Switch Patients From Atenolol to a Better Beta-Blocker

The recent atenolol shortage will renew debate about which beta-blocker to choose and how to switch.

Think of this as a good thing. Atenolol hasn't been shown to improve outcomes in hypertension, heart failure, or post-MI.

Use this as an opportunity to get patients on a better beta-blocker.

There are nearly 20 beta-blockers...but 4 will work in most cases.

Consider metoprolol succinate and carvedilol your workhorse agents.

Use either for patients with angina, hypertension, or post-MI...and for heart failure with reduced ejection fraction (HFrEF) or "hef-ref."

Choose metoprolol SUCCINATE (Toprol-XL, etc) instead of metoprolol TARTRATE (Lopressor, etc) when possible.

The succinate salt is dosed once-daily, improves outcomes in HFrEF, and costs about $50/month. The tartrate is about $3/month. But it's very short-acting...and this may be why it does NOT improve HFrEF outcomes.

Or consider carvedilol IR BID instead of Coreg CR. The IR works just as well and costs about $5/month versus $275/month for the CR.

Think of labetalol and propranolol as your niche beta-blockers.

Consider labetalol for hypertension in pregnancy. It has a good safety profile...and other beta-blockers may impair fetal growth.

Try propranolol for essential tremor or performance anxiety...or propranolol or metoprolol for migraine prophylaxis.

If patients need to switch from atenolol, consider why they're taking it...since there's no direct dose equivalence among beta-blockers.

For example, switch atenolol 100 mg/day to metoprolol succinate 100 mg/day for hypertension...and titrate if needed.

Be more cautious in heart failure patients. Switch atenolol 100 mg/day to carvedilol 6.25 mg BID or metoprolol succinate 25 mg/day...and titrate to target doses for HFrEF.

Listen to PL Voices to hear our team discuss interesting nuances among beta-blockers. And see our chart, Comparison of Oral Beta-Blockers, to see which agents are preferred for CV indications.

Key References

  • J Am Coll Cardiol 2017;70(6):776-803
  • Lancet 2004;364(9446):1684-9
  • BMJ 1999;318(7200):1730-7
Prescriber's Letter. Oct 2017, No. 331020

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