Are there combination medications that include both a beta blocker (BB) and an angiotensin II receptor blocker (ARB)?

Beta Blocker and ARB Combination Medications

There are no commercially available fixed-dose combination pills containing both a beta blocker and an ARB, and this combination is generally not recommended as initial or preferred therapy for hypertension. 1

Why This Combination Is Not Standard

• Both drug classes act on the renin-angiotensin system, making them mechanistically redundant rather than complementary for most hypertensive patients 2

• The 2024 ESC Guidelines recommend beta blockers be combined with other major BP-lowering drug classes only when there are compelling indications such as angina, post-myocardial infarction, heart failure with reduced ejection fraction, or heart rate control needs 1

• Preferred initial combinations explicitly exclude BB + ARB: The guidelines recommend RAS blockers (ACE inhibitor or ARB) combined with either a dihydropyridine calcium channel blocker OR a thiazide diuretic as first-line therapy 1

Available Fixed-Dose Combinations (What Actually Exists)

The 2003 JNC-7 guidelines list all FDA-approved fixed-dose antihypertensive combinations, which include 1:

• Beta blockers + diuretics: Atenolol-chlorthalidone, bisoprolol-hydrochlorothiazide, metoprolol-hydrochlorothiazide, nadolol-bendroflumethiazide, propranolol-hydrochlorothiazide, timolol-hydrochlorothiazide 1

• ARBs + diuretics: Candesartan-HCTZ, eprosartan-HCTZ, irbesartan-HCTZ, losartan-HCTZ, olmesartan-HCTZ, telmisartan-HCTZ, valsartan-HCTZ 1

• ARBs + calcium channel blockers: Amlodipine-olmesartan, amlodipine-valsartan 3

• Notably absent: Any beta blocker + ARB fixed-dose combination 1

When BB + ARB Might Be Used Together (As Separate Pills)

While not available as a single pill and not a preferred combination, there are specific clinical scenarios where both drugs may be prescribed separately 2:

• Heart failure with reduced ejection fraction: Patients require a beta blocker AND an ACE inhibitor or ARB as foundational therapy 4

• Post-myocardial infarction with hypertension: Beta blocker for secondary prevention plus ARB for BP control and remodeling prevention 1

• Resistant hypertension: When three or more drug classes are needed, a beta blocker may be added to an existing ARB-based regimen 1

Important Caveats

• The American Heart Association recommends avoiding beta blockers combined with thiazide diuretics unless specifically indicated (prior MI, active angina, heart failure), as this combination increases risk of new-onset diabetes 5

• BB + ARB is not an ideal combination because both act on the renin-angiotensin system, though it can be useful in specific clinical situations 2

• For resistant hypertension requiring multiple agents, the recommended escalation is: ARB + CCB + thiazide diuretic, then add spironolactone, then consider adding a beta blocker if not already indicated 1

Practical Algorithm for Combination Selection

If you need to combine an ARB with another agent 1, 4:

1. First choice: ARB + dihydropyridine calcium channel blocker (e.g., amlodipine-olmesartan) 1, 3
2. Second choice: ARB + thiazide diuretic (e.g., losartan-HCTZ) 1
3. Third drug if needed: Add the other class from above (creating ARB + CCB + thiazide) 1
4. Fourth drug if needed: Add spironolactone 1
5. Fifth drug if needed: Consider beta blocker only if not already prescribed for compelling indication 1

If you need to combine a beta blocker with another agent 1:

1. First choice: BB + dihydropyridine calcium channel blocker (e.g., carvedilol + amlodipine) 6, 7
2. Second choice: BB + ACE inhibitor or ARB (only for heart failure or post-MI) 4, 2
3. Avoid: BB + thiazide diuretic in patients at risk for diabetes 5