Nonselective
beta-adrenergic blocker (NSBB)
therapy for the prevention of initial and recurrent gastrointestinal
bleeding in cirrhotic patients with gastroesophageal
varices has been used for the past four decades. NSBB
therapy is considered the cornerstone of treatment for
varices, and has become the standard of care. However, a 2010 study from the group that pioneered β-blocker
therapy suggested a detrimental effect of NSBBs in decompensated
cirrhosis, especially in patients with refractory
ascites. Since then, numerous additional studies have incompletely resolved whether NSBBs are deleterious, although more recent evidence weighs against a harmful effect. The possibility of a "therapeutic window" has also been raised. We aimed to review the literature to analyze the pros and cons of using NSBBs in patients with
cirrhosis, not only with respect to
bleeding or mortality but also to other potential benefits and risks. β-blockers are highly effective in preventing first
bleeding and recurrent
bleeding. Furthermore, NSBBs improve congestion/
ischemia of the gut mucosa, decrease intestinal permeability, and therefore indirectly alleviate systemic
inflammation. β-blockers shorten the electrocardiographic prolonged QTc interval and may also decrease the incidence of
hepatocellular carcinoma. On the other hand, the possibility of deleterious effects in
cirrhosis has not been completely eliminated. NSBBs may be associated with an increased risk of portal vein
thrombosis, although this could be correlational artifact. Overall, we conclude that β-blockers in
cirrhosis are much more of a friend than enemy.