Carvedilol as an Adjunct to Endoscopic Cyanoacrylate Injection for Secondary Prophylaxis of Gastric Variceal Bleeding

Kaohsiung Veterans General Hospital

Status and phase: Completed; Phase 4

Conditions: Esophageal and Gastric Varices

Treatments: Drug: carvedilol; Drug: cyanoacrylate

Study type: Interventional

Funder types: Other

Identifiers

NCT02504723

VGHKS11-CT10-11

Details and patient eligibility

About

Gastric variceal obturation is the current endoscopic therapy of choice for gastric variceal bleeding but is associated with a high rebleeding rate. Carvedilol is a potent non-selective β-blocker. The role of carvedilol in the prevention of recurrent gastric variceal bleeding is not studied. This study aimed at evaluating the efficacy of carvedilol as an adjunct to gastric variceal obturation in the secondary prophylaxis of gastric variceal bleeding.

Full description

Gastric variceal bleeding is a lethal complication of portal hypertension. The rebleeding rate ranged between 30% to 50% in patients after initial hemostasis. Endoscopic cyanoacrylate injection is currently the choice of endoscopic therapy of acute gastric variceal bleeding and prevention of recurrent bleeding. However, the rebleeding rate is still high in the patients undergoing repeated endoscopic cyanoacrylate injection.

Non-selective β-blockers are frequently used for the secondary prophylaxis of variceal bleeding. In the case of esophageal varices, combination of non-selective β-blockers and endoscopic therapy significantly lowers the rebleeding rate compared with endoscopic therapy alone. However, propranolol failed to decrease the rebleeding rate as an adjunct to endoscopic cyanoacrylate injection and was associated with a higher incidence of adverse effects in gastric variceal bleeding patients. A more potent non-selective β-blocker than propranolol might further decrease portal pressure and decrease the rebleeding rate.

Carvedilol is a potent non-selective β-blocker with both beta and alpha-1 blocker effect. It significantly lowers portal pressure even in propranolol non-responders. However, it is unclear weather carvedilol will play a role in the prevention of recurrent gastric variceal bleeding. The investigators conducted a randomized controlled trial to compare the efficacy of carvedilol combined with endoscopic cyanoacrylate injection with endoscopic cyanoacrylate injection alone in secondary prophylaxis of gastric variceal bleeding.

Enrollment: 121 patients

Sex: All

Ages: 20 to 80 years old

Volunteers: No Healthy Volunteers

Inclusion criteria

• Age of 20 to 80 years
• Cirrhotic patients with acute gastric variceal bleeding proven by an endoscopy within 24 h of bleeding
• Stable hemodynamic condition for at least 3 days after cyanoacrylate injection

Exclusion criteria

• Previous treatment of gastric varices, including endoscopic therapy, transjugular intrahepatic porto-systemic shunt, or surgery
• Contraindications to non-selective beta-blockers or cyanoacrylate injection
• Serum total bilirubin >10 mg/dL
• Grade III/IV hepatic encephalopathy
• Hepato-renal syndrome
• Severe heart failure (NYHA Fc III/IV)
• Chronic kidney disease under renal replacement therapy
• Refractory ascites
• Malignancy other than hepatocellular carcinoma
• Pregnancy
• Pacemaker use
• Refusal to participate

Trial design

Primary purpose: Treatment

Allocation: Randomized

Interventional model: Parallel Assignment

Masking: None (Open label)

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121 participants in 2 patient groups

Cyanoacrylate injection plus carvedilol

Experimental group

Description:

The patients undergo repeated endoscopic cyanoacrylate injection every 3-4 weeks until obturation of gastric varices. Oral carvedilol is administrated during the whole study period, starting at 6.25 mg daily and increased until the maximum tolerated dose.

Treatment:

Drug: cyanoacrylate

Drug: carvedilol

Cyanoacrylate injection

Active Comparator group

Description:

The patients undergo repeated endoscopic cyanoacrylate injection every 3-4 weeks until obturation of gastric varices.

Treatment:

Drug: cyanoacrylate