Principles of Non-selective Beta-blocker Usage for Cirrhosis-associated Complications

Abstract Although cirrhosis has no definitive cure at present, its symptoms can be managed. Beta-blockers are hypotensive medications typically used to treat cardiovascular diseases. Here, we review the role of non-selective beta-blockers (NSBBs) in managing cirrhosis-induced complications. NSBBs can reduce cirrhosis-induced portal hypertension (carvedilol lowers portal pressure more than propranolol), prevent variceal bleeding and ascites, and help tackle portal hypertensive gastropathy. Essentially, beta-blockers can prevent the progression of compensated cirrhosis (earlier stage) to decompensated cirrhosis (advanced stage of cirrhosis). The Baveno VII consensus marks a shift towards preventive management in cirrhosis, with the potential for hepatic recompensation when the causal factor is removed. It highlights that in compensated patients with clinically significant portal hypertension, NSBBs prevent first and recurrent variceal bleeding, and reduce decompensation risk, particularly ascites formation. For preventing the first bleeding of oesophageal varices, NSBBs are comparable to endoscopic band ligation (former have added advantages of being non-invasive and addressing the underlying portal hypertension). NSBBs should be avoided or dose-adjusted in patients with refractory ascites with arterial hypotension or renal impairment, with the therapy paused if mean arterial pressure drops or there is acute kidney injury, and restarted when issues resolve. NSBBs show anti-inflammatory effects and can reduce infection in decompensated cirrhosis patients, but caution needs to be exercised. Using NSBBs for preventing hepatic encephalopathy (another complication of cirrhosis) has shown promising results, but these may also increase the risk of recurrence of hepatic encephalopathy. Thus, caution needs to be exercised when prescribing NSBBs to patients with cirrhosis.