What is the comparison between Nebivolol (Bystolic) and Propranolol?

From the Guidelines

Bystolic (nebivolol) is generally preferred over propranolol for patients with high blood pressure due to its selective beta-1 blocking activity and potential for fewer side effects, as well as its once-daily dosing convenience, as noted in the 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults 1.

Key Differences Between Bystolic and Propranolol

• Bystolic (nebivolol) is a newer, more selective beta-1 blocker that also promotes nitric oxide release, potentially causing fewer side effects like fatigue and sexual dysfunction.
• Propranolol is an older, non-selective beta-blocker that blocks both beta-1 and beta-2 receptors, making it effective for conditions like migraines, essential tremor, and performance anxiety, but potentially causing more respiratory side effects in patients with asthma or COPD.

Dosage and Administration

• Bystolic (nebivolol) is typically taken once daily at 5-40mg.
• Propranolol is usually taken 2-4 times daily at varying doses (10-80mg per dose) depending on the condition.

Considerations for Choosing Between Bystolic and Propranolol

• Patients with respiratory issues or those concerned about quality of life side effects may prefer nebivolol.
• Patients with migraines or anxiety may prefer propranolol.
• Both medications should not be stopped abruptly as this can cause rebound effects.
• The choice between them should be based on the specific condition being treated, potential side effects, dosing convenience, and cost considerations, as nebivolol is generally more expensive than generic propranolol 1.

From the FDA Drug Label

Nebivolol is a β-adrenergic receptor blocking agent. The FDA drug label does not answer the question.

From the Research

Comparison of Bystolic and Propranolol

• Bystolic, also known as nebivolol, is a third-generation β1-selective β-blocker with vasodilating properties, neutral metabolic effects, and good tolerability 2.
• Propranolol, on the other hand, is a non-cardioselective β1,2 blocker commonly used in the treatment of various cardiovascular conditions, such as hypertension, coronary artery disease, and tachyarrhythmias 3.

Efficacy in Hypertension Treatment

• The use of beta-blockers, including propranolol, as first-line agents in the treatment of uncomplicated hypertension has been questioned due to their relatively weak effect in reducing stroke and lack of protective effect with regard to coronary artery disease 4.
• Nebivolol, however, has been shown to have advantages over other β-blockers, making it a suitable option for a wide variety of hypertensive patients with or without comorbidities 2.

Off-Label Uses

• Propranolol has been used off-label in the treatment of various types of anxiety and stress, including stage fright and post-traumatic stress disorder (PTSD) 3.
• However, a recent systematic review and meta-analysis found no evidence to support the use of beta-blockers, including propranolol, in the treatment of anxiety disorders 5.

Lifestyle Modifications

• Lifestyle approaches, including physical activity, are recommended as first-line treatment for patients with mildly or moderately elevated blood pressure and blood cholesterol 6.
• Increasing physical activity has extensive benefits, including improving both blood pressure and blood cholesterol, and is a suitable lifestyle behavior treatment option for all patients, including those with mild-moderate-risk patients with elevated blood pressure and blood cholesterol 6.