{"entity":{"id":"io-varices-caution","kind":"pairing","name":"Caution: bevacizumab-based regimens with untreated varices","aka":[],"tldr":"Immunotherapy plus bevacizumab is standard in liver cancer, but the anti-VEGF part can cause fatal bleeding from swollen veins in the oesophagus unless they are checked first.","summary":"This caution concerns atezolizumab with bevacizumab, the standard first-line regimen in hepatocellular carcinoma, in patients whose liver disease, often from hepatitis B or C, has produced untreated oesophageal varices. VEGF blockade impairs mucosal healing and worsens the effects of portal pressure, and cirrhotic patients commonly have varices, so the anti-VEGF component can cause fatal variceal bleeding. IMbrave150 required endoscopy within six months of enrolment and treatment of any varices found, and upper gastrointestinal bleeding was still observed on atezolizumab-bevacizumab; the trial protocols and label warnings are the evidence. For patients at high bleeding risk, the durvalumab-based STRIDE regimen tested in HIMALAYA, or nivolumab with ipilimumab, are alternatives.","asOf":"2026-09-07","links":[{"label":"ClinicalTrials.gov NCT03434379: IMbrave150","url":"https://clinicaltrials.gov/study/NCT03434379"},{"label":"ClinicalTrials.gov NCT03298451: HIMALAYA","url":"https://clinicaltrials.gov/study/NCT03298451"}],"tags":[],"related":[],"cancers":["hcc"],"sections":[],"technologies":[],"targets":[],"drugs":["atezolizumab","durvalumab"],"companies":[],"institutions":[],"pathways":[],"terms":[],"trials":["imbrave150","himalaya"],"people":[],"bottlenecks":[],"keyPapers":[],"journals":[],"dependsOn":[],"notes":[],"a":"atezolizumab","b":"hbv-hcv","rationale":"VEGF blockade impairs mucosal healing and raises portal pressure effects; cirrhotic patients have varices.","evidence":"Trial protocols and label warnings.","pairingType":"caution"},"route":"/pairings/io-varices-caution/","neighbours":{"cancer":[{"id":"hcc","kind":"cancer","name":"Hepatocellular carcinoma","route":"/cancers/hcc/"}],"drug":[{"id":"atezolizumab","kind":"drug","name":"Atezolizumab","route":"/drugs/atezolizumab/"},{"id":"durvalumab","kind":"drug","name":"Durvalumab","route":"/drugs/durvalumab/"}],"trial":[{"id":"himalaya","kind":"trial","name":"HIMALAYA","route":"/trials/himalaya/"},{"id":"imbrave150","kind":"trial","name":"IMbrave150","route":"/trials/imbrave150/"}],"term":[{"id":"hbv-hcv","kind":"term","name":"Hepatitis B and C as cancer causes","route":"/terms/hbv-hcv/"}]}}