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Prevención del nuevo sangrado por varices
Jaume Bosch1, Juan Carlos García-Pagán
1Hepatic Haemodynamic Laboratory, Liver Unit, Institut de Malalties Digestives, Hospital Clínic, IDIBAPS, University of Barcelona, 08036, Barcelona, Spain. jbosch@medicina.ub.es
Lancet (London, England)
|March 22, 2003
Resumen
La prevención de la rehemorragia variceal en pacientes con cirrosis puede mejorarse agregando isosorbida-5-mononitrato (ISMN) a los betabloqueantes para aquellos con una reducción inadecuada de la presión portal. Esta terapia farmacológica dirigida mejora los resultados para las personas de alto riesgo.
Área de la Ciencia:
- Hepatología y Gastroenterología.
- Ensayos clínicos y terapéuticas.
Sus antecedentes:
- El sangrado variceal es una complicación grave de la hipertensión portal en pacientes con cirrosis, que conduce a altas tasas de rehemorragia y mortalidad.
- Las estrategias de prevención actuales incluyen la ligadura de banda endoscópica (EBL), TIPS y la terapia farmacológica con beta-bloqueantes, cada una con limitaciones.
- La identificación de pacientes que se beneficiarán de regímenes específicos de medicamentos es crucial para la prevención efectiva de la rehemorragia.
Objetivo del estudio:
- Evaluar la eficacia de la adición de isosorbida-5-mononitrato (ISMN) a la terapia con beta-bloqueantes en pacientes con cirrosis y hipertensión portal.
- Determinar si el monitoreo del gradiente de presión venosa hepática (HVPG, por sus siglas en inglés) puede orientar los ajustes del tratamiento para prevenir la rehemorragia variceal.
- Para comparar la efectividad de la terapia farmacológica optimizada con la ligadura de banda endoscópica (EBL).
Principales métodos:
- Ensayos controlados aleatorios que comparan la EBL con la terapia farmacológica (propranolol +/- ISMN) para los sobrevivientes de hemorragias variceal.
- Medición del gradiente de presión venosa hepática (HVPG) para evaluar la reducción de la presión portal en respuesta a la terapia farmacológica.
- Adición de ISMN a los betabloqueantes para pacientes que no logran la reducción objetivo de HVPG.
Principales resultados:
- La terapia farmacológica mostró tasas generales de rehemorragia similares a las de la EBL (44% frente a 54% en 1 año).
- La adición de ISMN a los betabloqueantes mejoró la reducción de HVPG en los no respondedores, reduciendo significativamente las tasas de rehemorragia (10% frente a 64%).
- No se observaron diferencias significativas en la supervivencia o complicaciones no hemorrágicas entre los grupos de tratamiento.
Conclusiones:
- La terapia farmacológica a largo plazo, particularmente cuando se guía por el monitoreo de HVPG y se ajusta con ISMN, es una estrategia efectiva para prevenir la rehemorragia variceal.
- El monitoreo de HVPG es esencial para identificar a los pacientes que requieren terapia farmacológica intensificada.
- Se necesitan más ensayos para establecer tratamientos óptimos para los que no responden a las terapias farmacológicas actuales.
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