Clinical algorithms for the prevention of variceal bleeding and rebleeding in patients with liver cirrhosis

Table 1 Recommended use of non-selective betablockers in patients with primary and secondary prophylaxis [adapted from the Austrian (Billroth III), European (Baveno VI) and American (Guidance by the AASLD 2017) guidelines][3,17,22]

Beta blocker	Initial dose	Goal	Treatment duration	Further guidance
Propranolol	20–40 mg twice daily	Maximum dosage of 160 mg/day; Or until the resting heart rate of 55–60 beats/min; Maximum dosage of 80 mg/day in patients with ascites	Indefinite	Adapt every 2-3 d until optimal dose is reached; Discontinue during spontaneous bacterial peritonitis, hyponatremia (Na < 125 mmol/L) or acute kidney injury; Systolic blood pressure should not decrease below 90 mmHg; EGD for further variceal screening is not needed
Carvedilol	6.25 mg once daily	Maximum dosage of 12.5 mg/day	Indefinite	Adapt dose after 3 d and increase to 6.25 mg twice daily; Discontinue during spontaneous bacterial peritonitis, hyponatremia (Na < 125mmol/L) or acute kidney injury; Systolic blood pressure should not decrease below 90 mmHg; EGD for further variceal screening is not needed; Potential switch from carvedilol to propranolol in case of new onset of ascites
Nadolol	20-40 mg once daily	Maximum dosage of 160 mg/day; Or until the resting heart rate of 55–60 beats/min; Maximum dosage of 80 mg/day in patients with ascites	Indefinite	Adapt every 2-3 d until optimal dose is reached; Discontinue during spontaneous bacterial peritonitis, hyponatremia (Na < 125mmol/L) or acute kidney injury; Systolic blood pressure should not decrease below 90 mmHg; EGD for further variceal screening is not needed

EGD: Esophagogastroduodenoscopy

Table 2 Recommended vasoactive agents for management of acute variceal bleeding [adapted from the Austrian (Billroth III), European (Baveno VI) and American (Guidance by the AASLD 2017) guidelines][3,17,22]

Regimen	Dosing	Duration of regimen	Further guidance
Somatostatin	Bolus of 500 μg, followed by 500 μg/h via continuous infusion (6 mg/50 mL, infusion rate of 4.2 mL/h)	2-5 d	Bolus can be repeated in case of uncontrolled bleeding
Terlipressin	Bolus of 2mg every 4 h for the first 24-48 h, followed by giving bolus of 1mg every 4 h; Or continuous infusion 2 mg/d; maximum 12 mg/d	2-5 d	Be caution in patients with coronary artery disease, peripheral arterial occlusive disease hyponatremia (< 125 mmol/L), cardiac arrhythmia and severe asthma or chronic occlusive pulmonary disease
Octreotide (somatostatin analogue)	Bolus of 50 μg, followed by 50 μg via continuous infusion	2-5 d	Bolus can be repeated in case of uncontrolled bleeding