2.4 Beta-adrenoceptor blocking drugs

ChoiceDrugDosage
1st choiceBisoprolol tablets 1.25mg, 2.5mg, 3.75mg, 5mg, 7.5mg, 10mg

Dose:
Maintenance: hypertension and angina, usually 2.5-10mg once daily
Stable, chronic heart failure, 1.25mg daily for one week, increased, if tolerated, to 2.5mg daily for one week, then 3.75mg daily for one week, then 5mg daily for four weeks, then 7.5mg daily for four weeks, then 10mg daily; max 10mg daily

2nd choicesCarvedilol tablets 3.125mg, 6.25mg, 12.5mg, 25mg

Dose:
Adjunct in heart failure (see BNF 2.5.5) initially 3.125mg twice daily (with food), dose increased at intervals of at least 2 weeks to 6.25mg twice daily, then to 12.5mg twice daily, then to 25mg twice daily; increase to highest dose tolerated, max 25mg twice daily in patients with severe heart failure or body-weight less than 85kg and 50mg twice daily in patients over 85kg
Other beta-blockers usually preferred in angina and hypertension

Or
Nebivolol tablets 5mg

Dose:
Hypertension, 5mg daily; ELDERLY initially 2.5mg daily, increased if necessary to 5mg daily
Adjunct in heart failure (see BNF 2.5.5), initially 1.25mg once daily, then if tolerated increased at intervals of 1-2 weeks to 2.5mg once daily, then to 5mg once daily, then to max 10mg once daily

N.B. if nebivolol 1.25-2.5mg dose is required it is more cost-effective to prescribe the 5mg tablet and request quarter/half tablet dosing(nebivolol is licensed to be divided in equal quarters)

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. Modified-release (MR) preparations permit once daily dosing but are expensive – standard release preparations are thus encouraged in preference to MR preparations except where compliance is an issue.
  • Labetalol is recommended as first line antihypertensive for the treatment of hypertension in pregnancy. See NICE NG133  Hypertension in pregnancy: diagnosis and management – June 2019.
  • For information on the use of beta-blockers post MI, please refer to NICE CG 172 Myocardial infarction: cardiac rehabilitation and prevention of further cardiovascular disease – November 2013.

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.
  • 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.