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Non-Selective Beta-Blocker with Alpha₁-Blocking Activity Pregnancy: Caution — beta-blockers cross placenta; risk of neonatal bradycardia, hypoglycaemia, and growth restriction. Use only if clearly indicated.

Carvedilol (Portal Hypertension)

Brand names: Eucardic

Adult dose

Dose: Primary prophylaxis of variceal bleeding: 6.25mg twice daily. Titrate to 12.5mg twice daily after 1 week if tolerated. Dose guided by resting heart rate (target 55–60 bpm) and blood pressure.
Route: Oral
Frequency: Twice daily (with food — reduces risk of orthostatic hypotension)
Max: 12.5mg twice daily (portal hypertension); 50mg twice daily (heart failure)
Baveno VII now recommends carvedilol over propranolol for primary prophylaxis of variceal bleeding — superior reduction in hepatic venous pressure gradient (HVPG) due to combined beta + alpha₁ blockade (reduces splanchnic resistance more than propranolol). Start at 6.25mg BD and uptitrate.

Paediatric dose

Route: N/A
Frequency: N/A
Max: Seek specialist opinion
Not established for portal hypertension in children. Seek specialist hepatology opinion. BNF for Children provides heart failure dosing (different indication): 0.05mg/kg BD, titrated slowly.

Dose adjustments

Renal

No dose adjustment required.

Hepatic

Significantly increased bioavailability in cirrhosis — start at lowest dose (6.25mg BD) and titrate carefully. Avoid in severe hepatic impairment (Child-Pugh C) if haemodynamically compromised.

Clinical pearls

  • Baveno VII (2022): carvedilol 6.25mg BD now preferred over propranolol for primary prophylaxis of oesophageal variceal bleeding — produces greater HVPG reduction.
  • Refractory ascites caution: non-selective beta-blockers (including carvedilol) may worsen outcomes in advanced cirrhosis with refractory ascites, spontaneous bacterial peritonitis, or acute kidney injury — reassess and consider stopping.
  • First dose hypotension: significant risk due to alpha₁ blockade. Take with food. Start at 3.125mg BD if hypotension concern; titrate every 2 weeks.
  • Carvedilol vs propranolol: carvedilol reduces portal pressure via beta + alpha blockade; propranolol via beta only. Carvedilol superior for HVPG reduction but more hypotension risk.

Contraindications

  • Asthma or severe COPD (non-selective beta-blockade causes bronchospasm)
  • Second or third degree AV block
  • Cardiogenic shock
  • Decompensated heart failure requiring IV inotropes
  • Severe peripheral vascular disease
  • Refractory ascites (relative — may worsen outcomes in advanced cirrhosis)

Side effects

  • Hypotension (especially first dose — orthostatic; take with food)
  • Bradycardia
  • Fatigue, dizziness
  • Cold extremities
  • Bronchospasm (non-selective beta-blockade — contraindicated in asthma)
  • Masking of hypoglycaemic symptoms in diabetes
  • Worsening of renal function in decompensated cirrhosis (reduced splanchnic perfusion)

Interactions

  • Verapamil / diltiazem: severe bradycardia and AV block — avoid combination
  • Insulin / oral hypoglycaemics: masks hypoglycaemia symptoms — monitor glucose
  • CYP2D6 inhibitors (fluoxetine, paroxetine): increased carvedilol levels
  • Rifampicin: significantly reduces carvedilol levels (CYP induction)

Monitoring

  • Resting heart rate (target 55–60 bpm)
  • Blood pressure (standing — orthostatic hypotension)
  • Renal function and electrolytes (monthly in cirrhosis)
  • Signs of decompensation (ascites, encephalopathy)

Reference: BNFc; BNF 90; Baveno VII Consensus 2022; EASL Cirrhosis Guidelines 2018. Verify against your local formulary and the latest BNF before prescribing.

Related

Curated clinical cross-links plus same-class fallbacks.

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