The Korean Journal of Medicine

The Korean Association of Internal Medicine (대한내과학회)
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Maximally Tolerable Versus Low Doses of Propranolol in the Prevention of Esophageal Variceal Rebleeding

Propranolol의 용량에 따른 식도 정맥류 재출혈 예방

  • Kwon, Hyuk Yong (Department of Internal Medicine, Catholic University of Daegu School of Medicine) ;
  • Ha, Kyung Ho (Department of Internal Medicine, Catholic University of Daegu School of Medicine) ;
  • Kim, Sun Young (Department of Internal Medicine, Catholic University of Daegu School of Medicine) ;
  • Park, Jin Hong (Department of Internal Medicine, Catholic University of Daegu School of Medicine) ;
  • Kim, Ji Suk (Department of Internal Medicine, Catholic University of Daegu School of Medicine) ;
  • Kim, Byung Seok (Department of Internal Medicine, Catholic University of Daegu School of Medicine) ;
  • Lee, Chang Hyeong (Department of Internal Medicine, Catholic University of Daegu School of Medicine)
  • 권혁용 (대구가톨릭대학교 의과대학 내과학교실) ;
  • 하경호 (대구가톨릭대학교 의과대학 내과학교실) ;
  • 김선영 (대구가톨릭대학교 의과대학 내과학교실) ;
  • 박진홍 (대구가톨릭대학교 의과대학 내과학교실) ;
  • 김지숙 (대구가톨릭대학교 의과대학 내과학교실) ;
  • 김병석 (대구가톨릭대학교 의과대학 내과학교실) ;
  • 이창형 (대구가톨릭대학교 의과대학 내과학교실)
  • Received : 2013.03.06
  • Accepted : 2013.05.15
  • Published : 2014.01.01
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Abstract

Background/Aims: Beta-blockers have been used extensively to prevent esophageal variceal (EV) rebleeding in patients with liver cirrhosis. The aim of this study was to compare the rate of EV rebleeding according to the dose of beta-blocker, between maximally tolerable dose (MTD) and low dose (LD) groups. Methods: A total of 95 patients, who were treated with emergent EV ligation for acute EV bleeding and have since then taken propranolol for 1 month or longer, were enrolled. Forty-nine patients took propranolol at the MTD ($154.7{\pm}10.1mg/day$), and 46 patients took propranolol at the LD ($39.1{\pm}5.8mg/day$). The end point was occurrence of EV rebleeding. Results: The MTD and LD groups were well matched for age, sex, etiologies for cirrhosis, presence of ascites or encephalopathy, serum creatinine levels, and follow-up periods. The MTD group showed relatively lower Child-Pugh scores, mode for end stage liver disease (MELD) scores, and serum bilirubin, as well as shorter prothrombin time, but a higher dose reduction rate, as compared with the LD group. The rate of EV rebleeding was lower in the MTD group than the LD group (38.8% vs. 67.4%, p = 0.007). In the univariate analysis, the risk factors for EV rebleeding were Child-Pugh classification and dose of propranolol. However, the dose of propranolol was only a significant risk factor for EV rebleeding according to the multivariate analysis. Conclusions: The effect of propranolol on the prevention of EV rebleeding was superior in the MTD group than in the LD group.

목적: 베타차단제는 간경변 환자의 식도 정맥류 재출혈 예방을 위해 널리 이용되어져 왔다. 하지만 베타 차단제를 사용하더라도 문맥압 감소가 충분하지 않으면 식도 정맥류의 재출혈을 유발할 수 있다. 본 연구의 목적은 최대 내약 용량군과 저용량군 사이에 식도 정맥류 재출혈률을 비교하는 것이다. 방법: 식도 정맥류 출혈로 응급 내시경적 정맥류 결찰술을 시행 후 베타차단제를 1개월 이상 복용하였던 95명이 등록되었다. 혈역학적 안정이 이루어진 뒤 모든 환자는 propranolol을 투약하였는데 49명은 최대 내약 용량($154.7{\pm}10.1mg/day$)을 나머지 46명은 저용량($39.1{\pm}5.8mg/day$)을 복용하였다. 식도 정맥류 재출혈 발생을 연구의 종료 시점으로 정하였다. 결과: 최대 내약 용량군과 저용량군 사이에 기본 특징을 비교했을 때, 나이, 성별비, 간경변의 원인, 복수와 뇌증의 유병률, 혈청 크레아티닌, 추적 기간은 차이가 없었다. 최대 내약 용량군에서 저용량군에 비해 Child-Pugh 등급, MELD 점수, 혈청 빌리루빈이 낮았고 프로트롬빈 시간은 짧았으며 베타차단제의 감량률은 높았다. 최대 내약 용량군에서 식도 정맥류 재출혈률은 저용량군에 비해 유의하게 낮았다(38.8% vs. 67.4%, p = 0.007). 식도 정맥류 재출혈에 관여하는 인자로는 Child-Pugh 등급과 propranolol의 용량이 단변량 분석에서 유의한 인자였다. 그러나 다변량 분석에서는 propranolol의 최대 내약 용량만이 식도 정맥류 재출혈을 감소시키는 유의한 인자였다. 결론: 식도 정맥류 재출혈 예방을 위한 propranolol의 효과를 용량에 따라 비교해 보았을 때 최대 내약 용량군이 저용량군보다 우수하였다. 본 연구는 식도 정맥류 재출혈을 예방하기 위해 propranolol을 최대 내약 용량으로 투약하는 것이 중요함을 보여주었다.

Keywords

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