General

Pronunciation:
nay-doe-lole

Trade Name(s)

• Corgard

Ther. Class.

antianginals

antihypertensives

Pharm. Class.

beta blockers

Indications

• Hypertension.
• Angina pectoris.

Unlabeled Use(s):

• Arrhythmias.
• Migraine prophylaxis.
• Tremors (essential, lithium-induced, parkinsonian).
• Aggressive behavior.
• Antipsychotic-associated akathisia.
• Situational anxiety.
• Esophageal varices.

Action

Blocks stimulation of beta₁  (myocardial) and beta₂  (pulmonary, vascular, and uterine) receptor sites.

Therapeutic Effect(s):

Decreased heart rate and BP.

Pharmacokinetics

Absorption: 30% absorbed after oral administration.

Distribution: Minimal penetration of the CNS.

Metabolism and Excretion: 70% excreted unchanged by the kidneys.

Half-life: 10–24 hr (↑ in renal impairment).

TIME/ACTION PROFILE (anithypertensive effects)

Contraindication/Precautions

Contraindicated in:

• Decompensated HF;
• Pulmonary edema;
• Cardiogenic shock;
• Bradycardia or heart block;
• Lactation:  Lactation.

Use Cautiously in:

• Renal impairment (CCr <50 mL/min);
• Hepatic impairment;
• Pulmonary disease (including asthma);
• Diabetes mellitus (may mask signs of hypoglycemia);
• Thyrotoxicosis (may mask symptoms);
• Patients with a history of severe allergic reactions (intensity of reactions may be ↑);
• OB:   Crosses the placenta and may cause fetal/neonatal bradycardia, hypotension, hypoglycemia, or respiratory depression;
• Pedi:   Safety and effectiveness not established in children;
• Geri:  Older adults may have ↑ sensitivity to beta-blockers; initial dose ↓ recommended.

Adverse Reactions/Side Effects

CV: ARRHYTHMIAS, BRADYCARDIA, HF, orthostatic hypotension, peripheral vasoconstriction, PULMONARY EDEMA

Derm: itching, rash

EENT: blurred vision, dry eye, nasal stuffiness

Endo: hyperglycemia, hypoglycemia

GI: constipation, diarrhea, nausea

GU: erectile dysfunction, ↓ libido

MS: arthralgia, back pain, muscle cramps

Neuro: fatigue, weakness, anxiety, depression, dizziness, drowsiness, insomnia, memory loss, mental status changes, nightmares, paresthesia

Resp: bronchospasm, wheezing

Misc: drug-induced lupus syndrome

* CAPITALS indicate life-threatening.
Underline indicate most frequent.

Interactions

Drug-Drug

•  General anesthesia,  IV   phenytoin,  diltiazem, and  verapamil  may cause additive myocardial depression.
• Additive bradycardia may occur with  digoxin.
• Additive hypotension may occur with other  antihypertensives, acute ingestion of  alcohol, or  nitrates.
• Concurrent use with  amphetamines,  cocaine,  ephedrine,  epinephrine,  norepinephrine,  phenylephrine, or  pseudoephedrine  may result in unopposed alpha-adrenergic stimulation (excessive hypertension, bradycardia).
• Concurrent use with  clonidine  ↑ hypotension and bradycardia.
• Concurrent  thyroid  administration may ↓ effectiveness.
• May alter the effectiveness of  insulins  or  oral hypoglycemic agents  (dosage adjustments may be necessary).
• May ↓ the effectiveness of  theophylline.
• May ↓ the effects of  dopamine  or  dobutamine.
• Use cautiously within 14 days of  MAO inhibitor   therapy  (may result in hypertension).
• Concurrent  NSAIDs  may ↓ antihypertensive action.

Route/Dosage

PO (Adults): Antianginal: 40 mg once daily initially; may ↑ by 40–80 mg/day every 3–7 days as needed (up to 240 mg/day).  Antihypertensive: 40 mg once daily initially; may ↑ by 40–80 mg/day every 7 days as needed (up to 320 mg/day).

Renal Impairment 
PO (Adults): CCr 31–50 mL/min: ↑ dosing interval to 24–36 hr;  CCr 10–30 mL/min: ↑ dosing interval to 24–48 hr;  CCr <10 mL/min: ↑ dosing interval to 40–60 hr.

Availability (generic available)

Tablets: 20 mg, 40 mg, 80 mg, 160 mg 

Assessment

• Monitor BP and pulse frequently during dose adjustment and periodically during therapy. Assess for orthostatic hypotension when assisting patient up from supine position.
• Monitor intake and output ratios and daily weight. Assess patient routinely for evidence of fluid overload (peripheral edema, dyspnea, rales/crackles, fatigue, weight gain, jugular venous distention).
• Hypertension: Check frequency of refills to determine compliance.
• Angina: Assess frequency and characteristics of angina periodically during therapy.

Lab Test Considerations:

May cause increased BUN, serum lipoprotein, potassium, triglyceride, and uric acid levels.

• May cause increased ANA titers.
• May cause increase in blood glucose levels.

Monitor patients receiving beta-blockers for signs of overdose (bradycardia, severe dizziness or fainting, severe drowsiness, dyspnea, bluish fingernails or palms, seizures). Notify physician or other health care professional immediately if these signs occur.

Implementation

• Discontinuation of concurrent clonidine should be done gradually, with beta-blocker discontinued first; then, after several days, discontinue clonidine.
• PO Take apical pulse before administering. If <50 bpm or if arrhythmia occurs, withhold medication and notify physician or other health care professional.
  • May be administered with food or on an empty stomach.
  • Tablets may be crushed and mixed with food.

Patient/Family Teaching

• Instruct patient to take medication exactly as directed, at the same time each day, even if feeling well; do not skip or double up on missed doses. Take missed doses as soon as possible up to 8 hr before next dose. Abrupt withdrawal may precipitate life-threatening arrhythmias, hypertension, or myocardial ischemia.
• Advise patient to ensure that enough medication is available for weekends, holidays, and vacations. A written prescription may be kept in wallet for emergencies.
• Teach patient and family how to check pulse and BP. Instruct them to check pulse daily and BP biweekly. Advise patient to hold dose and contact health care professional if pulse is <50 bpm or if BP changes significantly.
• May cause drowsiness or dizziness. Caution patients to avoid driving or other activities that require alertness until response to the drug is known.
• Advise patients to make position changes slowly to minimize orthostatic hypotension, especially during initiation of therapy or when dose is increased.
• Caution patient that this medication may increase sensitivity to cold.
• Instruct patient to consult health care professional before taking any OTC medications, especially cold preparations, concurrently with this medication.
• Patients with diabetes should closely monitor blood glucose, especially if weakness, malaise, irritability, or fatigue occurs. Medication may mask some signs of hypoglycemia, but dizziness and sweating may still occur.
• Advise patient to notify health care professional if slow pulse, difficulty breathing, wheezing, cold hands and feet, dizziness, confusion, depression, rash, fever, sore throat, unusual bleeding, or bruising occurs.
• Instruct patient to inform health care professional of medication regimen before treatment or surgery.
• Advise patient to carry identification describing disease process and medication regimen at all times.
• Rep:  Advise females of reproductive potential to notify health care professional if pregnancy is planned or suspected or if breastfeeding. Monitor neonates of women taking nadolol for symptoms of hypotension, bradycardia, hypoglycemia, and respiratory depression and manage accordingly. Monitor breastfed infants for bradycardia, dry mouth, skin or eyes, and diarrhea or constipation.
• Hypertension: Reinforce the need to continue additional therapies for hypertension (weight loss, sodium restriction, stress reduction, regular exercise, moderation of alcohol consumption, and smoking cessation). Medication controls but does not cure hypertension.
• Angina: Caution patient to avoid overexertion with decrease in chest pain.

Evaluation/Desired Outcomes

• Decrease in BP.

• Reduction in frequency of angina.

  • Increase in activity tolerance. May require up to 5 days before therapeutic effects are seen.