Atenolol

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Atenolol on Prescriptsy

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Atenolol is a cardioselective beta-blocker widely prescribed across the NHS for the management of high blood pressure (hypertension), angina pectoris and certain cardiac arrhythmias.

It belongs to the class of beta-1 adrenoceptor antagonists and works by reducing the rate and force of heart contraction, thereby lowering blood pressure and decreasing the oxygen demand of the heart muscle.

Atenolol has been in clinical use in the United Kingdom since 1976 and remains one of the most commonly dispensed cardiovascular medicines.

Hypertension affects approximately 1 in 3 adults in England, and the condition is a leading modifiable risk factor for stroke, myocardial infarction and chronic kidney disease.

While NICE guidelines (NG136) position beta-blockers as fourth-line therapy for uncomplicated hypertension behind ACE inhibitors, ARBs and calcium channel blockers, atenolol retains important first-line roles in patients with concurrent angina, certain arrhythmias, and those with specific clinical indications for heart rate control.

This product information has been reviewed by Dr.

Claire Phipps, MBBS MRCGP (GMC 7014359), and provides a detailed clinical overview of atenolol covering its mechanism of action, licensed indications, dosing, side effects, important warnings and practical guidance for patients prescribed this medicine in the UK.

Essential safety information about atenolol

Atenolol must never be stopped suddenly. Abrupt withdrawal of beta-blocker therapy can cause dangerous rebound effects including rapid heart rate, severe worsening of angina, and hypertensive crisis.

If your prescriber decides to stop atenolol, the dose will be reduced gradually over 1 to 2 weeks. Three situations require urgent medical attention:

• Resting heart rate below 50 beats per minute with dizziness, near-fainting or breathlessness, contact your GP urgently or call NHS 111
• New or worsening breathlessness, ankle swelling, or unexplained rapid weight gain suggesting heart failure, seek same-day medical review
• Severe allergic reaction with facial swelling, throat tightness or widespread rash, call 999 immediately

Atenolol is a prescription-only medicine (POM) and should only be taken as directed by your prescriber. Do not share your medication with others.

Keep your regular review appointments so your GP can monitor blood pressure, heart rate and overall cardiovascular health.

Always carry a list of your current medicines when attending any medical appointment or hospital visit.

What is atenolol and how does it work

Atenolol is a synthetic beta-1 selective adrenoceptor antagonist, commonly known as a cardioselective beta-blocker.

It works by blocking the effects of adrenaline and noradrenaline on beta-1 receptors concentrated in the heart muscle.

When these receptors are blocked, the heart beats more slowly and with less force, which reduces blood pressure, decreases the heart's oxygen consumption, and helps control abnormal heart rhythms.

The selectivity of atenolol for beta-1 receptors over beta-2 receptors is clinically significant. Beta-2 receptors are found predominantly in the airways and blood vessels.

By preferentially blocking beta-1 receptors, atenolol is less likely than non-selective beta-blockers (such as propranolol) to cause bronchospasm or peripheral vasoconstriction.

However, this selectivity is dose-dependent and not absolute, which is why caution remains necessary in patients with asthma or severe peripheral vascular disease.

Atenolol is hydrophilic (water-soluble), which means it does not cross the blood-brain barrier as readily as lipophilic beta-blockers.

This accounts for the lower incidence of central nervous system side effects such as nightmares and depression compared with propranolol.

The drug is absorbed from the gastrointestinal tract with a bioavailability of approximately 50%, reaches peak plasma concentration within 2 to 4 hours, and has an elimination half-life of 6 to 9 hours.

It is excreted largely unchanged by the kidneys, requiring dose adjustment in patients with significant renal impairment.

Licensed indications for atenolol in the UK

Hypertension

Atenolol is licensed for the management of essential hypertension in adults.

According to the BNF and NICE hypertension guidelines (NG136, updated 2022), beta-blockers are recommended as step 4 treatment for resistant hypertension, or earlier in the pathway when there is a specific indication such as heart rate control, intolerance to first-line agents, or pregnancy planning considerations.

The usual dose range for hypertension is 25 to 100mg once daily, with most patients controlled on 50mg.

Blood pressure targets under current NICE guidance are below 140/90 mmHg in clinic (or below 135/85 mmHg on home monitoring) for adults under 80, and below 150/90 mmHg for those aged 80 and over.

Angina pectoris

Atenolol is an established first-line treatment for stable angina pectoris.

Beta-blockers reduce the frequency and severity of anginal episodes by lowering heart rate and myocardial oxygen demand, particularly during physical exertion or emotional stress.

The dose for angina is typically 50 to 100mg once daily.

NICE guideline CG126 recommends beta-blockers or calcium channel blockers as initial antianginal therapy, with the choice guided by comorbidities, contraindications and patient preference.

Cardiac arrhythmias

Atenolol is used in the management of supraventricular tachycardia, atrial fibrillation with fast ventricular response, and other arrhythmias where heart rate control is the therapeutic goal.

In atrial fibrillation, NICE guideline NG196 recommends beta-blockers as a first-line rate-control strategy.

Atenolol provides a convenient once-daily option for rate control, though bisoprolol is more commonly initiated in current UK practice.

The dose for arrhythmia management is 50 to 100mg daily.

Acute myocardial infarction

Atenolol has a historical licence for early intervention in acute myocardial infarction, where intravenous dosing followed by oral maintenance was shown to reduce infarct size and early mortality in the ISIS-1 trial.

Current practice has moved towards using beta-blockers in the post-infarction period for secondary prevention, typically initiated once the patient is haemodynamically stable. Specialist guidance applies in acute settings.

Dosing guidance for atenolol

The standard oral dose of atenolol for adults is 50mg once daily , taken in the morning with or without food.

For hypertension, treatment may be initiated at 25mg in patients who are elderly, have mild disease, or are at risk of hypotension.

The dose can be increased to 100mg daily after an adequate trial period of at least 2 to 4 weeks if blood pressure remains above target.

For angina, the maintenance dose is usually 50 to 100mg once daily, adjusted according to symptom control and exercise tolerance.

For arrhythmia rate control, 50 to 100mg daily is typical, with the dose guided by resting and ambulatory heart rate monitoring.

Atenolol dosing in renal impairment follows BNF guidance: no adjustment is needed for eGFR above 35 ml/min, but the maximum dose should be reduced to 50mg daily for eGFR 15 to 35, and to 25mg daily or alternate-day dosing for eGFR below 15.

Atenolol is removed by haemodialysis, so a supplemental dose may be required after dialysis sessions. No specific hepatic dose adjustment is needed as atenolol undergoes minimal liver metabolism.

Elderly patients may be more sensitive to the bradycardic and hypotensive effects. Starting at 25mg with gradual titration is prudent. Atenolol is not routinely recommended for children, though specialist paediatric cardiologists may prescribe it off-label for specific indications.

Side effects of atenolol

Common side effects

The most frequently reported side effects of atenolol are related to its pharmacological action of slowing the heart and reducing sympathetic drive.

Fatigue and cold extremities are the most common complaints, affecting up to 10-15% of patients. Four groups of commonly encountered effects:

• Cardiovascular: bradycardia (slow pulse), cold hands and feet, postural dizziness, and occasional worsening of Raynaud phenomenon
• Neurological: tiredness, headache, sleep disturbance including vivid dreams, and reduced exercise tolerance
• Gastrointestinal: nausea, abdominal discomfort, and altered bowel habit
• Metabolic: potential masking of hypoglycaemic symptoms in patients with diabetes, particularly sweating and tachycardia

Less common and serious side effects

Less common effects include depression, erectile dysfunction, and exacerbation of psoriasis. Bronchospasm may occur even with cardioselective agents, particularly in patients with unrecognised airway reactivity.

Heart block progression and severe bradycardia are rare but require prompt medical assessment. Hypersensitivity reactions including rash, pruritus, and very rarely angioedema have been reported.

If you experience significant breathlessness, ankle swelling, fainting, a resting pulse consistently below 50bpm, or signs of severe allergic reaction, seek medical attention immediately.

Contact NHS 111 for non-emergency advice or call 999 in an emergency. Report suspected adverse reactions to the MHRA via the Yellow Card Scheme at yellowcard.mhra.gov.uk .

Important warnings and precautions

Atenolol is contraindicated in the following conditions: uncontrolled heart failure, cardiogenic shock, severe bradycardia (heart rate below 45-50bpm), second- or third-degree atrioventricular block, sick sinus syndrome without a pacemaker, untreated phaeochromocytoma, severe peripheral arterial disease, metabolic acidosis, and known hypersensitivity to atenolol or any excipient.

Caution is required in patients with compensated heart failure (beta-blockers may be beneficial under specialist supervision using a start-low-go-slow approach), first-degree heart block, diabetes mellitus (beta-blockers mask some warning signs of low blood sugar), Prinzmetal (vasospastic) angina, myasthenia gravis, and patients undergoing general anaesthesia.

Inform your anaesthetist that you are taking a beta-blocker before any planned surgery.

Drug interactions of clinical importance include verapamil and diltiazem (concurrent use can cause profound bradycardia, heart block, and hypotension), clonidine (beta-blocker should be withdrawn gradually before stopping clonidine to prevent rebound hypertension), insulin and sulfonylureas (impaired glycaemic awareness), non-steroidal anti-inflammatory drugs (reduced antihypertensive effect), digoxin (additive bradycardia), and sympathomimetic agents including adrenaline.

Always inform your prescriber of all medications, including those bought over the counter.

Atenolol in pregnancy and breastfeeding

Atenolol is generally avoided in pregnancy. Published data have linked its use, particularly in early pregnancy and throughout gestation, to intrauterine growth restriction and low birth weight.

Neonatal bradycardia, hypoglycaemia, and respiratory depression have been reported when beta-blockers are used close to delivery.

NICE guideline NG133 recommends labetalol as the preferred beta-blocker in pregnancy-related hypertension , with nifedipine and methyldopa as alternatives.

Atenolol is excreted into breast milk in significant concentrations relative to maternal plasma.

Monitoring the breastfed infant for signs of beta-blockade (slow heart rate, poor feeding, lethargy) is advisable if atenolol use is continued during breastfeeding.

Specialist advice should be sought from the UK Drugs in Lactation Advisory Service (UKDILAS) or the Breastfeeding Network if needed.

Practical considerations for UK patients

Atenolol is a prescription-only medicine dispensed on NHS or private prescription. In England, the standard NHS prescription charge is 9.90 pounds per item.

Prescriptions are free of charge in Scotland, Wales, and Northern Ireland.

If you have a long-term condition requiring multiple regular prescriptions, a Prescription Prepayment Certificate (PPC) may offer savings.

Atenolol is available as a generic medicine and is one of the lowest-cost cardiovascular drugs on the NHS Drug Tariff.

Storage: keep atenolol tablets in the original packaging, below 25 degrees Celsius, protected from light and moisture. Keep out of reach of children.

Do not use after the expiry date printed on the pack.

Return unused or expired tablets to your pharmacy for safe disposal, do not flush them down the toilet or put them in household waste.

Sources and further reading

• Electronic Medicines Compendium (EMC), Atenolol SmPC: medicines.org.uk/emc
• British National Formulary (BNF), Atenolol monograph: bnf.nice.org.uk
• NICE Guideline NG136, Hypertension in adults: nice.org.uk/guidance/ng136
• NICE Guideline CG126, Stable angina: nice.org.uk/guidance/cg126
• NICE Guideline NG196, Atrial fibrillation: nice.org.uk/guidance/ng196
• NHS, Beta-blockers: nhs.uk/medicines/atenolol
• MHRA Yellow Card Scheme: yellowcard.mhra.gov.uk