Cost-effectiveness analysis of preventing esophageal variceal rebleeding in liver cirrhosis / 中华消化杂志

Objective To compare cost-effectiveness between endoscopical esophageal variceal ligation (EVL) combined non-selective beta-receptor blocker strategies and covered-stents transjugular intrahepatic portosystemic shunt (cTIPS) in preventing esophageal variceal rebleeding in liver cirrhosis with portal hypertension.And to explore the threshold of cost-effectiveness in stents in China.Methods According to clinical practice and associated guidelines,a six state Markov-based decision analytic model was established with TreeAge Pro Suite 2014 to compare the cost-effectiveness between two interfering strategies after followed up for seven years.The parameters such as costs,life years (LY),quality-adjusted life-years (QALY) and incremental costeffectiveness ratio (ICER) were directed.Results The results of baseline research in the seven-year follow-up period indicated that the cost of endoscopical EVL combined non-selective beta-receptor blocker B was 7 444.25 United States dollar (USD)/each,and yielded 1.98 QALY.The expected cost of cTIPS was 13 151.69 USD/ each and could have 2.34 QALY.In the 7th year,ICER was 16 001.74 USD.Based on willingness-to-pay (WTP) threshold of China (19 887.00 USD),cTIPS had better cost-effectiveness than endoscopical EVL combined non-selective beta-receptor blocker B.The price of covered stents less than 5 401.52 USD had cost-effectiveness.The results of single factor sensitivity analysis indicated that rebleeding probability of endoscopical EVL combined non-selective beta-receptor blocker B group was the most influential factor in the result of model.The second important factor was the cost of cTIPS.The probabilistic sensitivity analysis reported cTIPS to be the optimal strategy at WTP of 19 887.00 USD in 83％ of the iterations.Conclusions Seven-year follow-up indicates that cTIPS may be a more cost-effective strategy than endoscopical EVL combined non-selective beta-receptor blocker B in preventing esophageal variceal rebleeding.The price of covered stents less than 5 401.52 USD which have cost-effectiveness in China.

Effects of candesartan and propranolol combination therapy versus propranolol monotherapy in reducing portal hypertension

BACKGROUND/AIMS: Angiotensin receptor blockers (ARBs) inhibit activated hepatic stellate cell contraction and are thought to reduce the dynamic portion of intrahepatic resistance. This study compared the effects of combined treatment using the ARB candesartan and propranolol versus propranolol monotherapy on portal pressure in patients with cirrhosis in a prospective, randomized controlled trial. METHODS: Between January 2008 and July 2009, 53 cirrhotic patients with clinically significant portal hypertension were randomized to receive either candesartan and propranolol combination therapy (26 patients) or propranolol monotherapy (27 patients). Before and 3 months after the administration of the planned medication, the hepatic venous pressure gradient (HVPG) was assessed in both groups. The dose of propranolol was subsequently increased from 20 mg bid until the target heart rate was reached, and the candesartan dose was fixed at 8 mg qd. The primary endpoint was the HVPG response rate; patients with an HVPG reduction of >20% of the baseline value or to <12 mmHg were defined as responders. RESULTS: The mean portal pressure declined significantly in both groups, from 16 mmHg (range, 12-28 mmHg) to 13.5 mmHg (range, 6-20 mmHg) in the combination group (P<0.05), and from 17 mmHg (range, 12-27 mmHg) to 14 mmHg (range, 7-25 mmHg) in the propranolol monotherapy group (P<0.05). However, the medication-induced pressure reduction did not differ significantly between the two groups [3.5 mmHg (range, -3-11 mmHg) vs. 3 mmHg (range, -8-10 mmHg), P=0.674]. The response rate (55.6% vs. 61.5%, P=0.435) and the reductions in mean blood pressure or heart rate also did not differ significantly between the combination and monotherapy groups. CONCLUSIONS: The addition of candesartan (an ARB) to propranolol confers no benefit relative to classical propranolol monotherapy for the treatment of portal hypertension, and is thus not recommended.

Prevention of Variceal Rebleeding According to the Dose of Propranolol / 대한내과학회지

Esophageal variceal bleeding is a common complication of liver cirrhosis. Non-selective beta blockers (NSBB) have been established in numerous studies as one of the medical treatment for cirrhosis, especially in the primary and secondary prevention of variceal bleeding. The dose of NSBB is adjusted for a reduction in the resting heart rate by 25%, to 55 beat/min, or until the occurrence of adverse effect. The mean adjusted dose of propranolol in Korean study is 160 mg/day. Nevertheless, low dose propranolol is frequently used in real clinical field. A study by Kwon et al. showed that effect of propranolol in the prevention for esophageal rebleeding was superior in maximally-tolerable dose group of propranolol than low dose group. In this editorial, we have reviewed the studies of prevention for variceal rebleeding focusing on the dose of propranolol.

Prevention of Esophageal Variceal Bleeding / 대한소화기학회지

Esophageal varices(EV) are present in 40% and 60% of Child-Pugh A and C patients, respectively when cirrhosis is diagnosed. EV bleeding is a life-threatening complication of liver cirrhosis with a high probability of recurrence. Treatment to prevent first EV bleeding or rebleeding is mandatory. In small EV with high risk of bleeding, nonselective beta-blockers should be used for the prevention of first variceal bleeding. For medium to large EV, nonselective beta-blockers or endoscopic variceal ligation (EVL) may be recommended to high risk varices. But, nonselective beta-blockers are the first treatment option to non-high risk varices and EVL is an alternative when nonselective beta-blockers are contraindicated or not tolerated. For the prevention of rebleeding, a combination of nonselective beta-blockers and EVL may be the best option. A great improvement in the prevention of variceal bleeding has emerged over the last years. However, further therapeutic options that combine higher efficacy, better tolerance and fewer side effects are needed.