From the FDA Drug Label
Atenolol is excreted by the kidneys; consequently dosage should be adjusted in cases of severe impairment of renal function No significant accumulation of atenolol occurs until creatinine clearance falls below 35 mL/min/1. 73m2. The following maximum oral dosages are recommended for elderly, renally-impaired patients and for patients with renal impairment due to other causes: Creatinine Clearance (mL/min/1. 73m2) Atenolol Elimination Half-Life (h) Maximum Dosage 15-35 16-27 50 mg daily <15 >27 25 mg daily Patients on hemodialysis should be given 25 mg or 50 mg after each dialysis; this should be done under hospital supervision as marked falls in blood pressure can occur.
The best beta blocker option in patients with End-Stage Renal Disease (ESRD) is not explicitly stated in the provided drug label. However, based on the information provided for atenolol, dosage adjustments are necessary in patients with severe renal impairment.
- For patients with creatinine clearance between 15-35 mL/min, the maximum dosage is 50 mg daily.
- For patients with creatinine clearance less than 15 mL/min, the maximum dosage is 25 mg daily.
- For patients on hemodialysis, 25 mg or 50 mg should be given after each dialysis, under hospital supervision. 1
From the Research
Beta blockers, particularly carvedilol, are the best option for patients with End-Stage Renal Disease (ESRD), as they have been shown to improve survival rates and provide cardioprotective effects. When prescribing beta blockers for ESRD patients, it is essential to start with lower doses and titrate slowly while monitoring for side effects, such as hypotension and bradycardia 2. For example, begin with carvedilol 3.125 mg twice daily and gradually increase to 25 mg twice daily as tolerated, or metoprolol succinate 25 mg daily and increase to 200 mg daily if needed 3.
Key Considerations
- Beta blockers require minimal dose adjustment in renal failure, making them particularly suitable for ESRD patients 4.
- Carvedilol may be preferable to metoprolol due to its greater alpha-blocking effects, which can help prevent the development of chronic kidney disease during beta-blocker therapy for heart failure 5.
- The use of beta blockers in ESRD patients with cardiovascular disease has been associated with increased 28-day and 3-year survival rates 6.
Monitoring and Management
- Regular monitoring of heart rate, blood pressure, and symptoms of heart failure is essential when using beta blockers in ESRD patients 2.
- Patients should be closely monitored for signs of hypotension, bradycardia, and hyperkalemia, particularly during the initial titration phase 3.
- Dose adjustments should be made gradually, taking into account the patient's individual response to the medication and their underlying renal function 4.