APASL 2020|Prof.Guadalupe Garcia-Tsao: The Front of Beta Blockers, Statins for Treatment of Portal Hypertension

Portal Hypertension is a common complication in patients with chronic liver disease progressing to the stage of cirrhosis. Patients often have the risk of bleeding from varicose veins of the digestive tract. Therefore, it is very important to control portal vein pressure and prevent bleeding. At the invitation of the 29th Annual meeting of the Asian Pacific Association for the Study of the Liver (APASL 2020), Prof. Guadalupe Garcia-Tsao of Yale University in the United States introduced the latest advances in the treatment of portal hypertension, including the strategies currently under development but not included in the guidelines. Prof.Guadalupe Garcia-Tsao's team is one of the birthplace of clinical practice and academic research on portal hypertension worldwide, and one of the representatives of the development of portal hypertension in the world. The front reporter of Hepatology Digest had the honor to interview Professor Garcia-Tsao, and the interview contents are as follows for readers' reference.

<Hepatology Digest>: What are the main indications and contraindications of non-selective beta-blockers in patients with cirrhosis?

 

Dr Garcia-Tsao: Beta-blockers are perhaps the most important medication that we have for portal hypertension at this time. In the patient who has compensated cirrhosis, it has recently been shown that beta-blockers can actually prevent decompensation and variceal hemorrhage, as well as ascites, the most common complicating event. Where there are high-risk varices, beta-blockers have been shown to decrease the rate of first variceal hemorrhage, and because they act on the pathophysiology of portal hypertension by reducing portal pressure, they are a much more rational therapy than ligating those varices as a local therapy, for example. In the setting of a patient who has bled, once bleeding has resolved and TIPs was not used during the acute variceal hemorrhage, beta-blockers are the key component of combination therapy to prevent repeat bleeding episodes. The indications are: any patient with cirrhosis, compensated or decompensated; with or without varices; and patients who have bled from varices. The contraindications are where a patient gets hypotensive on the beta-blocker. Also where a patient has asthma (exacerbated by beta-blockers), and patients already with a low heart rate (resulting in syncope or other cardiovascular symptoms in the presence of beta-blockers).

<Hepatology Digest>: In your presentation, you raised the topic of statins in portal hypertension, and suggested they should be used with caution. Can you talk about that?

 

Dr Garcia-Tsao: In general, statins act on a separate plane to beta-blockers. Beta-blockers act by decreasing flow. Statins act by decreasing intrahepatic recesses. Therefore the use of statins plus beta-blockers has a cumulative effect because they act at different levels. Statins in the compensated patient are safe; they do not produce hepatotoxicity. In fact, in patients with NASH, by controlling hyperlipidemia, they improve aminotransferase levels. However, in jaundiced or decompensated patients, doses of 40mg or more of simvastatin have been associated with significant rhabdomyolysis. It is not really hepatotoxicity, but causing damage to muscle. So these patients can get into trouble with kidney failure from the rhabdomyolysis. We have to be cautious in these patients, and we need to wait for the outcomes of trials to see which groups of patients with cirrhosis are going to be candidates for statins.