of 50-55 beats per minute.
- Maintenance and follow up: Continue indefinitely without need to follow up endoscopy.
- Preferred regimen (2):
- Starting dose: Nadolol 40 mg PO daily; adjust every 2-3 days to achieve final goal; not exceed 160 mg daily.
- Therapeutic goals: Maximal tolerating dose; resting heart rate of 50-55 beats per minute.
- Maintenance and follow up: Continue indefinitely without need to follow up endoscopy.
- Preferred procedure (3): Endoscopic variceal ligation every 2-4 weeks. Only to used with non-selective beta-blockers.
- Alternative regimen (1):
- Starting dose: Isosorbide-5-mononitrate 10 mg PO at night daily; adjust every 2-3 days by adding 10 mg to morning and then evening; not exceed 20 mg q12h.
- Therapeutic goals: Maximal tolerating dose; systolic blood pressure remains more than 95 mmHg.
- Maintenance and follow up: Continue indefinitely.
- Preferred regimen (1):
- 2.2.1 Adult
- 2.3 High risk small varices
- 2.3.1 Adult
- Preferred regimen (1):
- Starting dose: Propranolol 20 mg PO q12h; adjust every 2-3 days to achieve final goal; not exceed 320 mg daily.
- Therapeutic goals: Maximal tolerating dose; resting heart rate of 50-55 beats per minute.
- Maintenance and follow up: Continue indefinitely without need to follow up endoscopy.
- Preferred regimen (2):
- Starting dose: Nadolol 40 mg PO daily; adjust every 2-3 days to achieve final goal; not exceed 160 mg daily.
- Therapeutic goals: Maximal tolerating dose; resting heart rate of 50-55 beats per minute.
- Maintenance and follow up: Continue indefinitely without need to follow up endoscopy.
- Alternative procedure (1): Endoscopic variceal ligation every 2-4 weeks. Only to used with non-selective beta-blockers.
- Alternative regimen (2):
- Starting dose: Isosorbide-5-mononitrate 10 mg PO at night daily; adjust every 2-3 days by adding 10 mg to morning and then evening; not exceed 20 mg q12h.
- Therapeutic goals: Maximal tolerating dose; systolic blood pressure remains more than 95 mmHg.
- Maintenance and follow up: Continue indefinitely.
- Preferred regimen (1):
- 2.3.1 Adult
- 2.1 Low-risk small varices[2]
- 3 Stage 3 - With esophageal varices which is bleeding
- 3.1 Basic Medical conditions
- 3.1.1 Airway, breathing, and circulation stabilization
- 3.2 Advance cirrhosis
- 3.2.1 Antibiotic prophylaxis[5]
- Preferred regimen (1): Ceftriaxon 1 g IV q12h
- Alternative regimen (1): Norfloxacin 400 mg IV q12h
- 3.2.2 Vasoactive agents
- Preferred regimen (1): Somatostatin 250 μg IV bolus, then 250-500 μg/h maintenance dose; for 5 days
- Preferred regimen (2): Octreotide 50 μg IV bolus, then 50 μg/h maintenance dose; for 5 days
- Preferred regimen (3): Vapreotide 50 μg IV bolus, then 50 μg/h maintenance dose; for 5 days
- Alternative regimen (1): Vasopressin 0.2-0.4 units/min IV infusion, always use with nitroglycerine; until 24 hours
- Alternative regimen (2): Terlipressin 2 mg IV q4h until control of bleeding, then 1 mg IV q4h for prevention of rebleeding; for 5 days
- 3.2.1 Antibiotic prophylaxis[5]
- 3.1 Basic Medical conditions
- 4 Stage 4 - With esophageal varices which has already bled
- 4.1 Patients with transjugular intrahepatic portosystemic shunt (TIPS)
- No need to treat portal hypertension anymore
- Check the shunt patency every 6 months
- 4.1 Patients without transjugular intrahepatic portosystemic shunt (TIPS)[6]
- 4.1.1 Adults
- Preferred regimen (1):
- Starting dose: Propranolol 20 mg PO q12h; adjust every 2-3 days to achieve final goal; not exceed 320 mg daily.
- Therapeutic goals: Maximal tolerating dose; resting heart rate of 50-55 beats per minute.
- Maintenance and follow up: Continue indefinitely without need to follow up endoscopy.
- Preferred regimen (2):
- Starting dose: Nadolol 40 mg PO daily; adjust every 2-3 days to achieve final goal; not exceed 160 mg daily.
- Therapeutic goals: Maximal tolerating dose; resting heart rate of 50-55 beats per minute.
- Maintenance and follow up: Continue indefinitely without need to follow up endoscopy.
- Alternative regimen (1):
- Starting dose: Isosorbide-5-mononitrate 10 mg PO at night daily; adjust every 2-3 days by adding 10 mg to morning and then evening; not exceed 20 mg q12h.
- Therapeutic goals: Maximal tolerating dose; systolic blood pressure remains more than 95 mmHg.
- Maintenance and follow up: Continue indefinitely.
- Preferred regimen (1):
- 4.1.1 Adults
- 4.1 Patients with transjugular intrahepatic portosystemic shunt (TIPS)
References
- ↑ Groszmann RJ, Garcia-Tsao G, Bosch J, Grace ND, Burroughs AK, Planas R, Escorsell A, Garcia-Pagan JC, Patch D, Matloff DS, Gao H, Makuch R (2005). "Beta-blockers to prevent gastroesophageal varices in patients with cirrhosis". N. Engl. J. Med. 353 (21): 2254–61. doi:10.1056/NEJMoa044456. PMID 16306522.
- ↑ Merkel C, Marin R, Angeli P, Zanella P, Felder M, Bernardinello E, Cavallarin G, Bolognesi M, Donada C, Bellini B, Torboli P, Gatta A (2004). "A placebo-controlled clinical trial of nadolol in the prophylaxis of growth of small esophageal varices in cirrhosis". Gastroenterology. 127 (2): 476–84. PMID 15300580.
- ↑ Gluud LL, Klingenberg S, Nikolova D, Gluud C (2007). "Banding ligation versus beta-blockers as primary prophylaxis in esophageal varices: systematic review of randomized trials". Am. J. Gastroenterol. 102 (12): 2842–8, quiz 2841, 2849. doi:10.1111/j.1572-0241.2007.01564.x. PMID 18042114.
- ↑ Bosch J, Abraldes JG, Berzigotti A, Garcia-Pagan JC (2008). "Portal hypertension and gastrointestinal bleeding". Semin. Liver Dis. 28 (1): 3–25. doi:10.1055/s-2008-1040318. PMID 18293274.
- ↑ Fernández J, Ruiz del Arbol L, Gómez C, Durandez R, Serradilla R, Guarner C, Planas R, Arroyo V, Navasa M (2006). "Norfloxacin vs ceftriaxone in the prophylaxis of infections in patients with advanced cirrhosis and hemorrhage". Gastroenterology. 131 (4): 1049–56, quiz 1285. doi:10.1053/j.gastro.2006.07.010. PMID 17030175.
- ↑ Bernard B, Lebrec D, Mathurin P, Opolon P, Poynard T (1997). "Beta-adrenergic antagonists in the prevention of gastrointestinal rebleeding in patients with cirrhosis: a meta-analysis". Hepatology. 25 (1): 63–70. doi:10.1053/jhep.1997.v25.pm0008985266. PMID 8985266.