Adherence and adequacy of therapy for esophageal varices prophylaxis

Esophageal varices (EVs) are prevalent among cirrhotics and their bleeding leads to substantial morbidity and mortality. Management guidelines available during this study recommended beta-blocker therapy for primary prophylaxis and beta-blocker or band ligation (EVL) for secondary prophylaxis. We evaluated prophylaxis practice patterns.

We performed a retrospective cohort study of in and outpatient cirrhotics with known EVs at two University of Texas Southwestern teaching institutions. Use of prophylactic therapy and its adequacy (defined using published guidelines) was measured.

A total of 419 patients with cirrhosis and EVs warranting prophylaxis were identified, including 276 inpatients and 143 outpatients. Of those admitted with a first bleed (i.e. eligible for primary prophylactic therapy), 30/104 (29%) were on beta blocker. In this group, only 3/104 (3%) received optimal therapy (heart rate <55). Among inpatients with a previous EV bleed, 120/172 (70%) were on a beta blocker or had undergone EVL, although only 66/172 (38%) received optimal therapy. In the inpatient cohort, ten patients died of gastrointestinal hemorrhage, three of whom were receiving optimal therapy. Among outpatients, 94/121 (78%) without previous bleeding received primary prophylaxis and 20/22 (91%) of those with previous bleeding received some form of secondary prophylaxis. However, only 11 (9%) received adequate primary prophylaxis therapy, while 9 (41%) received appropriate secondary prophylaxis.

Prophylaxis intent appears to be greatly improved compared to previous reports. However, implementation of optimal therapy appeared to be suboptimal. We conclude that efforts need to be made to ensure optimal treatment.