Portal hypertension medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:

Overview

Treatment with a non-selective beta blocker is often commenced once portal hypertension has been diagnosed, and almost always if there has already been bleeding from esophageal varices. Typically, this is done with either propranolol or nadolol. The addition of a nitrate, such as isosorbide mononitrate, to the beta blocker is more effective than using beta blockers alone and may be the preferred regimen in those people with portal hypertension who have already experienced variceal bleeding. In acute or severe complications of the hypertension, such as bleeding varices, intravenous octreotide (a somatostatin analogue) or intravenous terlipressin (an antidiuretic hormone analogue) is commenced to decrease the portal pressure.

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
  • No need to treat portal hypertension.
  • Treat underlying causes of cirrhosis, such as:
    • Hepatitis C
    • Hepatitis B
    • Non-alcoholic fatty liver disease
• 2 Stage 2 - With esophageal varices but not yet bleeding
  • 2.1 Low-risk small varices
    • 2.1.1 Adult
      • 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.
  • 2.2 Medium risk large varices
    • 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
      • Alternative regimen (1): Only to used with NSBBs.
        • 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.
  • 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
      • Alternative regimen (2): Only to used with NSBBs.
        • 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.
• 3 Stage 3 - With esophageal varices which is bleeding
  • 3.1 Basic Medical conditions
    • 3.1.1 Airway, breathing, and circulation stabilizing
  • 3.2 Advance cirrhosis
    • 3.2.1 Antibiotic prophylaxis
      • 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
• 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 more
    • Check the shunt patency every 6 months
  • 4.1 Patients without transjugular intrahepatic portosystemic shunt (TIPS)
    • 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): Only to used with NSBBs.
        • 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.