No other vasodilatory agents (eg, calcium channel blockers, nitrates) should be started at the same time when performing the switch between β‐blockers, because side effects are more likely to occur. Beta blockers equivalent dosing. (up to 300 mg total dose) until desired BP is reached or start continuous infusion: 2 mg/min (range: 1 to 3 mg… HHS Patients with an MI will often be started on an IV or oral agent on arrival at the hospital. Reprinted with permission from Packer et al.31. When clonidine and beta blockers are taken together and clonidine is to be stopped, it is recommended that the beta blocker be withdrawn first, and then clonidine can be tapered over 2 - 4 days. A randomized, controlled trial, Effects of metoprolol and carvedilol on pre‐existing and new onset diabetes in patients with chronic heart failure: data from the Carvedilol Or Metoprolol European Trial (COMET), Switching between beta blockers in heart failure patients: rationale and practical considerations, Differing effects of antihypertensive drugs on the incidence of diabetes mellitus among patients with hypertensive kidney disease, Effects of metoprolol and carvedilol on cause‐specific mortality and morbidity in patients with chronic heart failure—COMET, Exchange of beta‐blockers in heart failure patients. If the β-blocker was not withheld, switching to an equivalent dose can be facilitated by regular monitoring of vital signs, allowing for rapid and safe titration. and then up‐titrated at 1–2 week intervals (Table I). Welcome to the equivalent dose and drug conversions / transfers / switching section of the website for physicians and pharmacists. The 8‐year mortality rate in HF patients approaches 80%,1 and approximately 44% of patients hospitalized for HF will be rehospitalized within 1 year.2 Post‐MI patients have as high if not a higher risk for poor outcomes: 25% to 30% of patients with new or recurrent MI will die within 12 months, and a significant proportion will experience reinfarction or sudden death.3 In addition, approximately 40% of post‐MI patients will develop left ventricular systolic dysfunction (LVSD). Please enable it to take advantage of the complete set of features! Please check your email for instructions on resetting your password. This section features links to a wide range of clinical resources on equivalent doses and conversions for opioids, benzodiazepines, antidepressants, antipsychotics, corticosteroids and more.  |  Patients with a history of MI as well as patients diagnosed with HF are often prescribed multiple medications with complex dosing regimens to prevent the occurrence of future CV events. Education for all health care providers—physicians, nurses, hospitalists, and pharmacists—is key to ensure that patients switching from carvedilol to carvedilol CR are switched accurately. The following will be specifically addressed: (1) switching from twice‐daily carvedilol to carvedilol CR in patients with HF and post‐MI LVSD; (2) switching from other commonly used non–evidence‐based agents to an evidence‐based β‐blocker in HF; and (3) switching from other agents to carvedilol CR in post‐MI patients with LVSD. A potential concern is that a patient with HF currently taking 25 mg of carvedilol twice daily would be switched to 40 mg once daily instead of the appropriate proven equivalent dose of 80 mg. The focus of this article on carvedilol is a result of the introduction of carvedilol phosphate extended‐release (carvedilol CR), a once‐daily controlled‐release formulation of carvedilol, to our armamentarium. COVID-19 is an emerging, rapidly evolving situation. Additionally, most hospital-based formularies and guidelines do not provide recommendations around common challenges, like medication intolerance or adjustments for acute illness. blocker be changed to one of the recommended agents as above. Relationship between daily dose (mg/d) of metoprolol and carvedilol and magnitude of β1‐blockade in healthy volunteers and in patients with hypertension. Future trials may provide more evidence for dose equivalencies. The choice of β‐blocker for an individual patient with HF or after an MI is often based on answers to several practical questions: (1) Has the patient been on a β‐blocker for a prior indication (hypertension, angina, arrhythmia) when HF or post‐MI left ventricular dysfunction (LVD) is first diagnosed? Specifically, they have proven efficacy in: 1. Adapted from Packer30 and Sandberg et al.48, Suggested equivalent dose conversions from another β‐blocker to carvedilol twice daily in patients with HF and post‐MI LVD have previously been published.44, 49 The dose equivalencies for the HF algorithm were derived from both clinical experience and the degree of β1‐blockade (heart rate lowering) that can be expected with each dose. Drugs blocking beta adrenergic receptors (beta-blockers) have become central to the management of cardiovascular diseases. Following CHAMP initiation, prescription of medication at discharge increased: aspirin, from 68% to 92%, β‐blocker, 12% to 62%, ACE inhibitor, 6% to 58%, and statin, 6% to 86%. 2012 Jun;26(3):414-9. doi: 10.1053/j.jvca.2011.09.027. If a patient has received an IV β‐blocker in the acute setting, they will often be switched to the same oral β‐blocker while in the hospital. There is no definitive guidance for dose conversion between beta-blockers and clinical judgement will be required in considering where the metoprolol dose sits within the dose range of the alternative beta-blocker. Figure 1 shows the mean steady‐state concentration‐time profile for S(−)‐carvedilol, the enantiomer responsible for the β‐blocking effects of carvedilol, after administration of carvedilol and carvedilol CR.31 Notice that the peaks and troughs are similar in order of magnitude between the 2 formulations, while the once‐daily formulation has much slower onset and offset kinetics. Metoprolol tartrate, a twice‐daily agent, was reformulated to metoprolol succinate in order to be taken once daily. With ECG recordings in 42 patients we investigated the effect on sinus heart rate of four beta-blockers given at three successive daily doses. That is, many patients can now be treated with once‐daily ACE inhibitors or angiotensin receptor blockers, diuretics, and carvedilol CR as the mainstays of treatment for HF. 20 mg every 8 hours oral, equivalent to 0.5 mg/hour I.V. The presence of disease symptoms, however, may also influence patient adherence. Table I provides a switching protocol for transitioning stable patients from twice‐daily carvedilol to once‐daily carvedilol CR.38 This switch may be prudent in patients who are at risk for nonadherence to medication, patients on other once‐daily medications, the elderly, patients with mild or asymptomatic disease, and patients who may have a problem remembering their second dose. Conclusion: The switch from non-recommended short-acting beta-blockers to long-acting beta-blockers may be carried out safely in stable heart failure patients. For this non‐overlapping or abrupt switching, the current β blocker should be discontinued approximately 12 hours before the first dose of carvedilol. (3) Are there any other comorbid disease processes (eg, pulmonary disease, diabetes mellitus) present? Vascular surgery patients prescribed preoperative β-blockers experienced a decrease in the maximal heart rate observed during induction of general anesthesia. In these cases, please refer to the previous protocol by Abraham,44 which provides an overlapping schedule. Once the patient has tolerated carvedilol CR for 3 to 10 days, it may be uptitrated to the maximal dose, one that would provide similar benefits to a high dose of a β1‐blocking agent without the negative metabolic effects. We present a practical approach to switching between commonly prescribed β-blockers, which considers drug interchangeability for various indications, rationale for switching, necessary initial adjustments to dose/frequency, and differences in target/maximal doses. Discontinuation of medication after an MI is common and occurs early after discharge. Reprinted with permission from Packer et al.35. Intern Med J. Metoprolol is also indicated for situations where α‐blockade would be detrimental, such as in patients with severe hypotension or abnormal peripheral vasodilatation. Neef PA, Burrell LM, McDonald CF, Irving LB, Johnson DF, Steinfort DP. 1 1. Suggested Beta-blocker switch, based on COMET 12 Metoprolol succinate daily dose Consider switch to: 25 mg Carvedilol 3.125 mg BID or bisoprolol 0.625 mg daily 50 mg Carvedilol 6.25 mg BID or bisoprolol 1.25 mg daily 100 mg Carvedilol 12.5 mg BID or bisoprolol 2.5 mg daily 200 mg Carvedilol 25 mg BID or bisoprolol 5 mg (5) Can the patient adhere to the medication? Epub 2015 Sep 29. Why did my GP switch me to a different beta-blocker? In some settings, an acute presentation might necessitate urgent switches between β-blockers. Although metoprolol succinate has been shown to have different pharmacokinetics than metoprolol tartrate, an analysis by Packer and colleagues30 demonstrates that the degree of β1‐blocking effects of the 2 drugs would be expected to be similar if used at the appropriate doses in HF patients. Numerous studies have shown that adherence to lifesaving therapies in patients with heart disease is less than optimal. Multiple reports address the adherence rates for these types of patients, and the general consensus is that post‐MI and HF patients have lower than acceptable rates of adherence to treatment regimens. Atenolol is a much older drug and is now less often prescribed for cardiac patients. If it is determined that the patient has LVSD, it is appropriate to switch them from oral metoprolol or atenolol to carvedilol CR. In some instances, where the possibility of inducing ischemia or cardiac arrhythmias is of greater concern and especially in patients receiving higher doses of the first‐ or second‐generation agent, an overlapping schedule for initiating and uptitrating a change to carvedilol may be used. Compounding this picture in many CV disease patients is the challenge of poor patient adherence to medications, which is often overlooked or underappreciated by the health care delivery system. If carvedilol twice daily is used initially, it is reasonable to switch patients to the once‐daily carvedilol CR formulation prior to discharge in order to ensure good long‐term adherence. Doses are approximate; monitor response closely and adjust dose as appropriate. The equivalent doses for carvedilol and carvedilol CR are shown in Table I. (up to 300 mg total dose) until desired BP is reached or start continuous infusion: 2 mg/min (range: 1 to 3 mg… Usual adult dosing for ceftriaxone is 1-2 gm every 12-24 hours (max: 4 gm/day), usual adult dosing for Post‐MI patients with a prescription fill frequency of ≥80% for statins were half as likely as patients in the nonadherent group to experience a reinfarction within 1 year (hazard ratio [HR], 0.45; 95% confidence interval [CI], 0.20–0.99; P=.047).17 This associated reduction in MI was even more pronounced in patients younger than 65 years (HR, 0.14; 95% CI, 0.04–0.46; P=.001).17 The increased risk for mortality in patients who discontinue evidence‐based post‐MI medications such as aspirin, β‐blockers, and statins were seen in a multivariable survival analysis, where medication therapy discontinuation was independently associated with higher mortality (HR, 3.81; 95% CI, 1.88–7.72).18 A similar result was observed for β‐blockers and statins in a recent study of 31,455 post‐MI patients: those with the highest rate of adherence had a significantly lower 1‐year mortality rate (P<.0001).19, Discussing adherence to therapy is an aspect of patient care that is often disregarded but should be considered an important part of CV management.20 There are numerous reasons for poor adherence, including poor communication about the importance of therapy, the complexity of drug regimens, and the failure to initiate therapy in the hospital when the patient is most likely to relate the drug to wellness.20, 21 In addition to the utilization of evidence‐based pharmacologic and device therapy, the care that patients receive before they are discharged (medication, education) is a considerable predictive factor in prognosis. nifedipine) may be given with a beta blocker to prevent reflex tachycardia; however use PRECAUTION as possible negative inotropic effects. Carvedilol CR is indicated in patients with HF starting at 10 mg and with post‐MI LVD starting at 20 mg. A carvedilol immediate‐release dosage of 50 mg twice daily (2 tablets of 25 mg twice daily) has been used in patients who weigh >85 kg.34, 35 In this instance, the equivalent carvedilol CR dosage would be 160 mg once daily (2 tablets of 80 mg once daily). It is possible that a clinical scenario exists where a patient has received IV atenolol or metoprolol tartrate and, in the acute setting, it is known that the patient has LVSD. Clinical data support the use of β‐blockers in the treatment of HF and in post‐MI LVSD, but it is prudent to remember that not all β‐blockers are alike; both benefits and side effects can differ among individual agents. sidering switching HF patients from another β blocker to carvedilol (and also the occasions when switching from carvedilol to a β 1-selective agent may become necessary), discuss important issues to consider in the switching process, and provide practical approaches to successfully perform the medication change. Maximum: 2400 mg/day. In previous publications of carvedilol, it was noted that hypotension that might result from the vasodilatory actions of carvedilol may be somewhat ameliorated by spacing out the dosing at least 2 hours from when the ACE inhibitor is given (while ensuring patients take carvedilol with a normal meal, as recommended).44, 49 This recommendation was based on clinical practice and judgment. An ongoing trial of adherence to once‐daily carvedilol CR vs twice‐daily carvedilol will provide more information about adherence to β‐blocker use in HF patients.26 To this end, this paper will discuss the practical considerations of the use of carvedilol CR. sidering switching HF patients from another β blocker to carvedilol (and also the occasions when switching from carvedilol to a β 1-selective agent may become necessary), discuss important issues to consider in the switching process, and provide practical approaches to successfully perform the medication change. Hypertensive emergency: 20mg IV slow injection, then 40-80 mg IV every 10 minutes as needed. We present a practical approach to switching between commonly prescribed β-blockers, which considers drug interchangeability for various indications, rationale for switching, necessary initial adjustments to dose/frequency, and differences in target/maximal doses. Although better adherence through the use of once‐daily β‐blockers has not yet been determined in a clinical trial, the availability of carvedilol CR will allow a simplified dosing regimen that may in many instances promote both convenience and adherence for many patients. Switching From Carvedilol to Carvedilol CR in Patients With HF and Post‐MI LVD. Two protocols for switching between carvedilol, a third-generation nonselective agent with vasodilation through alpha1 blockade, and a beta1-selective agent (e.g., metoprolol, atenolol) are described. 44, 49 The dose equivalencies for the HF algorithm were derived from both clinical experience and the degree of β 1 ‐blockade (heart rate lowering) that can be expected with each dose. Treatment of 4 mg daily: 40: Ramipril (Altace®) 2.5 mg daily: 20: Lisinopril (Prinivil®, Zestril®) 10 mg daily: 80: Quinapril (Accupril®) 10 mg daily: 40: Fosinopril (Monopril®) Consider extent of control and disease severity when switching. Important Considerations When Switching β‐Blockers. Diabetic nephropathy 150 mg once dailyb 300 mg once daily 300 mg 150/12.5 mg, 300/12.5 mg Losartan Hypertension 25 mg once dailya,b 50–100 mg once dailyb 100 mg 25 mg, 50 mg, 100 mg losartan/HCTZ: Diabetic nephropathy 50 mg once dailyb 50–100 mg once daily depending on BP 100 mg 50/12.5 mg, 100/25 mg Heart failure (60 years of age or older) 2003 Sep-Oct;9(5):271-8. doi: 10.1111/j.1527-5299.2003.02001.x. The merits of switching post‐MI patients with LVD from a non–evidence‐based β‐blocker such as atenolol or metoprolol tartrate have been published, and a practical algorithm for switching to carvedilol following IV β‐blocker administration or after initiation of an oral β‐blocker was discussed.49. Epub 2011 Dec 3. Experiences from the poststudy phase of COMET (the Carvedilol or Metoprolol European Trial), Pharmacokinetic and pharmacodynamic properties of a new controlled‐release formulation of metoprolol: a comparison with conventional tablets, Practical considerations of beta‐blockade in the management of the post‐myocardial infarction patient, Effect of metoprolol CR/XL in chronic heart failure: Metoprolol CR/XL Randomised Intervention Trial in Congestive Heart Failure (MERIT‐HF), Cardiovascular risk factors in hypertension: rationale and design of studies to investigate the effects of controlled‐release carvedilol on regression of left ventricular hypertrophy and lipid profile, https://doi.org/10.1111/j.1751-7133.2008.00013.x, Post‐myocardial infarction left ventricular dysfunction, Patients with mild to moderate heart failure (HF) who are not already on a β‐blocker (without contraindications) should be immediately started on metoprolol succinate (25 mg) or carvedilol controlled‐release (CR) (10 mg), Patients with severe HF or post‐myocardial infarction left ventricular dysfunction (MI LVD) (without contraindications) should be immediately started on carvedilol CR (10 mg in severe HF; 20 mg in post‐MI LVD), Patients currently taking carvedilol should be switched to carvedilol CR because of the potential for better adherence, Patients with HF taking a non–evidence‐based β‐blocker such as atenolol or metoprolol tartrate should be switched to carvedilol CR at an equivalent dose based on the algorithms provided, All patients should be stable prior to switching and should be counseled about the possibility of side effects precipitated by α‐blockade, HF patients with reactive airway disease should be preferentially started or switched to metoprolol succinate, Patients switched based on the recommended doses should always be closely monitored and then uptitrated to the highest recommended dose as tolerated every 3 to 10 days. Clipboard, Search History, and several other advanced features are temporarily unavailable. In a study of hypertensive diabetics (Glycemic Effect in Diabetes Mellitus: Carvedilol‐Metoprolol Comparison in Hypertensives [GEMINI]),40 all receiving renin‐angiotensin system blockers (either an ACE inhibitor or angiotensin receptor blocker), the average doses of metoprolol tartrate vs carvedilol needed to achieve similar blood pressure lowering were 128 mg and 17.5 mg twice daily, respectively. Disclosures: I would like to report the following relationships: research grant—Amgen, Biotronik, CHF Solutions, GSK, HFSA, Medtronic, Myogen, NIH, Orqis Medical, Otsuka Maryland, Paracor, and Scios; consultant/ speakers’ bureau—Amgen, AstraZeneca, Boehringer‐Ingelheim, CHF Solutions, GSK, Guidant, Medtronic, Merck, Pfizer, ResMed, Respironics, Scios, and St Jude Medical; advisory board member—CardioKine, CardioKinetix, CHF Solutions, Department of VA Cooperative Studies Program, Inovise, NIH, and Savacor; honoraria—AstraZeneca, Boehringer‐Ingelheim, GSK, Guidant, Medtronic, Merck, Pfizer, ResMed, Respironics, Scios, and St Jude Medical; editorial board involvement—Congestive Heart Failure, Current Cardiology Reviews, Current Heart Failure Reports, Expert Review of Cardiovascular Therapy, Journal Watch Cardiology, PACE–Pacing and Clinical Electrophysiology, The American Heart Hospital Journal, and The Journal of Heart Failure. It is reasonable to focus on carvedilol because it is widely used, is 1 of only 3 evidence‐based β‐blockers for the management of HF, and is the only β‐blocking agent approved by the FDA for the treatment of post‐MI LVSD. Commencement of cardioselective beta-blockers during hospitalisation for acute exacerbations of chronic obstructive pulmonary disease. CR indicates controlled‐release; IR, immediate‐release; ↓, decrease. A therapeutically equivalent drug may be dispensed following the development of objective interchange ... selection, the following factors should be considered: mechanism of action, adverse effect profile, dosing schedule, monitoring parameters, potential drug interactions, and cost. Medications that slow the heart rate - All beta blockers slow the heart rate. Low adherence rates, in both the long and short term, have been shown in post‐MI populations. beta-Blockers are used as if they were equivalent. Why did my GP switch me to a different beta-blocker? Dose Equivalents (mg/day) Ceftriaxone is the preferred third generation cephalosporin in adult patients. While rates of adherence with the prescribed carvedilol twice‐daily regimens in clinical trials were high, generally exceeding 80%,31 the rates of adherence in a real‐world setting are far below this number. Starting with the last question—whether the patient can adhere to the medication—conventional wisdom and a wealth of published literature (some cited above) suggest that many patients who currently receive carvedilol would benefit from switching to carvedilol CR.  |  Clin Ther. infusion 30 mg every 8 hours oral, equivalent to 1.2 mg/hour I.V. Metoprolol doses this high are rarely used in clinical practice, while the carvedilol dose falls within the usual dose range used to treat hypertension, HF, and post‐MI LVSD. It should also be noted that carvedilol and metoprolol succinate have never been compared directly with respect to metabolic effects in a clinical trial. Refer people who are taking high-dose diuretics (equivalent to 80 mg furosemide or more) to secondary care to initiate ARB treatment. (2) Is there a history of intolerance or poor response to a specific agent? Although quality monitoring (such as that performed by the Centers for Medicare & Medicaid Services) and cardiovascular (CV) quality performance‐improvement programs (such as the Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients With Heart Failure [OPTIMIZE‐HF])9 have helped to narrow these gaps, suboptimal application of evidence‐based, guideline‐recommended therapies persists. Dosing (Adults): Oral: initial: 100 mg orally twice a day.Usual: 200-400mg orally twice a day. An ongoing trial comparing the effect of carvedilol vs metoprolol succinate on lipid profile in patients with hypertension will also assess the mean change in blood pressure and heart rate after 6 months.51 Prior to those results, the best clinical advice may be to start a patient on a slightly lower dose of carvedilol CR to ensure that the patient tolerates the α‐blocking effects of carvedilol. Dosing (Adults): Oral: initial: 100 mg orally twice a day.Usual: 200-400mg orally twice a day. In the post‐MI patient with LVSD, once‐daily aspirin, clopidogrel (if indicated), and eplerenone can be used to round out the evidence‐based treatment regimen. Bisoprolol was developed to be more cardio-specific than atenolol.