Beta blockers may be considered as initial therapy for hypertension particularly if intolerant or C/I to ACEI/ARB for:
• younger people (under 55)
• women of childbearing age
• people with evidence of increased sympathetic drive
• at Step 4 if further diuretic therapy is not tolerated, C/I or ineffective
Evidence suggests the combination of beta-blocker and thiazide increases risk of Type 2 DM and this is generally considered to be dose related.
Cardioselective beta-blockers may be used in well-controlled asthmatic patients, or COPD without significant reversible component for Heart Failure or following an MI. Treatment should be initiated at a low-dose & the patient monitored carefully for adverse effects.
Recent evidence-based guidance for angina states that beta-blockers should be the first line therapy for the long-term prevention of angina.
Patients with heart failure should only be prescribed with beta-blockers licensed for this indication.
NICE guidance on Atrial Fibrillation: https://www.nice.org.uk/guidance/ng196
Offer either a standard beta-blocker (that is, a beta-blocker other than sotalol) or a rate-limiting calcium-channel blocker (diltiazem or verapamil) as initial rate-control monotherapy to people with atrial fibrillation unless the person has the features described in recommendation 1.7.4.
Base the choice of drug on the person’s symptoms, heart rate, comorbidities and preferences. 
For people with atrial fibrillation and concomitant heart failure, follow the recommendations on the use of beta-blockers and avoiding calcium-channel blockers in NICE’s guideline on chronic heart failure. 
If monotherapy does not control the person’s symptoms, and if continuing symptoms are thought to be caused by poor ventricular rate control, consider combination therapy with any 2 of the following:
• a beta-blocker
• digoxin.  In April 2021, this was an off-label use of diltiazem. See NICE’s information on prescribing medicines.
In people with atrial fibrillation presenting acutely with suspected concomitant acute decompensated heart failure, seek senior specialist input on the use of beta-blockers and do not use calcium-channel blockers. 
|Therapeutic Area||Formulary Choices||Cost for 28|
(unless otherwise stated)
|Rationale for decision / comments|
|Beta-blockers||Bisoprolol||1.25mg tablets: £0.91|
2.5mg tablets: £0.82
3.75mg tablets: £1.10
5mg tablets: £0.81
7.5mg tablets: £1.15
10mg tablets: £0.90
|Bisoprolol is included in the formulary for:
• Heart failure: Patients’ with heart failure should be prescribed a beta-blocker licensed for heart failure. Bisoprolol is first line drug, initiate at 1.25mg and slowly titrate, assessing heart rate, blood pressure and clinical status after each titration.
• Hypertension: in line with NICE guidance. Alternative to Atenolol
• Angina: as alternative to Metoprolol
• Post-MI: as alternative to Metoprolol
|Atenolol||25mg tablets: £0.71|
50mg tablets: £0.82
100mg tablets: £0.82
|Atenolol is included in the formulary for:
• Hypertension: in line with NICE guidance. Atenolol dose for hypertension should not normally exceed 50mg daily.
• Angina: for prophylaxis of symptoms, some additional benefit may be obtained by increasing the dose to 100mg.
|Metoprolol||50mg tablets: £1.03|
100mg tablets: £1.07
|Metoprolol is included in the formulary for:
• Hypertension: in line with NICE guidance. Alternative to Atenolol or Bisoprolol
• Angina: as alternative to Bisoprolol
• Post-MI: as alternative to Bisoprolol
Sotalol is no longer recommended for AF.