Prescribing Notes
- As per NICE CG126, a beta-blocker +/- a calcium channel blocker is a first-line option to reduce symptoms of stable angina.
- Beta-blocker choice is dependent on individual patient factors (co-morbidities, contra-indications, preference) and the primary indication for use. Once-a-day drugs may improve compliance.
- As per NICE NG136, beta-blockers are no longer preferred as a routine initial therapy for hypertension (unless the patient has a co-morbidity for which a beta-blocker is indicated). In the past beta-blockers were sometimes used along with thiazides for hypertension, either as separate agents or as combination product. This is now discouraged to reduce the risk of developing diabetes.
- Do not offer beta-blockers to people with second or third degree heart block who do not have a pace maker, or to people with bradycardia (less than 50 beats per minute)
- Patients currently prescribed atenolol should be reviewed opportunistically and a switch considered to an alternative formulary choice of beta-blocker unless specifically indicated due to intolerance of other beta-blockers.
- Propranolol is a choice for other indications, see sections 4.9.3 and 4.7.2
- Labetalol is recommended as first line antihypertensive for the treatment of hypertension in pregnancy. Refer to NICE NG133
- For information on the use of beta-blockers post MI, please refer to NICE NG185 Acute Coronary Syndromes.
- It may be reasonable to stop beta-blocker one year after MI, provided LV function is normal and there is full revascularisation. Discuss with rehabilitation nurse or specialist.
Beta-blockers in heart failure
- Refer to NICE NG106 Chronic heart failure in adults.
- The beta-blockers bisoprolol and carvedilol reduce mortality in patients with stable heart failure and left ventricular systolic dysfunction.
- Nebivolol is licensed for use in stable mild to moderate heart failure in patients aged ≥70 years.
- Beta-blocker treatment should be started at a very low dose and titrated very slowly over a period of weeks. Aim for the target dose or failing that, the maximum tolerated dose. Symptoms may deteriorate initially, calling for adjustment of concomitant therapy. Please follow recommendations given by heart failure specialist teams and contact them for advice if necessary.
- Patients should be monitored for heart rate, oedema, breathlessness and blood pressure after each dose increment.
- Due to the high cost of other nebivolol strengths, nebivolol 5mg tablets should be prescribed where possible for doses 2.5 to 10mg. Please see table for dosing:
| Nebivolol Dose Required | Prescribe (where appropriate) |
| 2.5mg | 5mg tablets: Take half a tablet daily |
| 5mg | 5mg tablets: Take one daily |
| 10mg | 5mg tablets: Take two tablets daily |
| 1.25mg* | 2.5mg tablets: Take half a tablet daily |
| * due to the very high cost of nebivolol 1.25mg tablets
NB: heart failure titration dose only |
|
Cautions
- Beta-blockers can precipitate bronchospasm, refer to BNF treatment summary for more details.
- Elderly patients are particularly susceptible to the side-effects of beta-blockers which include cold extremities, bradycardia, conduction disorders, heart failure and fatigue. Reduced doses of beta-blockers may be required in the elderly.
- There is some evidence that sudden withdrawal may cause an exacerbation of angina or transitory worsening of heart failure and therefore gradual reduction of dose is preferable when beta-blockers are to be stopped, unless there is a need to stop treatment immediately.