NHS Dudley Health Economy Medicines Formulary
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2.4 Beta-adrenoceptor blocking drugs

General guidance

For Dudley Hypertension Pathway click here  or the Dudley Hypertension Clinic Reference Guide. 

  • Many beta-blockers are now available and in general they are all equally effective. There are, however, differences between them, which may affect choice in treating particular disease or individual patients.
  • Beta-blockers (systemically and in eye drop forms) may precipitate asthma and this effect can be dangerous. Relatively cardioselective drugs may have a lesser effect on airways resistance but are not free of this side effect. Therefore extreme caution is required even with these drugs.
  • Beta-blockers are not contra-indicated in diabetetes; however they can lead to a small deterioration of glucose tolerance and interfere with metabolic and autonomic responses to hypoglycaemia. Cardioselective drugs may be preferable and beta-blockers should be avoided altogether in those with frequent episodes of hypoglycaemia.
  • Beta-blockers are available in a variety of combined preparations and modified release preparations – such products should be avoided.
  • Atenolol is a suitable first line agent. Bisoprolol appears to be more cardioselective than atenolol and may be a useful alternative agent in those experiencing adverse effects to atenolol. In low doses bisoprolol reduces mortality in heart failure (careful initiation required). Nebivolol appears to be more cardioselective than either atenolol or bisoprolol and has vasodilating properties, it is therefore a useful third line agent.
  • Hypertension: beta-blockers are effective antihypertensives. In general the dose of the beta-blocker does not have to be high; for example atenolol should be given in a dose of 50mg daily and it is not necessary to increase the dose to 100mg.
  • Angina: beta-blockers are effective at reducing the symptoms of angina and alter mortality. There is no good evidence of the superiority of any one drug, although occasionally a patient may respond better to one beta-blocker than to another.
  • Heart failure: in mild to moderate heart failure the judicious use of certain beta-blockers has been shown to reduce mortality. However, bradycardia and worsening heart failure are important risks and therapy should only be initiated at low doses under the supervision of a hospital specialist. It is unclear whether this is a class effect or if the risks and benefits are similar for all drugs therefore only bisoprolol and carvedilol should be used in this way.
  • Anxiety and migraine: beta-blockers are effective therapeutic options in these conditions, often modified release preparations are used. However, these should generally be avoided plain propranolol twice daily in a low dose provides an effective treatment.

Recommended drugs

1st line: Atenolol £

               Propranolol for migraine or anxiety £

2nd line: Bisoprolol ££

3rd line:  Nebivolol £££


Left ventricular dysfunction

1st line:  Bisoprolol ££

2nd line: Carvedilol £


Ischaemic heart disease

Bisoprolol ££


Obstetrics and resistant hypertension

Labetalol £££


Drug Traffic Light Key:

Green – On Formulary

Amber – Restricted use, see local guidelines

Purple – Specialist use/initiation

Red – Non Formulary


Relative Costs Key (where indicated):

£££££ - high

£££ - moderate

£ - low

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