Journal Article

Hemodynamic Effects of Adding Simvastatin to Carvedilol for Primary Prophylaxis of Variceal Bleeding: A Randomized Controlled Trial

Choudhary, Ashok, Jindal, Ankur, Kumar, Guresh, Sarin, Shiv K., Vijayaraghavan, Rajan, Arora, Vinod

2020

Overview

Beta-blockers are the mainstay agents for portal pressure reduction and to modestly reduce hepatic venous pressure gradient (HVPG). We studied whether addition of simvastatin to carvedilol in cirrhotic patients for primary prophylaxis improves the hemodynamic response. Cirrhotic patients with esophageal varices and with baseline HVPG > 12 mm Hg were prospectively randomized for primary prophylaxis to receive either carvedilol (group A, n = 110) or carvedilol plus simvastatin (group B, n = 110). Primary objective was to compare hemodynamic response (HVPG reduction of ≥20% or <12 mm Hg) at 3 months, and secondary objectives were to compare first bleed episodes, death, and adverse events. The groups were comparable at baseline. The proportion of patients achieving HVPG response at 3 months was comparable between groups (group A-36/62 [58.1%], group B-36/59 [61%], P = 0.85). The degree of mean HVPG reduction (17.3% and 17.8%, respectively, P = 0.98) and hemodynamic response (odds ratio [OR]: 0.88; 95% confidence interval [CI]: 0.43-1.83, P = 0.74) was also not different between the groups. Patients who achieved target heart rate with no hypotensive episodes in either group showed better hemodynamic response (77.8% vs 59.2%, P = 0.04). Failure to achieve target heart rate (OR: 0.48; 95% CI: 0.22-1.06) and Child C cirrhosis (OR: 4.49; 95% CI: 1.20-16.8) predicted nonresponse. Three (3.7%) patients on simvastatin developed transient transaminitis and elevated creatine phosphokinase and improved with drug withdrawal. Two patients in each group bled (P = 0.99). Three patients and 1 patient, respectively, in group A and B died (P = 0.32), with sepsis being the cause of death. Addition of simvastatin to carvedilol for 3 months for primary prophylaxis of variceal bleeding does not improve hemodynamic response over carvedilol monotherapy. Simvastatin usage should be closely monitored for adverse effects in Child C cirrhotic patients.

• Publisher: Wolters Kluwer,Wolters Kluwer Health Medical Research, Lippincott Williams & Wilkins
• Subject: Adrenergic beta-Antagonists - therapeutic use / Adult / Beta blockers / Biopsy / Carvedilol - therapeutic use / Catheters / Clinical trials / Drug Therapy, Combination / Endoscopy / Esophageal and Gastric Varices - drug therapy / Esophageal and Gastric Varices - etiology / Esophageal and Gastric Varices - physiopathology / Esophagus / Female / Gastroenterology / Gastrointestinal Hemorrhage - etiology / Gastrointestinal Hemorrhage - physiopathology / Gastrointestinal Hemorrhage - prevention & control / Heart rate / Hemodynamics / Hepatic Veins - physiopathology / Hepatitis / Humans / Hydroxymethylglutaryl-CoA Reductase Inhibitors - therapeutic use / Hypertension / Liver / Liver cirrhosis / Liver Cirrhosis - complications / Liver Cirrhosis - drug therapy / Liver Cirrhosis - physiopathology / Male / Middle Aged / Patients / Portal Pressure - physiology / Primary Prevention / Simvastatin - therapeutic use / Treatment Outcome / Venous Pressure - physiology