Using β-Blockers in Clinical Practice

As a clinical pharmacist, you will be asked about the use of β-adrenoceptor antagonists in clinical practice.

Don't hesitate to start a β-blocker in an outpatient setting when appropriate. But consider inpatient initiation for elderly or frail patients or those with more advanced disease. Start low and go slow—initiate at a low dose and up-titrate every 2–4 weeks, ensuring the pulse remains > 50/minute and systolic BP stays > 90mmHg.

Be cautious with first-degree heart block and avoid use in higher-degree heart block. Never start a β-blocker in decompensated heart failure (e.g., pulmonary or peripheral edema, or patients in the ICU on inotropes).

NPS-adv

Push the dose up to the maximum tolerated level. If a patient on a β-blocker is admitted with decompensated heart failure, try to continue the current dose if possible or reduce it by one decrement. Only stop the β-blocker if absolutely necessary. Don't confuse metoprolol succinate with metoprolol tartrate—the evidence base is for the succinate (Seloken Zoc) form, not the shorter-acting tartrate (Lopressor).

---

References

1. Gardner, R.S., McDonagh, T.A. and Walker, N.L. (2014). Pharmacological management. Heart Failure, [online] pp.51–62. https://doi.org/10.1093/med/9780199674152.003.0005.
2. Farzam K, Jan A. Beta Blockers. [Updated 2023 Aug 22]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK532906.

---

‌