Meta-Analysis: Pharmacotherapy Is As Effective As Endoscopic Therapy in the Secondary Prevention of Esophageal Variceal Bleeding

Abstract

Introduction: Gastroesophageal variceal bleeding recurs in 70% of patients, leading to death in 20- 35% of them. Endoscopic sclerotherapy (ES), variceal ligation (EVL) and medications are all effective in reducing this rebleeding rate and death. Clinical trials comparing endoscopic procedures and drug therapy or the combination of the two are ongoing and have yielded mixed results. Although previous meta-analyses have summarized the results of these studies comparing ES with medications alone or combined with ES, there are none comparing medications with EVL. We analyzed the data from these studies to investigate if medications were as effective as ES or EVL and if adding medications to these interventions improved their efficacy. Materials and Methods: We performed a systematic literature search using Pubmed, Embase and Cochrane Central databases for English articles. Randomized clinical trials that compared Medications (beta-blockers ± nitrates) with or without ES to ES and those that compared Medications with or without EVL to EVL in patients who had at least one prior episode of gastroesophageal variceal bleeding were included. Studies that evaluated at least 1 of the following outcomes: overall mortality, mortality due to gastroesophageal bleeding, recurrence of bleeding or recurrence of bleeding from esophageal varices were included. Data was extracted on an intention-to-treat basis. Heterogeneity of the studies was analyzed by the Cochran's Q statistics. The Mantel-Haenszel fixed-effect model was used to calculate combined relative risks for those outcomes where the studies were homogenous and the random effect model when the studies were heterogenic. Results:Twenty six studies representing a total of 2268 patients fulfilled inclusion criteria. Medications were non inferior to endoscopic therapy in all outcomes. Serious adverse events were not significantly different between any two groups compared. The results are summarized in the table below: Conclusion:Beta Blockers ± nitrates are at least as effective as endoscopic therapy in reducing rebleeding rates and all cause mortality and can potentially reduce cost. They are more effective than endoscopic interventions alone when added to them. Tabled 1Results Treatment groups Rebleeding OR(95% CI) Rebleeding from varices OR(95% CI) All cause mortality OR(95% CI) Death from bleeding OR(95% CI) Meds vs ES 1.09 (0.84-1.42) 1.12 (0.66-1.90) 1.17 (0.91-1.51) 1.42 (0.92-2.19) Meds vs EVL 1.04 (0.64-1.71) 1.20 (0.55-2.63) 0.78 (0.57-1.05) 0.13 (0.06-0.29) Meds vs all endoscopic therapy 1.07 (0.86-1.32) 1.14 (0.79-1.65) 0.98 (0.82-1.18) 1.16 (0.82-1.63) Meds + ES vs ES 0.66 (0.54-0.80) 0.67 (0.47-0.96) 0.81 (0.58-1.14) 0.99 (0.50-1.95) Meds + EVL vs EVL 0.48 (0.33-0.71) 0.38 (0.19-0.75) 0.69 (0.38-1.27) 0.43 (0.15-1.25) Meds + all endoscopic therapy vs all endoscopic therapy 0.62 (0.52-0.74) 0.60 (0.44-0.82) 0.78 (0.58-1.05) 0.78 (0.44-1.38) EVL- Endoscopic variceal ligation ES- Endoscopic sclerotherapy Open table in a new tab EVL- Endoscopic variceal ligation ES- Endoscopic sclerotherapy