Does asymptomatic tachycardia due to autonomic dysfunction in a patient with a history of Alcohol Use Disorder (AUD) require treatment with a beta-blocker?

From the Guidelines

The treatment of asymptomatic tachycardia from autonomic dysfunction in someone with alcohol use disorder does not necessarily require beta-blocker therapy. The primary approach should focus on addressing the underlying cause through alcohol cessation and supportive care. Beta-blockers like propranolol or metoprolol may be considered in select cases where the tachycardia is persistent, symptomatic, or causing hemodynamic concerns, typically starting at low doses (propranolol 10-20mg twice daily or metoprolol 25-50mg twice daily) 1. However, these medications should be used cautiously in patients with alcohol use disorder due to potential interactions with alcohol, risk of masking withdrawal symptoms, and concerns about adherence. Non-pharmacological approaches are preferable initially, including:

• Adequate hydration
• Electrolyte replacement (particularly magnesium and potassium)
• Nutritional support with thiamine supplementation (100mg daily)
• Gradual physical reconditioning

The autonomic dysfunction often improves with sustained abstinence from alcohol, as chronic alcohol use disrupts normal autonomic nervous system function, leading to sympathetic overactivity during both intoxication and withdrawal periods 1. Regular monitoring of heart rate, blood pressure, and cardiac function is important during recovery, with treatment decisions individualized based on the patient's specific clinical presentation, comorbidities, and recovery progress. According to the 2024 ESC guidelines for the management of atrial fibrillation, rate control therapy may include beta-blockers, but the decision to use them should be based on the patient's individual risk factors and clinical presentation 1.

From the FDA Drug Label

When discontinuing chronically administered metoprolol succinate extended-release tablets, particularly in patients with ischemic heart disease, the dosage should be gradually reduced over a period of 1 to 2 weeks and the patient should be carefully monitored Patients should be warned against interruption or discontinuation of therapy without the physician's advice Because coronary artery disease is common and may be unrecognized, it may be prudent not to discontinue metoprolol succinate extended-release tablets therapy abruptly even in patients treated only for hypertension. Beta-blockers may mask tachycardia occurring with hypoglycemia, but other manifestations such as dizziness and sweating may not be significantly affected. Beta-adrenergic blockade may mask certain clinical signs (e.g., tachycardia) of hyperthyroidism.

The use of beta-blockers in patients with asymptomatic tachycardia from autonomic dysfunction and a history of alcohol use disorder is not directly addressed in the provided drug label.

• The label discusses the use of metoprolol succinate in various conditions, such as ischemic heart disease, hypertension, and bronchospastic diseases.
• It also provides guidance on the discontinuation of therapy and the potential risks associated with beta-blockade.
• However, it does not provide specific information on the treatment of asymptomatic tachycardia from autonomic dysfunction in patients with a history of alcohol use disorder.
• Therefore, no conclusion can be drawn regarding the need for beta-blocker treatment in this specific scenario 2.

From the Research

Asymptomatic Tachycardia from Autonomic Dysfunction

• Asymptomatic tachycardia from autonomic dysfunction in someone with a history of alcohol use disorder is a complex condition that requires careful consideration of the underlying causes and treatment options.
• According to 3, autonomic dysfunction is a known consequence of chronic and excessive alcohol consumption, and the most important risk factor for this condition is the total lifetime dose of ethanol.
• The study 3 also suggests that abstinence is the only management strategy currently explored in the literature, which appears to lead to significant improvement in autonomic investigations.

Treatment with Beta-Blockers

• There is no direct evidence in the provided studies to suggest that asymptomatic tachycardia from autonomic dysfunction in someone with a history of alcohol use disorder should be treated with a beta-blocker.
• However, 4 and 5 discuss the treatment of autonomic dysfunction and cardiac arrhythmias, and suggest that pharmacologic interventions should be added only when conservative approaches are insufficient to improve symptoms.
• The study 6 highlights the importance of autonomic modulation in the treatment of cardiac arrhythmias, but does not specifically address the use of beta-blockers in this context.

Management of Autonomic Dysfunction

• The management of autonomic dysfunction should focus on improving symptoms and functional status, rather than targeting arbitrary hemodynamic values 5.
• A structured and stepwise approach should be taken for treatment, starting with patient education, lifestyle modifications, and use of physical counter-pressure manoeuvres and devices to improve venous return 5.
• Pharmacologic interventions, including beta-blockers, may be considered in certain cases, but the evidence for their use in asymptomatic tachycardia from autonomic dysfunction in someone with a history of alcohol use disorder is limited 7, 3, 4, 5, 6.