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    Michael L. Aaronson, MD
    Kidney Doctor and High Blood Pressure Specialist
    7401 O Street Lincoln, NE 68510
    Phone: 402-484-5600

    Saturday, February 23, 2019

    Doc Wants Me Off Atenolol. Should I Switch My Blood Pressure Medication?

    Question submitted to Michael Aaronson, MD, Hypertension Specialist in Lincoln, Nebraska: My family practice doctor wants to take me off atenolol and switch me to another beta blocker to treat my blood pressure. I have been on atenolol for years and am doing fine. My blood pressure is great! Should I switch?

    Dr. Aaronson, Author of this Medical Blog: Thank you for submitting that question on using atenolol for the treatment of high blood pressure. I have been wanting to discuss this topic on my medical blog for some time. Atenolol, also known as Tenormin, is a commonly prescribed medication with 26,739,323 prescriptions written in 2016. If you add the diuretic combination atenolol with chlorthalidone to the mix, you can include 1,690,331 more scripts to the total.

    Atenolol is one of many beta blockers available for use in the United States. What are beta blockers? Beta blockers are used for the treatment of hypertension (high blood pressure), heart failure, heart attacks, and other indications.

    Some of the available beta blockers include: carvedilol, propranolol, metoprolol, nebivolol, labetalol, atenolol, and bisoprolol. There are other beta blockers. Some specific beta blockers are preferred over others in certain settings, for example in heart failure, heart attacks, or funny heart rhythms (also referred to as arrhythmias). We will restrict this discussion to using beta blockers for the treatment of high blood pressure alone.

    I'm not surprised that your family practice doc wants to make the switch. Over time, many providers are taking patients off atenolol and starting people on an alternative beta blocker. The data supports this: although there are many patients still taking atenolol, the number is declining over time as shown in the figure:

    Notice the steady decline in the use of the beta blocker atenolol from 2006 until 2016. The question you might ask is why are the atenolol numbers declining?  My opinion is that some believe that atenolol when used for the treatment of high blood pressure may be associated with an increased risk of stroke compared to other blood pressure medications, especially in elderly patients. Elderly in this setting is defined as people older than 60 years of age. What is interesting is that when atenolol is evaluated in younger patients, less than 60 years of age, the increased statistical risk for stroke goes away.

    Given there are so many beta blockers to offer patients, and so many are generic, I think some doctors have chosen to make the switch to avoid possible stroke risk. Most clinicians today wouldn't start a patient on atenolol. They would pick an alternative beta blocker. The issue is that so many people are already on atenolol therapy and are doing fine on it, why switch? Should we switch a patient to a different medication who is doing great? Some hypertension specialists say "yes" given the data, others say "no."

    The cost of atenolol is $3.73 monthly. It's extremely cost effective. That said, some of the other beta blockers in the class are also inexpensive. Others in the beta blocker antihypertensive (blood pressure lowering) class are much more expensive. Cost of therapy needs to be factored into the equation when considering making a change in therapy for the patient. If a patient cannot afford a therapy, the person may not take it. This is a conversation that you need to have with your doctor.

    Sometimes there is a compelling indication to change therapy. Patients with heart failure usually get switched to either metoprolol, bisoprolol, or carvedilol for evidence-based reasons. You should ask if you fall into that category. If you do, you should switch.

    We must also take into consideration the paradigm shift with respect to blood pressure therapy in 2019. There are times when a blood pressure specialist will favor a particular kind of medication or brand over another. But at the end of the day what is most important is blood pressure reduction. Said other way: some blood pressure reduction is better than no blood pressure lowering if a patient can't tolerate a particular therapy or reacts to it (the person has side effects), for example. If there is no other option, blood pressure reduction with a beta blocker such as atenolol is better than living with hypertension and no therapy.

    I would opine a patient with high blood pressure is more likely to get a stroke than that same person on atenolol with perfectly controlled, at target blood pressure. Some patients are very sensitive to medication and can only tolerate certain meds. So please reflect on these points prior to requesting a switch. The decision should be made between you and your provider.

    So your next step might be meeting with your provider and asking why now is the time to make a change. What is the thought process? Based on the conversation you can make an informed decision. The worst case scenario with switching is that the new therapy fails and you have to switch back to atenolol. If you need additional consideration, sometimes a hypertension specialist can help with decision making to get everyone on the same page and get your blood pressure to goal.