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TENORMIN 25mg, 50mg and 100mg Tablet

Atenolol intervals until a response is observed, up to a maxi-
Film-coated tablets and solution for injection mum dosage of 10mg. If Tenormin is given by infu-
Composition sion, 0.15mg/kg bodyweight may be administered
Tablets containing 25 mg, 50 mg or 100 mg of over a 20 minute period. If required, the injec-
Atenolol Ph. Eur. tion or infusion may be repeated every 12 hours.
Having controlled the arrhythmias with intravenous
Injection for intravenous use presented as an iso-
Tenormin, a suitable oral maintenance dosage is
tonic, citrate buffered, aqueous solution, containing
50-100mg daily, given as a single dose.
5mg of Atenolol Ph. Eur. in 10ml.
For excipients see List of excipients. Myocardial Infarction
Early intervention after acute myocardial infarction:
Therapeutic Indications For patients suitable for treatment with intravenous
I)Hypertension. beta-blockade and presenting within 12 hours of the
II)Angina pectoris. onset of chest pain, Tenormin 5-10mg should be
III)Cardiac arrhythmias. given by slow intravenous injection (1mg/minute)
IV)Myocardial infarction. Early and late intervention. followed by Tenormin 50mg orally about 15 minutes
Posology and method of administration later, provided no untoward effects have occurred
The dose must always be adjusted to individual from the intravenous dose. This should be followed
requirements of the patients, with the lowest pos- by a further 50mg orally 12 hours after the intrave-
sible starting dosage. The following are guidelines. nous dose and then 12 hours later by 100mg orally,
Adults once daily. If bradycardia and/or hypotension requir-
Hypertension ing treatment, or any other untoward effects occur,
One tablet daily. Most patients respond to 100mg Tenormin should be discontinued.
daily given orally as a single dose. Some patients, Late intervention after acute myocardial infarction:
however, will respond to 50mg given as a single For patients who present some days after suffer-
daily dose. The effect will be fully established after ing an acute myocardial infarction an oral dose of
one to two weeks. A further reduction in blood pres- Tenormin (100mg daily) is recommended for long-
sure may be achieved by combining Tenormin with term prophylaxis of myocardial infarction.
other antihypertensive agents. For example, co- Elderly
administration of Tenormin with a diuretic, provides Dosage requirements may be reduced, especially in
a highly effective and convenient antihypertensive patients with impaired renal function.
therapy. Children
Angina There is no paediatric experience with Tenormin
Most patients with angina pectoris will respond to and for this reason it is not recommended for use in
100mg given orally once or 50mg given twice daily. children.
It is unlikely that additional benefit will be gained by
Renal Failure
increasing the dose. Since Tenormin is excreted via the kidneys the dos-
Cardiac Arrhythmias age should be reduced in cases of severe impair-
A suitable initial dose of Tenormin is 2.5mg (5ml) ment of renal function.
injected intravenously over a 2.5 minute period (i.e. No significant accumulation of Tenormin occurs in
1mg/minute). This may be repeated at 5 minute patients who have a creatinine clearance greater
ASTRAZENECA-TENORMIN 25mg, 50mg and 100mg Tablet - p.1/5
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than 35ml/min/1.73m2 (normal range is 100-150ml/ - although contraindicated in uncontrolled heart

min/1.73m2). failure (see Contraindications), may be used in
For patients with a creatinine clearance of 15-35ml/ patients whose signs of heart failure have been
min/1.73m2 (equivalent to serum creatinine of 300- controlled. Caution must be exercised in patients
600 micromol/litre) the oral dose should be 50mg whose cardiac reserve is poor.
daily and the intravenous dose should be 10mg -may increase the number and duration of angina
once every two days. attacks in patients with Prinzmetals angina due
For patients with a creatinine clearance of <15ml/ to unopposed alpha-receptor mediated coronary
min/1.73m2 (equivalent to serum creatinine of >600 artery vasoconstriction. Tenormin is a beta1-selec-
micromol/litre) the oral dose should be 25mg daily tive beta-blocker; consequently, its use may be
or 50mg on alternate days and the intravenous considered although utmost caution must be exer-
dose should be 10mg once every four days. cised.
Patients on haemodialysis should be given 50mg although contraindicated in severe periph-
orally after each dialysis; this should be done under eral arterial circulatory disturbances (see
hospital supervision as marked falls in blood pres- Contraindications), may also aggravate less severe
sure can occur. peripheral arterial circulatory disturbances.
-due to its negative effect on conduction time, cau-
Contraindications tion must be exercised if it is given to patients with
Tenormin, as with other beta-blockers, should not first degree heart block.
be used in patients with any of the following: known -may mask the symptoms of hypoglycaemia, in par-
hypersensitivity to the active substance, or any of ticular, tachycardia.
the excipients; bradycardia (<45bpm); cardiogen- -may mask the signs of thyrotoxicosis.
ic shock; hypotension; metabolic acidosis; severe -will reduce heart rate, as a result of its pharmaco-
peripheral arterial circulatory disturbances; second logical action. In the rare instances when a treated
or third degree heart block; sick sinus syndrome; patient develops symptoms which may be attribut-
untreated phaeochromocytoma; uncontrolled heart able to a slow heart rate and the pulse rate drops
failure. to less than 50-55bpm at rest, the dose should be
Special warnings and precautions for use reduced.
Tenormin as with other beta-blockers: -
may cause a more severe reaction to a variety of
should not be withdrawn abruptly. The dosage allergens, when given to patients with a history
should be withdrawn gradually over a period of of anaphylactic reaction to such allergens. Such
7-14 days, to facilitate a reduction in beta-blocker patients may be unresponsive to the usual doses
dosage. Patients should be followed during with- of adrenaline used to treat the allergic reactions.
drawal, especially those with ischaemic heart - may cause a hypersensitivity reaction including
disease. angioedema and urticaria
-when a patient is scheduled for surgery, and a should be used with caution in the elderly, starting
decision is made to discontinue beta-blocker ther- with a lesser dose (see Posology and method of
apy, this should be done at least 24 hours prior administration).
to the procedure. The risk-benefit assessment of Since Tenormin is excreted via the kidneys, dos-
stopping beta-blockade should be made for each age should be reduced in patients with a creatinine
patient. If treatment is continued, an anaesthet- clearance of below 35ml/min/1.7m2.
ic with little negative inotropic activity should be Although cardioselective (beta1) beta-blockers
selected to minimise the risk of myocardial depres- may have less effect on lung function than non-
sion. The patient may be protected against vagal selective beta-blockers, as with all, beta-blockers,
reactions by intravenous administration of atropine. these should be avoided in patients with reversible
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obstructive airways disease, unless there are com- sugar lowering effects of these drugs. Symptoms
pelling clinical reasons for their use. Where such of hypoglycaemia, particularly tachycardia, may be
reasons exist, Tenormin may be used with caution. masked (see Special warnings and precautions for
Occasionally, some increase in airways resistance use).
may occur in asthmatic patients, however, and this Concomitant use of prostaglandin synthetase inhib-
may usually be reversed by commonly used dosage iting drugs (e.g. ibuprofen, indomethacin), may
of bronchodilators such as salbutamol or isoprenaline. decrease the hypotensive effects of beta-blockers.
As with other beta-blockers, in patients with a phae- Caution must be exercised when using anaesthetic
ochromocytoma, an alpha-blocker should be given agents with Tenormin. The anaesthetist should be
concomitantly. informed and the choice of anaesthetic should be an
Interactions agent with as little negative inotropic activity as pos-
Combined use of beta-blockers and calcium chan- sible. Use of beta-blockers with anaesthetic drugs
nel blockers with negative inotropic effects e.g. may result in attenuation of the reflex tachycardia and
verapamil, diltiazem can lead to an exaggeration of increase the risk of hypotension. Anaesthetic agents
these effects particularly in patients with impaired causing myocardial depression are best avoided.
ventricular function and/or sino-atrial or atrio-ven- Pregnancy and lactation
tricular conduction abnormalities. This may result in Tenormin crosses the placental barrier and appears
severe hypotension, bradycardia and cardiac failure. in the cord blood. No studies have been performed
Neither the beta-blocker nor the calcium channel on the use of Tenormin in the first trimester and
blocker should be administered intravenously within the possibility of foetal injury cannot be excluded.
48 hours of discontinuing the other. Tenormin has been used under close supervision for
Concomitant therapy with dihydropyridines e.g. nife- the treatment of hypertension in the third trimester.
dipine, may increase the risk of hypotension, and Administration of Tenormin to pregnant women in
cardiac failure may occur in patients with latent car- the management of mild to moderate hypertension
diac insufficiency. has been associated with intra-uterine growth retar-
Digitalis glycosides, in association with beta-block- dation.
ers, may increase atrio-ventricular conduction time. The use of Tenormin in women who are, or may
Beta-blockers may exacerbate the rebound hyper- become, pregnant requires that the anticipated bene-
tension, which can follow the withdrawal of cloni- fit be weighed against the possible risks, particularly
dine. If the two drugs are co-administered, the beta- in the first and second trimesters, since beta-blockers,
blocker should be withdrawn several days before in general, have been associated with a decrease in
discontinuing clonidine. If replacing clonidine by placental perfusion which may result in intra-uterine
beta-blocker therapy, the introduction of beta-block- deaths, immature and premature deliveries.
ers should be delayed for several days after cloni- There is significant accumulation of Tenormin in
dine administration has stopped. (See also prescrib- breast milk.
ing information for clonidine). Neonates born to mothers who are receiving
Caution must be exercised when prescribing a beta- Tenormin at parturition or breast-feeding may be at
blocker with Class 1 antiarrhythmic agents such as risk for hypoglycemia and bradycardia.
disopyramide and quinidine. Caution should be exercised when Tenormin is
Concomitant use of sympathomimetic agents, administered during pregnancy or to a woman who
e.g. adrenaline, may counteract the effect of beta- is breast-feeding.
blockers. Effect on ability to drive and use machines
Concomitant use with insulin and oral antidiabetic Use is unlikely to result in any impairment of the
drugs may lead to the intensification of the blood ability of patients to drive or operate machinery.
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However it should be taken into account that occa- General treatment should include: close supervi-
sionally dizziness or fatigue may occur. sion, treatment in an intensive care ward, the use
Undesirable effects of gastric lavage, activated charcoal and a laxative
Tenormin is well tolerated. In clinical studies, the to prevent absorption of any drug still present in the
undesired events reported are usually attributable to gastrointestinal tract, the use of plasma or plasma
the pharmacological actions of atenolol. substitutes to treat hypotension and shock. The use
of haemodialysis or haemoperfusion may be consi-
The following undesired events, listed by body sys-
tem, have been reported.
Excessive bradycardia can be countered with atro-
-Cardiovascular: bradycardia; heart failure deterio-
pine 1-2mg intravenously and/or a cardiac pace-
ration; postural hypotension which may be associa-
maker. If necessary, this may be followed by a bolus
ted with syncope; cold extremities. In susceptible
dose of glucagon 10mg intravenously. If required,
patients: precipitation of heart block; intermittent
this may be repeated or followed by an intrave-
claudication; Raynauds phenomenon.
nous infusion of glucagon 1-10mg/hour depend-
-CNS: confusion; dizziness; headache; mood chan-
ing on response. If no response to glucagon occurs
ges; nightmares; psychoses and hallucinations;
or if glucagon is unavailable, a beta-adrenoceptor
sleep disturbances of the type noted with other
stimulant such as dobutamine 2.5 to 10 micro-
grams/kg/minute by intravenous infusion may be
Gastrointestinal: dry mouth, gastrointestinal dis-
given. Dobutamine, because of its positive inotro-
turbances, elevations of transaminase levels have
pic effect could also be used to treat hypotension
been seen infrequently, rare cases of hepatic tox-
and acute cardiac insufficiency. It is likely that these
icity including intrahepatic cholestasis have been
doses would be inadequate to reverse the cardiac
effects of beta-blocker blockade if a large overdose
-Haematological: purpura; thrombocytopenia.
has been taken. The dose of dobutamine should
Integumentary: alopecia; dry eyes; psoriasiform
therefore be increased if necessary to achieve the
skin reactions; exacerbation of psoriasis; skin rash-
required response according to the clinical condition
of the patient.
-Neurological: paraesthesia.
-Reproductive: impotence Bronchospasm can usually be reversed by broncho-
-Respiratory: bronchospasm may occur in patients dilators.
with bronchial asthma or a history of asthmatic Pharmacodynamic properties
complaints. Betablocking agents, plain selective, CO7A B03
-Special senses: visual disturbances. Atenolol is a beta-blocker which is beta1-selective
-Others: hypersensitivity reactions, including angio-
(i.e. acts preferentially on beta1-adrenergic recep-
edema and urticaria; fatigue; an increase in ANA tors in the heart). Selectivity decreases with increas-
(Antinuclear Antibodies) has been observed, how- ing dose.
ever, the clinical relevance of this is not clear. Atenolol is without intrinsic sympathomimetic and
Discontinuance of the drug should be considered membrane stabilising activities and as with other
if, according to clinical judgement, the well-being of
beta-blockers, has negative inotropic effects (and
the patient is adversely affected by any of the aboveis therefore contraindicated in uncontrolled heart
reactions. failure).
Overdose As with other beta-blockers, the mode of action of
The symptoms of overdosage may include brady- atenolol in the treatment of hypertension is unclear.
cardia, hypotension, acute cardiac insufficiency and It is probably the action of atenolol in reducing car-
bronchospasm. diac rate and contractility which makes it effective
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in eliminating or reducing the symptoms of patients 90% of that absorbed reaches the systemic circula-
with angina. tion unaltered. The plasma half-life is about 6hours
It is unlikely that any additional ancillary properties but this may rise in severe renal impairment since
possessed by S (-) atenolol, in comparison with the the kidney is the major route of elimination. Atenolol
racemic mixture, will give rise to different therapeutic penetrates tissues poorly due to its low lipid solu-
effects. bility and its concentration in brain tissue is low.
Tenormin is effective and well-tolerated in most eth- Plasma protein binding is low (approximately 3%).
nic populations although the response may be less List of excipients
in black patients. -Tablets: Gelatin, Glycerol, Magnesium carbonate,
Tenormin is effective for at least 24 hours after a Magnesium stearate, Maize starch, Hypromellose,
single oral dose. The drug facilitates compliance Sodium lauryl sulphate, Titanium hydroxide.
by its acceptability to patients and simplicity of -100mg tablets only: Macrogol 300, Sunset yellow
dosing. The narrow dose range and early patient lake.
response ensure that the effect of the drug in indi- -
Injection: Citric acid, Sodium chloride, Sodium
vidual patients is quickly demonstrated. Tenormin is hydroxide, Water for injection
compatible with diuretics, other hypotensive agents Incompatibilities
and antianginal agents (see Interactions). Since it Compatibility with intravenous infusion fluids
acts preferentially on beta-receptors in the heart, Tenormin Injection is compatible with sodium chlo-
Tenormin may, with care, be used successfully in ride intravenous\infusion (0.9%w/v) and Glucose
the treatment of patients with respiratory disease, Intravenous Infusion BP (5% w/v).
who cannot tolerate non-selective beta-blockers. Shelf-life
Early intervention with Tenormin in acute myocar- Please refer to expiry date on the blister strip or
dial infarction reduces infarct size and decreases outer carton.
morbidity and mortality. Fewer patients with a threat- Special precautions for storage
ened infarction progress to frank infarction; the Tenormin Tablets: Do not store above 25C. Protect
incidence of ventricular arrhythmias is decreased from light and moisture.
and marked pain relief may result in reduced need Tenormin Injection: Do not store above 25C.
of opiate analgesics. Early mortality is decreased. Protect from light.
Tenormin is an additional treatment to standard cor-
onary care. Pack Size
Please refer to the outer carton for pack size.
Pharmacokinetic properties
Following intravenous administration, the blood lev- Date of revision of the text
els of atenolol decay tri-exponentially with an elimi- April 2004
nation half-life of about 6 hours. Throughout the
intravenous dose range of 5-10mg the blood level
profile obeys linear pharmacokinetics and beta-
adrenoceptor blockade is still measurable 24 hours
after a 10mg intravenous dose.
Absorption of atenolol following oral dosing is con-
sistent but incomplete (approximately 40-50%) with
peak plasma concentrations occurring 2-4 hours
after dosing. The atenolol blood levels are consis-
tent and subject to little variability. There is no signi-
ficant hepatic metabolism of atenolol and more than