Drugs Used for Portal Hypertension & Esophageal Varices

Pathophysiology

• Portal hypertension results from increased intrahepatic resistance

• Elevated intrahepatic resistance leads to development of collateral circulation
• Portal blood is diverted into systemic circulation
• Results in gastroesophageal varices
• Treatment aim is to reduce splanchnic blood flow
Non Selective Beta Blocker

• Include propranolol, nadolol

• Act on beta 1 receptors causing splanchnic vasoconstriction and reduction of
portal inflow
• Used for primary and secondary prevention of variceal hemorrhage
• Dose reduction or discontinuation:
Bradycardia
Hypotension
• Heart failure
Unstable diabetes
• Pregnancy Category C
• Propranolol is preferred agent
Nitrates

• Include isosorbide-5-mononitrate

• Mechanism unknown
• Cause hypotension
• Not useful primary prophylaxis
Vasopressin Analogs - Terlipressin

• Management of acute variceal hemorrhage

• Acute reduction in portal pressure
• Terlipressin is a prodrug
• Acts on VI receptors to cause splanchnic vasoconstriction
Adverse Effects
• Dilutional hyponatremia — blocking receptors
• Vasoconstriction, ischemic complications
• Abdominal pain
• Arrhythmia
• Skin necrosis

• Avoid in pregnancy
Somatostatin Analogs - Octreotide

• Alternative to terlipressin in acute variceal hemorrhage

• Inhibition of glucagon mediated vasodilatation
• Reduces gut hyperemia
• Given as a continuous infusion
• Side effects are rare and mild
• Nausea Diarrhea
• Hypoglycemia Hepatitis
• Pancreatitis Arrhythmias
• Dyspnea Alopecia, rash
• Reduced dose of anti diabetic drugs in DM
• Pregnancy category B