What pharmacological treatments are indicated for the prevention of variceal bleeding in patients with portal hypertension?

For the prevention of variceal bleeding in patients with portal hypertension, specifically those with medium or large oesophageal varices, the indicated pharmacological treatments are carvedilol or propranolol ¹. These are non-selective beta-blockers ¹.

When initiating treatment with either carvedilol or propranolol in people with cirrhosis to prevent bleeding from medium or large varices, a low dosage should be used, for example, 6.25 mg a day for carvedilol or 40 mg twice a day for propranolol ¹. The dose should be adjusted based on heart and blood pressure monitoring ¹. It is important to note that carvedilol and propranolol should be used with caution in people with cirrhosis due to their potential greater effect on heart rate and blood pressure ¹. Carvedilol should be avoided in individuals with severe hepatic impairment, such as those with large-volume or refractory ascites ¹. As of September 2023, the use of carvedilol for preventing variceal bleeding was considered off-label ¹. If a person is already taking non-selective beta-blocker therapy for primary prevention, further variceal surveillance may not be needed ³.

If carvedilol or propranolol are not tolerated or contraindicated, or if the person cannot take tablets regularly due to their circumstances, endoscopic variceal band ligation is an alternative option for people with medium or large oesophageal varices ¹. The comprehensive approach to esophageal variceal bleeding, including prevention, is a significant area of focus in medical literature (Alqahtani and Jang, 2021; Singh et al., 2024).