Usual Adult Dose for Hypertension

Initial dose: 50 mg orally once a day
Maintenance dose: 50 to 100 mg orally once a day
Maximum dose: 100 mg per day

Comments:

• If desired response not achieved after 1 to 2 weeks, increase to 100 mg may be beneficial.
• Doses greater than 100 mg once a day did not result in significant additional antihypertensive effects.

Use: For the treatment of hypertension alone or in combination with other antihypertensive agents.

Usual Adult Dose for Angina Pectoris Prophylaxis

Initial dose: 50 mg orally once a day

• Increase to 100 mg orally once a day after 1 week if optimal response not achieved

Maintenance dose: 50 to 200 mg orally once a day
Maximum dose: 200 mg per day

Comments:

• Some patients may require 200 mg per day to attain optimal effect.

Use: For the long-term management of angina pectoris due to coronary atherosclerosis.

Usual Adult Dose for Angina Pectoris

Initial dose: 50 mg orally once a day

• Increase to 100 mg orally once a day after 1 week if optimal response not achieved

Maintenance dose: 50 to 200 mg orally once a day
Maximum dose: 200 mg per day

Comments:

• Some patients may require 200 mg per day to attain optimal effect.

Use: For the long-term management of angina pectoris due to coronary atherosclerosis.

Usual Adult Dose for Myocardial Infarction

50 mg orally twice a day or 100 mg orally once a day

Comments:

• If IV beta blockers are contraindicated or inappropriate, oral therapy should continue for at least 7 days post-myocardial infarction (MI).
• Treatment with beta blockers post MI should generally continue for 1 to 3 years if there are no contraindications.

Use: For the management of hemodynamically stable patients with definite or suspected acute myocardial infarction to reduce cardiovascular mortality.

Usual Geriatric Dose for Hypertension

Initial dose: Consider reducing the starting dose to 25 mg orally once a day

Renal Dose Adjustments

Creatinine clearance 15 to 35 mL/min: Maximum dose is 50 mg per day
Creatinine clearance less than 15 mL/min: Maximum dose is 25 mg per day

Hypertension:

• Initial dose: Consider reducing the starting dose to 25 mg orally once a day
• Assessment regarding efficacy should be made just prior to the next dose to ensure satisfactory blood pressure treatment

Liver Dose Adjustments

Use caution

Dose Adjustments

Bronchospastic disease:

• Use not recommended
• However, if use is necessary, consider an initial dose of 50 mg orally once a day and ensure a bronchodilator is available
• For higher doses, consider dividing dosage to avoid higher peak blood levels associated with once a day dosing

Cessation of therapy:

• Abrupt discontinuation should be avoided; taper therapy gradually
• If withdrawal symptoms occur, therapy may be temporarily reinstituted

Precautions

US BOXED WARNING:

• CESSATION OF THERAPY: Increased risk of severe angina exacerbation, myocardial infarction, and ventricular arrhythmia was observed after therapy was abruptly discontinued in patients with angina or coronary artery disease. If discontinuation of this drug is planned, patients should be gradually tapered off, closely monitored, and advised to limit physical activity.

NARROW THERAPEUTIC INDEX:

• This drug should be considered a narrow therapeutic index (NTI) drug as small differences in dose or blood concentrations may lead to serious therapeutic failures or adverse drug reactions.

Recommendations:

• Generic substitution should be done cautiously, if at all, as current bioequivalence standards are generally insufficient for NTI drugs.
• Additional and/or more frequent monitoring should be done to ensure receipt of an effective dose while avoiding unnecessary toxicities.

Safety and efficacy have not been established in patients younger than 18 years.

Consult WARNINGS section for additional precautions.

Dialysis

25 or 50 mg orally after each dialysis session; blood pressure should be closely monitored as a marked fall in blood pressure may occur.

Other Comments

Administration advice:

• Take orally
• If a dose is missed, take it as soon as remembered; if it is close to the next dose, skip the missed dose; do not double the dose

General:

• In a clinical study, elderly patients (n=2644) with systolic blood pressure less than 120 mmHg may be less likely to benefit from this drug.
• If discontinuation is necessary, gradually taper over 2 weeks, monitor for the signs and symptoms of heart failure and limit exercise.
• Inform healthcare professionals when using this drug, especially if surgery is planned.
• This drug interferes with allergic reaction modulation and may increase the risk of anaphylactic reactions; additionally, patients may be refractory to epinephrine in treatment for anaphylactic reactions.

Monitoring:

• Heart rate and blood pressure
• Signs and symptoms of heart failure (e.g., shortness of breath, edema, and weight gain), especially in at risk patients
• Signs and symptoms of angina in patients with coronary heart disease, especially during withdrawal

Patient advice:

• Warn patients to avoid interruptions or abrupt discontinuation of this drug.
• Instruct the patient to notify their healthcare provider upon signs and symptoms of angina, bradycardia, hypotension, or heart failure (e.g., shortness of breath, edema, and weight gain).
• Avoid driving or operating machinery until the full effects are known.
• Advise patient to speak to healthcare provider if pregnant, intend to become pregnant, or are breastfeeding.
• Patients with diabetes should be informed that this drug may mask hypoglycemic reactions.

Frequently asked questions

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