# Caution: bevacizumab-based regimens with untreated varices

Source: https://onco.cc/pairings/io-varices-caution/  
OnCo record `io-varices-caution` (Pairing). Data CC BY-NC 4.0, attribute "Data from OnCo (onco.cc)"; commercial use needs a licence.

## TL;DR

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.

## Fields

- Kind: Pairing
- Last checked: 2026-09-07
- Pairs: Atezolizumab + Hepatitis B and C as cancer causes
- Type: caution
- Rationale: VEGF blockade impairs mucosal healing and raises portal pressure effects; cirrhotic patients have varices.
- Evidence: Trial protocols and label warnings.

## Sources

- ClinicalTrials.gov NCT03434379: IMbrave150: https://clinicaltrials.gov/study/NCT03434379
- ClinicalTrials.gov NCT03298451: HIMALAYA: https://clinicaltrials.gov/study/NCT03298451

## Connected records

- cancers: [Hepatocellular carcinoma](https://onco.cc/cancers/hcc/)
- drugs: [Atezolizumab](https://onco.cc/drugs/atezolizumab/), [Durvalumab](https://onco.cc/drugs/durvalumab/)
- trials: [HIMALAYA](https://onco.cc/trials/himalaya/), [IMbrave150](https://onco.cc/trials/imbrave150/)
- terms: [Hepatitis B and C as cancer causes](https://onco.cc/terms/hbv-hcv/)

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