Dear Editor,
We thank Doctors Wang and Chen for their reply [
1] to our recently published editorial [
2] on their study investigating non-invasive tests (NITs) for prognostication in HBV-related compensated advanced chronic liver disease (cACLD) [
3].
We were particularly interested in the authors’ perspective on the limited use of prophylactic carvedilol/propranolol treatment in their cohort comprising many patients with high-risk varices (HRV) [
3]. We acknowledge the listed concerns related to the implementation of NIT-guided carvedilol therapy in cACLD patients with a high estimated probability of clinically significant portal hypertension (CSPH)/decompensation [
1], although we still encourage this concept. Nonetheless, we want to emphasize that prophylactic medical or, if contraindicated, endoscopic treatment remains the globally endorsed standard of care for HRV that have not bled [
4-
6].
Along these lines, we may briefly share our recent experience with decompensation/bleeding prophylaxis in cACLD. Among 60 patients with CSPH (steatotic liver disease: 67%, viral hepatitis: 25%, other etiologies: 8%; any varices: 42%, HRV: 23%) treated at our centre who were included in the Non-Invasive CSPH Estimated Risk (NICER) cohort [
7] between 2022 and 2023, prophylactic treatment was initiated in 49 (82%; carvedilol: n=45, propranolol: n=4) patients. Only 11 (18%) patients could not receive prophylactic treatment owing either to contraindications or incompliance. Of note, HRV were present in only one of these patients, who then underwent endoscopic variceal ligation.
Meanwhile, during a median follow-up of 1.5 (25th percentile: 0.8, 75th percentile: 1.8) years, only two (4%) patients who received carvedilol/propranolol therapy developed adverse events that warranted treatment withdrawal, i.e., symptomatic bradycardia in one and symptomatic hypotension in the other patient.
Taken together, prophylactic carvedilol treatment is broadly applied at our centre and tolerated well by Austrian patients. Monitoring blood pressure is recommended, particularly during the first weeks of treatment. Moreover, careful titration to target doses depending on tolerability is important. At our centre, we generally aim at a dose of 12.5 mg when using carvedilol, although higher doses are encouraged if arterial hypertension is present.
In summary, we recommend initiating carvedilol in patients with cACLD upon CSPH diagnosis, either via minimally invasive hepatic venous pressure gradient measurement or via NITs [
4-
6,
8,
9]. Moreover, we strongly encourage the conduct of implementation research in the author’s region to identify barriers to primary prophylaxis of variceal bleeding in those with HRV [
1]. As we and others [
10] perceive the latter as a key quality indicator, initiatives designed to overcome the identified barriers are pertinent to the deliver high-value cirrhosis care.
As previously stated in our editorial and correctly reinforced by the authors, the scientific merit of their study is not impaired by these observations. We want to extend our congratulations to all authors who contributed to this important work and are looking forward to learning about the findings of the above-mentioned initiatives.
FOOTNOTES
-
Authors’ contribution
Both authors contributed equally to conceptualization and writing of the editorial (M.J., M.M.).
-
Acknowledgements
M.J. and M.M. receive financial support from “Clinical Research Group MOTION, Medical University of Vienna, Vienna, Austria – a project funded by the Clinical Research Groups Programme of the Ludwig Boltzmann Gesellschaft (Grant Nr: LBG_KFG_22_32) with funds from the Fonds Zukunft Österreich”.
-
Conflicts of Interest
The authors declare no conflict of interest regarding this work. Outside the submitted work, the authors declare the following potential conflicts of interest:
M.J. served as a speaker and/or consultant for Gilead.
M.M. served as a speaker and/or consultant and/or advisory board member for AbbVie, Echosens, Eli Lilly, Gilead, Ipsen, Takeda, and W. L. Gore & Associates and received travel support from AbbVie and Gilead.
Abbreviations
compensated advanced chronic liver disease
clinically significant portal hypertension
hepatic venous pressure gradient
REFERENCES
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