Midodrine plus propranolol versus propranolol alone in preventing first bleed in patients with cirrhosis and severe ascites: a randomized controlled trial
Background Propranolol, a non-selective beta-blocker, commonly used to prevent variceal bleed, but might precipitate circulatory dysfunction in severe ascites. Midodrine, an alpha-1 adrenergic agonist improves renal perfusion and systemic hemodynamics. Addition of midodrine might facilitate higher m...
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| Veröffentlicht in: | Hepatology international 2024-08, Vol.18 (4), p.1261-1270 |
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| description | Background
Propranolol, a non-selective beta-blocker, commonly used to prevent variceal bleed, but might precipitate circulatory dysfunction in severe ascites. Midodrine, an alpha-1 adrenergic agonist improves renal perfusion and systemic hemodynamics. Addition of midodrine might facilitate higher maximum tolerated dose (MTD) of propranolol, thereby less risk of variceal bleed in cirrhosis patients with severe ascites.
Methods
140 patients with cirrhosis and severe/refractory ascites were randomized- propranolol and midodrine (Gr.A,
n
= 70) or propranolol alone (Gr.B,
n
= 70). Primary outcome was incidence of bleed at 1 year. Secondary outcomes included ascites control, achievement of target heart rate (THR), HVPG response and adverse effects.
Results
Baseline characteristics were comparable between two groups. Cumulative incidence of bleed at 1 year was lower in Gr.A than B (8.5%vs.27.1%,
p
-0.043). The MTD of propranolol was higher in Gr.A (96.67 ± 36.6 mg vs. 76.52 ± 24.4 mg;
p
-0.01) and more patients achieved THR (84.2%vs.55.7%,
p
-0.034). Significantly higher proportion of patients in Gr.A had complete resolution of ascites [17.1%vs.11.4%,
p
-0.014), diuretic tolerance (80%vs.60%,
p
-0.047) at higher doses(
p
-0.02) and lesser need for paracentesis. Patients in Gr.A also had greater reduction in variceal grade (75.7%vs.55.7%;
p
-0.01), plasma renin activity (54.4% from baseline) (
p
= 0.02). Mean HVPG reduction was greater in Gr.A than B [4.38 ± 2.81 mmHg(23.5%) vs. 2.61 ± 2.87 mmHg(14.5%),
p
-0.045]. Complications like post-paracentesis circulatory dysfunction and spontaneous bacterial peritonitis on follow-up were higher in Gr.B than A (22.8%vs.51.4%,
p
= 0.013 and 10%vs.15.7%,
p
= 0.03, respectively).
Conclusion
Addition of midodrine facilitates effective use of propranolol in higher doses and greater HVPG reduction, thereby preventing first variceal bleed, reduced paracentesis requirements with fewer ascites- related complications in patients with cirrhosis with severe/refractory ascites. |
| doi_str_mv | 10.1007/s12072-024-10687-1 |
| format | Article |
| fullrecord | <record><control><sourceid>proquest_cross</sourceid><recordid>TN_cdi_proquest_miscellaneous_3053982059</recordid><sourceformat>XML</sourceformat><sourcesystem>PC</sourcesystem><sourcerecordid>3087694841</sourcerecordid><originalsourceid>FETCH-LOGICAL-c326t-82ca8f1f3c3c2b2f55727551be896fde9a6b7d4ca500be792338f033c7074d193</originalsourceid><addsrcrecordid>eNp9kc1u1TAQhS1ERUvhBVggS2zYhPonjh12qOJPatUNrCPHnrSufO2Lx2kFj8LT4ttbitQFK4883zn2zCHkFWfvOGP6BLlgWnRM9B1ng9Edf0KO-CiHjqmeP32opTwkzxGvGVNq4MMzciiNFlobdkR-nweffQkJ6DauSLclb4tNOeZIb6DgoysbcyNDapdwA6mGdEmXULDSOQL4u46toXWQ3oZ6RV0o5SpjQGqTp9hEBahFFyrge2ppM_Z5E341rcuplhxjK2sJNr4gB4uNCC_vz2Py_dPHb6dfurOLz19PP5x1ToqhdkY4axa-SCedmMWiVJtNKT6DGYfFw2iHWfveWcXYDHoUUpqFSek0071vKzomb_e-bdAfK2CdNgEdxGgT5BUn2TY4GsHUDn3zCL3Oa0ntd40yehh70_NGiT3lSkYssEzbEja2_Jw4m3bJTfvkppbcdJfctBO9vrde5w34B8nfqBog9wC2VrqE8u_t_9j-AVuMpzU</addsrcrecordid><sourcetype>Aggregation Database</sourcetype><iscdi>true</iscdi><recordtype>article</recordtype><pqid>3087694841</pqid></control><display><type>article</type><title>Midodrine plus propranolol versus propranolol alone in preventing first bleed in patients with cirrhosis and severe ascites: a randomized controlled trial</title><source>MEDLINE</source><source>Springer Nature - Complete Springer Journals</source><creator>Ranjan, Abhijeet ; Jindal, Ankur ; Maiwall, Rakhi ; Vashishtha, Chitranshu ; Vijayaraghavan, Rajan ; Arora, Vinod ; Sarin, Shiv K.</creator><creatorcontrib>Ranjan, Abhijeet ; Jindal, Ankur ; Maiwall, Rakhi ; Vashishtha, Chitranshu ; Vijayaraghavan, Rajan ; Arora, Vinod ; Sarin, Shiv K.</creatorcontrib><description>Background
Propranolol, a non-selective beta-blocker, commonly used to prevent variceal bleed, but might precipitate circulatory dysfunction in severe ascites. Midodrine, an alpha-1 adrenergic agonist improves renal perfusion and systemic hemodynamics. Addition of midodrine might facilitate higher maximum tolerated dose (MTD) of propranolol, thereby less risk of variceal bleed in cirrhosis patients with severe ascites.
Methods
140 patients with cirrhosis and severe/refractory ascites were randomized- propranolol and midodrine (Gr.A,
n
= 70) or propranolol alone (Gr.B,
n
= 70). Primary outcome was incidence of bleed at 1 year. Secondary outcomes included ascites control, achievement of target heart rate (THR), HVPG response and adverse effects.
Results
Baseline characteristics were comparable between two groups. Cumulative incidence of bleed at 1 year was lower in Gr.A than B (8.5%vs.27.1%,
p
-0.043). The MTD of propranolol was higher in Gr.A (96.67 ± 36.6 mg vs. 76.52 ± 24.4 mg;
p
-0.01) and more patients achieved THR (84.2%vs.55.7%,
p
-0.034). Significantly higher proportion of patients in Gr.A had complete resolution of ascites [17.1%vs.11.4%,
p
-0.014), diuretic tolerance (80%vs.60%,
p
-0.047) at higher doses(
p
-0.02) and lesser need for paracentesis. Patients in Gr.A also had greater reduction in variceal grade (75.7%vs.55.7%;
p
-0.01), plasma renin activity (54.4% from baseline) (
p
= 0.02). Mean HVPG reduction was greater in Gr.A than B [4.38 ± 2.81 mmHg(23.5%) vs. 2.61 ± 2.87 mmHg(14.5%),
p
-0.045]. Complications like post-paracentesis circulatory dysfunction and spontaneous bacterial peritonitis on follow-up were higher in Gr.B than A (22.8%vs.51.4%,
p
= 0.013 and 10%vs.15.7%,
p
= 0.03, respectively).
Conclusion
Addition of midodrine facilitates effective use of propranolol in higher doses and greater HVPG reduction, thereby preventing first variceal bleed, reduced paracentesis requirements with fewer ascites- related complications in patients with cirrhosis with severe/refractory ascites.</description><identifier>ISSN: 1936-0533</identifier><identifier>ISSN: 1936-0541</identifier><identifier>EISSN: 1936-0541</identifier><identifier>DOI: 10.1007/s12072-024-10687-1</identifier><identifier>PMID: 38727780</identifier><language>eng</language><publisher>New Delhi: Springer India</publisher><subject><![CDATA[a1-Adrenergic receptors ; Adrenergic alpha-1 Receptor Agonists - administration & dosage ; Adrenergic alpha-1 Receptor Agonists - therapeutic use ; Adrenergic beta-Antagonists - administration & dosage ; Adrenergic beta-Antagonists - therapeutic use ; Adult ; Aged ; Ascites ; Ascites - etiology ; Bleeding ; Cirrhosis ; Colorectal Surgery ; Diuretics ; Drug Therapy, Combination ; Esophageal and Gastric Varices - etiology ; Female ; Gastrointestinal Hemorrhage - etiology ; Gastrointestinal Hemorrhage - prevention & control ; Heart rate ; Hemodynamics ; Hepatology ; Humans ; Liver cirrhosis ; Liver Cirrhosis - complications ; Male ; Medicine ; Medicine & Public Health ; Middle Aged ; Midodrine - administration & dosage ; Midodrine - therapeutic use ; Original Article ; Peritonitis ; Propranolol ; Propranolol - administration & dosage ; Propranolol - therapeutic use ; Renal function ; Renin ; Surgery ; Sympathomimetics ; Treatment Outcome]]></subject><ispartof>Hepatology international, 2024-08, Vol.18 (4), p.1261-1270</ispartof><rights>Asian Pacific Association for the Study of the Liver 2024. Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.</rights><rights>2024. Asian Pacific Association for the Study of the Liver.</rights><lds50>peer_reviewed</lds50><woscitedreferencessubscribed>false</woscitedreferencessubscribed><cites>FETCH-LOGICAL-c326t-82ca8f1f3c3c2b2f55727551be896fde9a6b7d4ca500be792338f033c7074d193</cites><orcidid>0000-0002-0544-5610</orcidid></display><links><openurl>$$Topenurl_article</openurl><openurlfulltext>$$Topenurlfull_article</openurlfulltext><thumbnail>$$Tsyndetics_thumb_exl</thumbnail><linktopdf>$$Uhttps://link.springer.com/content/pdf/10.1007/s12072-024-10687-1$$EPDF$$P50$$Gspringer$$H</linktopdf><linktohtml>$$Uhttps://link.springer.com/10.1007/s12072-024-10687-1$$EHTML$$P50$$Gspringer$$H</linktohtml><link.rule.ids>314,776,780,27902,27903,41466,42535,51296</link.rule.ids><backlink>$$Uhttps://www.ncbi.nlm.nih.gov/pubmed/38727780$$D View this record in MEDLINE/PubMed$$Hfree_for_read</backlink></links><search><creatorcontrib>Ranjan, Abhijeet</creatorcontrib><creatorcontrib>Jindal, Ankur</creatorcontrib><creatorcontrib>Maiwall, Rakhi</creatorcontrib><creatorcontrib>Vashishtha, Chitranshu</creatorcontrib><creatorcontrib>Vijayaraghavan, Rajan</creatorcontrib><creatorcontrib>Arora, Vinod</creatorcontrib><creatorcontrib>Sarin, Shiv K.</creatorcontrib><title>Midodrine plus propranolol versus propranolol alone in preventing first bleed in patients with cirrhosis and severe ascites: a randomized controlled trial</title><title>Hepatology international</title><addtitle>Hepatol Int</addtitle><addtitle>Hepatol Int</addtitle><description>Background
Propranolol, a non-selective beta-blocker, commonly used to prevent variceal bleed, but might precipitate circulatory dysfunction in severe ascites. Midodrine, an alpha-1 adrenergic agonist improves renal perfusion and systemic hemodynamics. Addition of midodrine might facilitate higher maximum tolerated dose (MTD) of propranolol, thereby less risk of variceal bleed in cirrhosis patients with severe ascites.
Methods
140 patients with cirrhosis and severe/refractory ascites were randomized- propranolol and midodrine (Gr.A,
n
= 70) or propranolol alone (Gr.B,
n
= 70). Primary outcome was incidence of bleed at 1 year. Secondary outcomes included ascites control, achievement of target heart rate (THR), HVPG response and adverse effects.
Results
Baseline characteristics were comparable between two groups. Cumulative incidence of bleed at 1 year was lower in Gr.A than B (8.5%vs.27.1%,
p
-0.043). The MTD of propranolol was higher in Gr.A (96.67 ± 36.6 mg vs. 76.52 ± 24.4 mg;
p
-0.01) and more patients achieved THR (84.2%vs.55.7%,
p
-0.034). Significantly higher proportion of patients in Gr.A had complete resolution of ascites [17.1%vs.11.4%,
p
-0.014), diuretic tolerance (80%vs.60%,
p
-0.047) at higher doses(
p
-0.02) and lesser need for paracentesis. Patients in Gr.A also had greater reduction in variceal grade (75.7%vs.55.7%;
p
-0.01), plasma renin activity (54.4% from baseline) (
p
= 0.02). Mean HVPG reduction was greater in Gr.A than B [4.38 ± 2.81 mmHg(23.5%) vs. 2.61 ± 2.87 mmHg(14.5%),
p
-0.045]. Complications like post-paracentesis circulatory dysfunction and spontaneous bacterial peritonitis on follow-up were higher in Gr.B than A (22.8%vs.51.4%,
p
= 0.013 and 10%vs.15.7%,
p
= 0.03, respectively).
Conclusion
Addition of midodrine facilitates effective use of propranolol in higher doses and greater HVPG reduction, thereby preventing first variceal bleed, reduced paracentesis requirements with fewer ascites- related complications in patients with cirrhosis with severe/refractory ascites.</description><subject>a1-Adrenergic receptors</subject><subject>Adrenergic alpha-1 Receptor Agonists - administration & dosage</subject><subject>Adrenergic alpha-1 Receptor Agonists - therapeutic use</subject><subject>Adrenergic beta-Antagonists - administration & dosage</subject><subject>Adrenergic beta-Antagonists - therapeutic use</subject><subject>Adult</subject><subject>Aged</subject><subject>Ascites</subject><subject>Ascites - etiology</subject><subject>Bleeding</subject><subject>Cirrhosis</subject><subject>Colorectal Surgery</subject><subject>Diuretics</subject><subject>Drug Therapy, Combination</subject><subject>Esophageal and Gastric Varices - etiology</subject><subject>Female</subject><subject>Gastrointestinal Hemorrhage - etiology</subject><subject>Gastrointestinal Hemorrhage - prevention & control</subject><subject>Heart rate</subject><subject>Hemodynamics</subject><subject>Hepatology</subject><subject>Humans</subject><subject>Liver cirrhosis</subject><subject>Liver Cirrhosis - complications</subject><subject>Male</subject><subject>Medicine</subject><subject>Medicine & Public Health</subject><subject>Middle Aged</subject><subject>Midodrine - administration & dosage</subject><subject>Midodrine - therapeutic use</subject><subject>Original Article</subject><subject>Peritonitis</subject><subject>Propranolol</subject><subject>Propranolol - administration & dosage</subject><subject>Propranolol - therapeutic use</subject><subject>Renal function</subject><subject>Renin</subject><subject>Surgery</subject><subject>Sympathomimetics</subject><subject>Treatment Outcome</subject><issn>1936-0533</issn><issn>1936-0541</issn><issn>1936-0541</issn><fulltext>true</fulltext><rsrctype>article</rsrctype><creationdate>2024</creationdate><recordtype>article</recordtype><sourceid>EIF</sourceid><recordid>eNp9kc1u1TAQhS1ERUvhBVggS2zYhPonjh12qOJPatUNrCPHnrSufO2Lx2kFj8LT4ttbitQFK4883zn2zCHkFWfvOGP6BLlgWnRM9B1ng9Edf0KO-CiHjqmeP32opTwkzxGvGVNq4MMzciiNFlobdkR-nweffQkJ6DauSLclb4tNOeZIb6DgoysbcyNDapdwA6mGdEmXULDSOQL4u46toXWQ3oZ6RV0o5SpjQGqTp9hEBahFFyrge2ppM_Z5E341rcuplhxjK2sJNr4gB4uNCC_vz2Py_dPHb6dfurOLz19PP5x1ToqhdkY4axa-SCedmMWiVJtNKT6DGYfFw2iHWfveWcXYDHoUUpqFSek0071vKzomb_e-bdAfK2CdNgEdxGgT5BUn2TY4GsHUDn3zCL3Oa0ntd40yehh70_NGiT3lSkYssEzbEja2_Jw4m3bJTfvkppbcdJfctBO9vrde5w34B8nfqBog9wC2VrqE8u_t_9j-AVuMpzU</recordid><startdate>20240801</startdate><enddate>20240801</enddate><creator>Ranjan, Abhijeet</creator><creator>Jindal, Ankur</creator><creator>Maiwall, Rakhi</creator><creator>Vashishtha, Chitranshu</creator><creator>Vijayaraghavan, Rajan</creator><creator>Arora, Vinod</creator><creator>Sarin, Shiv K.</creator><general>Springer India</general><general>Springer Nature B.V</general><scope>CGR</scope><scope>CUY</scope><scope>CVF</scope><scope>ECM</scope><scope>EIF</scope><scope>NPM</scope><scope>AAYXX</scope><scope>CITATION</scope><scope>7U7</scope><scope>C1K</scope><scope>K9.</scope><scope>NAPCQ</scope><scope>7X8</scope><orcidid>https://orcid.org/0000-0002-0544-5610</orcidid></search><sort><creationdate>20240801</creationdate><title>Midodrine plus propranolol versus propranolol alone in preventing first bleed in patients with cirrhosis and severe ascites: a randomized controlled trial</title><author>Ranjan, Abhijeet ; Jindal, Ankur ; Maiwall, Rakhi ; Vashishtha, Chitranshu ; Vijayaraghavan, Rajan ; Arora, Vinod ; Sarin, Shiv K.</author></sort><facets><frbrtype>5</frbrtype><frbrgroupid>cdi_FETCH-LOGICAL-c326t-82ca8f1f3c3c2b2f55727551be896fde9a6b7d4ca500be792338f033c7074d193</frbrgroupid><rsrctype>articles</rsrctype><prefilter>articles</prefilter><language>eng</language><creationdate>2024</creationdate><topic>a1-Adrenergic receptors</topic><topic>Adrenergic alpha-1 Receptor Agonists - administration & dosage</topic><topic>Adrenergic alpha-1 Receptor Agonists - therapeutic use</topic><topic>Adrenergic beta-Antagonists - administration & dosage</topic><topic>Adrenergic beta-Antagonists - therapeutic use</topic><topic>Adult</topic><topic>Aged</topic><topic>Ascites</topic><topic>Ascites - etiology</topic><topic>Bleeding</topic><topic>Cirrhosis</topic><topic>Colorectal Surgery</topic><topic>Diuretics</topic><topic>Drug Therapy, Combination</topic><topic>Esophageal and Gastric Varices - etiology</topic><topic>Female</topic><topic>Gastrointestinal Hemorrhage - etiology</topic><topic>Gastrointestinal Hemorrhage - prevention & control</topic><topic>Heart rate</topic><topic>Hemodynamics</topic><topic>Hepatology</topic><topic>Humans</topic><topic>Liver cirrhosis</topic><topic>Liver Cirrhosis - complications</topic><topic>Male</topic><topic>Medicine</topic><topic>Medicine & Public Health</topic><topic>Middle Aged</topic><topic>Midodrine - administration & dosage</topic><topic>Midodrine - therapeutic use</topic><topic>Original Article</topic><topic>Peritonitis</topic><topic>Propranolol</topic><topic>Propranolol - administration & dosage</topic><topic>Propranolol - therapeutic use</topic><topic>Renal function</topic><topic>Renin</topic><topic>Surgery</topic><topic>Sympathomimetics</topic><topic>Treatment Outcome</topic><toplevel>peer_reviewed</toplevel><toplevel>online_resources</toplevel><creatorcontrib>Ranjan, Abhijeet</creatorcontrib><creatorcontrib>Jindal, Ankur</creatorcontrib><creatorcontrib>Maiwall, Rakhi</creatorcontrib><creatorcontrib>Vashishtha, Chitranshu</creatorcontrib><creatorcontrib>Vijayaraghavan, Rajan</creatorcontrib><creatorcontrib>Arora, Vinod</creatorcontrib><creatorcontrib>Sarin, Shiv K.</creatorcontrib><collection>Medline</collection><collection>MEDLINE</collection><collection>MEDLINE (Ovid)</collection><collection>MEDLINE</collection><collection>MEDLINE</collection><collection>PubMed</collection><collection>CrossRef</collection><collection>Toxicology Abstracts</collection><collection>Environmental Sciences and Pollution Management</collection><collection>ProQuest Health & Medical Complete (Alumni)</collection><collection>Nursing & Allied Health Premium</collection><collection>MEDLINE - Academic</collection><jtitle>Hepatology international</jtitle></facets><delivery><delcategory>Remote Search Resource</delcategory><fulltext>fulltext</fulltext></delivery><addata><au>Ranjan, Abhijeet</au><au>Jindal, Ankur</au><au>Maiwall, Rakhi</au><au>Vashishtha, Chitranshu</au><au>Vijayaraghavan, Rajan</au><au>Arora, Vinod</au><au>Sarin, Shiv K.</au><format>journal</format><genre>article</genre><ristype>JOUR</ristype><atitle>Midodrine plus propranolol versus propranolol alone in preventing first bleed in patients with cirrhosis and severe ascites: a randomized controlled trial</atitle><jtitle>Hepatology international</jtitle><stitle>Hepatol Int</stitle><addtitle>Hepatol Int</addtitle><date>2024-08-01</date><risdate>2024</risdate><volume>18</volume><issue>4</issue><spage>1261</spage><epage>1270</epage><pages>1261-1270</pages><issn>1936-0533</issn><issn>1936-0541</issn><eissn>1936-0541</eissn><abstract>Background
Propranolol, a non-selective beta-blocker, commonly used to prevent variceal bleed, but might precipitate circulatory dysfunction in severe ascites. Midodrine, an alpha-1 adrenergic agonist improves renal perfusion and systemic hemodynamics. Addition of midodrine might facilitate higher maximum tolerated dose (MTD) of propranolol, thereby less risk of variceal bleed in cirrhosis patients with severe ascites.
Methods
140 patients with cirrhosis and severe/refractory ascites were randomized- propranolol and midodrine (Gr.A,
n
= 70) or propranolol alone (Gr.B,
n
= 70). Primary outcome was incidence of bleed at 1 year. Secondary outcomes included ascites control, achievement of target heart rate (THR), HVPG response and adverse effects.
Results
Baseline characteristics were comparable between two groups. Cumulative incidence of bleed at 1 year was lower in Gr.A than B (8.5%vs.27.1%,
p
-0.043). The MTD of propranolol was higher in Gr.A (96.67 ± 36.6 mg vs. 76.52 ± 24.4 mg;
p
-0.01) and more patients achieved THR (84.2%vs.55.7%,
p
-0.034). Significantly higher proportion of patients in Gr.A had complete resolution of ascites [17.1%vs.11.4%,
p
-0.014), diuretic tolerance (80%vs.60%,
p
-0.047) at higher doses(
p
-0.02) and lesser need for paracentesis. Patients in Gr.A also had greater reduction in variceal grade (75.7%vs.55.7%;
p
-0.01), plasma renin activity (54.4% from baseline) (
p
= 0.02). Mean HVPG reduction was greater in Gr.A than B [4.38 ± 2.81 mmHg(23.5%) vs. 2.61 ± 2.87 mmHg(14.5%),
p
-0.045]. Complications like post-paracentesis circulatory dysfunction and spontaneous bacterial peritonitis on follow-up were higher in Gr.B than A (22.8%vs.51.4%,
p
= 0.013 and 10%vs.15.7%,
p
= 0.03, respectively).
Conclusion
Addition of midodrine facilitates effective use of propranolol in higher doses and greater HVPG reduction, thereby preventing first variceal bleed, reduced paracentesis requirements with fewer ascites- related complications in patients with cirrhosis with severe/refractory ascites.</abstract><cop>New Delhi</cop><pub>Springer India</pub><pmid>38727780</pmid><doi>10.1007/s12072-024-10687-1</doi><tpages>10</tpages><orcidid>https://orcid.org/0000-0002-0544-5610</orcidid></addata></record> |
| fulltext | fulltext |
| identifier | ISSN: 1936-0533 |
| ispartof | Hepatology international, 2024-08, Vol.18 (4), p.1261-1270 |
| issn | 1936-0533 1936-0541 1936-0541 |
| language | eng |
| recordid | cdi_proquest_miscellaneous_3053982059 |
| source | MEDLINE; Springer Nature - Complete Springer Journals |
| subjects | a1-Adrenergic receptors Adrenergic alpha-1 Receptor Agonists - administration & dosage Adrenergic alpha-1 Receptor Agonists - therapeutic use Adrenergic beta-Antagonists - administration & dosage Adrenergic beta-Antagonists - therapeutic use Adult Aged Ascites Ascites - etiology Bleeding Cirrhosis Colorectal Surgery Diuretics Drug Therapy, Combination Esophageal and Gastric Varices - etiology Female Gastrointestinal Hemorrhage - etiology Gastrointestinal Hemorrhage - prevention & control Heart rate Hemodynamics Hepatology Humans Liver cirrhosis Liver Cirrhosis - complications Male Medicine Medicine & Public Health Middle Aged Midodrine - administration & dosage Midodrine - therapeutic use Original Article Peritonitis Propranolol Propranolol - administration & dosage Propranolol - therapeutic use Renal function Renin Surgery Sympathomimetics Treatment Outcome |
| title | Midodrine plus propranolol versus propranolol alone in preventing first bleed in patients with cirrhosis and severe ascites: a randomized controlled trial |
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