Evaluating Combination Therapy for the Prevention of a First Variceal Bleed

A team of scientists in Taiwan recently completed a study evaluating the combination of band ligation and nadolol to prevent a first variceal bleed due to cirrhosis, finding that the combination is not effective and may actually increase adverse events.

Study leader Gin-Ho Lo, MD, and the team of researchers initiated the investigation because this combination therapy is known to be effective in preventing secondary variceal bleeding, but no research existed about its effectiveness for a first variceal bleed. The team examined cirrhotic patients with high-risk esophageal varices but without a history of bleeding. These patients were randomized to receive band ligation plus nadolol (combined group, 70 patients) or nadolol alone (nadolol group, 70 patients). During the median follow-up period of 26 months, “18 patients (26%) in the Combined group and 13 patients (18%) in the Nadolol group experienced upper gastrointestinal bleeding (P = NS),” the researchers wrote in Hepatology. “Esophageal variceal bleeding occurred in 10 patients (14%) in the Combined group and nine patients (13%) in the Nadolol group (P = NS).”

Although 16 patients from each group died, a disparity in adverse events was observed. In the combined group, adverse events were noted in 48 patients (68%), while 28 patients (40%) in the Nadolol group suffered adverse events.

Writing in Hepatology, the researchers conclude: “The addition of ligation to nadolol may increase adverse events and did not enhance effectiveness in the prophylaxis of first variceal bleeding.”

Currently, according to the researchers, the World Gastroenterology Association’s guideline for esophageal varices in patients with cirrhosis and medium or large varices, but no hemorrhage, recommends “nonselective beta blockers (propranolol or nadolol) or endoscopic variceal ligation (EVL) for prevention of first variceal hemorrhage for patients at highest risk, and propranolol or nadolol for those who are not high risk or in whom EVL is not tolerated.”