title: A specialized, nurse-run titration clinic: a feasible option for optimizing beta-blockade in non-clinical trial patients.
abstract: OBJECTIVE
  Randomized controlled trials of variceal bleeding prophylaxis demonstrate beta-blocker (BB) withdrawal rates of about 15%. We aimed to evaluate the dosing and tolerance of BBs achievable in a specialized, nurse-run BB titration clinic with non-trial participants.
  
  
  METHODS
  We analyzed prospectively collected data from 154 patients seen at the clinic between 2004 and 2009. BBs were titrated to patient tolerance. The therapeutic target (TT) was defined as a heart rate between 50 and 60 beats per minute (bpm) on the last clinic visit and/or maximum doses of BBs (propranolol 320 mg, nadolol 160 mg).
  
  
  RESULTS
  Eight of 154 patients were lost to follow-up, leaving 146. Fifty-five percent were male (mean age, 55; mean model for end-stage liver disease (MELD) score, 9), with 74% Child-Pugh class A. Median end-of-study doses were 120 mg propranolol and 60 mg nadolol. Seventy-nine percent of patients reached the TT before they were discharged from the clinic. Side effects were experienced by 72% of patients. Thirty-four percent had no need for dose reduction; 17% required transient dose reduction, 16% permanent dose reduction, and 5% BB discontinuation. Among patients requiring permanent dose reduction or discontinuation, the top reasons were fatigue and orthostatic symptoms. Independent predictors of achieving higher doses of BB were the absence of side effects, younger age, and diabetes.
  
  
  CONCLUSIONS
  This study provides evidence that a specialized BB titration clinic attains low withdrawal rates and higher doses, similar to those in clinical trials. Nurse-led clinics can contribute to successful titration of these important medications.
authors.affiliation: Hospital Clinic, University of Barcelona, Barcelona, Spain.
authors.forename: Puneeta
authors.initials: P
authors.lastname: Tandon
authors.forename: Rosa
authors.initials: R
authors.lastname: Saez
authors.forename: Annalisa
authors.initials: A
authors.lastname: Berzigotti
authors.forename: Juan G
authors.initials: JG
authors.lastname: Abraldes
authors.forename: Juan Carlos
authors.initials: JC
authors.lastname: Garcia-Pagan
authors.forename: Jaime
authors.initials: J
authors.lastname: Bosch
mesh_terms: D000319:Adrenergic beta-Antagonists / Q000008:administration & dosage / Q000627:therapeutic use; D000554:Ambulatory Care Facilities; D004932:Esophageal and Gastric Varices / Q000150:complications* / Q000188:drug therapy; D005260:Female; D006471:Gastrointestinal Hemorrhage / Q000188:drug therapy / Q000209:etiology / Q000517:prevention & control*; D006801:Humans; D008297:Male; D008875:Middle Aged; D009248:Nadolol / Q000008:administration & dosage* / Q000627:therapeutic use; D057184:Practice Patterns, Nurses'; D011433:Propranolol / Q000008:administration & dosage* / Q000627:therapeutic use; D011446:Prospective Studies; D016896:Treatment Outcome
chemical_list: D000319:Adrenergic beta-Antagonists; D009248:Nadolol; D011433:Propranolol