New Paradigm in Treating Varices and Cirrhosis Management (in Adults)

2021 Halloween Pics:

G Garcia-Tsao, JG Abraldes. Gastroenterol 2021; 161: 770-773. Open Access: Nonselective Beta-Blockers in Compensated Cirrhosis: Preventing Variceal Hemorrhage or Preventing Decompensation?

Key points:

  • Carvedilol (not approved in children) is a NSBB that has additional α1 adrenergic blocking activity that enhances the portal pressure–reducing effect, compared to other NSBBs (eg. nadolol, propranolol).
  • New paradigm focuses on “the most relevant end point in compensated cirrhosis…development of decompensation”  (ascites, variceal hemorrhage, and/or hepatic encephalopathy).
  • In the PREDESCI study with 201 patients with compensated cirrhosis and CSPH, with no or small varices, to NSBBs or placebo…”clinical decompensation, was significantly lower in the NSBB arm than in the placebo arm (from 27% to 17% over a median follow-up of 37 months: HR 0.51, 95% CI 0.26–0.97)”
  • This model favors carvedilol over endoscopic variceal ligation; the “only RCT of carvedilol vs EVL in the prevention of first variceal hemorrhage showed a survival benefit of carvedilol over EVL.” Carvediol has been associated with improved survival in patients with cirrhosis (McDowell H.R. et al. Carvedilol is associated with improved survival in patients with cirrhosis: a long-term follow-up study. Aliment Pharmacol Ther. 2021; 5: 531-539)
  • This model “consists of identifying those with CSPH (by means of noninvasive methods) and treating them with carvedilol, with the goal of preventing any decompensating event (not only variceal hemorrhage).”
  • Screening endoscopy would still be recommended in newly-diagnosed decompensated cirrhosis and those intolerant to NSBBs.

My take: This new paradigm is one approach for portal hypertension in adults. More studies are needed in the pediatric age group to help determine whether medical therapy can obviate the need for EVL in most children with cirrhosis.

Whereas the existing paradigm focuses on the use of NSBBs for the prevention of variceal bleeding, in the new paradigm the presence of CSPH [clinically significant portal hypertension ](determined noninvasively) establishes the indication for NSBBs with the goal of preventing cirrhosis decompensation. CSPH, clinically significant portal hypertension; EVL, endoscopic variceal ligation; NSBB, nonselective beta-blocker; LS, liver stiffness; PLT, platelet count. ∗Patients with LS <20 kPa and PLT >150,000/mm3 can circumvent endoscopy because the risk of having high-risk varices is minimal

Related blog posts:

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NY Times: Cutting Sugar Improves Children’s Health in Just 10 Days

Perhaps this is not the best day of the year for this topic….

A recent small study of 43 children is summarized by the NY Times: Cutting Sugar Improves Children’s Health in Just 10 Days

An excerpt:

Obese children who cut back on their sugar intake see improvements in their blood pressure, cholesterol readings and other markers of health after just 10 days, a rigorous new study found.

The new research may help shed light on a question scientists have long debated: Is sugar itself harming health, or is the weight gain that comes from consuming sugary drinks and foods mainly what contributes to illness over the long term?

In the new study, which was financed by the National Institutes of Health and published Tuesday in the journal Obesity, scientists designed a clinical experiment to attempt to answer this question. They removed foods with added sugar from a group of children’s diets and replaced them with other types of carbohydrates so that the subjects’ weight and overall calorie intake remained roughly the same.

After 10 days, the children showed dramatic improvements, despite losing little or no weight. The findings add to the argument that all calories are not created equal, and they suggest that those from sugar are especially likely to contribute to Type 2 diabetes and other metabolic diseases, which are on the rise in children, said the study’s lead author, Dr. Robert Lustig, a pediatric endocrinologist at the Benioff Children’s Hospital of the University of California, San Francisco.

My take:  For a long time, I have been telling patients that if they make only one change, I would start by eliminating sugar-sweetened beverages. While this is a small study, it reinforces the view that sugar intake needs to be limited.

This post included last year’s pumpkin (Halloween 2014):  NASPGHAN Postgraduate Course 2014 -Liver Module – gutsandgrow

This year’s pumpkin:

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