beta blockers are some times used in anxiety... propranolol (ciplar) and atenolol are used for anxiety

I prescribe Inderal (propranolol) in consultation with internists/cardiologists for treatment of lithium tremor and occasionally performance anxiety. Others (e.g., Yudosky and Silver) have published extensively on using high dose propranolol for rage attacks in persons with TBI.  Other than that, I do not prescribe beta blockers.

Thanks for the answers. Anyway, it is usually very important clinical question, who and which beta-clockers will be prescribed to psychiatric patients with several medications and high comorbidity. Very important role for the use in hypertension is: The role for β-blockers in hypertension was downgraded to third/fourth-line, as they perform less appropriately or effectively than newer drugs, particularly in the elderly (ACE-inhibitors, CA-antagonists and diuretics are in front).

Next .... Patient with heart failure need beta-blockers, because ... Trials have shown beta blockers reduce the absolute risk of death by 4.5% over a 13-month period (Mayo Clin Proc. 2002 Aug;77(8):839-45; quiz 845-6.).

Why I am against the use of atenolol:

- Unlike propranolol, atenolol does not pass through the blood–brain barrier thus avoiding various central nervous system side effects. This feature is appropriate, when We do not want a CNS adverse effects/effects, which is usually seen in propranolol. Atenolol was made after propranolol (first beta-blocker). Provisional data suggests that antihypertensive therapy with atenolol provides weaker protective action against cardiovascular complications (e.g. myocardial infarction and stroke) compared to other antihypertensive drugs.

Atenolol has many DDIs with several antidepressants (e. g. escitalopram, quetiapine, ziprasidone, clozapine) and with this medicals is better to avoid it.

The second important information is drug efficacy, because the newest beta-blockers (e.g. carvedilol, bisoprolol, nebivolol). Bisoprolol, carvedilol and sustained-release metoprolol are specifically indicated as adjuncts to standard ACE inhibitor and diuretic therapy in congestive heart failure and atenolol is usually less effective.

- the best choices for heart failure and psychiatric comorbidity are under bisoprolol and carvedilol. Bisoprolol is very selective drug, especially for beta1 receptors, which should be blocked by medicalc in heart failure (renin secretion, heart rate controle). For example If we use atenolol the drug of its lower efficacy was choosen (compare to bisoprolo or carvedilol) and many more DDIs with psychopharmaceuticals are possible (see above).

- in the patients with stable angina (not heart failure) the best option in psychiatric patients is absolutely pindolol Pindolol is a nonselective beta blocker with partial beta-adrenergic receptor agonist activity. It possesses ISA (Intrinsic Sympathomimetic Activity). This means that pindolol, particularly in high doses, exerts effects like epinephrine or isoprenaline (increased pulse rate, increased blood pressure, bronchodilation), but these effects are limited. Pindolol also shows membrane stabilizing effects like quinidine, possibly accounting for its antiarrhythmic effects. It also functions as a 5-HT1A receptor weak partial agonist / antagonist.

Because of its 5HT1A receptors profile activity there are many benefits within its use (compare with other beta-blockers). Hum Psychopharmacol. 2015 Feb 17. doi: 10.1002/hup.2465. Once-daily high-dose pindolol (7.5 mg qd) appears to show a promising benefit in these patients (in depressed patients resistant to selective serotonin reuptake inhibitor (SSRI) therapy) (Evid Based Ment Health. 2004 Nov;7(4):107.). 

- propranolol has many benefits over the newest beta-blockers, especially its mode of action in CNS and therefore is appropriate (more) in tremor cases. However, officially, beta blockers are not approved for anxiolytic use by the U.S. Food and Drug Administration.

If I conclude, there are several questions which beta-blockers should be used. I think cooperation with clinical pharmacist and/or pharmacologist is very important in psychiatric patients, which are treated with psychopharmaceuticals (especially elderly) and beta-blockers.

If beta blockers required to trear CCF only carvidilol, labetalol and metoprolol are approved. not propranolol.

Considering QTc prolongation, my observations are the worst with bisoprolol. And, for neuropsychiatric use I use B-blockers only for two occasions: essential tremor and performance anxiety. Usually low doses of propranolol. In the case of essential tremor, always after consultation with internal medicine specialist or geriatrician, if appropriate.

Also, to my experience, the trouble is mostly with lack of co-operation between specialists. We commonly do not know about each others' treatments and particularly some cardiologists prefer to advice psychiatric drugs discontinuation than adjusting their algorithms...

Dear Tomasz You have right ... In countries, where is a lack of clinical pharmacist and/or pharmacologist, it is more often happens that are medicines prescribed in a inappropriate way. Often psychotropics are included, especially antipsychotics with QTc prolongation potential. Co-operation among specialists is usually the most important and smth very hard process.

However If I add answer on your answer ... Yes, because of tremor propranolol is smth used, however often patients have been already treated with beta-blockers and beta-blockers polypharmacy should be avoided. Especially If we have patient with CHF which is on bisoprolol. What to do in these cases? We do not have so good results (outcomes) with propranolol and patient with CHF. 

In these cases a 'trial' with propranolol and discontinuation of bisoprolo is valuable option. However, doses of propranolol should be higher, because of CHF. Usually the doses for tremor are lower and titrated up to 160 mg of propranolol daily. After adverse effects removal, a direct switching to bisoprolol with discontinuation of propranolol is important. I think this is important clinical question.

Another thing is anxiety ... We have some evidence about efficacy of beta-blockers, especially in resistant cases, however not many. in the Performance anxiety use of propranolol is appropriate, however if long term use is necessary it is better to use another drugs in the patiets with CHF.

My choose is bisoprolol. It is highly selective beta- blockers with minimum side effects and interaction. There is no data in PDR about interaction with anti phsycotic agents and minimal influence on depression (0,2%) and insomnia (1-2%).

Thanks everybody for an interesting talk. The question is very easy, however the answers are very different, which is very important for optimal pharmacotherapy choices.

My big choice is bisoprolol, if we do not have important or even very significant kidney failure. However when we have patient with very significant kidney failure (without psoriasis) the carvedilol is better option, especially with quetiapine combination in patients with dementia. If anxiety is important it is better to use pregabalin than switching to propranolol, especially with patients with polypharmacy and hypotension.

If We have only CHF, with high hypotensia and several psychopharmaceuticals metoprolol is also one treatment option, because hypotensia is usually big problem with the use of several psychopharmaceuticals (e.g. quetiapine, olanzapine, clozapine, trazodone). In these cases avoiding the hypotension is very important clinical issue, especially in elderly patients with dementia.

Considering both issues and foreseeing the primary and secondary downstream comp. It's still better to consider a combination of SSRI, Carbidolol and ARBs plus life style modification will be the right choice. It's also equally  important to classify and stage the CHF to make the right action/approach.

Dear Jaffer,

I totally agree with You that lifestyle is very important issue in the treatment of CHF in psychiatric patients. However in long term trials patients with CHF with EF less than 35 will need beta blockers ASAP. In these cases one of them should be prescribed. Also there are some important issues in prescribing of clonidine, which is also used in patients with ADHD (or guanfacine similar drug, with small differences especialy without action on I1-imidazoline receptor). If there is a patient with CHF comorbidity there is very important which beta-blockers would be used. Another important diagnosis is schizofrenia or delusions in elderly geriatric patients, where often hypotensia is seen. Usually the quetipine is used or even clozapine where we should choose between appropriate treatment of CHF or psychiatric disorder. Several drugs within this group have big differenes in their action and pharmacokinetics and therefore cooperation with clinical pharmacist is beneficial for these patients. Anyway, often antidepressants are prescribed (e. g. trazodone), which have impact on hypotension, which can lead to serious falls (e. g. hip fracture) and deaths in elderly patients.

Very important steps are within this process:

- evaluation of beta blockers in patients in CHF (especially elderly psychogeriatric patients),

- very careful prescribing of psychopharmaceuticals (e. g. slow titration, avoiding of DDIs),

- Monitoring (long-term), this step is usually lacking and patients have long term prescribed antipsychotic or even polypharmacy (this step is very important, because we have many trials about mortality and morbidity in connection with antipsychotics),

- Because of slow and inappropriate monitoring patients take usually another drugs, for example stimulants for hypotensia, lower doses of beta blockers because of inappropriate long term of antipsychotic use, 

- Consequnces of inappropriate prescribing are seen often and because of bad coomunication or even too 'high' respect to pharmacotherapy prescribed by friends or another specialists this can lead to several complications and harms.

Regards,

Mathew

http://www.aafp.org/afp/2000/1201/p2453.html ---a detail discussion on beta blockers in CCF, hope its helpful.

For patients who have experienced depression with metoprolol or other beta blockers, I have had reasonable success in switching to Atenolol, which has less penetration into the blood-brain barrier.

Thanks to all of you for wonderful answers,

However after brief discussion I have still several concerns about comorbidity of CHF and anxiety. In these situation metoprolol is smth not very appropriate, because can lead to dellirium, especially in elderly patients or/and restlesssnes.

Atenolol .... I have several concerns about use of atenolol, because its efficacy is very small and more or less all BETA-blockers were more sucessful in term of efficacy than atenolol. Atenolol is also very old beta-blockers.

In these situations I would suggest bisoprolol, because it has very few penetration into the blood-brain barrier. Especially in terms of comorbidity bisoprolol is very good option (e.g. COPB etc ... ).

If we have problems with long-term anxiety we can use propranolol, however its use should be with a great caution, because of many adverse effects (especially in combinations with antihypertensive drugs). Hypotensia could be a big problem and one of the key issues in the treatment of psychiatric patients, because usually psychopharmaceuticals, except venlafaxine, duloxetine ..., usually have big impact on lower pressure. This problem is even more serious if patients are treated with antipsychotics and have CHF comorbidity. In these situations it is better to use for example pregabalin with antipsychotic as combination with antidepressant which has serious impact on lower blood pressure (e.g. trazodone).

Among antipsychotics amisulpride is usually forgotten, although has many positive effect in terms of blood pressure and efficacy, especially in combination treatment (e.g. clozapine, aripiprazole, olanzapine and risperidone). QTc interval prolongation could be have a problem, however this adverse event can be limitated by serious measurements.

If I sum up, I would suggest the use of bisoprolo in psychiatric patients with CHF and pregabalin in the patients with anxiety disorder instead of use of propranolol. However, the cooperation among cardiologist, psychiatrist and clinical pharmacist is positive step towards the best possible clinical outcomes.

carvedilol2.5 mg twice a day  seems to work up properly with antipsychotics

You mean bisoprolol 2,5 mg (carvedilol is not 2,5 mg)=

Bisoprolol has few possibilities for DDIs