Comparison of Oral Beta-Blockers

Transcription

1 This Clinical Resource gives subscribers additional insight related to the Recommendations published in March 2017 ~ Resource # Comparison of Oral Beta-Blockers Noncardioselective s (beta-1 and beta-2 antagonist activity) More likely to cause peripheral vasoconstriction or bronchoconstriction, delay recovery from hypoglycemia in type 1 diabetes, and impair exercise performance. 4 Nadolol Corgard Low lipophilicity Renal excretion Long half-life Propranolol, immediate-release Inderal (brand no longer available) High lipophilicity Extensive first-pass Bioavailability variable; increased 50% by highprotein food Angina/ HTN: Start with 40 mg once daily. Usual dose mg once daily. Max dose: mg once daily for angina, mg once daily for HTN. Angina: mg/day, divided BID-QID A Fib: mg TID-QID Essential tremor: Start with 40 mg BID. Usual dose 120 mg/day. Max dose 320 mg/day. HTN: Start with 40 mg BID. Usual dose mg/day, divided BID or TID. Max dose 640 mg/day. Hypertrophic subaortic stenosis: mg TID-QID Post-MI: 40 mg TID, titrated to target dose of mg/day divided BID-QID. Start with 80 mg/day, divided. Usual dose mg/day. Pheochromocytoma (with alphablocker): 60 mg/day, divided, for 3 days before surgery, or 30 mg/day, divided, for inoperable tumors. A fib: For rate control. Usual dose mg once daily. 1 Probably effective. 2 Usual dose 80 mg once daily. 3 Max 240 mg once daily. 3 A Fib: For rate control. Usual maintenance dose mg TID-QID. 1 Post-MI: Reduces cardiovascular and total mortality (BHAT) Established efficacy 3 Adjust dosing interval for CrCl 50 ml/min Substrate of CYP2D6, CYP1A2, CYP2C19, and P-gp Caution with renal or hepatic impairment Low concentrations in breast milk. 8 Risk of fatigue slightly higher than newer agents 5 Wide dosing range may lead to more dosage adjustments than other agents 4 20, 40, 80 mg scored tabs $ for 80 mg once daily 10, 20, 40, 60, 80 mg scored tabs; 20 mg/5 ml, 40 mg/5 ml oral solution $5.49 for 40 mg TID (generic tabs) IV formulation available

2 (Clinical Resource #330356: Page 2 of 9) Noncardioselective s, continued Propranolol, extended-release Inderal LA, Inderal XL Once-daily sustainedrelease formulation High lipophilicity Extensive first-pass Inderal LA produces lower blood levels than immediate-release formulation at the same dose. Inderal LA Angina: Start with 80 mg once daily. Usual dose 160 mg once daily. Max dose 320 mg once daily. HTN: Start with 80 mg once daily. Usual dose mg once daily. Max dose 640 mg once daily. Hypertrophic subaortic stenosis: Usual dose mg once daily. Start with 80 mg once daily. Usual dose mg once daily. Inderal XL HTN: Start with 80 mg HS. May increase up to 120 mg HS. Established efficacy 3 Substrate of CYP2D6, CYP1A2, CYP2C19, and P-gp Caution with renal or hepatic impairment Risk of fatigue slightly higher than newer agents 5 Inderal LA 60, 80, 120, 160 mg extended-release caps Inderal XL 80, 120 mg extended-release caps $72.67 for 120 mg once daily ***can t be substituted for Inderal XL*** $ for 120 mg once daily (Inderal XL) Timolol Blocadren (brand discontinued) Low to moderate lipophilicity 4 Moderate first-pass 4 HTN: Start with 10 mg BID. Usual dose of mg/day. Max dose 60 mg/day, divided BID. Post-MI: 10 mg BID Start with 10 mg BID. Can give 20 mg once daily as maintenance dose. Max dose 30 mg/day, divided BID. Some patients may only need 10 mg once daily. Post-MI: Reduces cardiovascular and total mortality, including sudden death, and reduces risk of nonfatal reinfarction (NMS) 5 Established efficacy 2 Substrate of CYP2D6 4 Caution with renal or hepatic impairment. Risk of fatigue slightly higher than newer agents 5 5 mg tabs; 10, 20 mg scored tabs $ (average wholesale price) for 20 mg BID

3 (Clinical Resource #330356: Page 3 of 9) Cardioselective s (beta-1 antagonist activity only) Selectivity is not absolute and is lost with higher doses. Atenolol Tenormin Bioavailability about 50% Renal elimination Betaxolol Kerlone (brand discontinued) Low first-pass hepatic elimination Bioavailability about 90% Mostly hepatic elimination Bisoprolol Zebeta Low first-pass Bioavailability 80% 50% renal elimination Angina: Start with 50 mg once daily. May increase to 100 mg once daily. Max dose 200 mg once daily. HTN: Start with 50 mg once daily. May be increased to 100 mg once daily. Post-MI: 50 mg BID or 100 mg once daily HTN: Start 10 mg once daily. May increase to 20 mg once daily. Max dose 40 mg once daily. HTN: Start 5 mg once daily. Increase to 10 mg, then 20 mg once daily if needed. A fib: For rate control. Usual maintenance dose mg once daily. 1 HTN: Losartan had fewer strokes and greater regression of LVH than atenolol in LIFE study. 9 Amlodipine +/ perindopril had lower mortality and stroke than atenolol +/ bendroflumethiazide in ASCOT. 10 Probably effective. 2 Usual dose 100 mg once daily. 3 A Fib: For rate control. Usual maintenance dose mg once daily. 1 HF: Reduces mortality (CIBIS-II). Usual starting dose is 1.25 mg once daily titrated to target dose of 10 mg once daily. 13 Reduce dose for CrCl 35 ml/min Experts emphasize that atenolol may not reduce CV risk in patients with hypertension. 12 FDA-approved for early use post-mi after IV betablockade. Due to increased risk of cardiogenic shock in COMMIT/CCS-2 trial of IV metoprolol, IV beta-blockade is used selectively. 16 Reduce dose in severe renal impairment Reduce starting dose to 2.5 mg once daily for CrCl <40 ml/min, liver disease, or bronchospastic disease 25, 50 (scored), 100 mg tabs <$1 for 50 mg once daily 10 mg scored tabs, 20 mg tabs $15.32 for 10 mg once daily 5 mg scored tabs, 10 mg tabs $21.38 for 10 mg once daily

4 (Clinical Resource #330356: Page 4 of 9) Cardioselective s, continued Metoprolol tartrate, immediate-release Lopressor Bioavailability about 40%-50% due to first-pass 4 Clinical Benefit in * Comments Availability Regimens b Angina: Start with 50 mg BID. Max dose 400 mg/day. HTN: Start with 100 mg once daily or divided. Max dose 450 mg/day. If effect does not last 24 h with once-daily dosing, divide dose. Post-MI: Start with 50 mg every six hours, decreasing to 25 mg if not tolerated, for 48 hours. Thereafter, dose is 100 mg BID. A fib: For rate control. Usual maintenance dose is mg BID. 1 HF: Greater reduction in mortality with carvedilol than with immediate-release metoprolol tartrate in COMET. 14 Post-MI: Reduces total mortality, sudden death, and reinfarction (Goteborg). 15 Established efficacy. 2 Usual dose mg/day. 2 Substrate of CYP2D6 Half-life prolonged in hepatic impairment FDA-approved for early use post-mi after IV betablockade. Due to increased risk of cardiogenic shock in COMMIT/CCS-2 trial of IV metoprolol, IV beta-blockade is used selectively , 100 mg scored tabs $2.36 for 100 mg BID IV formulation available Metoprolol succinate, extended-release Toprol-XL Sustained-release formulation that maintains therapeutic plasma concentrations for 24 hours Bioavailability about 40%-50% due to first-pass 4 Angina: Start with 100 mg once daily. Max dose 400 mg/day. HF: Start with 25 mg once daily for Class II HF, or 12.5 mg once daily for more severe HF. Target dose is highest dose tolerated. Max dose 200 mg/day. HTN: Start with mg once daily. Max dose 400 mg/day. A fib: For rate control. Usual maintenance dose is mg once daily. 1 HF: Reduces mortality and cardiovascular hospitalization (MERIT-HF). Reduce starting dose in hepatic impairment 25, 50, 100, 200 mg scored extended-release tabs $45.30 for 200 mg once daily

5 (Clinical Resource #330356: Page 5 of 9) Cardioselective s, continued Nebivolol Bystolic Bioavailability not determined Clinical Benefit in * Comments Availability Regimens b HTN: Start with 5 mg once daily. Max dose 40 mg/day. HF: Reduced composite endpoint of mortality and cardiovascular hospitalizations in the elderly (SENIORS) 11 Start with 1.25 mg once daily, titrated to target dose of 10 mg once daily. 11 Possibly effective. 2 Dose is 5 mg once daily. 3 Substrate of CYP2D6 Starting with 2.5 mg once daily for CrCl <30 ml/min or moderate hepatic impairment. Contraindicated in severe liver impairment. Causes peripheral vasodilation by increasing nitric oxide production 4 2.5, 5, 10, 20 mg tabs $ for 5 mg once daily s with alpha-1 antagonist activity These agents cause peripheral vasodilation 4 Carvedilol, immediate-release Coreg Not cardioselective 4 Bioavailability 25% to 35% due to first-pass HF: Start with mg BID, titrated to target dose of 25 mg BID (can use 50 mg BID for patients over 85 kg with mildmoderate HF). Reduce dose if HR <55. HTN: Start with 6.25 mg BID. Max dose 25 mg BID. LVD after MI: Start with 6.25 mg BID, titrated to target dose of 25 mg BID. A Fib: For rate control. Usual maintenance dose mg BID. 1 HF: Reduces mortality in NYHA stage 2-4; has the strongest evidence for benefit in severe failure (COPERNICUS). Greater reduction in mortality than with immediate-release metoprolol tartrate in COMET. 14 Substrate of CYP2D6 Contraindicated in severe hepatic impairment 3.125, 6.25,12.5, 25 mg tabs $3.51 for 12.5 mg BID Post-MI with LVD: Reduces mortality and reinfarction in patients taking an ACEI (CAPRICORN)

6 (Clinical Resource #330356: Page 6 of 9) s with alpha-1 antagonist activity, continued Carvedilol phosphate, extended-release Coreg CR Sustained-release formulation that maintains therapeutic plasma concentrations for 24 hours Not cardioselective 4 Bioavailability 25% to 35% due to first-pass HF: Start with 10 mg once daily, titrated to a target dose of 80 mg once daily (equal to 25 mg BID immediate-release product). Reduce dose if HR <55. HTN: Start 20 mg once daily. Max dose 80 mg once daily. LVD after MI: Start with mg once daily. Max dose 80 mg once daily. None Should not be used in patients with severe hepatic impairment. When switching from carvedilol immediate-release 12.5 mg BID or 25 mg BID, consider a starting dose of Coreg CR 20 mg or 40 mg once daily, respectively, especially in patients at increased risk of hypotension, dizziness, or syncope (e.g., the elderly). 10, 20, 40, 80 mg extended-release caps $ for 40 mg QD Labetalol Trandate Not cardioselective 4 Bioavailability 20% to 40% due to first-pass metabolism. Bioavailability may be increased by food. 4 4 HTN: Start with 100 mg BID. Usual dose mg BID. Max dose 2,400 mg/day. If nausea and/or dizziness occur, consider TID dosing. Wide dosing range may lead to more dosage adjustments than other agents Caution with hepatic impairment Rare hepatic injury A preferred antihypertensive in pregnancy. Low concentrations in breast milk. 100, 200, 300 mg scored tabs $26.67 for 200 mg BID IV formulation available for hypertensive emergencies

7 (Clinical Resource #330356: Page 7 of 9) s with intrinsic sympathomimetic activity (ISA) Decrease in resting heart rate and negative inotropic activity may be less than with other beta-blockers. 4 Acebutolol Sectral possibly ineffective; avoid. 2 Cardioselective Mild ISA Bioavailability 40% due to first-pass metabolism to active metabolite which is excreted in urine HTN: Start with 400 mg/day once daily or divided BID. Usual dose mg/day. Max dose 600 mg BID. Ventricular arrhythmias: Start with 200 mg BID. Max dose mg BID. Reduce dose for CrCl <50 ml/min. s without ISA are preferred for hypertension in patients with angina , 400 mg caps $14.46 for 200 mg BID Penbutolol Levatol Not cardioselective 4 High lipophilicity 4 Hepatic metabolites excreted in urine Pindolol Visken (brand no longer available) Not cardioselective HTN: Start with 20 mg once daily. Benefit of increasing dose to 40 or 80 mg/day not demonstrated. HTN: Start with 5 mg BID. Max dose 60 mg/day. None Possibly effective mg scored tabs $ for 20 mg once daily 5, 10 mg scored tabs $71.91 for 10 mg BID Abbreviations: ACEI = angiotensin converting-enzyme inhibitor; ACS = acute coronary syndrome; A fib = atrial fibrillation; BID = twice daily; CrCl = creatinine clearance; CV = cardiovascular; CYP = cytochrome P450; HF = heart failure; HR = heart rate; HS = at bedtime; HTN = hypertension; ISA = intrinsic sympathomimetic activity; LVD = left ventricular dysfunction; LVH = left ventricular hypertrophy; MI = myocardial infarction; NYHA = New York Heart Association; P-gp = P-glycoprotein; QID = four times daily; TID = three times daily. a. Cost is wholesale acquisition cost (WAC) unless otherwise noted. b. Consider reducing starting doses in elderly patients. 11

8 (Clinical Resource #330356: Page 8 of 9) * Clinical Trial Acronyms: ASCOT = Anglo-Scandinavian Cardiac Outcomes Trial, BHAT = Beta-Blocker Heart Attack Trial, CAPRICORN = Carvedilol Post Infarction Survival Control in Left Ventricular Dysfunction, CIBIS-II = Cardiac Insufficiency Bisoprolol Study II, COMET = Carvedilol or Metoprolol European Trial, COMMIT/CCS-2 = Clopidogrel and Metoprolol in Myocardial Infarction Trial Second Chinese Cardiac Study, COPERNICUS = Carvedilol Prospective Randomized Cumulative Survival, LIFE = Losartan Intervention For Endpoint Reduction in Hypertension, MERIT-HF = Metoprolol CR/XL Randomized Intervention Trial in Congestive Heart Failure, NMS = Norwegian Multicenter Study, SENIORS = Study of the Effects of Nebivolol Intervention on Outcomes and Rehospitalisation in Seniors with Heart Failure. ** Sotalol (Betapace) excluded from chart because of restrictions for use and the fact that it is not considered a typical beta-blocker. Esmolol (Brevibloc) is not included, as it is available only as an IV formulation. U.S. product labeling used for the above chart (unless otherwise noted): Corgard (July 2013); propranolol immediate-release (Impax, May 2016); Inderal LA (June 2012); Inderal XL (November 2013), timolol (Mylan, August 2006); Tenormin (December 2014); betaxolol (Marlex, July 2016); Zebeta (October 2015); Lopressor (August 2015); Toprol-XL (June 2016); Bystolic (January 2014); Coreg (October 2015); Coreg CR (October 2015); Trandate (November 2010); Sectral (April 2008); Levatol (May 2011); pindolol (Mylan, November 2016). Users of this resource are cautioned to use their own professional judgment and consult any other necessary or appropriate sources prior to making clinical judgments based on the content of this document. Our editors have researched the information with input from experts, government agencies, and national organizations. Information and internet links in this article were current as of the date of publication.

9 (Clinical Resource #330356: Page 9 of 9) Project Leader in preparation of this clinical resource (330356): Melanie Cupp, Pharm.D., BCPS References 1. January CT, Wann LS, Alpert JS, et al AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. Circulation 2014;130:e Silberstein SD, Holland S, Freitag F, et al. Evidencebased guideline update: pharmacologic treatment for episodic migraine prevention in adults: report of the Quality Standards Subcommittee of the American Academy of Neurology and the American Headache Society. Neurology 2012;78: Clinical Pharmacology [database online]. Tampa, FL: Gold Standard, Inc.; (Accessed January 23, 2017). 4. Westfall TC, Westfall DP. Adrenergic agonists and antagonists. In: Chabner BA, Brunton LL, Knollmann BC, Eds. Goodman & Gilman s The Pharmacological Basis of Therapeutics. 12th ed. New York: McGraw-Hill; Ko DT, Hebert PR, Coffey CS, et al. Beta-blocker therapy and symptoms of depression, fatigue, and sexual dysfunction. JAMA 2002;288: Cefalu WT, Bakris G, Blonde L, et al. American Diabetes Association standards of medical care in diabetes Diabetes Care 2016;40:S Fleisher LA, Fleischmann KE, Auerbach AD, et al ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2014;64:e American College of Obstetricians and Gynecologists. Task Force on Hypertension in Pregnancy And-Publications/Task-Force-and-Work-Group- Reports/Hypertension-in-Pregnancy. (Accessed January 28, 2017). 9. Dahlof B, Devereux RB, Kjeldsen SE, et al. Cardiovascular morbidity and mortality in the Losartan Intervention For Endpoint reduction in hypertension study (LIFE): a randomised trial against atenolol. Lancet 2002;359: Ostergren J, Poulter NR, Sever PS, et al. The Anglo-Scandinavian Cardiac Outcomes Trial: blood pressure-lowering limb: effects in patients with type II diabetes. J Hypertens 2008;26: Flather MD, Shibata MC, Coats AJ, et al. Randomized trial to determine the effect of nebivolol on mortality and cardiovascular hospital admission in elderly patients with heart failure (SENIORS). Eur Heart J 2005;26: Karagiannis A, Athyros VG, Papageorgiou A, et al. Should atenolol still be recommended as first-line therapy for primary hypertension? Hellenic J Cardiol 2006;47: [No authors listed]. The Cardiac Insufficiency Bisoprolol Study II (CIBIS-II): a randomised trial. Lancet 1999;353: Poole-Wilson PA, Swedberg K, Cleland JG, et al. Comparison of carvedilol and metoprolol on clinical outcomes in patients with chronic heart failure in the Carvedilol OR Metoprolol European Trial (COMET): randomised controlled trial. Lancet 2003;362: Hjalmarson A, Herlitz J, Holmberg S, et al. The Goteborg metoprolol trial. Effects on mortality and morbidity in acute myocardial infarction. Circulation 1983;67(6 Pt 2):i Rosendorff C, Lackland DT, Allison M, et al. Treatment of hypertension in patients with coronary artery disease: a scientific statement from the American Heart Association, American College of Cardiology, and American Society of Hypertension. J Am Soc Hypertens 2015;9: Cite this document as follows: Clinical Resource, Comparison of Oral Beta-Blockers. Pharmacist s Letter/Prescriber s Letter. March Evidence and Recommendations You Can Trust 3120 West March Lane, Stockton, CA ~ TEL (209) ~ FAX (209) Copyright 2017 by Therapeutic Research Center Subscribers to the Letter can get clinical resources, like this one, on any topic covered in any issue by going to PharmacistsLetter.com, PrescribersLetter.com, PharmacyTechniciansLetter.com, or NursesLetter.com