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Beta-1 Selective Adrenoceptor Blocker (Cardioselective Beta-Blocker) Pregnancy: Caution should be exercised when atenolol is administered during pregnancy or to a woman who is breast-feeding. Atenolol crosses the placental barrier and appears in cord blood; no studies have been performed in the first trimester and the possibility of foetal injury cannot be excluded. Use in the management of mild to moderate hypertension has been associated with intra-uterine growth retardation, and the anticipated benefit must be weighed against the possible risks, particularly in the first and second trimesters. There is significant accumulation in breast milk — neonates born to mothers receiving atenolol at parturition or breast-feeding may be at risk of hypoglycaemia and bradycardia.

Atenolol

Brand names: Tenormin

Atenolol is a relatively cardioselective beta-blocker used for hypertension, angina and certain arrhythmias, and after myocardial infarction.

Adult dose

Dose: Hypertension: one tablet daily — most patients respond to 100 mg daily given orally as a single dose; some patients will respond to 50 mg given as a single daily dose. Angina: most patients respond to 100 mg given orally once daily, or 50 mg given twice daily
Route: Oral — SPC §4.2 method of administration: 'For administration by the oral route'
Frequency: Once daily (angina alternatively 50 mg twice daily)
Max: In angina, 'it is unlikely that additional benefit will be gained by increasing the dose' above 100 mg once daily or 50 mg twice daily
The dose must always be adjusted to the individual requirements of the patient, with the lowest possible starting dosage. Hypertension: the effect will be fully established after one to two weeks; a further reduction in blood pressure may be achieved by combining atenolol with other antihypertensive agents, for example a diuretic. Oral maintenance after control of cardiac arrhythmias: 50 to 100 mg daily, given as a single dose. Elderly: dosage requirements may be reduced, especially in patients with impaired renal function; start with a lesser dose. WITHDRAWAL: should not be withdrawn abruptly — the dosage should be withdrawn gradually over a period of 7 to 14 days, with patients followed during withdrawal, especially those with ischaemic heart disease. If a patient is scheduled for surgery and a decision is made to discontinue beta-blocker therapy, this should be done at least 24 hours prior to the procedure. PARENTERAL REGIMENS NOT REPRODUCED HERE: this SPC is for Atenolol 100 mg film-coated tablets and its §4.2 also outlines intravenous regimens for cardiac arrhythmias and for myocardial infarction, but it explicitly defers to a separate product, stating '(See also prescribing information for Atenolol Injection.)'. Those intravenous doses belong to a different product and have deliberately not been transcribed onto this oral monograph — clinician to source the Atenolol Injection SPC if an IV regimen is required for this page. PAEDIATRIC: 'There is no paediatric experience with Atenolol and for this reason it is not recommended for use in children.' SOURCE: UK SPC for Atenolol 100 mg film-coated tablets (eMC product 14163).

Dose adjustments

Renal

Atenolol is excreted via the kidneys, so the dosage should be adjusted in severe impairment of renal function. No significant accumulation occurs in patients with a creatinine clearance greater than 35 mL/min/1.73 m2. Creatinine clearance 15-35 mL/min/1.73 m2 (serum creatinine 300-600 micromol/L): the oral dose should be 50 mg daily. Creatinine clearance below 15 mL/min/1.73 m2 (serum creatinine above 600 micromol/L): the oral dose should be 25 mg daily or 50 mg on alternate days. Patients on haemodialysis should be given 50 mg orally after each dialysis, under hospital supervision as marked falls in blood pressure can occur. (The SPC also states intravenous dose reductions for these renal bands; those figures relate to Atenolol Injection and are not reproduced on this oral monograph.)

Dose independently re-sourced from UK Summary of Product Characteristics (SPC) via the eMC; US FDA prescribing information (openFDA / DailyMed) — cross-check; US labelling may differ from UK — clinician-reviewed. Always confirm against the product SmPC and your local formulary before prescribing.

Contraindications

  • Hypersensitivity to the active substance or to any of the excipients
  • Cardiogenic shock
  • Uncontrolled heart failure
  • Sick sinus syndrome
  • Second- or third-degree heart block
  • Untreated phaeochromocytoma
  • Metabolic acidosis
  • Bradycardia (below 45 bpm)
  • Hypotension
  • Severe peripheral arterial circulatory disturbances

Side effects

  • Bradycardia (common)
  • Cold extremities (common)
  • Gastrointestinal disturbances and fatigue (common)
  • Postural hypotension which may be associated with syncope, Raynaud's phenomenon, and increased intermittent claudication if already present (rare)
  • Sleep disturbances (uncommon); dizziness, headache and paraesthesia (rare); bronchospasm in patients with bronchial asthma or a history of asthmatic complaints (rare)
  • Elevations of transaminase levels (uncommon); hepatic toxicity including intrahepatic cholestasis (rare)

Interactions

  • Catecholamine-depleting drugs (e.g. reserpine) — additive effect; observe closely for hypotension and/or marked bradycardia
  • Calcium channel blockers — may have an additive effect when given with atenolol
  • Disopyramide — associated with severe bradycardia, asystole and heart failure when administered with beta-blockers
  • Amiodarone — negative chronotropic properties that may be additive to those seen with beta-blockers
  • Clonidine — beta-blockers may exacerbate the rebound hypertension that can follow clonidine withdrawal; the beta-blocker should be withdrawn several days before the gradual withdrawal of clonidine
  • Prostaglandin synthase inhibiting drugs (e.g. indometacin) — may decrease the hypotensive effects of beta-blockers
  • This interaction list may be incomplete — check the full SPC. Some of this information is from US labelling, which may differ from the UK SPC — check the full SPC.

Clinical monograph

How it works

It selectively blocks beta-1 adrenoceptors in the heart, reducing heart rate, myocardial contractility and conduction velocity, thereby lowering cardiac workload and blood pressure.

Prescribing in practice

  • Do not stop abruptly, as sudden withdrawal can precipitate rebound angina, arrhythmia or myocardial infarction, so taper when discontinuing.
  • It is renally excreted and accumulates in renal impairment, so dose reduction is needed as function declines.
  • Use caution in asthma, peripheral arterial disease and with other rate-limiting drugs, and be aware it may mask signs of hypoglycaemia in diabetes.

Monitoring

Monitor heart rate and blood pressure, and assess renal function as it influences dosing and accumulation.

Counselling the patient

  • Do not stop the medicine suddenly without medical advice.
  • Report marked dizziness, breathlessness, wheeze or a very slow pulse.
  • Be aware it may blunt the usual warning symptoms of low blood sugar if you have diabetes.

Evidence & guidelines

Beta-blockade after myocardial infarction reduces mortality, and NICE positions atenolol within the management of hypertension, angina and arrhythmia.

Reference: NICE NG133 (Hypertension in adults, 2019 updated 2023); NICE NG185 (ACS, 2020); ESC/ESH Hypertension Guidelines (2023); Drug verified in RxNorm (NLM); confirm dosing against the manufacturer SPC (eMC). Verify against your local formulary and current prescribing references before prescribing. The structured dose values shown have been reviewed by a clinician. Monograph status: clinician-reviewed (2026-07-04).

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