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Beta-Blockers Pregnancy: Avoid if possible — associated with intrauterine growth restriction, neonatal bradycardia and hypoglycaemia; labetalol preferred in pregnancy

Atenolol

Brand names: Tenormin

Adult dose

Dose: 25–100 mg once daily (hypertension and angina); 50–100 mg once daily (post-MI)
Route: Oral
Frequency: Once daily
Max: 100 mg/day
Can be given with or without food. Once-daily dosing improves adherence vs bisoprolol/metoprolol in some patients. IV formulation: 2.5 mg IV over 2.5 minutes for acute MI rate control.

Paediatric dose

Dose: 0.5–1 mg/kg once daily mg/kg
Route: Oral
Frequency: Once daily
Max: 100 mg/day
Used in paediatric hypertension and some arrhythmias; seek specialist paediatric cardiology opinion

Dose adjustments

Renal

Significant renal adjustment required — atenolol is renally excreted unchanged: eGFR 15–35 → max 50 mg/day; eGFR under 15 → max 25 mg/day; haemodialysis patients receive dose post-dialysis

Hepatic

No dose adjustment required — atenolol is not hepatically metabolised

Paediatric weight-based calculator

Used in paediatric hypertension and some arrhythmias; seek specialist paediatric cardiology opinion

Clinical pearls

  • Mechanism: cardioselective (beta-1 preferential) adrenoceptor blocker — water-soluble (unlike propranolol); minimal CNS penetration reduces neurological side effects (less depression, fatigue, nightmares than lipophilic beta-blockers)
  • CLINICAL NICHE: water-soluble beta-blocker — preferred in patients with depression, nightmares, or neurological side effects from lipophilic beta-blockers (bisoprolol, metoprolol, propranolol); renal excretion is a disadvantage in CKD
  • LIFE trial (Lancet 2002): atenolol vs losartan in hypertension + LVH — losartan significantly superior for stroke reduction despite similar BP lowering; atenolol now SECOND-LINE for hypertension in ESC guidelines
  • Post-MI: atenolol was first-line post-MI beta-blocker historically (ISIS-1 trial); now superseded by high-evidence bisoprolol/carvedilol/metoprolol succinate for HFrEF, but atenolol remains appropriate for rate control post-MI in normal LV function
  • RENAL DOSING CRITICAL: atenolol accumulates in renal failure — no hepatic metabolism; unique among common beta-blockers; remember to halve dose in dialysis patients
  • MHRA: atenolol licensed for hypertension, angina, and cardiac arrhythmias; available as 25 mg, 50 mg, and 100 mg tablets

Contraindications

  • Second or third degree AV block
  • Sick sinus syndrome (without pacemaker)
  • Severe bradycardia
  • Cardiogenic shock
  • Uncontrolled heart failure
  • Prinzmetal angina (worsens coronary spasm)

Side effects

  • Bradycardia
  • Fatigue and lethargy
  • Bronchospasm (less than non-selective beta-blockers — cardioselective — but still occurs at higher doses)
  • Cold extremities
  • Depression
  • Erectile dysfunction
  • Hypoglycaemia masking (particularly in diabetics)

Interactions

  • Verapamil and diltiazem (AVOID IV combination — fatal bradycardia and AV block; oral combination with caution)
  • Digoxin (additive AV block — monitor HR and rhythm)
  • Clonidine (rebound hypertension on clonidine withdrawal if atenolol masks tachycardia)
  • NSAIDs (reduce antihypertensive effect)
  • Insulin and oral hypoglycaemics (masks hypoglycaemia — sweating preserved as warning sign)

Monitoring

  • Heart rate and blood pressure
  • Renal function (eGFR — dose adjustment threshold)
  • Glucose in diabetic patients (hypoglycaemia masking)
  • Respiratory status in asthmatic patients
  • Symptoms of worsening HF

Reference: BNFc; BNF 90; LIFE trial Lancet 2002;359(9311):995-1003; ISIS-1 Lancet 1986;2(8498):57-66; ESC Hypertension Guidelines 2018; MHRA SPC. Verify against your local formulary and the latest BNF before prescribing.

Related

Curated clinical cross-links plus same-class fallbacks.

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