Worst Pills, Best Pills

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Drug Profile

The information on this site is intended to supplement and enhance, not replace, the advice of a physician who is familiar with your medical history. Decisions about your health should always be made ONLY after detailed conversation with your doctor.

Generic drug name: acebutolol (ace ah butte o lole)
Brand name(s):
GENERIC: available FAMILY: Beta Blockers
Find the drug label by searching at DailyMed.

Generic drug name: atenolol (a TEN ah lole)
Brand name(s): TENORMIN
GENERIC: available FAMILY: Beta Blockers
Find the drug label by searching at DailyMed.

Generic drug name: betaxolol - heart (bait AX o lole)
Brand name(s):
GENERIC: available FAMILY: Beta Blockers
Find the drug label by searching at DailyMed.

Generic drug name: bisoprolol (bis OH proe lole)
Brand name(s):
GENERIC: available FAMILY: Beta Blockers
Find the drug label by searching at DailyMed.

Generic drug name: carvedilol (car VEH di lole)
Brand name(s): COREG, COREG CR
GENERIC: available FAMILY: Beta Blockers
Find the drug label by searching at DailyMed.

Generic drug name: labetalol (la BET a lole)
Brand name(s): NORMODYNE, TRANDATE
GENERIC: available FAMILY: Beta Blockers
Find the drug label by searching at DailyMed.

Generic drug name: metoprolol succinate (me toe PROE lole)
Brand name(s): KAPSPARGO SPRINKLE, LOPRESSOR, TOPROL XL
GENERIC: available FAMILY: Beta Blockers
Find the drug label by searching at DailyMed.

Generic drug name: nadolol (nay DOE lole)
Brand name(s): CORGARD
GENERIC: available FAMILY: Beta Blockers
Find the drug label by searching at DailyMed.

Generic drug name: penbutolol (pen BYOO toe lole)
Brand name(s): LEVATOL
GENERIC: available FAMILY: Beta Blockers
Find the drug label by searching at DailyMed.

Generic drug name: pindolol (pin DOE lole)
Brand name(s): VISKEN
GENERIC: available FAMILY: Beta Blockers
Find the drug label by searching at DailyMed.

Generic drug name: propranolol (pro PRAN oh lole)
Brand name(s): HEMANGEOL, INDERAL, INDERAL LA, INDERIDE, INNOPRAN XL
GENERIC: available FAMILY: Beta Blockers
Find the drug label by searching at DailyMed.

Generic drug name: timolol [heart] (TYE mo lole)
Brand name(s): BLOCADREN
GENERIC: available FAMILY: Beta Blockers
Find the drug label by searching at DailyMed.

Limited Use [what does this mean?]
Generic drug name: atenolol and chlorthalidone (a TEN ah lole and klor THALi done)
Brand name(s): TENORETIC
GENERIC: available FAMILIES: Beta Blockers, Thiazide Diuretics
Find the drug label by searching at DailyMed.

Limited Use [what does this mean?]
Generic drug name: bisoprolol and hydrochlorothiazide (bis OH pro lol and hye droe klor oh THYE a zide)
Brand name(s): ZIAC
GENERIC: available FAMILIES: Beta Blockers, Thiazide Diuretics
Find the drug label by searching at DailyMed.

Limited Use [what does this mean?]
Generic drug name: metoprolol and hydrochlorothiazide (me toe PROE lole and hye droe klor oh THYE a zide)
Brand name(s): DUTOPROL, LOPRESSOR HCT
GENERIC: available FAMILIES: Beta Blockers, Thiazide Diuretics
Find the drug label by searching at DailyMed.

Limited Use [what does this mean?]
Generic drug name: propranolol and hydrochlorothiazide (proe PRAN oh lole and hye droe klor oh THYE a zide)
Brand name(s): INDERIDE LA
GENERIC: available FAMILIES: Beta Blockers, Thiazide Diuretics
Find the drug label by searching at DailyMed.

Limited Use [what does this mean?]
Generic drug name: timolol and hydrochlorothiazide (TYE mo lole and hye droe klor oh THYE a zide)
Brand name(s): TIMOLIDE
GENERIC: available FAMILIES: Beta Blockers, Thiazide Diuretics
Find the drug label by searching at DailyMed.

Pregnancy and Breast-feeding Warnings [top]

Pregnancy Warning

These drugs caused death of embryos, decreased fetal body weight, and delayed skeletal development in animal studies. Because of the potential for serious adverse effects to the human fetus, including small size, these drugs should not be used by pregnant women.

Breast-feeding Warning

Because of the potential for serious adverse effects in nursing infants from beta-blockers, especially low blood sugar and slow heart rate, as well as perinatal and neonatal distress, you should not take these drugs while nursing.

Safety Warnings For This Drug [top]

Warning

A fixed-combination drug should not be the first drug used to treat your high blood pressure. You may not need more than one drug. If you do need two drugs, the fixed-combination product may not contain the dose of each drug that is right for you. Your doctor has to regularly check your condition and reevaluate the effect of the drug(s) you take. This may mean adjusting doses, and even changing drugs, to ensure proper treatment. This fixed-combination drug may be the best drug for you, but it should be used only after you have tried each of its ingredients separately, in varying doses. If the doses that you need to control your high blood pressure match those in this fixed-combination product, use it if the combination drug is more convenient.

Heat Stress Alert

These drugs can affect your body’s ability to adjust to heat, putting you at risk of “heat stress.” If you live alone, ask a friend to check on you several times during the day. Early signs of heat stress are dizziness, lightheadedness, faintness, and slightly high temperature. Call your doctor if you have any of these signs. Drink more fluids (water, fruit and vegetable juices) than usual—even if you’re not thirsty—unless your doctor has told you otherwise. Do not drink alcohol.

Certain beta-blocker drugs have a black-box warning like the following:

Cessation of Therapy with Atenolol

Patients with coronary artery disease, who are being treated with atenolol, should be advised against abrupt discontinuation of therapy. Severe exacerbation of angina and the occurrence of myocardial infarction and ventricular arrhythmias have been reported in angina patients following the abrupt discontinuation of therapy with beta-blockers. The last two complications may occur with or without preceding exacerbation of the angina pectoris. As with other beta-blockers, when discontinuation of atenolol tablet, USP, is planned, the patients should be carefully observed and advised to limit physical activity to a minimum. If the angina worsens or acute coronary insufficiency develops, it is recommended that atenolol tablet, USP be promptly reinstituted, at least temporarily. Because coronary artery disease is common and may be unrecognized, it may be prudent not to discontinue atenolol tablet, USP, therapy abruptly even in patients treated only for hypertension.

Facts About This Drug [top]

Beta-blocking drugs are used to treat high blood pressure (hypertension), chest pain (angina), heart attacks, irregular heartbeats (arrhythmias) and tremor of unknown origin. Some beta blockers are also used to decrease the frequency of migraine headaches. If you are over 60, you will generally need to take less than the usual adult dose, especially if your kidney function is impaired.

These drugs can be divided into two groups: those that work primarily by binding to beta receptors in the...

Beta-blocking drugs are used to treat high blood pressure (hypertension), chest pain (angina), heart attacks, irregular heartbeats (arrhythmias) and tremor of unknown origin. Some beta blockers are also used to decrease the frequency of migraine headaches. If you are over 60, you will generally need to take less than the usual adult dose, especially if your kidney function is impaired.

These drugs can be divided into two groups: those that work primarily by binding to beta receptors in the heart (cardioselective beta blockers) and those that act by binding to beta receptors throughout the body, including those in the lung (non-cardioselective). The cardioselective beta blockers include acebutolol (generic only), atenolol (TENORMIN), betaxolol (generic only), bisoprolol (generic only) and metoprolol (LOPRESSOR, KAPSPARGO SPRINKLE, TORPOL XL).

Public Citizen lists the following five beta-blocker-diuretic combinations as Limited Use drugs: atenolol and chlorthalidone (TENORETIC), bisoprolol and hydrochlorothiazide (ZIAC), metoprolol and hydrochlorothiazide (LOPRESSOR HCT), propranolol and hydrochlorothiazide (INDERIDE LA), and timolol and hydrochlorothiazide (TIMOLIDE).

Beta blockers have long been a mainstay of hypertension drug treatment. Yet in recent years, studies have shown these drugs to be less effective than other antihypertensive drugs at preventing stroke, other cardiovascular events or death, particularly for adults older than age 60 and smokers.[1]

For African-Americans and older adults, beta-blockers are less effective as the sole treatment. For these groups of people, doctors usually prescribe another type of drug called a diuretic (water pill) to lower blood pressure, adding a second drug only if the diuretic alone is not enough.

In general, beta-blockers should not be taken by patients who have asthma, bronchospasm, severe allergies or heart block. These drugs also should be avoided by patients with chronic obstructive pulmonary disease (COPD) unless they have suffered a heart attack.

For patients with heart failure, beta-blockers can cause dramatic improvement but must be taken under careful supervision. A baseline electrocardiogram (ECG, EKG) should be taken before a beta-blocker is first prescribed to be sure that the patient does not have heart block.

Smoking will aggravate some of the respiratory side effects, but it greatly reduces the level of drug in the body.

Side effects

Allergic reactions

The drug label for carvedilol (COREG) was updated in 2009 to include information that there have been reports of serious allergic reactions in patients taking this drug. These reactions include hives or swelling of the face, lips, tongue and/or throat that may cause difficulty breathing or swallowing. These reports have been rare but the reactions can be life-threatening.[2]

Birth defects

There have been reports of small placentas and congenital anomalies (birth defects) in infants whose mothers received propranolol (INDERAL, INDERAL LA) during pregnancy.[3]

Blood sugar

Beta-blockers may mask some of the manifestations of low blood sugar (hypoglycemia), particularly rapid heart rate (tachycardia). Nonselective beta-blockers may increase the risk of insulin-induced hypoglycemia and delay recovery of serum glucose levels.

Patients who are subject to spontaneous hypoglycemia, or diabetic patients who are receiving insulin or oral hypoglycemic agents, should be cautioned about these possibilities.

In congestive heart failure patients, there is a risk of worsening hyperglycemia (high blood sugar).[4]

In a study designed to examine the effects of carvedilol on glycemic control in a population with mild to moderate hypertension and well-controlled type 2 diabetes, carvedilol had no adverse effect on glycemic control, based on HbA1c measurements.[4]

In 2016, Pediatrics published a study showing an increased risk of hypoglycemia and bradycardia (slow heart rate) in infants when beta-blockers were used at the end of pregnancy.[5]

Heart

Overdoses of beta blockers can cause dangerously low heart rate and blood pressure and interfere with the pumping of the heart, leading to shock, convulsions, coma and death.

Lungs

Beta-blockers can cause a spasm in the air passages of the lungs (bronchospasm) and bring on asthmatic wheezing. This effect can occur even when using beta-blocker eye drops to treat glaucoma. Therefore, beta-blockers should not be used if you have asthma or bronchospasm. Patients with COPD should avoid beta-blockers unless they have suffered a heart attack; in such patients the use of beta-blockers improves survival.

Patients who experience breathing difficulty while taking a beta-blocker should call their doctor immediately.

Potassium imbalance

Beta blockers rarely can cause a dangerous rise in blood potassium levels, known as hyperkalemia.

Drug interaction

Beta blockers can block epinephrine (ADRENACLICK, ADRENALIN, AUVI-Q, EPIPEN) when it is taken as an injection for allergic reactions. This can make the epinephrine less effective.

An interaction between green tea and nadolol has been reported. A study in healthy volunteers showed that drinking green tea resulted in a decrease in the blood concentration of nadolol. This suggests that green tea may decrease the drug’s effectiveness in patients with hypertension.[6]

First-line treatment for high blood pressure

For patients with high blood pressure, the best way to reduce or eliminate the need for medication is by improving diet, losing weight, exercising, and decreasing salt and alcohol intake. Mild hypertension can be controlled by proper nutrition and exercise. If these measures do not lower your blood pressure enough and you need medication, hydrochlorothiazide (ESIDRIX, HYDRODIURIL, MICROZIDE), a water pill, is the drug of choice, starting with a low dose of 12.5 milligrams daily. It also costs less than other blood pressure drugs.

There is growing evidence that thiazide diuretics, such as hydrochlorothiazide, significantly decrease the rate of bone mineral loss in both men and women because they reduce the amount of calcium lost in the urine.[7] Research now suggests that thiazide diuretics may protect against hip fracture.[8]

For patients with high blood pressure that is more severe and that is not controlled with hydrochlorothiazide alone, another family of high blood pressure-lowering drugs may be added to your treatment. In this case, your doctor would prescribe the hydrochlorothiazide and the second drug separately, with the dose of each drug adjusted to meet your needs, rather than using a product that combines the drugs in a fixed combination.

Whatever drugs you take for high blood pressure, once your blood pressure has been normal for a year or more, a cautious decrease in dose and renewed attention to nondrug treatment may be worth trying, according to The Medical Letter on Drugs and Therapeutics.[9]

An editorial in the British Medical Journal (BMJ) stated:

Treatment of hypertension is part of preventive medicine, and like all preventive strategies, its progress should be regularly reviewed by whoever initiates it. Many problems could be avoided by not starting antihypertensive treatment until after prolonged observation. ... Patients should no longer be told that treatment is necessarily for life: the possibility of reducing or stopping treatment should be mentioned at the outset.[10]

The May 2012 issue of Worst Pills, Best Pills News highlighted a BMJ study indicating that patients taking several types of commonly used antihypertensive medications are at increased risk of developing gout, a type of arthritis.

The BMJ study also showed that a small number of other antihypertensive drugs appear to have the opposite effect, decreasing the risk of gout.

All patients should be informed of the risk of gout with diuretics, beta-blockers, angiotensin-converting enzyme inhibitors (ACE inhibitors) and non-lorsartan angiotensin II receptor blockers (ARBs) when starting these medications or whenever the dose of the medications is increased.[11]

Studies show...

Regulatory actions surrounding these drugs

2011: In March, the FDA issued the following warning concerning the use of hydrochlorothiazide products:

Hydrochlorothiazide, a sulfonamide, can cause an idiosyncratic reaction, resulting in acute transient myopia and acute angle-closure glaucoma. Symptoms include acute onset of decreased visual acuity or ocular pain and typically occur within hours to weeks of drug initiation. Untreated acute angle-closure glaucoma can lead to permanent vision loss. The primary treatment is to discontinue hydrochlorothiazide as rapidly as possible. Prompt medical or surgical treatments may need to be considered if the intraocular pressure remains uncontrolled. Risk factors for developing acute angle-closure glaucoma may include a history of sulfonamide or penicillin allergy.[12]

In July, the FDA updated the product label of carvedilol to include information on Intraoperative Floppy Iris Syndrome (IFIS). IFIS has been observed during cataract surgery in some patients currently taking or previously treated with alpha-1 blockers. If you are having cataract surgery and are taking or have taken an alpha-1 blocker, be sure to alert the operating physician.[13]

Before You Use This Drug [top]

Do not use if you have or have had:

  • heart failure
  • low blood pressure
  • heart block
  • slow heart rate
  • asthma
  • emphysema or chronic bronchitis

Tell your doctor if you have or have had:

  • allergies to drugs, foods, or insects
  • pregnancy or are breast-feeding
  • angina
  • gout
  • alcohol dependence
  • mental depression
  • kidney, liver, lung, or pancreas disease
  • diabetes
  • lupus erythematosus
  • difficulty breathing
  • poor blood circulation
  • Raynaud’s syndrome
  • thyroid problems
  • myasthenia gravis
  • psoriasis

Tell your doctor about any other drugs you take, including aspirin, herbs, vitamins, and other nonprescription products.

When You Use This Drug [top]

  • Learn to take your pulse, and get immediate medical help if your pulse slows to 50 beats per minute or slower, even if you are feeling well. Some people have suffered from slowed heart rate and heart failure while taking these drugs.
  • Until you know how you react to this drug, do not drive or perform other activities requiring alertness.
  • Be careful not to overexert yourself, even though your chest pain may feel better.
  • Do not stop taking this drug suddenly. Your doctor must give you a schedule to decrease your dose gradually, to prevent chest pain and possible heart attack. Have enough medication on hand to get through weekends, holidays, and vacations.
  • You may feel dizzy when rising from a lying or sitting position. When getting out of bed, hang your legs over the side of the bed for a few minutes, then get up slowly. When getting up from a chair, get up slowly and stay beside the chair until you are sure that you are not dizzy. 
  • Caution diabetics (See Diabetes Prevention and Treatment).
  • If you plan to have any surgery, including dental, tell your doctor that you take this drug.
  • Do not take other drugs without talking to your doctor first — especially nonprescription drugs for appetite control, asthma, colds, coughs, hay fever, sinus problems, or alcohol.

How to Use This Drug [top]

  • If you miss a dose, take it as soon as you remember, but skip it if it is less than eight hours until your next scheduled dose or if it is less than four hours for acebutolol, bisoprolol, metoprolol, pindolol, or timolol. Do not take double doses.
  • Do not share your medication with others.
  • Take the drug at the same time(s) each day.
  • Ask your doctor whether to take your drug with food or on an empty stomach.
  • Extended-release dosage forms must not be crushed; others can be crushed and mixed with water, or swallowed whole with water.
  • Store at room temperature with lid on tightly. Do not store in the bathroom. Do not expose to heat, moisture, or strong light. Keep out of reach of children.
  • Ask your doctor if you should check your pulse.

Interactions with Other Drugs [top]

The following drugs, biologics (e.g., vaccines, therapeutic antibodies), or foods are listed in Evaluations of Drug Interactions 2003 as causing “highly clinically significant” or “clinically significant” interactions when used together with any of the drugs in this section. In some sections with multiple drugs, the interaction may have been reported for one but not all drugs in this section, but we include the interaction because the drugs in this section are similar to one another. We have also included potentially serious interactions listed in the drug’s FDA-approved professional package insert or in published medical journal articles. There may be other drugs, especially those in the families of drugs listed below, that also will react with this drug to cause severe adverse effects. Make sure to tell your doctor and pharmacist the drugs you are taking and tell them if you are taking any of these interacting drugs:

ALDOMET, AMARYL, amiodarone, ANZEMET, arbutamine, CALAN SR, CATAPRES, chlorpromazine, cimetidine, clonidine, cocaine, CORDARONE, COUMADIN, COVERA-HS, dolasetron, ELIXOPHYLLIN, ephedrine, FLUOTHANE, fluoxetine, furosemide, glimepiride, GLYSET, halothane, HUMALOG, HUMULIN, INDOCIN, indomethacin, insulin, ISOPTIN SR, LASIX, lidocaine, LITHOBID, LITHONATE, MAXALT, methyldopa, miglitol, MINIPRESS, moxisylyte, NORVIR, prazosin, PROZAC, RIFADIN, rifampin, ritonavir, rizatriptan, SLO-BID, TAGAMET, theophylline, THEO-24, THORAZINE, thioridazine, THYROID STRONG, tobacco, TUBARINE, tubocurarine, verapamil, VERELAN, warfarin, XYLOCAINE, zileuton, zolmitriptan, ZOMIG, ZYFLO.

Adverse Effects [top]

Call your doctor immediately if you experience:

  • difficulty breathing and/or wheezing
  • dizziness
  • weight increase
  • cold hands or feet
  • depression
  • skin rash
  • swelling of ankles, feet, or legs
  • slow pulse
  • back or joint pain
  • chest pain
  • confusion
  • dark urine
  • fever and sore throat
  • hallucinations
  • irregular heartbeat
  • red, scaling, or crusted skin
  • unusual bleeding and bruising
  • yellow eyes or skin
  • convulsions
  • bluish-colored fingernails or palms

Call your doctor if these symptoms continue:

  • headache
  • dizziness, lightheadedness
  • nausea, vomiting, stomachache
  • diarrhea
  • unusual tiredness or weakness
  • disturbed sleep, nightmares
  • decreased sexual ability
  • anxiety or nervousness
  • constipation
  • stuffy nose
  • dry, sore eyes, changes in taste, frequent urination (acebutolol and carteolol)
  • itching skin; numbness; tingling fingers, toes, skin; nightmares (labetolol)

Call your doctor if these symptoms continue after you stop using the medication:

  • fast or irregular heartbeat
  • chest pain
  • headache
  • shortness of breath
  • sweating
  • trembling
  • feelings of discomfort, weakness, or illness

Periodic Tests[top]

Ask your doctor which of these tests should be done periodically while you are taking this drug:

  • blood pressure and pulse rate
  • heart function tests, such as electrocardiogram (ECG, EKG)
  • kidney function tests
  • liver function tests
  • blood glucose levels

last reviewed March 31, 2021