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Nadolol Plus Isosorbide to Prevent Recurrent Variceal Bleeding
The rate of recurrent bleeding in patients with bleeding esophageal varices was lower with combined ß-blocker/nitrate therapy than with sclerotherapy in a previous trial (JW Jul 15 1996, p. 110, accession number 960705001, and N Engl J Med 1996; 334:1624). Since then, ligation has superseded sclerotherapy as the preferred endoscopic treatment; thus, it is now appropriate to compare ligation with medical therapy.
Spanish researchers randomized 144 patients with cirrhosis who were hospitalized with bleeding esophageal varices to receive either endoscopic ligation (performed at randomization, at 1 week, and then every 2 to 3 weeks until varices were eradicated) or nadolol plus isosorbide mononitrate. Compared with ligation patients, medically treated patients had a lower probability of recurrent bleeding related to portal hypertension (49 percent vs. 33 percent, P=0.04) and a lower rate of severe complications (12 percent vs. 3 percent, P=0.05) during a median follow-up of 21 months. Among medically treated patients, a decrease in hepatic venous pressure gradient correlated with lower risk for recurrent bleeding. Mortality rates were similar in the ligation and medication groups.
Comment: To prevent recurrent variceal bleeding, drug therapy with a ß-blocker and nitrate appears to be not only more effective than endoscopic ligation but also safer. In this study, only 2 medically treated patients stopped therapy because of drug side effects; other populations might not tolerate these drugs so well.
— AS Brett
Published in Journal Watch General Medicine August 31, 2001
Citation(s):
Villanueva C et al. Endoscopic ligation compared with combined treatment with nadolol and isosorbide mononitrate to prevent recurrent variceal bleeding. N Engl J Med 2001 Aug 30 345 647-655.
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