Non-selective Beta blockers (NSBB)

The Aspirin of Hepatologist

Ahmed Abdul Ghany

Why?

• Decrease portal pressure

• Decrease risk of bleeding from hypertensive gastropathy

• Lower incidence of bacterial translocation

• Decrease development of spontaneous bacterial peritonitis

NSBBs achieve their effects through

Reducing cardiac output via Beta 1 receptor blockade

Reducing portal blood flow through splanchnic vasoconstriction via Beta 2 receptor blockade

Several studies in cirrhotic patients withoutNSBB treatment established a correlation between BP and transplantation-free survival

As cirrhosis progress, cardiovascular system looses it’s compensatory ability, thus patients with low mean arterial Bp (< 82 mmHg) had lower survival

Liach. Gastro 1988

Modified peripheral vasodilatation hypothesis

Arroyo V, et al 2009

Predictors of worse survival

• Mean arterial Bp < 80 mmHg

• Cardiac index below 1.5 l/min/m2

Krag gut 2010

How effective are NSBBs in advanced liver cirrhosis ?

Krag, et al,. 2012

Window of opportunity opened by

Presence of varices

Start NSBB

Closed by

Refractory ascitesSBPHRSLow MAP

STOP NSBB

Paracentesis induced circulatory dysfunction (PICD)

Refractory ascites is characterized by repeated paracentsis, which has been shown to trigger PICD.

PICD defined as increase in renin level at least 50% one week after paracentesis.

Lack of cardiac adaptation after paracentesisunder beta blockers may explain the increase in PICD incidence.

Patients with PICD who are on NSBB medications, have a higher incidence of acute kidney injury (AKI) reaching 71%.

Serste et al., Liver International 2015

Transplantation-free survival with SBP

Mandofer M, et al., 2014

Mandofer M, et al., gastro 2014