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Comparison of Therapies for Primary Prevention of Esophageal Variceal Bleeding: A Systematic Review and Network Meta-analysis
Sharma M, Singh S, Desai V, Shah VH, Kamath PS, Murad MH, Simonetto DA
Hepatology (Baltimore, Md.). 2018
Abstract
BACKGROUND AND AIMS We performed a systematic review with network meta-analysis (NMA) to compare the efficacy of different approaches in primary prevention of esophageal variceal bleeding and overall survival in cirrhotic patients with large varices. METHODS Thirty-two randomized clinical trials (RCT) with 3362 cirrhotic adults with large esophageal varices and no prior history of bleeding, with minimum 12m follow-up were included. Nonselective beta- blockers (NSBB), isosorbide-mononitrate (ISMN), carvedilol and variceal band ligation (VBL), alone or in combination, were compared to each other or placebo. Primary outcomes were reduction of all-cause mortality, and prevention of esophageal variceal bleeding. Random effects NMA was performed and summary estimates were expressed as odds ratio and 95% confidence intervals (OR; CI). Quality of evidence was critically appraised using Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. RESULTS Moderate quality evidence supports NSBB monotherapy (0.70; 0.49-1.00) or in combination with VBL (0.49; 0.23-1.02) or ISMN (0.44; 0.21-0.93) for decreasing mortality in cirrhotic patients with large esophageal varices and no prior history of bleeding. Moderate quality evidence supports carvedilol (0.21; 0.08-0.56) and VBL monotherapy (0.33; 0.19-0.55) or in combination with NSBB (0.34; 0.14-0.86), and low quality evidence supports NSBB monotherapy (0.64; 0.38-1.07) for primary prevention of variceal bleeding. VBL carries a higher risk of serious adverse events compared to NSBB. CONCLUSION NSBB monotherapy may decrease all-cause mortality and the risk of first variceal bleeding in cirrhotic patients with large esophageal varices. Additionally, NSBB carry a lower risk of serious complications compared to VBL. Therefore, NSBB may be the preferred initial approach for primary prophylaxis of esophageal variceal bleeding. This article is protected by copyright. All rights reserved.