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Nadolol

Class
Adrenergic receptor blockers
Subclass
Non-cardioselective β-blockers
Substance name
Nadolol
Brand names
Corgard®
Common formulations
Tablet
Dosage and administration
Adults patients
Treatment
Angina pectoris
•
Start at: 40 mg PO daily
•
Maintenance: 40-80 mg PO daily
•
Maximum: 240 mg per day
Titrate in 40 to 80 mg increments every 3 to 7 days until the optimal clinical response is achieved.
Hypertension
•
Start at: 40 mg PO daily
•
Maintenance: 40-80 mg PO daily
•
Maximum: 320 mg per day
Titrate in 40 to 80 mg increments until the optimal clinical response is achieved.
AF • Off-label
•
10-240 mg PO daily
Thyrotoxicosis • Off-label
•
40-160 mg PO daily
Prevention
Prevention of migraine attacks • Off-label
•
40-80 mg PO daily
Other off-label uses
•
Treatment of atrial flutter
•
Treatment of familial long QT syndrome
•
Treatment of premature ventricular contractions
•
Treatment of SVT
•
Prevention of variceal hemorrhage in patients with liver cirrhosis
•
Secondary prevention of variceal hemorrhage in patients with liver cirrhosis
Indications for use
Labeled indications
Adults
•
Treatment of angina pectoris
•
Treatment of hypertension
Off-label indications
Adults
•
Treatment of AF
•
Treatment of atrial flutter
•
Treatment of familial long QT syndrome
•
Treatment of premature ventricular contractions
•
Treatment of SVT
•
Treatment of thyrotoxicosis
•
Prevention of migraine attacks
•
Prevention of variceal hemorrhage in patients with liver cirrhosis
•
Secondary prevention of variceal hemorrhage in patients with liver cirrhosis
Safety risks
Boxed warnings
Exacerbation of myocardial infarction, ventricular arrhythmia, angina
•
Do not discontinue abruptly, especially in patients with coronary artery disease, as this may cause severe exacerbations of angina, myocardial infarction, or ventricular arrhythmias. Gradually reduce the dose over 1-2 weeks while monitoring the patient. If symptoms worsen or acute coronary insufficiency develops, promptly reinstitute nadolol and take appropriate measures. Avoid abrupt discontinuation even in patients treated for hypertension, as coronary artery disease may be unrecognized.
Contraindications
Hypersensitivity to nadolol or any of its excipients
Bronchial asthma
Sinus bradycardia, second- or third-degree AV block, cardiogenic shock, or decompensated HF
Warnings and precautions
Exacerbation of angina
•
Use caution in vasospastic angina, as β-blockers without alpha1-blocking activity can cause unopposed coronary vasoconstriction, worsening symptoms.
Exacerbation of bronchospasm
•
Use extreme caution in patients with bronchospastic diseases, as nadolol may impair bronchodilation by blocking beta2 receptors, its use is generally discouraged.
Exacerbation of HF
•
Use caution in patients with compensated HF. Monitor closely for signs of decompensation, and discontinue gradually if HF develops.
Exacerbation of muscle weakness, double vision
•
Use caution in patients with myasthenia gravis.
Exacerbation of psoriasis
•
Use caution in patients with psoriasis.
Exacerbation of Raynaud's phenomenon, peripheral vascular disease
•
Use caution in patients with peripheral circulatory disorders, including Raynaud's disease or syndrome and peripheral occlusive vascular disease.
Hypertension
•
Use extreme caution in patients with untreated pheochromocytoma. Ensure adequate α-blockade is achieved before initiating nadolol to prevent a paradoxical increase in BP.
Major surgery
•
Maintain a high level of suspicion, as β-blockers should not be routinely withdrawn before major surgery, but their effect on adrenergic response may increase anesthesia and surgical risks.
Mask symptoms of hyperthyroidism
•
Use caution in patients with hyperthyroidism. Avoid abrupt withdrawal of β-blocker therapy to prevent symptom exacerbation or the precipitation of a thyroid storm.
Mask symptoms of hypoglycemia
•
Use caution in patients with diabetes.
Specific populations
Renal impairment
eGFR > 50 mL/min/1.73 m²
•
Use with caution. Do not exceed frequency of once daily. Titrate to response.
eGFR 31-50 mL/min/1.73 m²
•
Use with caution. Do not exceed frequency of q24-36h. Titrate to response.
eGFR 10-30 mL/min/1.73 m²
•
Use with caution. Do not exceed frequency of q24-48h. Titrate to response.
eGFR < 10 mL/min/1.73 m²
•
Use with caution. Do not exceed frequency of q40-60h. Titrate to response.
Renal replacement therapy
Continuous renal replacement
•
Use with caution. Dose as in eGFR 10-30 mL/min/1.73 m². Maximal frequency of q24-48h. Titrate to response.
Intermittent hemodialysis
•
Use with caution. Dose as in eGFR < 10 mL/min/1.73 m². Maximal frequency of q40-60h. Titrate to response.
Peritoneal dialysis
•
Use with caution. Dose as in eGFR < 10 mL/min/1.73 m². Maximal frequency of q40-60h. Titrate to response.
Hepatic impairment
Any severity
•
No guidance available.
Pregnancy and breastfeeding
Pregnancy
All trimesters
•
Use only if benefits outweigh potential risks. Evidence of fetal harm in animals. There are no adequate, well-controlled studies in pregnant women. Neonates exposed to nadolol at parturition have shown bradycardia, hypoglycemia, and related symptoms; therefore, use caution during labor and delivery.
Breastfeeding
Do not use during breastfeeding.
Unknown amount excreted in breastmilk.
Unknown drug levels in breastfed infants.
No overt adverse effects on lactation reported.
Adverse reactions
Very common > 10%
•
Drowsiness, insomnia
Common 1-10%
•
AV block, bradycardia, cold extremities, cardiac arrhythmias, edema, hypotension, palpitations, heart failure, hypotension, raynaud's phenomenon, depression, dizziness, fatigue
Uncommon < 1%
•
Abdominal swelling, bronchospasm, ↓ GFR, facial edema, pneumonitis, abdominal discomfort, constipation, cough, diarrhea, dry mouth, erectile dysfunction, flatulence, generalized pruritus, headache, indigestion, loss of appetite, nasal congestion, nausea, paresthesia, sexual dysfunction, skin rash, somnolence, sweating, vomiting, weight gain, speech disturbance
Unknown frequency
•
Acute pancreatitis, alopecia, carpal tunnel syndrome, ↓ blood glucose, drug withdrawal syndrome, peripheral vascular insufficiency, dyslipidemia, ↑ serum potassium, myasthenia gravis, papilledema, gum bleeding, intermittent claudication
Interactions
Drug(s)
Check Interactions
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