What are alternatives to propranolol (beta-blocker)?

Alternatives to Propranolol (Beta-Blocker)

There are several effective alternatives to propranolol, with metoprolol succinate extended-release being the most appropriate sustained-release alternative according to current guidelines. 1

Beta-Blocker Alternatives

Cardioselective Beta-Blockers

• Metoprolol

  • Metoprolol succinate (extended-release): 50-200 mg once daily 2
  • Metoprolol tartrate: 100-200 mg twice daily 2
  • Benefits: Cardioselective (beta-1 selective), preferred in patients with bronchospastic airway disease requiring a beta-blocker 2

• Atenolol: 25-100 mg twice daily 2

  • Benefits: Cardioselective, once or twice daily dosing

• Bisoprolol: 2.5-10 mg once daily 2

  • Benefits: Highly cardioselective, once-daily dosing, preferred in heart failure patients 1

• Betaxolol: 5-20 mg once daily 2

  • Benefits: Cardioselective, once-daily dosing

• Nebivolol: 5-40 mg once daily 2

  • Benefits: Cardioselective with vasodilatory properties through nitric oxide induction 2

Non-Cardioselective Beta-Blockers

• Nadolol: 40-120 mg once daily 2
  • Benefits: Long half-life allowing once-daily dosing
  • Caution: Avoid in patients with reactive airways disease 2

Combined Alpha and Beta-Blockers

• Carvedilol: 12.5-50 mg twice daily 2

  • Benefits: Preferred in patients with heart failure with reduced ejection fraction (HFrEF) 2
  • Carvedilol phosphate: 20-80 mg once daily 2

• Labetalol: 200-800 mg twice daily 2

  • Benefits: Combined alpha and beta blockade, useful in hypertensive emergencies

Algorithm for Selecting a Propranolol Alternative

1. Assess patient's comorbidities:

   • Respiratory disease: Choose a cardioselective agent (metoprolol, bisoprolol, atenolol) 2
   • Heart failure: Prefer carvedilol, metoprolol succinate, or bisoprolol 2
   • Coronary artery disease: Any beta-blocker is appropriate, with preference for those studied post-MI (metoprolol, propranolol, atenolol) 2

2. Consider dosing convenience:

   • Once-daily preference: Metoprolol succinate ER, bisoprolol, nadolol
   • Twice-daily requirement: Metoprolol tartrate, carvedilol

3. Special populations:

   • Elderly patients: Consider starting with lower doses, particularly with metoprolol 1
   • Women: May require lower doses of metoprolol than men (approximately 50% reduction) 1
   • Hepatic dysfunction: Dose adjustment needed for metoprolol 1

Important Precautions

• Avoid abrupt cessation of any beta-blocker to prevent rebound hypertension or tachycardia 2

• Contraindications for all beta-blockers:

  • Marked first-degree AV block (PR interval >0.24s)
  • Second or third-degree AV block without pacemaker
  • Severe bradycardia
  • Cardiogenic shock
  • Decompensated heart failure 2, 1

• Initiation protocol:

  • Start with low doses and gradually titrate upward
  • For metoprolol and most beta-blockers, begin with the lowest effective dose and increase at 1-2 week intervals 2
  • Monitor heart rate, blood pressure, and symptoms during titration 1

Conversion from Propranolol

When converting from propranolol to another beta-blocker, consider these approximate equivalencies:

• Propranolol 80 mg ≈ Metoprolol 100 mg ≈ Atenolol 50 mg ≈ Bisoprolol 5 mg ≈ Carvedilol 25 mg 1

Beta-blockers remain essential medications for cardiovascular conditions, and selecting the right alternative to propranolol should be based on patient-specific factors including comorbidities, dosing convenience, and specific indications.