What are the clinical indications for nadolol?

Clinical Indications for Nadolol

Nadolol is FDA-approved for two primary indications: long-term management of angina pectoris and treatment of hypertension to reduce cardiovascular events including stroke and myocardial infarction. 1

FDA-Approved Indications

Hypertension

• Nadolol is indicated for lowering blood pressure, which reduces the risk of fatal and nonfatal cardiovascular events, primarily strokes and myocardial infarctions. 1
• Nadolol is specifically listed among guideline-directed medical therapy (GDMT) beta-blockers for blood pressure control in patients with stable ischemic heart disease (SIHD), alongside carvedilol, metoprolol tartrate, metoprolol succinate, bisoprolol, propranolol, and timolol. 2
• The target blood pressure in adults with SIHD and hypertension should be less than 130/80 mm Hg. 2
• Nadolol may be used alone or in combination with other antihypertensive agents, especially thiazide-type diuretics. 1

Angina Pectoris

• Nadolol is indicated for the long-term management of patients with angina pectoris. 1
• Beta-blockers are effective drugs for preventing angina pectoris, improving exercise time until the onset of angina, reducing exercise-induced ischemic ST-segment depression, and preventing coronary events. 2

Guideline-Supported Indications in Specific Cardiovascular Contexts

Stable Ischemic Heart Disease (SIHD) with Hypertension

• In adults with SIHD and hypertension (BP ≥130/80 mm Hg), nadolol should be used as first-line therapy for compelling indications such as previous MI or stable angina, with addition of other drugs (dihydropyridine CCBs, thiazide diuretics, mineralocorticoid receptor antagonists) as needed. 2
• For patients who have had an MI or acute coronary syndrome, it is reasonable to continue GDMT beta-blockers (including nadolol) beyond 3 years as long-term therapy for hypertension. 2

Post-Myocardial Infarction

• In randomized long-term trials, use of beta-blockers after MI reduced all-cause mortality by 23%. 2
• Given the established efficacy of beta-blockers for treating hypertension and SIHD, their use continuing beyond 3 years after MI is reasonable. 2

Pharmacokinetic Advantages Supporting Once-Daily Dosing

• Nadolol has an inherently long duration of activity (half-life 12.2-20 hours) making it suitable for once-daily administration in both hypertension and angina pectoris. 3, 4, 5
• Nadolol is excreted entirely in unmetabolized form, which may offer advantages in specific patients compared to hepatically metabolized beta-blockers. 3
• Significant beta-receptor blockade occurs 24 hours after a single 80-mg dose of nadolol. 6

Important Clinical Considerations

Avoid Beta-Blockers with Intrinsic Sympathomimetic Activity

• Guidelines specifically recommend avoiding beta-blockers with intrinsic sympathomimetic activity when treating hypertension and SIHD. 2

Atenolol Should Not Be Used

• The beta-blocker atenolol should not be used because it is less effective than placebo in reducing cardiovascular events. 2

Renal Dosing Considerations

• The half-life of nadolol increases to 18.2-68.6 hours in patients with chronic kidney disease, requiring dose adjustment. 4
• Nadolol can be effectively removed by hemodialysis. 4

Drug Interactions

• The bioavailability of nadolol is greatly reduced by coadministration of green tea. 4
• Activated charcoal decreases nadolol bioavailability due to enterohepatic circulation. 4