Beta-blockers or Placebo for Primary Prophylaxis (BOPPP) of oesophageal varices: Study protocol for a randomised controlled trial
Authors: Patel Vishal C , McPhail Mark J , Uddin Ruhama , Jafari Hassan , Lawrence Vanessa , Le Boutillier Clair , Shearer James , Yaziji Nahel , Cape Angela , Ahmed Haroon , Ward Christopher , Walsh Peter , Besly Kevin , Zamalloa Ane , Kelly Joanna ,   BOPPP study group, Carter Ben 
Published: December 2023

Background

Liver disease is within the top five causes of premature death in adults. Deaths caused by complications of cirrhosis continue to rise, while deaths related to other non-liver disease areas are declining. Portal hypertension, the primary sequalae of cirrhosis and is associated with the development of variceal haemorrhage, ascites, hepatic encephalopathy and infection, collectively termed hepatic decompensation, that lead to hospitalisation and mortality. It remains uncertain whether administering a non-selective beta-blocker (NSBB), specifically carvedilol, at an earlier stage i.e. when oesophageal varices are small, can prevent VH and reduce all-cause decompensation (ACD).

Methods/design

The BOPPP trial is a pragmatic, multicentre, placebo-controlled, triple-blinded, randomised controlled trial (RCT) in England, Scotland, Wales and Northern Ireland. Patients aged 18 years or older with cirrhosis and small oesophageal varices that have never bled will be recruited, subject to exclusion criteria. The trial aims to enrol 740 patients across 55 hospitals in the UK. Patients are allocated randomly on a 1:1 ratio to receive either carvedilol 6.25mg (a NSBB) or a matched placebo, once or twice daily, for 36 months, to attain adequate power to determine the effectiveness of carvedilol in preventing or reducing ACD.

The primary outcome is time to first decompensating event. It is a composite primary outcome made up of variceal haemorrhage (VH, new or worsening ascites, new or worsening hepatic encephalopathy (HE), spontaneous bacterial peritonitis (SBP), hepatorenal syndrome, an increase in Child Pugh grade by 1 grade or MELD score by 5 points, and liver-related mortality. Secondary outcomes include progression to medium or large oesophageal varices, development of gastric, duodenal, or ectopic varices, participant quality of life, healthcare costs and transplant-free survival.

Discussion

The BOPPP trial aims to investigate the clinical and cost effectiveness of carvedilol in patients with cirrhosis and small oesophageal varices to determine whether this non-selective beta-blocker can prevent or reduce hepatic decompensation. There is clinical equipoise on whether intervening in cirrhosis, at an earlier stage of portal hypertension, with NSBB therapy is beneficial. Should the trial yield a positive result, we anticipate that the administration and use of carvedilol will become widespread with pathways developed to standardise the administration of the medication in primary care.

Ethics and dissemination

The trial has been approved by the National Health Service (NHS) Research Ethics Committee (REC) (reference number: 19/YH/0015). The results of the trial will be submitted for publication in a peer-reviewed scientific journal. Participants will be informed of the resultsviathe BOPPP website (www.boppp-trial.org) and partners in the British Liver Trust (BLT) organisation.

Trial registration

EUDRACT reference number: 2018-002509-78

ISRCTN reference number: ISRCTN10324656