To Study the Hemodynamic Response of Early Addition of Carvedilol to Terlipressin in Acute Variceal Bleed in Child's B and C Cirrhosis

Aim and Objective To compare the hemodynamic response of early addition of carvedilol with terlipressin in patients with cirrhosis presenting with acute esophageal variceal bleeding.

Primary objective • To study the hemodynamic response (HVPG reduction of ≥20% from baseline or absolute reduction of HVPG </= 12 mmHg) in the groups at 5-days.

Secondary objective

• Rebleeding rate in the two groups at 5-days
• Rebleeding rate at 6-weeks
• Reduction of HVPG <16mm Hg in both groups at 5-days
• Salvage treatment, TIPS in both groups at 5-days and at 6-weeks
• Salvage treatment, SEMS, SB tube placement in-between groups at 5-days and at 6- weeks
• Survival at 6-weeks
• Liver related decompensation in-between groups at 6-weeks
• Adverse events between the groups at 6-weeks

Methodology:

Study population: Patients with Child's B and C cirrhosis who present with acute esophageal variceal bleed, between 18-75 years will be enrolled and randomized based on inclusion and exclusion criteria.

Study design- Prospective open label RCT

Study period - 1.5 years

Sample Size:Sample size will be calculated assuming that baseline characteristics (22.2±5.0 mmHg) are same and HVPG reduction on 5th day with terlipressin is 19.1±5 mmHg [7] and estimating a further reduction of 15% with addition of carvedilol [14] (16.3±4.3 mmHg), with an alpha value equal to 5 % and power of 80%, we need to enrol 45 cases in both arms. Assuming an attrition rate of 10%, it was decided to enrol 100 cases, 50 in each group, randomly allocated by block randomization method with block size of 10.

Intervention: All patients to receive Inj. Terlipressin, 1 mg at 4 hours along with standard management for acute variceal bleed as per institutional protocol

Arm A- Carvedilol will be initiated on day 2, at a dose of 3.125mg twice a day (6.25mg/day), along with standard management as per institutional protocol for AVB.

Arm B- Carvedilol will be initiated on day 6, at a dose of 3.125mg twice a day (6.25mg/day), along with standard management as per institutional protocol for AVB.

• Monitoring and assessment: Patients will be admitted in GI-bleed ICU and will be randomized into the study groups after successful endoscopic control of the bleed. Each patient will be monitored as per the institutional protocol for management of upper GI bleed. A detailed clinical history will be taken, and blood investigations and other relevant investigations required will be done as mentioned in the table 2. Patient will undergo HCC surveillance as per the guideline. Once discharged, patient will be called for OPD visits and routine investigations as planned will be done. Patient will be assessed for the tolerance of carvedilol and dose escalation to a maximum dose of 6.25mg twice a day (12.5mg/day) will be achieved. Each patient will maintain a "patient diary" for ease in recording details.

Table 2: Investigations

Day 0-5 Complete physical evaluation Hemogram, Kidney function test, Liver function test, INR Ultrasound abdomen with spleno-portal axis doppler Fibroscan-liver and spleen Coagulation parameter, vWF, ADAMTS-13 2D-ECHO, ECG Rest investigation, monitoring, antibiotics as per hospital protocol HVPG on Day 1 and at Day 5 Planned OPD visits on day 7, 14, 28, 42 Hemogram, Kidney function test, Liver function test, INR Follow-up visits Repeat upper GI endoscopy every 3 weeks till variceal eradication

Expected outcome of the project:

HVPG guided treatment and achieving hemodynamic response post bleed will reduce rebleeding rates and will prevent further decompensation and reduce mortality in patients with Child B and C cirrhosis.