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Medication Safety Issues
Sound-alike/look-alike issues:
Atenolol may be confused with albuterol, Altenol®, timolol, Tylenol®
Tenormin® may be confused with Imuran®, Norpramin®, thiamine, Trovan®
International issues:
Betanol® [Bangladesh] may be confused with Patanol® which is a brand name for olopatadine in the U.S.
Pronunciation
(a TEN oh lole)
U.S. Brand Names
Generic Available
Yes: Tablet
Canadian Brand Names
Pharmacologic Category
Pharmacologic Category Synonyms
Use
Treatment of hypertension, alone or in combination with other agents; management of angina pectoris, postmyocardial infarction patients
Use: Unlabeled/Investigational
Acute ethanol withdrawal, supraventricular and ventricular arrhythmias, and migraine headache prophylaxis
Pregnancy Risk Factor
D
Pregnancy Implications
Atenolol crosses the placenta; beta-blockers have been associated with persistent bradycardia, hypotension, and IUGR; IUGR is probably related to maternal hypertension. Available evidence suggests beta-blockers are generally safe during pregnancy (JNC 7). Cases of neonatal hypoglycemia have been reported following maternal use of beta-blockers at parturition or during breast-feeding. Monitor breast-fed infant for symptoms of beta-blockade.
Lactation
Enters breast milk/use caution
Breast-Feeding Considerations
Symptoms of beta-blockade including cyanosis, hypothermia, and bradycardia have been reported in nursing infants.
Contraindications
Hypersensitivity to atenolol or any component of the formulation; sinus bradycardia; sinus node dysfunction; heart block greater than first-degree (except in patients with a functioning artificial pacemaker); cardiogenic shock; uncompensated cardiac failure; pulmonary edema; pregnancy
Warnings/Precautions
Concerns related to adverse events:
• Anaphylactic reactions: Use caution with history of severe anaphylaxis to allergens; patients taking beta-blockers may become more sensitive to repeated challenges. Treatment of anaphylaxis (eg, epinephrine) in patients taking beta-blockers may be ineffective or promote undesirable effects.
Disease-related concerns:
• Bronchospastic disease: In general, patients with bronchospastic disease should not receive beta-blockers; however, atenolol, with B1 selectivity, has been used cautiously with close monitoring.
• Conduction abnormality: Consider pre-existing conditions such as sick sinus syndrome before initiating.
• Diabetes: Use with caution in patients with diabetes mellitus; may potentiate hypoglycemia and/or mask signs and symptoms.
• Heart failure (HF): Use with caution in patients with compensated heart failure and monitor for a worsening of the condition (efficacy of atenolol in HF has not been demonstrated).
• Myasthenia gravis: Use with caution in patients with myasthenia gravis.
• Peripheral vascular disease (PVD): Use with caution in patients with PVD (including Raynaud's).
• Pheochromocytoma (untreated): Adequate alpha-blockade is required prior to use of any beta-blocker.
• Psychiatric disease: Use with caution in patients with a history of psychiatric illness; may cause or exacerbate CNS depression.
• Renal impairment: Use with caution in patients with renal impairment; dosage adjustment required.
Concurrent drug therapy issues:
• Anesthetic agents: Use with caution in patients receiving anesthetic agents which decrease myocardial function.
• Calcium channel blockers: Use with caution in patients on concurrent verapamil or diltiazem; bradycardia or heart block can occur. Avoid concurrent I.V. use of both agents.
Special populations:
• Pediatrics: Safety and efficacy have not been established in children.
Other warnings/precautions:
• Abrupt withdrawal: Beta-blocker therapy should not be withdrawn abruptly (particularly in patients with CAD), but gradually tapered to avoid acute tachycardia, hypertension, and/or ischemia.
Adverse Reactions
1% to 10%:
Cardiovascular: Persistent bradycardia, hypotension, chest pain, edema, heart failure, second- or third-degree AV block, Raynaud's phenomenon
Central nervous system: Dizziness, fatigue, insomnia, lethargy, confusion, mental impairment, depression, headache, nightmares
Gastrointestinal: Constipation, diarrhea, nausea
Genitourinary: Impotence
Miscellaneous: Cold extremities
<1% (Limited to important or life-threatening): Alopecia, dyspnea (especially with large doses), hallucinations, impotence, liver enzymes increased, lupus syndrome, Peyronie's disease, positive ANA, psoriasiform rash, psychosis, thrombocytopenia, wheezing
Drug Interactions
Alpha-blockers (prazosin, terazosin): Concurrent use of beta-blockers may increase risk of orthostasis.
Ampicillin, in single doses of 1 gram, decreases atenolol's pharmacologic actions.
Anilidopiperidine opioids (eg, fentanyl): May enhance the bradycardic and hypotensive effects of beta-blockers.
Antacids (magnesium-aluminum, calcium antacids or salts) may reduce the bioavailability of atenolol.
Clonidine: Hypertensive crisis after or during withdrawal of either agent.
Drugs which slow AV conduction (digoxin): Effects may be additive with beta-blockers.
Glucagon: Atenolol may blunt the hyperglycemic action of glucagon.
Insulin and oral hypoglycemics: Atenolol masks the tachycardia that usually accompanies hypoglycemia.
NSAIDs (ibuprofen, indomethacin, naproxen, piroxicam) may reduce the antihypertensive effects of beta-blockers.
Salicylates may reduce the antihypertensive effects of beta-blockers.
Sulfonylureas: Beta-blockers may alter response to hypoglycemic agents.
Verapamil or diltiazem may have synergistic or additive pharmacological effects when taken concurrently with beta-blockers.
Ethanol/Nutrition/Herb Interactions
Food: Atenolol serum concentrations may be decreased if taken with food.
Herb/Nutraceutical: Avoid dong quai if using for hypertension (has estrogenic activity). Avoid ephedra, yohimbe, ginseng (may worsen hypertension). Avoid garlic (may have increased antihypertensive effect).
Storage
Protect from light.
Compatibility
Stable in D5W, NS.
Y-site administration: Compatible: Meperidine, meropenem, morphine. Incompatible: Amphotericin B cholesteryl sulfate complex.
Mechanism of Action
Competitively blocks response to beta-adrenergic stimulation, selectively blocks beta1-receptors with little or no effect on beta2-receptors except at high doses
Pharmacodynamics/Kinetics
Onset of action: Peak effect: Oral: 2-4 hours
Duration: Normal renal function: 12-24 hours
Absorption: Incomplete
Distribution: Low lipophilicity; does not cross blood-brain barrier
Protein binding: 3% to 15%
Metabolism: Limited hepatic
Half-life elimination: Beta:
Neonates: ?35 hours; Mean: 16 hours
Children: 4.6 hours; children >10 years may have longer half-life (>5 hours) compared to children 5-10 years (<5 hours)
Adults: Normal renal function: 6-9 hours, prolonged with renal impairment; End-stage renal disease: 15-35 hours
Excretion: Feces (50%); urine (40% as unchanged drug)
Dosage
Oral:
Children: Hypertension: 0.5-1 mg/kg/dose given daily; range of 0.5-1.5 mg/kg/day; maximum dose: 2 mg/kg/day up to 100 mg/day
Adults:
Hypertension: 25-50 mg once daily, may increase to 100 mg/day. Doses >100 mg are unlikely to produce any further benefit.
Angina pectoris: 50 mg once daily, may increase to 100 mg/day. Some patients may require 200 mg/day.
Postmyocardial infarction: Follow I.V. dose with 100 mg/day or 50 mg twice daily for 6-9 days postmyocardial infarction.
I.V.:
Hypertension: Dosages of 1.25-5 mg every 6-12 hours have been used in short-term management of patients unable to take oral enteral beta-blockers
Postmyocardial infarction: Early treatment: 5 mg slow I.V. over 5 minutes; may repeat in 10 minutes. If both doses are tolerated, may start oral atenolol 50 mg every 12 hours or 100 mg/day for 6-9 days postmyocardial infarction.
Dosing interval for oral atenolol in renal impairment:
Clcr 15-35 mL/minute: Administer 50 mg/day maximum.
Clcr <15 mL/minute: Administer 50 mg every other day maximum.
Hemodialysis: Moderately dialyzable (20% to 50%) via hemodialysis; administer dose postdialysis or administer 25-50 mg supplemental dose.
Peritoneal dialysis: Elimination is not enhanced; supplemental dose is not necessary.
Administration: I.V.
When administered acutely for cardiac treatment, monitor ECG and blood pressure. The injection can be administered undiluted or diluted with a compatible I.V. solution. May administer by rapid infusion (I.V. push) at a rate of 1 mg/minute or by slow infusion over ?30 minutes. Necessary monitoring for surgical patients who are unable to take oral beta-blockers (prolonged ileus) has not been defined. Some institutions require monitoring of baseline and postinfusion heart rate and blood pressure when a patient's response to beta-blockade has not been characterized (ie, the patient's initial dose or following a change in dose). Consult individual institutional policies and procedures.
Administration: I.V. Detail
pH: 5.5-6.5
Monitoring Parameters
Acute cardiac treatment: Monitor ECG and blood pressure with I.V. administration; heart rate and blood pressure with oral administration
Test Interactions
Increased glucose; decreased HDL
Dietary Considerations
May be taken without regard to meals.
Patient Education
Do not take any new medication during therapy unless approved by prescriber. Take exactly as directed; with or without regard to meals; do not take with antacids. Do not adjust dosage or discontinue medication without consulting prescriber. Take pulse daily (prior to medication) and follow prescriber's instruction about holding medication. If you have diabetes, monitor serum sugar closely (drug may alter glucose tolerance or mask signs of hypoglycemia). May cause fatigue, dizziness, or postural hypotension (use caution when changing position from lying or sitting to standing, when driving, or climbing stairs until response to medication is known). Alteration in sexual performance (reversible); or constipation (increased dietary bulk and fluids and exercise may help). Report unresolved swelling of extremities, respiratory difficulty or new cough, unresolved fatigue, unusual weight gain, unresolved constipation, or unusual muscle weakness. Pregnancy/breast-feeding precautions: Do not get pregnant or cause a pregnancy (males) while using this medication. Consult prescriber for appropriate contraceptive measures. Consult prescriber if breast-feeding.
Geriatric Considerations
Due to alterations in the beta-adrenergic autonomic nervous system, beta-adrenergic blockade may result in less hemodynamic response than seen in younger adults. Studies indicate that despite decreased sensitivity to the chronotropic effects of beta-blockade with age, there appears to be an increased myocardial sensitivity to the negative inotropic effect during stress (ie, exercise). Controlled trials have shown the overall response rate for propranolol to be only 20% to 50% in the elderly. Therefore, all beta-adrenergic blocking drugs may result in a decreased response as compared to younger adults. Since many elderly have Clcr <35 mL/minute, creatinine clearance should be estimated or measured such that appropriate dose adjustment can be made.
Anesthesia and Critical Care Concerns/Other Considerations
Atenolol may mask signs and symptoms of hypoglycemia; may potentiate hypoglycemia in a patient with diabetes.
Surgery: The ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery recommend beta-blockers be continued in patients undergoing surgery who are receiving beta-blockers to treat angina, symptomatic arrhythmias, hypertension, or other ACC/AHA Class I guideline indications (Class I recommendation). The guidelines also recommend that beta-blockers be given to patients undergoing vascular surgery who have myocardial ischemia demonstrated during preoperative testing (Class I recommendation). More recent clinical trials have not shown a benefit to perioperative beta-blockade for noncardiac surgery (Yang, 2006 and Juul, 2006); however, the majority of previously published trials suggest a benefit.
Based on available evidence, beta-blockers should be started days to weeks before elective surgery when possible and titrated to a heart rate <65 beats per minute. Additional data suggest that long-acting beta-blockers may be superior to short-acting ones.
Cardiovascular Considerations
Atrial Fibrillation: Beta-blocker therapy provides effective rate control in patients with atrial fibrillation.
Chronic Stable Angina: Beta-blockers are effective in the treatment of chronic stable angina as monotherapy or when combined with nitrates and/or calcium channel blockers. In patients with severe intractable angina requiring negative cardiac chronotropic medications, pacemaker placement has been carried out to maintain heart rate in the setting of large doses of beta-blockers and/or calcium channel blockers. Beta-blockers are ineffective in the treatment of pure vasospastic (Prinzmetal) angina.
Hypertension: Beta-blocker therapy in the treatment of hypertension has been associated with improved cardiovascular outcomes. According to the 2003 JNC-VII guidelines for the treatment of hypertension, most patients with hypertension will require treatment with at least 2 antihypertensives. First-line therapy for hypertension is a diuretic (eg, hydrochlorothiazide or chlorthalidone). When a diuretic cannot be used or when a compelling indication exists for another drug, other types of antihypertensives may be used (eg, ACEIs, ARBs, beta-blockers, CCBs). Beta-blockers are among the multiple choices of agents that have shown benefit in a number of different patient subtypes. Compelling indications for a beta-blocker include patients with heart failure, postmyocardial infarction, high coronary disease risk, or diabetes. In type 2 diabetic patients, a UK Prospective Diabetes Study Group (UKPDS) trial showed that beta-blocker therapy (atenolol) was as effective as an ACE inhibitor in reducing cardiovascular events and that the benefits of therapy were related more to the degree of antihypertensive efficacy rather than the class of drug used.
Treatment should be targeted to a goal blood pressure of <140/90 mm Hg. If diabetes or renal disease coexists, the blood pressure goal should be <130/80 mm Hg.
ST-Segment Elevation Myocardial Infarction (STEMI): Beta-blockers, without intrinsic sympathomimetic activity (ISA), have been shown to decrease morbidity and mortality when initiated in the acute treatment of STEMI and continued long-term. Oral beta-blockade should be initiated promptly in patients without contraindications (eg, signs of heart failure, evidence of a low output state, risk of cardiogenic shock, or other beta-blocker contraindications) (Class I recommendation). Use of intravenous beta-blockade may be considered and given promptly if the patient is experiencing concomitant hypertension or a tachyarrhythmia (Class IIa recommendation).
Unstable Angina/Non-ST-Segment Elevation MI (UA/NSTEMI): In the treatment of UA/NSTEMI, oral beta-blockade should be initiated within the first 24 hours in patients without contraindications (eg, signs of heart failure, evidence of a low output state, risk of cardiogenic shock, or other beta-blocker contraindications) (Class I recommendation). Use of intravenous beta-blockade should only be considered if the patient is experiencing concomitant hypertension upon presentation (Class IIa recommendation).
Withdrawal: Beta-blocker therapy should not be withdrawn abruptly, but gradually tapered to avoid acute tachycardia and hypertension.
Dental Health: Effects on Dental Treatment
Atenolol is a cardioselective beta-blocker. Local anesthetic with vasoconstrictor can be safely used in patients medicated with atenolol. Nonselective beta-blockers (ie, propranolol, nadolol) enhance the pressor response to epinephrine, resulting in hypertension and bradycardia; this has not been reported for atenolol. Many nonsteroidal anti-inflammatory drugs, such as ibuprofen and indomethacin, can reduce the hypotensive effect of beta-blockers after 3 or more weeks of therapy with the NSAID. Short-term NSAID use (ie, 3 days) requires no special precautions in patients taking beta-blockers.
Dental Health: Vasoconstrictor/Local Anesthetic Precautions
No information available to require special precautions
Mental Health: Effects on Mental Status
May cause fatigue, insomnia, and confusion which can clinically look like depression
Mental Health: Effects on Psychiatric Treatment
Concurrent use with other psychotropics may produce an additive hypotensive response (especially low-potency antipsychotics and TCAs)
Nursing: Physical Assessment/Monitoring
Assess potential for interactions with other prescriptions, OTC medications, or herbal products patient may be taking. I.V.: Requires cardiac and hemodynamic monitoring and hypotensive precautions. Oral: Assess blood pressure and heart rate prior to and following first dose and any change in dosage. Assess therapeutic effectiveness and adverse effects (eg, CHF, edema, new cough, dyspnea, unresolved fatigue). Advise patients with diabetes to monitor glucose levels closely (beta-blockers may alter glucose tolerance). Do not discontinue abruptly; taper dose gradually. Teach patient appropriate use, possible side effects/interventions (hypotension precautions), and adverse symptoms to report.
Dosage Forms
Excipient information presented when available (limited, particularly for generics); consult specific product labeling. [DSC] = Discontinued product
Injection, solution:
Tenormin®: 0.5 mg/mL (10 mL) [DSC]
Tablet: 25 mg, 50 mg, 100 mg
Tenormin®: 25 mg, 50 mg, 100 mg
Pricing: U.S. (www.drugstore.com)
Tablets (Atenolol)
25 mg (90): $11.99
50 mg (90): $17.99
100 mg (90): $15.89
Tablets (Tenormin)
25 mg (30): $55.99
50 mg (30): $55.99
100 mg (30): $75.99
Extemporaneously Prepared
A 2 mg/mL atenolol oral liquid compounded from tablets and a commercially available oral diluent was found to be stable for up to 40 days when stored at 5°C or 25°C.
Garner SS, Wiest DB, and Reynolds ER, “Stability of Atenolol in an Extemporaneously Compounded Oral Liquid,” Am J Hosp Pharm, 1994, 51(4):508-11.
References
American Academy of Pediatrics Committee on Drugs, “The Transfer of Drugs and Other Chemicals Into Human Milk,” Pediatrics, 2001, 108(3):776-89.
Anderson JL, Adams CD, Antman EM, et al, "ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction) Developed in Collaboration With the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons Endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine," J Am Coll Cardiol, 2007, 50(7):e1-e157.
Antman EM, Anbe DT, Armstrong PW, et al, "ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1999 Guidelines for the Management of Patients with Acute Myocardial Infarction)," Circulation, 2004, 110(9):e82-292.
Chobanian AV, Bakris GL, Black HR, et al, “The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: The JNC 7 Report,” JAMA, 2003, 289(19):2560-71.
“Consensus Recommendations for the Management of Chronic Heart Failure. On Behalf of the Membership of the Advisory Council to Improve Outcomes Nationwide in Heart Failure,” Am J Cardiol, 1999, 83(2A):1A-38A.
Fleisher LA, Beckman JA, Brown KA, et al, “ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery) Developed in Collaboration With the American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, and Society for Vascular Surgery,” J Am Coll Cardiol, 2007, 50(17):e159-241.
Gibbons RJ, Abrams J, Chatterjee K, et al, “ACC/AHA 2002 Guideline Update for the Management of Patients With Chronic Stable Angina - Summary Article: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on the Management of Patients With Chronic Stable Angina),” J Am Coll Cardiol, 2003, 41(1):159-68.
Hirsch AT, Haskal ZJ, Hertzer NR, et al, “ACC/AHA Guidelines for the Management of Patients With Peripheral Arterial Disease (Lower Extremity, Renal, Mesenteric, and Abdominal Aortic): Executive Summary. A Collaborative Report of the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease),” Circulation , 2006, 113(11):1474-1547. Available at: http://www.acc.org/clinical/guidelines/pad/index.pdf. Last accessed: May 23, 2006.
Juul AB, Wetterslev J, Gluud C, et al, “Effect of Perioperative Beta Blockade in Patients With Diabetes Undergoing Major Non-Cardiac Surgery: Randomized Placebo Controlled, Blinded Multicentre Trial. DIPOM Trial Group,” BMJ, 2006, 332(7556):1482.
Lang DM, “Anaphylactoid and Anaphylactic Reactions. Hazards of Beta-Blockers,” Drug Saf, 1995, 12(5):299-304.
Lindenauer PK, Pekow P, Wang K, et al, "Perioperative Beta-Blocker Therapy and Mortality After Major Noncardiac Surgery," N Engl J Med, 2005, 353(4):349-61.
Mangano DT, Layug EL, Wallace A, et al, “Effect of Atenolol on Mortality and Cardiovascular Morbidity After Noncardiac Surgery. Multicenter Study of Perioperative Ischemia Research Group,” N Engl J Med, 1996, 335(23):1713-20.
Mokhlesi B, Leikin JB, Murray P, et al, “Adult Toxicology in Critical Care: Part II: Specific Poisonings,” Chest, 2003, 123(3):897-922.
National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents, “The Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents,” Pediatrics, 2004, 114 (2 Suppl):555-76.
Radack K and Deck C, “Beta-Adrenergic Blocker Therapy Does Not Worsen Intermittent Claudication in Subjects With Peripheral Arterial Disease. A Meta-Analysis of Randomized Controlled Trials,” Arch Intern Med, 1991, 151(9):1769-76.
UK Prospective Diabetes Study Group, “Efficacy of Atenolol and Captopril in Reducing Risk of Macrovascular and Microvascular Complications in Type 2 Diabetes: UKPDS 39,” BMJ, 1998, 317(7160):713-20.
Yang H, Raymer K, Butler R, et al, “The Effects of Perioperative Beta-Blockade: Results of the Metoprolol After Vascular Surgery (MaVS) Study, a Randomized Controlled Trial,” Am Hear J, 2006, 152(5):983-90.
International Brand Names
Lexi-Comp.com
Last full review/revision May 2008
Content last modified May 2008
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