Drugs plus ligation to prevent rebleeding in cirrhosis: an updated systematic review. (24th January 2014)

• Record Type: Journal Article
• Authors: Puente, Angela; Hernández‐Gea, Virginia; Graupera, Isabel; Roque, Marta; Colomo, Alan; Poca, Maria; Aracil, Carles; Gich, Ignasi; Guarner, Carlos; Villanueva, Càndid
• Is Part Of: Liver international. Volume 34:Number 6(2014:Aug.)
• Page Start: 823
• Page End: 833
• Publication Date: 2014-01-24
• Subjects: Liver -- Periodicals; Liver -- Diseases -- Periodicals; 616.362
• DOI: 10.1111/liv.12452
• Languages: English
• ISSNs: 1478-3223

Abstract

<abstract abstract-type="main" id="liv12452-abs-0001"> <title>Abstract</title> <sec id="liv12452-sec-0001" sec-type="section"> <title>Background & Aims</title> <p>Combined therapy with endoscopic variceal ligation (EVL) and β‐blockers ± isosorbide mononitrate (ISMN) is currently recommended to prevent variceal rebleeding. However, the role of this combined therapy has been challenged by some studies. We performed a systematic review to assess the value of combined therapy with EVL and β‐blockers ± ISMN as compared with each treatment alone to prevent rebleeding.</p> </sec> <sec id="liv12452-sec-0002" sec-type="section"> <title>Methods</title> <p>Databases, references and meeting abstracts were searched to retrieve randomized trials comparing combined therapy with EVL and β‐blockers ± ISMN vs either treatment alone, to prevent variceal rebleeding in cirrhosis. Random‐effects model was used for meta‐analysis.</p> </sec> <sec id="liv12452-sec-0003" sec-type="section"> <title>Results</title> <p>We identified five studies comparing EVL alone or combined with drugs, including a total of 476 patients. Combination therapy reduced overall rebleeding [risk ratios (RR) = 0.44, 95% confidence interval (CI) = 0.28–0.69], and showed a trend towards lower mortality (RR = 0.58, 95% CI = 0.33–1.03), without increasing complications. We identified four trials comparing drugs alone or associated with EVL, including 409 patients. All used β‐blockers plus ISMN. Variceal rebleeding decreased with combined therapy (<italic>P</italic> < 0.01) but rebleeding from oesophageal ulcers increased (<italic>P</italic> = 0.01). Overall, there was a trend towards lower rebleeding (RR = 0.76, 95% CI = 0.58–1.00) without effect on mortality (RR = 1.24, 95% CI = 0.90–1.70).</p> </sec> <sec id="liv12452-sec-0004" sec-type="section"> <title>Conclusions</title> <p>The addition of drug therapy to EVL improves the efficacy of EVL alone. However, the addition of EVL to β‐blockers and ISMN achieves a non‐significant decrease of rebleeding with no effect on mortality. Although combination therapy with EVL plus β‐blockers ± ISMN is adequate to prevent rebleeding, β‐blockers + ISMN alone may be a valid alternative.</p> </sec> </abstract>