Can Atenolol Be Given in CKD?
Yes, atenolol can be given to patients with CKD, but requires dose adjustment based on creatinine clearance, with maximum doses of 50 mg daily for CrCl 15-35 mL/min/1.73m² and 25 mg daily for CrCl <15 mL/min/1.73m², and should be administered after hemodialysis sessions in dialysis patients. 1
Dosing Recommendations Based on Renal Function
The FDA label provides explicit dosing guidance for atenolol in renal impairment 1:
- CrCl 15-35 mL/min/1.73m²: Maximum dose 50 mg daily (elimination half-life 16-27 hours)
- **CrCl <15 mL/min/1.73m²**: Maximum dose 25 mg daily (elimination half-life >27 hours)
- Hemodialysis patients: Give 25-50 mg after each dialysis session under hospital supervision due to risk of marked blood pressure drops 1
Pharmacokinetic Rationale
Atenolol is renally excreted, making dose adjustment essential in CKD 1:
- In terminal renal failure (CrCl <5 mL/min), the plasma half-life increases dramatically from 6 hours to 73 hours without dialysis 2
- Peak plasma levels are significantly increased (up to sixfold) in patients with CrCl <30 mL/min 3
- During hemodialysis, the half-life temporarily drops to 7.5 hours but returns to 51 hours post-dialysis, with plasma levels rising for several hours after dialysis ends 2
- No significant accumulation occurs until CrCl falls below 35 mL/min/1.73m² 1
Clinical Efficacy in Hemodialysis
Atenolol has demonstrated effectiveness specifically in hemodialysis patients 4:
- Supervised administration of 25 mg atenolol three times weekly after hemodialysis reduced mean 44-hour ambulatory blood pressure from 144/80 to 127/69 mmHg (P<0.001) 4
- Blood pressure control persisted for 44 hours between dialysis sessions 4
- No increase in intradialytic hypotensive episodes or changes in serum potassium occurred 4
- Particularly valuable for noncompliant hemodialysis patients due to supervised administration 4
Important Limitations and Considerations
Atenolol is not a preferred beta-blocker for rate control in atrial fibrillation due to its short biological half-life, and other beta-blockers are recommended as specific rate control therapy 5. This is an important caveat when selecting beta-blockers for CKD patients with AF.
Atenolol may be less effective than other antihypertensive agents for primary hypertension management, with evidence suggesting it is not sufficiently effective as a primary tool to treat hypertension compared to other agents 6. However, this does not preclude its use when appropriately dosed in CKD.
Monitoring Requirements
- Assess renal function before initiating therapy, as evaluation should always include assessment of renal function 1
- Monitor blood pressure carefully, especially in hemodialysis patients where marked falls can occur 1
- For elderly patients with CKD, start at the low end of the dosing range (25 mg daily for hypertension) and assess efficacy carefully, including trough blood pressure measurements 1
Common Pitfalls to Avoid
- Failing to adjust dose for renal function: Using standard doses (50-100 mg daily) in patients with CrCl <35 mL/min leads to drug accumulation and increased risk of adverse effects 1, 3
- Timing in dialysis patients: Not administering atenolol after dialysis sessions results in drug removal during dialysis and inadequate blood pressure control 2, 4
- Abrupt discontinuation: If withdrawal is planned in patients with angina, it must be achieved gradually with careful observation and limited physical activity 1