Sectral (Acebutolol) Prescribing Guidelines for Hypertension
Primary Recommendation
Acebutolol is generally not recommended as a first-line agent for hypertension unless the patient has specific compelling indications such as ischemic heart disease or heart failure. 1
Dosing for Hypertension
Initial dose: 400 mg daily, which can be given as a single daily dose or divided twice daily for adequate 24-hour blood pressure control. 2
- Optimal response is usually achieved with 400-800 mg per day 2
- Some patients may be maintained on as little as 200 mg daily 2
- Patients with more severe hypertension or inadequate control may require up to 1200 mg daily (administered twice daily) or addition of a second antihypertensive agent 2
- Beta-1 selectivity diminishes as dosage increases 2
Special Dosing Considerations
Elderly patients have approximately 2-fold increase in bioavailability and require lower maintenance doses—avoid doses above 800 mg/day in this population. 2
Guideline Position on Beta-Blockers
Beta-blockers are not recommended as first-line agents for hypertension unless the patient has ischemic heart disease (IHD) or heart failure. 1
- Acebutolol is specifically classified as a beta-blocker with intrinsic sympathomimetic activity (ISA), which should generally be avoided, especially in patients with IHD or heart failure 1
- Beta-blockers are less effective at stroke prevention compared to other antihypertensive drug classes 1
Combination Therapy
When acebutolol is used for hypertension, combination with a thiazide diuretic is particularly effective where greater antihypertensive effect is required. 3
- The 2017 ACC/AHA guidelines recommend thiazide-type diuretics or calcium channel blockers as preferred initial therapy, with beta-blockers reserved for specific indications 1
Contraindications and Precautions
Absolute Contraindications
Asthma and A-V block (grade 2 or 3) are compelling contraindications to beta-blocker use. 1
Relative Contraindications (Possible)
- Peripheral artery disease 1
- Metabolic syndrome 1
- Glucose intolerance 1
- Athletes and physically active patients 1
- Chronic obstructive pulmonary disease 1
Pregnancy Considerations
Beta-blockers, including acebutolol, can be used in pregnancy but require careful consideration. 1
- Methyldopa and calcium channel blockers are preferred over beta-blockers for hypertension in pregnancy 1
- Atenolol should be given with caution during pregnancy due to reports of fetal growth retardation related to duration of treatment 1
- For women planning pregnancy, it may be prudent to change to medications known to be safe during pregnancy, such as methyldopa or beta-blockers, prior to conception 1
- ACE inhibitors and ARBs must be discontinued prior to attempts at conception or as soon as pregnancy is confirmed 1
Asthma and Reactive Airways Disease
Avoid acebutolol in patients with reactive airways disease, despite its cardioselectivity. 1
- While acebutolol is cardioselective and possesses intrinsic sympathomimetic activity, which may reduce bronchospasm risk compared to non-selective beta-blockers, it should still be avoided in asthma 4, 5
- Cardioselective beta-blockers are preferred in patients with bronchospastic airway disease requiring a beta-blocker, but acebutolol's ISA makes it less suitable for cardiac indications 1
Monitoring Parameters
Blood Pressure Monitoring
Target blood pressure is <130/80 mmHg for most patients, with reassessment within 1 month after initiation of therapy, then every 3-6 months after meeting BP goal. 1
Heart Rate Monitoring
Acebutolol produces significantly smaller reductions in resting heart rate compared to propranolol, metoprolol, and atenolol due to its intrinsic sympathomimetic activity. 4, 6
- Monitor for excessive bradycardia, though this is less common with acebutolol than with beta-blockers without ISA 7
Metabolic Monitoring
Acebutolol has minimal metabolic effects and does not elevate blood lipids during long-term therapy; HDL cholesterol may actually increase. 5
- This contrasts with some other beta-blockers that may worsen glucose intolerance and lipid profiles 1
Drug Interactions
Avoid abrupt cessation of acebutolol, which may precipitate rebound hypertension or cardiac events. 1
- Dosage should be reduced gradually over approximately two weeks if treatment is to be discontinued 2
Clinical Advantages Specific to Acebutolol
Acebutolol's cardioselectivity, intrinsic sympathomimetic activity, hydrophilicity, and considerable extrarenal excretion may offer advantages in specific patients. 4
- Low lipid solubility reduces risk of central nervous system side effects 7
- Low protein binding means displacement interactions with other drugs are unlikely 7
- Both renal and hepatic excretion pathways provide an alternative route if either is compromised through disease 7
- Lower incidence of tiredness and cold extremities compared to other beta-blockers 7
When to Consider Acebutolol
Consider acebutolol specifically for patients with:
- Hypertension plus ischemic heart disease requiring beta-blockade 1
- Hypertension plus heart failure with reduced ejection fraction (though other beta-blockers like carvedilol are preferred) 1
- Hypertension plus angina pectoris 1, 5
- Hypertension plus ventricular arrhythmias requiring suppression 2, 5
- Patients who cannot tolerate other beta-blockers due to excessive bradycardia 6
Efficacy Data
Acebutolol is as effective as propranolol, diuretics, metoprolol, labetalol, and atenolol at lowering blood pressure, and more effective than methyldopa. 4