Carvedilol (Portal Hypertension)

How it works

Non-selective beta-blockade reduces cardiac output and produces splanchnic vasoconstriction that lowers portal inflow, while the added alpha-1 blockade reduces intrahepatic and portocollateral vascular resistance, giving a greater fall in portal pressure than traditional non-selective beta-blockers.

Prescribing in practice

• Monitor blood pressure carefully and avoid in patients with refractory or diuretic-resistant ascites and significant hypotension, where excessive blood-pressure lowering may worsen outcomes.
• Start low and titrate against heart rate and blood-pressure tolerance, and avoid abrupt withdrawal which can precipitate rebound effects.
• Use with caution in decompensated liver disease and in asthma or significant bradyarrhythmia given its non-selective beta-blockade.

Monitoring

Monitor heart rate, blood pressure and tolerability at initiation and titration, and review for hypotension particularly where ascites is present.

Counselling the patient

• This medicine is taken to lower the pressure in the veins around the liver and reduce bleeding risk.
• Do not stop it suddenly; speak to your team if you feel dizzy or light-headed.
• Report worsening swelling, breathlessness, or fainting.

Evidence & guidelines

Hepatology guidance supports non-selective beta-blockers including carvedilol for primary prophylaxis against variceal bleeding in cirrhosis, with caution where refractory ascites is present.