What intravenous beta blocker drugs are available in India?

Intravenous Beta Blocker Drugs Available in India

The intravenous beta blockers available in India include metoprolol, esmolol, propranolol, atenolol, and labetalol. These medications are used in various acute cardiovascular conditions requiring rapid heart rate or blood pressure control.

Available IV Beta Blockers and Their Characteristics

Cardioselective Beta Blockers (Beta-1 Selective)

• Metoprolol

  • Dosage: 5 mg increments by slow IV administration (5 mg over 1-2 minutes), repeated every 5 minutes for a total initial dose of 15 mg 1
  • Duration: Intermediate acting
  • Primary uses: Acute coronary syndromes, hypertension, tachyarrhythmias
  • Available as: Metoprolol tartrate injection

• Esmolol

  • Dosage: Loading dose of 0.5 mg/kg over 2-5 minutes, followed by infusion of 0.10-0.20 mg/kg/min 1, 2
  • Duration: Ultra-short acting (half-life of 9.2 minutes) 2
  • Primary uses: Supraventricular tachyarrhythmias, perioperative tachycardia and hypertension
  • Advantage: Rapid onset and offset of action, making it ideal for titration in critical care settings 2

• Atenolol

  • Dosage: Available for IV administration but with longer half-time than esmolol 1
  • Duration: Longer-acting
  • Primary uses: Hypertension, angina

Non-selective Beta Blockers

• Propranolol
  • Dosage: 0.05-0.15 mg per kg of body weight every 4-6 hours 1 or initial dose of 0.5-1.0 mg 1
  • Duration: Intermediate acting
  • Primary uses: Hypertension, arrhythmias, aortic dissection

Combined Alpha and Beta Blockers

• Labetalol
  • Dosage: Available for IV administration with both alpha and beta blocking properties 1, 3
  • Mechanism: Combines selective alpha-1 and non-selective beta-adrenergic receptor blocking actions 3
  • Primary uses: Hypertensive emergencies, aortic dissection
  • Special indication: Particularly useful in hypertensive emergencies associated with catecholamine excess 1

Clinical Applications and Selection Criteria

Acute Aortic Dissection

• Beta blockers are first-line agents to reduce the force of left ventricular ejection (dP/dt)
• Preferred agents: Esmolol, labetalol 1
• Target: Reduce systolic blood pressure to 100-120 mmHg 1
• Note: Beta blockade should precede vasodilator administration 1

Acute Coronary Syndromes

• Preferred agents: Esmolol, labetalol, metoprolol 1
• Contraindications: Moderate-to-severe LV failure with pulmonary edema, bradycardia (<60 bpm), hypotension (SBP <100 mmHg), poor peripheral perfusion, second or third-degree heart block, and reactive airways disease 1

Atrial Fibrillation

• For rate control in AF, intravenous beta blockade with propranolol, atenolol, metoprolol, or esmolol is effective 1
• Atenolol and metoprolol provide better control of exercise-induced tachycardia than digoxin 1

Special Considerations

Respiratory Disease

• In patients with bronchial asthma or significant chronic obstructive pulmonary disease:
  • Use cardioselective agents (metoprolol, esmolol) cautiously at reduced doses 1
  • For mild wheezing, consider a short-acting cardioselective agent at reduced dose (e.g., 12.5 mg of metoprolol) 1
  • Esmolol's short half-life makes it suitable to test beta-blocker tolerance 1

Hemodynamic Instability

• Avoid early aggressive beta blockade in hemodynamically unstable patients 1
• Risk factors for shock with beta blockers: older age, female sex, time delay, higher Killip class, lower blood pressure, higher heart rate, ECG abnormality, and previous hypertension 1

Monitoring Requirements

• During IV beta-blocker therapy:
  • Frequent checks of heart rate and blood pressure
  • Continuous ECG monitoring
  • Auscultation for rales and bronchospasm 1

Practical Dosing Guidelines

Metoprolol IV

• Initial: 5 mg increments by slow IV administration (over 1-2 min)
• Repeat: Every 5 minutes up to total initial dose of 15 mg
• Follow-up: If tolerated, start oral therapy 15 minutes after last IV dose at 25-50 mg every 6 hours 1

Esmolol IV

• Loading: 0.5 mg/kg over 2-5 minutes
• Maintenance: 0.10-0.20 mg/kg/min infusion
• Note: Maximum concentration is only 10 mg/ml; high doses constitute substantial volume load 1

Propranolol IV

• Initial: 0.5-1.0 mg
• Follow-up: Oral therapy 40-80 mg every 6-8 hours 1

Labetalol IV

• For hypertensive emergencies: Can be administered as continuous IV infusion
• Effective in lowering blood pressure by average of 60/35 mmHg 3

Remember that the choice of IV beta blocker should be based on the specific clinical scenario, patient comorbidities, and the desired duration of action. Cardioselective agents are generally preferred in patients with respiratory conditions, while combined alpha-beta blockers like labetalol are particularly useful in hypertensive emergencies.