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

From Pathophysiology to Practice: Evolving Pharmacological Therapies, Clinical Complications, and Pharmacogenetic Considerations in Portal Hypertension

Background: Portal hypertension is a major complication of chronic liver diseases, leading to serious issues such as esophageal variceal bleeding. The increase in portal vein pressure is driven by both an organic component and a functional component, including tonic contraction of hepatic stellate cells. These processes result in a pathological rise in intrahepatic vascular resistance, stemming from partial impairment of hepatic microcirculation, which is further exacerbated by abnormalities in extrahepatic vessels, including increased portal blood flow. Objectives: This review aims to provide a comprehensive overview of the evolving pharmacological therapies for portal hypertension, with consideration and discussion of pathophysiological mechanisms, clinical complications, and pharmacogenetic considerations, highlighting potential directions for future research. Methods: A review of recent literature was performed to evaluate current knowledge and potential therapeutic strategies in portal hypertension. Results: For over 35 years, non-selective beta-blockers have been the cornerstone therapy for portal hypertension by reducing portal vein inflow as an extrahepatic target, effectively preventing decompensation and variceal hemorrhages. However, since not all patients exhibit an adequate response to non-selective beta-blockers (NSBBs), and some may not tolerate NSBBs, alternative or adjunctive therapies that enhance the effects of NSBBs on portal pressure are being investigated in preclinical and early clinical studies. Conclusions: A better understanding of pharmacogenetic factors and pathophysiological mechanisms could lead to more individualized and effective treatments for portal hypertension. These insights highlight potential directions for future research.

β-arrestin-2 predicts the clinical response to β-blockers in cirrhotic portal hypertension patients: A prospective study

BACKGROUND

Portal hypertension, a common complication associated with liver cirrhosis, can result in variceal bleeding, which greatly impacts patient survival. Recently, β-arrestin-2 has been shown to predict the acute hemodynamic response to nonselective β-blocker therapy for cirrhotic portal hypertension. However, more data is needed on the long-term effects of and changes in β-arrestin-2 following nonselective β-blocker therapy.

AIM

To investigate the expression and role of β-Arrestin-2 in predicting the long-term response to nonselective β-blockers in cirrhotic portal hypertensive patients.

METHODS

We prospectively enrolled 91 treatment-naïve patients with cirrhotic portal hypertension. Baseline clinical and laboratory data were obtained. Gastroscopy was performed for grading and treating varices and obtaining gastric antral biopsies. We measured the serum and antral expression of β-arrestin-2 and obtained Doppler measurement of the portal vein congestion index. Treatment with nonselective β-blockers was then started. The patients were followed up for 18 mo, after which they have undergone a repeat antral biopsy and re-evaluation of the portal vein congestion index.

RESULTS

A higher serum level and antral expression of β-arrestin-2 was associated with longer bleeding-free intervals, greater reduction in the portal vein congestion index, and improved grade of varices. Among patients with a low β-arrestin-2 expression, 17.6% were nonselective β-blocker responders, whereas, among those with high expression, 95.1% were responders (P < 0.001). A serum β-arrestin-2 value ≥ 2.23 ng/mL was associated with a lower likelihood of variceal bleeding (90% sensitivity and 71% specificity). β-arrestin-2 expression significantly decreased after nonselective β-blocker therapy.

CONCLUSION

β-arrestin-2 expression in cirrhotic portal hypertension predicts the clinical response to long-term nonselective β-blocker treatment. Serum β-arrestin-2 is a potential noninvasive biomarker for selecting the candidate patients for nonselective β-blockers.