Combined drug therapy outperforms endoscopic ligation for recurrent variceal bleeding


WESTPORT, CT (Reuters Health) – Mounting evidence suggests that combined medical treatment with nadolol and isosorbide mononitrate is safer and more effective than endoscopic ligation for the prevention of recurrent variceal bleeding.

The latest study, published in the August 30th issue of The New England Journal of Medicine, is the work of Dr. Candid Villanueva and colleagues from Hospital de la Santa Creu i Sant Pau in Barcelona.

They randomly assigned 144 patients hospitalized with cirrhosis and esophageal variceal bleeding to endoscopic ligation or combined medical therapy with nadolol and isosorbide mononitrate. Ligation was repeated every 2 to 3 weeks, if needed, until varices were eradicated.

"Our results suggest that once acute esophageal variceal bleeding has been controlled, this combined medical therapy has significant advantages over endoscopic ligation," the team writes.

That is, after a median follow-up of 21 months, recurrent bleeding occurred significantly less often in patients treated medically than in those treated with endoscopic ligation (P=0.04). The rate of major complications was also significantly lower in the medically treated group compared with the ligation group.

The authors think the increased efficacy of medical therapy may be due to
hemodynamic changes. More patients in the medical group than in the ligation group had a hemodynamic response, defined as a decrease in the hepatic venous pressure gradient of more than 20% from baseline or to a value of less than 12 mm Hg.

This suggests that "monitoring of the hepatic venous pressure gradient identifies patients with a poor response, in whom more aggressive alternative therapies may be warranted," they conclude.

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