Editorial: use of beta‐blockers and band ligation in preventing first and recurrent variceal bleeding—“real life” vs evidence‐based decisions. Authors’ reply

We thank Drs. Berzigotti and Bosch for their interesting thoughts on our study. The most recent European, as well as our national guidelines recommend combined therapy with non-selective betablockers (NSBB) and endoscopic band ligation (EBL) for secondary prophylaxis of variceal bleeding. These recommendations are further supported by a recent meta-analysis based on individual patient data and our study demonstrating improved survival, if combination therapy was used in secondary prophylaxis. However, in our cohort, only 62% of patients on secondary prophylaxis were treated according to the guidelines, while the others were treated by EBL alone. The potential reason for this ‘non-adherence’ to guidelines needs to be critically discussed: In our study, we included patients from January 2000 until June 2015. The Baveno-III-consensus was published in 2000, and the Baveno-IV-consensus was then published in 2005. Importantly, both documents recommended either NSBB or EBL for the prevention of recurrent variceal bleeding. Thus, patients recruited from the first 10 years of the study received the current standard of care. However, Baveno-IV-consensus already stated that combination treatment might be the best treatment option for secondary prophylaxis. In this regard, we assessed if the proportion of patients receiving combined treatment increased after 2005. Indeed, 57.8% of patients were treated with NSBB+EBL before/in 2005 and 65.3% received NSBB + EBL therapy after 2005, respectively. Another important aspect regarding physicians’ adherence to the guidelines are their considerations about tolerance and side-effects of NSBB therapy. Starting in 2010, the debate of potential detrimental effects of NSBB in patients with refractory ascites might have also contributed to the decision to not use NSBBs in some patients with ascites.However, in previous studies NSBBs had no impact on renal function and even improved survival in patients with uncomplicated ascites, while increasing the risk of hepatorenal syndrome and negatively impacting survival in patients with spontaneous bacterial peritonitis. We agree with Drs. Bosch and Berzigotti that ‘reluctance to accept objective evidence, lack of information and the influence of the personal attitude of prestigious colleagues’ are likely additional factors contributing to non-adherence to the guidelines for the treatment of complications of portal hypertension. Similarly, another recent real-life study showed that about onethird of patients with cirrhosis and acute variceal bleeding meet the criteria for early-TIPS placement, however, only around 7% underwent early-TIPS placement. Even in tertiary-care-centers, current recommendations for early-TIPS placement were not followed in a considerable proportion of patients. This is concerning, as the number needed to treat to prevent one bleeding-related death was as low as 3.3 in another study. Every patient deserves the best treatment for the specific stage of liver disease, and thus, potential reasons for non-adherence to the evidence-based recommendations should be further explored. Thus, we will conduct a survey among physicians from Austrian hepatology/endoscopy units about their preferences for primary and secondary prophylaxis of variceal bleeding. This might allow us to identify gaps between clinical practice and guidelines and to subsequently educate the community in order to optimise the care of patients with cirrhosis and portal hypertension.