hyperkalemia in hemodialysis patients. Nephron 2002; 91:222. 37. McCauley J, Murray J, Jordan M, et al. Labetalol-induced hyperkalemia in renal transplant recipients. Am J Nephrol 2002; 22:347. 38. Gheorghiade M, Eichhorn EJ. Practical aspects of using beta-adrenergic blockade in systolic heart failure. Am J Med 2001; 110 Suppl 7A:68S. 39. Ko DT, Hebert PR, Coffey CS, et al. Beta-blocker therapy and symptoms of depression, https://www.uptodate.com/contents/major-side-effects-of-beta-blockers/print 12/19 7/5/23, 8:23 AM Major side effects of beta blockers - UpToDate fatigue, and sexual dysfunction. JAMA 2002; 288:351. 40. Silvestri A, Galetta P, Cerquetani E, et al. Report of erectile dysfunction after therapy with beta-blockers is related to patient knowledge of side effects and is reversed by placebo. Eur Heart J 2003; 24:1928. 41. Sharma AM, Pischon T, Hardt S, et al. Hypothesis: Beta-adrenergic receptor blockers and weight gain: A systematic analysis. Hypertension 2001; 37:250. 42. Leslie WS, Hankey CR, Lean ME. Weight gain as an adverse effect of some commonly prescribed drugs: a systematic review. QJM 2007; 100:395. 43. Stephen SA. Unwanted effects of propranolol. Am J Cardiol 1966; 18:463. 44. Booth RJ, Wilson JD, Bullock JY. Beta-adrenergic-receptor blockers and antinuclear antibodies in hypertension. Clin Pharmacol Ther 1982; 31:555. 45. Self-poisoning with beta-blockers. Br Med J 1978; 1:1010. 46. Frishman W, Jacob H, Eisenberg E, Ribner H. Clinical pharmacology of the new beta- adrenergic blocking drugs. Part 8. Self-poisoning with beta-adrenoceptor blocking agents: recognition and management. Am Heart J 1979; 98:798. Topic 967 Version 30.0 https://www.uptodate.com/contents/major-side-effects-of-beta-blockers/print 13/19 7/5/23, 8:23 AM Major side effects of beta blockers - UpToDate GRAPHICS Beta blocker properties Alpha Beta-1 Half l Drug ISA MSA Lipophilicity Usual dose* blockade selectivity hour Acebutolol No Yes Yes Yes Low 100 to 400 mg 3 to 4 twice per day Atenolol No Yes No No Low 50 to 200 mg once daily 6 to 9 Betaxolol No Yes No Yes Low 10 to 20 mg once daily 14 to 22 Bisoprolol No Yes No No Moderate 2.5 to 20 mg once daily 9 to 12 Carteolol No No Yes No Low 2.5 to 5 mg once daily 6 Carvedilol Yes No No Yes High 3.125 to 25 mg twice per day 7 to 10 Esmolol No Yes No No Low IV only 250 to 500 9 minut micrograms/kg over one minute then 25 to 50 micrograms/kg per minute as IV infusion; titrate incrementally up to maximum of 300 microgram/kg per minute https://www.uptodate.com/contents/major-side-effects-of-beta-blockers/print 14/19 7/5/23, 8:23 AM Major side effects of beta blockers - UpToDate Labetalol Yes No Yes (Beta ) 2 Low Moderate IV 20 mg 3 to 4 Orally 100-400 mg two or three times per day Metoprolol tartrate No Yes No Low Moderate IV 1.25 to 5 mg 3 to 4 (7 to 9 h in poor Orally 25 to 100 mg two metabo times per day Metoprolol succinate No Yes No Low Moderate Orally 50 to 400 mg once Apparen half-life (extended daily prolong release) continu osmotic release ~20 hou Nadolol No No No No Low 40 to 160 mg 20 to 24 once daily Nebivolol No Yes No No High 5 to 40 mg once daily 10 to 12 (19 to 32 poor metabo Oxprenolol No No Yes Yes Moderate 40 to 80 mg three times per day 1.5 Penbutolol No No Yes No High 10 to 40 mg once daily 5 Pindolol No No Yes Low Moderate 5 to 30 mg 3 to 4 twice per day Propranolol No No No Yes High IV 1 to 5 mg 3 to 4 Orally 10 to 80 mg two to four times daily Sotalol No No No No Low 80 to 160 mg 12 twice per day Timolol No No No No Moderate 10 to 30 mg 4 to 5 twice per day https://www.uptodate.com/contents/major-side-effects-of-beta-blockers/print 15/19 7/5/23, 8:23 AM Major side effects of beta blockers - UpToDate ISA: intrinsic sympathomimetic activity; MSA: membrane stabilizing activity; IV: intravenous. Range of usual, oral, anti-hypertensive dose, unless "IV" noted. Duration of hypotensive effect, in general, is longer than may be predicted by serum half-life. Usual initial IV dose. Subsequent dosing generally needed. See drug monograph for detail. Not available in US. Sotalol has independent class III antiarrhythmic activity. Prepared with data from: 1. Frishman WH, Alwarshetty M. -Adrenergic blockers in systemic hypertension pharmacokinetic considerations related to current guidelines. Clin Pharmacokinet 2002; 41:505. 2. Brubacher JR. -Adrenergic Antagonists. In: Goldfrank's Toxicologic Emergencies, 9th ed, Nelson LS (Ed), McGraw-Hill, New York 2010. Graphic 82571 Version 11.0 https://www.uptodate.com/contents/major-side-effects-of-beta-blockers/print 16/19 7/5/23, 8:23 AM Major side effects of beta blockers - UpToDate Major drug interactions with beta blockers Drug Possible effects Precautions Aluminum hydroxide gel Decreased beta-blocker Avoid beta-blocker-aluminum adsorption and therapeutic effect hydroxide combination Aminophylline Mutual inhibition Observe patient's response Amiodarone May induce cardiac arrest Combination should be used with extreme caution Antidiabetic agents Enhanced hypoglycemia; Monitor for altered diabetic response hypertension Calcium channel inhibitors Potentiation of bradycardia, Avoid use, although few patients show (verapamil, diltiazem) myocardial depression, and hypotension ill effects Cimetidine Prolongs half-life of Combination should be used with propranolol caution Clonidine Hypertension during clonidine withdrawal Monitor for hypertensive response; withdraw beta blocker before withdrawing clonidine Digitalis glycosides Potentiation of bradycardia Observe patient's response; interactions may benefit angina patients with abnormal ventricular function Epinephrine Hypertension; bradycardia Administer epinephrine cautiously; cardioselective beta blocker may be safer Ergot alkaloids Excessive vasoconstriction Observe patient's response; few patients show ill effects Glucagon Inhibition of hyperglycemic Monitor for reduced response effect Halofenate Reduced beta-blocking activity; induction of Observe for impaired response to beta blockade propranolol withdrawal rebound Indomethacin Inhibition of antihypertensive Observe patient's response response to beta blockade Isoproterenol Mutual inhibition Avoid concurrent use or choose cardiac-selective beta blocker https://www.uptodate.com/contents/major-side-effects-of-beta-blockers/print 17/19 7/5/23, 8:23 AM Major side effects of beta blockers - UpToDate Levodopa Antagonism of levodopa's hypotensive and positive Monitor for altered response; interaction may have favorable results inotropic effects Lidocaine Propranolol pretreatment increases lidocaine levels with Combination should be used with caution; use lower doses of lidocaine potential toxicity Methyldopa Hypertension during stress Monitor for hypertensive episodes MAO inhibitors Uncertain, theoretical Manufacturer of propranolol considers concurrent use contraindicated Phenothazines Additive hypotensive effects Monitor for altered response, especially with high doses of phenothiazines Phenylpropranolamine Severe hypertensive reaction Phenytoin Additive cardiac depressant effects Administer IV phenytoin with great caution Quinidine Additive cardiac depressant Observe patient's response; few effects patients show ill effects Reserpine Excessive sympathetic Observe patient's response blockade Rifampin Increased metabolism of beta blockers Observe patient's response Smoking Increased metabolism of beta blockers Observe patient's response Tricyclic antidepressants Inhibits negative inotropic and chronotropic effects of beta blockers Observe patient's response Tubocurarine Enhanced neuromuscular blockade Observe response in surgical patients, especially after high doses of propranolol IV: intravenous. Graphic 77171 Version 3.0 https://www.uptodate.com/contents/major-side-effects-of-beta-blockers/print 18/19 7/5/23, 8:23 AM Major side effects of beta blockers - UpToDate Contributor Disclosures Philip J Podrid, MD, FACC No relevant financial relationship(s) with ineligible companies to disclose. Samuel L vy, MD No relevant financial relationship(s) with ineligible companies to disclose. Nisha Parikh, MD, MPH No relevant financial relationship(s) with ineligible companies to disclose. Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by vetting through a multi-level review process, and through requirements for references to be provided to support the content. Appropriately referenced content is required of all authors and must conform to UpToDate standards of evidence. Conflict of interest policy https://www.uptodate.com/contents/major-side-effects-of-beta-blockers/print 19/19