Non-selective beta-blockers in cirrhosis: Current concepts and controversies

Table 2 Types of non-selective beta-blocker used in cirrhosis

	Propanolol	Carvedilol	Nadalol
Proposed mechanism of action	β-1 activity to reduce cardiac output and reduce portal blood flow through splanchnic vasoconstriction viaβ-2 blockade	β-1 activity to reduce cardiac output and reduce portal blood flow through splanchnic vasoconstriction viaβ-2 blockade. Additional intrinsic α1-adrenergic activity	β-1 activity to reduce cardiac output and reduce portal blood flow through splanchnic vasoconstriction viaβ-2 blockade
Side efffects/cautions1	Hypotension, bradycardia, caution in peripheral vascular disease/asthma.	Hypotension (more profound than others), bradycardia, caution in peripheral vascular disease/asthma.	Hypotension, bradycardia, caution in peripheral vascular disease/asthma.
	To be discontinued at time of SBP, renal impairment and hypotension1	To be discontinued at time of SBP, renal impairment and hypotension1	To be discontinued at time of SBP, renal impairment and hypotension1
Indications	Primary prophylaxis of variceal haemorrhage (Level 1A, grade A). In combination with VBL for secondary prevention (Level 1a, grade A)2	Primary prophylaxis of variceal haemorrhage (Level 1a, grade A). In combination with VBL for secondary prevention (Level 1b, grade B)2	Primary prophylaxis of variceal haemorrhage (Level 1a, grade A). In combination with VBL for secondary prevention (Level 1a, grade A)2
Dose	40 mg BD if tolerated or once HR < 50-55 bpm	12.5 mg OD if tolerated or once HR < 50-55 bpm	40mg OD (maximum dose 240 mg) or once HR < 50-55 bpm
Mode of administration	Oral	Oral	Oral

¹For consideration of re-introduction after acute event and depending on clinical judgement;

²NSBB combined with VBL as standard of care in secondary prevention[23,65]. BD: Bi-daily; OD: Once daily; SBP: Spontaneous bacterial peritonitis; VBL: Variceal band ligation; NSBB: Non-selective beta-blocker.