Do some beta blockers cause less fatigue than others?
November 21, 2012 9:52 AM   Subscribe

Do some beta blockers tend to have more side effects than others?

My endocrinologist prescribed Bystolic (nebivolol) to prevent my migraines and lower my blood pressure. She said it has fewer side effects than other beta blockers. Since I have serious problems with fatigue due to another condition, she said I should not even bother with other beta blockers that have more fatigue as a side effect.

I asked my primary care physician about it, suspecting my endo might be being unintentionally influenced by drug salespeople, but my PCP agreed that Bystolic is less likely to cause fatigue and that I should keep taking it even though it costs more than other beta blockers.

Bystolic has been treating me well. The amount of excess fatigue is acceptable, and I'm not getting nearly as many migraines. As a bonus, I feel much calmer on the beta blocker. I take it at bedtime, 10 mg a day.

Unfortunately, now my health insurer has decreed that they will not pay for Bystolic any more. A three-month supply costs $250. They advise me to try a different drug that they do cover. I guess I should at least give it a try. The drugs they recommend as alternatives include acebutolol, atenolol, betapace, betaxolol, bisoprolol, metoprolol, nadolol, pindolol, propranolol, and timolol, as well as several others that are clearly unsuitable.

Obviously I am going to ask my doctors for their advice again, but I'm interested in whether there is any general feeling that some beta blockers tend to cause less in the way of side effects, such as fatigue, than others. Is this widely known, or just what the Bystolic salesmen are saying? Even though it varies from person to person, it seems likely that some drugs really are more fatigue-inducing than others, for most people.

Wikipedia says that atenolol does not pass through the blood brain barrier so it avoids some central nervous system side effects. Does atenolol cause less fatigue than other beta blockers, as a result? It says that propranolol and metoproplol have a high penetration across the blood brain barrier. Does this make a difference to how commonly they have unacceptable side effects? Why is Bystolic supposed to have fewer side effects? Is it just because it's not out of patent yet?
posted by artistic verisimilitude to Health & Fitness (7 answers total) 4 users marked this as a favorite
I was on a number of beta blockers and HCT for high blood pressure. Finding one on the formulary, that didn't give me some weird side effect was a freaking nightmare.

I'm on Micardis HCT and instead of being a beta blocker, it's an angiotensin II antagonist (whatever THAT is.)

On some formularies, it's expensive. On my current insurance my co-pay is $12.

Take your entire formulary into your doctor and discuss your options. You can also appeal your insurer's decision, but you'll need your doctor on-board to say that THIS drug is the one and only drug for you.
posted by Ruthless Bunny at 10:21 AM on November 21, 2012 [1 favorite]

FWIW, I've been on a daily low dose of atenolol for forever for HBP (thanks, genetics!) with no ill effects. It's literally been 15 years, at least. I don't experience any fatigue from it AFAIK, though I may have experienced a little in the first week or two of starting it. Obviously, everyone is different, but I have nothing bad to say about atenolol - atenolol and the above-mentioned Micardis HCT are wonder drugs in my opinion -- all good/no bad for this MeFite. (IANAD; TINMA).
posted by mosk at 10:52 AM on November 21, 2012 [1 favorite]

Beta-blockers as a class inhibit the binding of the neurotransmitters norepinephrine and epinephrine to beta-adrenoceceptors (neurotransmitter receptors on the surface of cells), However, individual beta-blockers vary a lot in terms of their effects. Some of them block all beta receptors, some of them only block one type of receptor but not others, some block one type but actually increase activity at other types, some are long-acting/short acting, some cross the blood-brain barrier, etc. Bystolic is in a newer class that also has some effect on dilating blood vessels in addition to selectively blocking beta-1 receptors.

So yes, it does matter to some extent. Some beta-blockers have been better studied in migraine as well. Propranolol was sort of the classic migraine beta-blocker for a long time but has now largely been replaced by meds that are better tolerated. Atenolol was originally developed as a version of propranolol that would have fewer side effects (attenuated--thus the name).

Discuss with your doctor--one option is to try switching to a medication that's covered, but the alternative is to ask your doc if he/she is willing to ask the insurance company for prior authorization for Bystolic, which is basically a request to the insurance company to cover a medication because it's better for you for XYZ reason than the meds on their formulary. Insurance companies make it a giant pain in the neck to do this for obvious reasons, but it is usually possible. Sometimes they insist that you try a covered medication first but others will accept "You're doing well on this medication that you're already taking and you have legitimate concerns about fatigue" and cover it.
posted by The Elusive Architeuthis at 12:23 PM on November 21, 2012 [2 favorites]

First-line therapy for migraine prophylaxis is propranolol or timolol. It's true that these drugs are more likely to cause CNS side effects, though the issue is not just BBB permeability (nebivolol is BBB-permeable as well) but selectivity. Propranolol and timolol are nonselective beta-blockers, which results in more side effects. Nebivolol, in contrast, does not effect B2 receptors, but still causes vasodilation via effects on nitric oxide (whereas other selective beta-blockers do not).

Your options are 1) try propranolol or timolol and see how well you tolerate the side effects, 2) try another selective beta-blocker, though realize that these are not specifically approved for migraine prophylaxis (neither is nebivolol, for that matter) and may not be effective due to a lack of vasodilatory effects, or 3) treat your migraine and blood pressure as two separate problems with two separate drugs. It goes without saying that your doctor should advise you in this decision.
posted by dephlogisticated at 1:07 PM on November 21, 2012 [1 favorite]

I was on metoprolol for sinus tachycardia. I am currently off beta-blockers for a month or so, because the side effects from the metoprolol were starting to become intrusive (fatigue, mainly). My cardiologist specified that, if no beta-blockers doesn't work out for me, there are other beta-blockers to try with fewer side effects.

So, anecdotally from my doctor, it is true that not all beta-blockers are created equal.
posted by lydhre at 1:28 PM on November 21, 2012 [1 favorite]

Definitely, some drugs cause different side effects than others. You may find this database helpful:

The database contains both clinical trial data and post-marketing surveillance data. The clinical trial data are much more reliable. Nebivolol has only postmarketing surveillance data available on the potential side effects (no incidence rates available).

On the other hand, atenolol has an up to 13% incidence rate for fatigue vs. placebo. And propanalol has a 3.4% incidence rate for fatigue vs. placebo.
posted by acridrabbit at 5:12 PM on November 21, 2012

I agree that atenolol causes fatigue and cognitive impairment.

You didn't mention whether your endo prescribed nebivolol because of its supposedly better vasodilation effects, blood pressure control, heart problems, or the off-label reasons such as stage fright and palpitations? It sounds like migraine relief and anxiety control are more to you than lowering blood pressure?

Now if you want to try another beta-blocker, then you'd probably want to ask for something on your drug plan's formulary that is β1-selective (as nebivolol is). Propranolol and Timolol are licensed for migraines, but they're non-selective and have side effects that nebivolol doesn't.

If you want to try another drug class, you might want to talk to your doc about calcium channel blockers or angiotensin receptor blockers that have anti-anxiety effects as well.

(paper on potential anti-anxiety effects of ARBs)
posted by magic_skyjuice at 9:05 PM on July 24, 2013

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