Carvedilol or propranolol; which is better in cirrhosis?

Review by Prof. Ahad Eshraghian (Iran)

Study Summary 

In patients with liver cirrhosis, beta-blockers are used to reduce portal pressure and prevent variceal bleeding.  However, there is little data comparing carvedilol with non-selective classic beta-blockers like propranolol. In a multicenter retrospective study, 546 patients with compensated and decompensated liver cirrhosis with clinically significant portal hypertension were included. These patients underwent measurements of hepatic venous pressure gradient (HVPG) prior to prophylaxis for variceal bleeding to assess response to intravenous propranolol. They were then randomized to carvedilol or a non-selective beat blocker and followed for a median of 36 months. Carvedilol, when compared to non-selective beta blockers, was associated with a significant reduction in risk for first decompensation in compensated cirrhosis and further decompensation/death in decompensated cirrhosis. Repeat measurements of HVPG performed in 353 compensated and decompensated patients showed that patients with liver cirrhosis who were non-responders to acute intravenous propranolol showed a higher likelihood of achieving a chronic hemodynamic response with carvedilol.

Commentary 

This study demonstrated that carvedilol was superior to non-selective beta blockers for prevention of first decompensation in compensated liver cirrhosis and further decompensation/death in patients with decompensated cirrhosis. Due to the retrospective nature of the study, results cannot be generalized to all patients with decompensated liver cirrhosis. 

Citation

Fortea JI, et al. Carvedilol vs. propranolol for the prevention of decompensation and mortality in patients with compensated and decompensated cirrhosis. J Hepatol. 2025;83:70-80. doi: 10.1016/j.jhep.2024.12.017.

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