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2.4 Beta-adrenoceptor blocking drugs

ChoiceDrug
1st choiceBisoprolol tablets 1.25mg, 2.5mg, 3.75mg, 5mg, 7.5mg, 10mg
2nd choicesCarvedilol tablets 3.125mg, 6.25mg, 12.5mg, 25mg
Or

Nebivolol tablets 2.5mg, 5mg

N.B. Prescribe 5mg tablets for doses from 2.5mg-10mg, see Beta-blockers in Heart Failure below. If a 1.25mg dose is required prescribe 2.5mg tablets and request half tablet dosing.

Prescribing Notes

  • As per NICE NG136  Hypertension in adults: diagnosis and management  – August 2019, 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.
  • Beta-blocker choice is dependent on individual patient factors and the primary indication for use. Once a day drugs may improve compliance.
  • Beta-blockers are contra-indicated in those with second or third degree heart block.
  • Patients currently prescribed atenolol should be reviewed opportunistically and a switch considered to an alternative formulary choice of beta-blocker.
  • Propranolol is a non-cardioselective beta-blocker indicated for treatment of anxiety, thyrotoxicosis, essential tremors and the prophylaxis of migraine.
  • Labetalol is recommended as first line antihypertensive for the treatment of hypertension in pregnancy. See NICE NG133  Hypertension in pregnancy: diagnosis and management.
  • 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 – September 2018.
  • 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.
  • Due to the high cost of other nebivolol strengths, nebivolol 5mg tablets should be prescribed where possible for doses 2.5-10mg. 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

  • Beta-blocker treatment should be started at a very low dose and titrated very slowly over a period of weeks or months. 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 HF 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.

Cautions

  • Beta-blockers, even those with apparent cardioselectivity, should only be initiated under specialist supervision in patients with asthma. They should be used with caution in patients with obstructive airways disease.
  • 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.