Can Non-Selective Beta-Blockers (NSBBs) Prevent Enlargement of Small Esophageal Varices in Patients with Cirrhosis? A Meta-analysis

Ashish Kumar; Praveen Sharma; Shrihari A Anikhindi; Ritesh Prajapati; Rachit Agarwal; Bhupendra Sharma; Naresh Bansal; Vikas Singla; Anil Arora

doi:10.1016/j.jceh.2017.09.003

Can Non-Selective Beta-Blockers (NSBBs) Prevent Enlargement of Small Esophageal Varices in Patients with Cirrhosis? A Meta-analysis

J Clin Exp Hepatol. 2017 Dec;7(4):275-283. doi: 10.1016/j.jceh.2017.09.003. Epub 2017 Oct 3.

Authors

Ashish Kumar¹, Praveen Sharma¹, Shrihari A Anikhindi¹, Ritesh Prajapati¹, Rachit Agarwal¹, Bhupendra Sharma¹, Naresh Bansal¹, Vikas Singla¹, Anil Arora¹

Affiliation

¹ Institute of Liver, Gastroenterology, & Pancreatico-Biliary Sciences, Ganga Ram Institute for Postgraduate Medical Education & Research (GRIPMER), Sir Ganga Ram Hospital, New Delhi 110 060, India.

Abstract

Background: Non-selective beta-blockers (NSBBs) are recommended for prophylaxis of first variceal bleeding in patients of cirrhosis with large esophageal varices. However, the data is conflicting whether NSBBs can also prevent growth of small esophageal varices to large size.

Aim: To perform a meta-analysis of the randomized clinical trials comparing NSBBs with placebo for prevention of development of large esophageal varices in patients of cirrhosis with small esophageal varices.

Methods: The PubMed, EMBASE, Science Direct, and Cochrane library databases were searched for relevant papers. A meta-analysis was performed using risk ratios (RRs) with 95% confidence interval (CI) as the effect sizes.

Results: Overall, 314 trials were initially retrieved from the database searches, of which five randomized controlled trials were included in the meta-analysis. The incidence of development of large varices (RR = 0.91, 95%CI: 0.29-2.86; P = 0.87) was similar between NSBB and placebo groups. However, the heterogeneity among studies was significant (P < 0.01) with an I² of 93%. The incidences of first variceal bleeding (RR = 0.72, 95%CI: 0.25-2.12; P = 0.55) and death (RR = 0.76, 95%CI: 0.50-1.15; P = 0.19) were also similar between NSBB and placebo groups; with no heterogeneity. The incidence of adverse events was significantly higher in the NSBB group compared with the placebo group (RR = 4.66, 95%CI: 1.36-15.91; P = 0.01).

Conclusion: The results of this meta-analysis indicate that NSBBs are not effective in preventing growth of small varices and may lead to significant adverse effects. Hence, NSBBs should not be recommended for cirrhotic patients with small varices.

Keywords: CI, confidence interval; NIHR, National Institute for Health Research; NSBB, non-selective beta-blockers; PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses; PROSPERO, Prospective Register of Systematic Reviews; RR, risk ratio; acute variceal bleeding; cirrhosis; esophageal varices; non-selective beta-blockers; portal hypertension.