Nadolol is used for the management of hypertension and angina. Nadolol has been used for the management of supraventricular tachyarrhythmias (e.g., atrial flutter or fibrillation) and for the prophylaxis of sinus headache.
The choice of a β-adrenergic blocking agent (β-blocker) depends on numerous factors, including pharmacologic properties (e.g., relative β-selectivity, intrinsic sympathomimetic activity, membrane-stabilizing activity, lipophilicity), pharmacokinetics, intended use, and adverse effect profile, as well as the patient's coexisting disease states or conditions, response, and tolerance. While specific pharmacologic properties and other factors may appropriately influence the choice of a β-blocker in individual patients, evidence of clinically important differences among the agents in terms of overall efficacy and/or safety is limited. Patients who do not respond to or cannot tolerate one β-blocker may be successfully treated with a different agent.
In the management of hypertension or chronic stable angina pectoris, many clinicians prefer to use low dosages of a β1-selective adrenergic blocking agent (e.g., atenolol, metoprolol), rather than a nonselective agent like nadolol, in patients with chronic obstructive pulmonary disease (COPD) or insulin-dependent diabetes mellitus. However, selectivity of these agents is relative and dose dependent. Some clinicians also will recommend using a β1-selective agent or pindolol (because of its ISA), rather than a nonselective agent, for the management of hypertension or angina pectoris in patients with peripheral vascular disease, but there is no evidence that the choice of β-blocker substantially affects efficacy.
Nadolol is used alone or in combination with other classes of antihypertensive agents in the management of hypertension. Although β-blockers were previously considered a drug of choice for the initial management of hypertension, most current guidelines no longer recommend these drugs as first-line therapy because of the lack of established superiority over other recommended drug classes and at least one study demonstrating that they may be less effective than angiotensin II receptor antagonists in preventing cardiovascular death, myocardial infarction, or stroke. However, β-blockers may still be considered in hypertensive patients who have a compelling indication (e.g., prior myocardial infarction, ischemic heart disease, heart failure) for their use or as add-on therapy in those who do not respond adequately to the preferred drug classes (angiotensin-converting enzyme [ACE] inhibitors, angiotensin II receptor antagonists, calcium-channel blockers, or thiazide diuretics). and
In general, black hypertensive patients tend to respond better to monotherapy with thiazide diuretics or calcium-channel blocking agents than to monotherapy with β-blockers. Although β-blockers have lowered blood pressure in all races studied, monotherapy with these agents has produced a smaller reduction in blood pressure in black hypertensive patients; however, this population difference in response does not appear to occur during combined therapy with a β-blocker and a thiazide diuretic. and
In contrast to many other antihypertensive agents, nadolol and other β-blockers lower blood pressure equally well in the upright or supine position. The drug appears to be safe and effective in the treatment of hypertension in patients with renal damage. Nadolol reduces blood pressure in patients with low, normal, or elevated plasma renin levels. Tolerance to the hypotensive effect of nadolol apparently does not occur during long-term treatment.
For additional information on the role of β-blockers in the management of hypertension, and . For information on overall principles and expert recommendations for treatment of hypertension, .
Chronic Stable Angina
Nadolol is used for the long-term prophylactic management of chronic stable angina pectoris and is as effective as other β-blockers in angina patients. Conventional measures in the management of angina pectoris are aimed at reducing the frequency, duration, and severity of attacks, and include discontinuance of smoking, weight control, rest, avoidance of precipitating circumstances (e.g., eating heavy meals, getting emotionally upset, performing strenuous exercise, exposure to cold air) and, if possible, treatment of the underlying cause. Like other β-adrenergic blockers, nadolol may reduce the frequency of anginal attacks in patients who suffer frequent attacks, allow a decrease in nitrate dosage, and increase the patients' exercise tolerance. Some authorities state that β-blockers are the anti-ischemic drugs of choice in geriatric patients with stable angina.
Combination therapy with a β-blocker and a nitrate appears to be more effective than either drug alone because β-blockers attenuate the increased sympathetic tone and reflex tachycardia associated with nitrate therapy while nitrate therapy (e.g., nitroglycerin) counteracts the potential increase in left-ventricular volume and end-diastolic pressure and wall tension associated with a decrease in heart rate. Combined therapy with a β-blocker and a slow-release or long-acting dihydropyridine-derivative calcium-channel blocker also may be useful because the tendency to develop tachycardia with the calcium-channel blocker is counteracted by the β-blocker. However, caution should be exercised in the concomitant use of β-blockers and the nondihydropyridine calcium-channel blockers verapamil or diltiazem because of the potential for marked fatigue (with high-dose verapamil or diltiazem), extreme bradycardia, or atrioventricular (AV) block.
(See Drug Interactions: Cardiovascular Drugs.)
Unstable Angina and Non-ST-Segment Elevation Myocardial Infarction
A β-blocker is used as part of the standard therapeutic measures for managing unstable angina or non-ST-segment elevation myocardial infarction; these measures also include therapy with aspirin and/or clopidogrel, low-molecular weight or unfractionated heparin, and nitrates (e.g., nitroglycerin) followed by either conservative medical management or early aggressive management, such as angiographic evaluation and revascularization procedures (e.g., percutaneous coronary intervention [PCI], coronary artery bypass grafting [CABG], coronary artery stent implantation) as required. The American College of Cardiology (ACC) and the American Heart Association (AHA) recommend administration of an IV β-blocker followed by oral β-blocker therapy for patients with unstable angina at high risk of death or nonfatal myocardial infarction (i.e., patients with at least one of the following features: accelerating tempo of ischemic symptoms in preceding 48 hours; prolonged ongoing pain at rest; angina at rest with transient ST-segment changes exceeding 0.5 mV; new or presumed new bundle branch block; sustained ventricular tachycardia; hypotension, bradycardia, or tachycardia; age exceeding 75 years; elevated serum cardiac markers [e.g., troponin T or I concentrations exceeding 0.1 ng/mL]; new or worsening mitral regurgitation murmur; S3 gallop or new/worsening rales; or pulmonary edema likely resulting from ischemia) who do not have contraindications to these drugs; oral β-blocker therapy is recommended for lower-risk patients. β-Blockers without intrinsic sympathomimetic activity (e.g., metoprolol, atenolol, propranolol, esmolol) are preferable in the management of unstable angina. For additional information on the use of β-blockers and other drug therapy in the management of unstable angina and non-ST-segment elevation myocardial infarction, see
Nadolol has been used in patients with atrial flutter or fibrillation for the management of frequent ventricular premature complexes, paroxysmal atrial tachycardia, and sinus tachycardia and to decrease heart rate.
Nadolol has been used for the prophylaxis of migraine headache. The US Headache Consortium states that there is some evidence of efficacy for this indication from randomized clinical trials of the drug and that clinical experience suggests that nadolol produces clinically important improvement in most patients receiving the drug for migraine prophylaxis.