What is the recommended dosage and management plan for using Nebivolol (Nebivolol) and ISMN (Isosorbide Mononitrate) together in a patient with hypertension and angina?

From the Guidelines

When managing a patient with both hypertension and angina, a typical regimen might include Nebivolol starting at 5 mg once daily, which can be titrated up to 10 mg daily if needed for blood pressure control, and Isosorbide mononitrate (ISMN) initiated at 30-60 mg once daily in the morning using extended-release formulations, with potential titration up to 120 mg daily based on angina symptoms, as recommended by recent guidelines 1.

Key Considerations

• Nebivolol provides blood pressure control through selective beta-1 blockade with nitric oxide-mediated vasodilation, while ISMN offers antianginal effects through nitric oxide-mediated vasodilation.
• When administering these medications together, it's essential to monitor for potential hypotension, especially during initial dosing and dose adjustments.
• ISMN should be given in the morning with a nitrate-free period overnight to prevent tolerance.

Monitoring and Follow-up

• Patients should be advised about possible side effects including headache, dizziness, and fatigue.
• Regular follow-up is crucial to assess efficacy and adjust dosages as needed, typically every 2-4 weeks during initial treatment and then every 3-6 months once stabilized.

Evidence-Based Recommendations

• The use of beta-blockers, such as Nebivolol, is recommended for the long-term management of patients with hypertension-related left ventricular systolic dysfunction 1.
• The addition of ISMN to a beta-blocker is recommended when angina persists despite treatment with a beta-blocker, to relieve angina 1.
• The combination of Nebivolol and ISMN is a reasonable approach for managing patients with both hypertension and angina, as it addresses both conditions and has a favorable safety profile 1.

From the Research

Recommended Dosage and Management Plan

The recommended dosage and management plan for using Nebivolol and ISMN together in a patient with hypertension and angina is not explicitly stated in the provided studies. However, the following information can be gathered:

• Nebivolol is a third-generation β1-selective β-blocker with vasodilating properties, neutral metabolic effects, and good tolerability, making it suitable for a wide variety of hypertensive patients with or without comorbidities 2, 3, 4.
• The typical dosage of Nebivolol is 5 mg once daily, which has been shown to be an effective antihypertensive agent 5.
• ISMN is typically administered at a dose of 20 mg 2-3 times daily, orally, and has been shown to be effective in reducing the frequency of angina and improving exercise capacity in patients with stable angina pectoris 6.

Key Considerations

When using Nebivolol and ISMN together, the following key considerations should be taken into account:

• The combination of Nebivolol and ISMN may enhance the antianginal efficacy and improve exercise capacity in patients with hypertension and angina.
• The safety and tolerability of Nebivolol and ISMN have been established in various studies, with headache being the only adverse effect observed in some patients 6.
• The dosage of Nebivolol and ISMN may need to be adjusted based on individual patient response and tolerability.

Potential Interactions

Potential interactions between Nebivolol and ISMN include:

• Concomitant treatment with serotonin uptake inhibitors may lead to overdosing of Nebivolol, as it is metabolized by CYP450 2D6 3.
• The combination of Nebivolol and ISMN may increase the risk of hypotension, and patients should be monitored closely for signs of orthostatic hypotension.

Patient Monitoring

Patients taking Nebivolol and ISMN together should be monitored regularly for:

• Blood pressure and heart rate
• Signs of orthostatic hypotension
• Adverse effects such as headache
• Efficacy of treatment in reducing the frequency of angina and improving exercise capacity.