Carvedilol superior to propranolol in preventing decompensation, death in cirrhosis

A recent study has provided data bolstering the current recommendation of using carvedilol to prevent a first decompensation of cirrhosis in patients with compensated cirrhosis.

This finding also suggests extending the recommendation to those with decompensated cirrhosis without recurrent or refractory ascites.

This multicentre retrospective study included 540 patients with compensated and decompensated cirrhosis with clinically significant portal hypertension. Participants underwent measurement of hepatic venous pressure gradient (HVPG) to assess acute haemodynamic response to intravenous propranolol (ie, HVPG decrease ≥10 percent from baseline value) prior to primary prophylaxis for variceal bleeding.

The investigators adjusted the outcomes using inverse probability of treatment weighting in a competitive risk framework.

Of the participants, 256 had compensated and 284 decompensated cirrhosis. Among patients with compensated cirrhosis, 111 received classical nonselective beta-blockers (cNSBBs; ie, propranolol and nadolol) and 145 received carvedilol. In the decompensated group, 134 were treated with cNSBBs and 150 with carvedilol. The median follow-up was 36.3 and 30.7 months, respectively.

After covariate balancing, carvedilol use resulted in a significant reduction in the risk of a first decompensation in compensated patients (subdistribution hazard ratio [sHR], 0.61, 95 percent confidence interval [CI], 0.41–0.92; p=0.019) and a combined endpoint of further decompensation or death in decompensated patients (sHR, 0.57, 95 percent CI, 0.42–0.77; p<0.0001) vs cNSBBs.

The investigators performed a second HVPG on 176 (68.8 percent) compensated and 177 (62.3 percent) decompensated patients. Acute nonresponders, both compensated (11.1 percent vs 29.4 percent; p=0.422) and decompensated (16.0 percent vs 43.6 percent; p=0.0247) patients, had a higher chance of achieving a chronic haemodynamic response with carvedilol.

Moreover, the safety profile of each type of NSBB was similar in both treatment groups.

"Our results support the preferential use of carvedilol in both settings due to its superior efficacy in reducing first and further decompensation,” the investigators said.

“However, owing to the retrospective nature of the study and inherent selection biases, we advise against broadly applying these findings to patients with decompensated cirrhosis who exhibit signs of circulatory dysfunction or recurrent/refractory ascites,” they added.