DDSEP® 8 Quick Quiz

September 2018 Question 2

Q2. A 63-year-old man presents to your clinic for follow-up of his known cirrhosis. He had an upper endoscopy 1 month ago, where he was found to have large varices with no high-risk stigmata. The patient was placed on nadolol 20 mg daily, and is tolerating it without side effects. On physical exam, he has no clinical ascites. His vitals are as follows: temperature, 98.4º F; blood pressure, 114/75 mm Hg; heart rate 55 beats/minute.

What is the next most appropriate step to manage these varices?

DDSEP® 8 Quick Quiz - September 2018 Question 2

A) Increase nadolol to 40 mg daily

B) Repeat EGD and perform variceal band ligation

C) Change to nadolol to carvedilol

D) Continue current medical management

Q2. Correct Answer: D

Rationale
This patient is on nadolol, a nonselective beta-blocker, for the primary prophylaxis of large esophageal varices. The dose of nonselective beta-blockers should be increased in a stepwise manner until the maximum tolerated dose or until a resting heart rate of 50-55/min is met. Since this patient is already at target heart rate, there is no indication to increase the dose. Repeat endoscopy is not indicated to assess change in size of varices once initiated on nonselective beta-blockers and at target heart rate. The choice between beta-blockers or endoscopic variceal ligation depends on local resources and expertise, patient preference and characteristics, side effects, and contraindications. Carvedilol, a nonselective beta-blocker with vasodilatory properties, is a promising alternative therapy that deserves further evaluation. However, given that nadolol has achieved target heart rate and patient is tolerating it, there is no indication to change management.

Reference
1. Garcia-Tsao G., Sanyal A.J., Grace N.D., Carey W.. Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. Hepatology. 2007;46(3):922-38.
2. Tripathi D., Ferguson J.W., Kochar N., et al. Randomized controlled trial of carvedilol versus variceal band ligation for the prevention of the first variceal bleed. Hepatology. 2009;50(3):825-33.

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