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 NICE NG50. These are non-selective beta-blockers NICE NG50.

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 NICE NG50. The dose should be adjusted based on heart and blood pressure monitoring NICE NG50. 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 NICE NG50. Carvedilol should be avoided in individuals with severe hepatic impairment, such as those with large-volume or refractory ascites NICE NG50. As of September 2023, the use of carvedilol for preventing variceal bleeding was considered off-label NICE NG50. If a person is already taking non-selective beta-blocker therapy for primary prevention, further variceal surveillance may not be needed NICE CKS.

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 NICE NG50. The comprehensive approach to esophageal variceal bleeding, including prevention, is a significant area of focus in medical literature Alqahtani & Jang 2021Singh et al. 2024.