Article ; Online: Improving primary prophylaxis of variceal bleeding by adapting therapy to the clinical stage of cirrhosis. A competing-risk meta-analysis of individual participant data.
Alimentary pharmacology & therapeutics
2023 Volume 59, Issue 3, Page(s) 306–321
Abstract: Background & aims: Non-selective β-blockers (NSBBs) and endoscopic variceal-ligation (EVL) have similar efficacy preventing first variceal bleeding. Compensated and decompensated cirrhosis are markedly different stages, which may impact treatment ... ...
| Abstract | Background & aims: Non-selective β-blockers (NSBBs) and endoscopic variceal-ligation (EVL) have similar efficacy preventing first variceal bleeding. Compensated and decompensated cirrhosis are markedly different stages, which may impact treatment outcomes. We aimed to assess the efficacy of NSBBs vs EVL on survival in patients with high-risk varices without previous bleeding, stratifying risk according to compensated/decompensated stage of cirrhosis. Methods: By systematic review, we identified RCTs comparing NSBBs vs EVL, in monotherapy or combined, for primary bleeding prevention. We performed a competing-risk, time-to-event meta-analysis, using individual patient data (IPD) obtained from principal investigators of RCTs. Analyses were stratified according to previous decompensation of cirrhosis. Results: Of 25 RCTs eligible, 14 failed to provide IPD and 11 were included, comprising 1400 patients (656 compensated, 744 decompensated), treated with NSBBs (N = 625), EVL (N = 546) or NSBB+EVL (N = 229). Baseline characteristics were similar between groups. Overall, mortality risk was similar with EVL vs. NSBBs (subdistribution hazard-ratio (sHR) = 1.05, 95% CI = 0.75-1.49) and with EVL + NSBBs vs either monotherapy, with low heterogeneity (I Conclusions: In patients with compensated cirrhosis and high-risk varices on primary prophylaxis, NSBBs significantly improved survival vs EVL, with no additional benefit noted adding EVL to NSBBs. In decompensated patients, survival was similar with both therapies. The study suggests that NSBBs are preferable when advising preventive therapy in compensated patients. |
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| MeSH term(s) | Humans ; Esophageal and Gastric Varices/drug therapy ; Esophageal and Gastric Varices/prevention & control ; Gastrointestinal Hemorrhage ; Ligation ; Adrenergic beta-Antagonists/therapeutic use ; Liver Cirrhosis/complications ; Liver Cirrhosis/drug therapy ; Varicose Veins/drug therapy |
| Chemical Substances | Adrenergic beta-Antagonists |
| Language | English |
| Publishing date | 2023-12-18 |
| Publishing country | England |
| Document type | Meta-Analysis ; Journal Article ; Review |
| ZDB-ID | 639012-2 |
| ISSN | 1365-2036 ; 0269-2813 ; 0953-0673 |
| ISSN (online) | 1365-2036 |
| ISSN | 0269-2813 ; 0953-0673 |
| DOI | 10.1111/apt.17824 |
| Database | MEDical Literature Analysis and Retrieval System OnLINE |
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