Antiarrhythmics Pregnancy: Not recommended in pregnancy; if considered necessary, monitor uteroplacental blood flow and foetal growth and closely monitor the newborn (risk of hypoglycaemia, hypotension, bradycardia). Should not be used during breast-feeding.

Esmolol

Brand names: Brevibloc

Esmolol is an ultra-short-acting intravenous beta-blocker used for rapid, titratable heart-rate and blood-pressure control in supraventricular tachyarrhythmias and in perioperative or acute hypertensive and ischaemic settings.

Auto-extracted from the source labelling — not yet independently clinician-verified. These values were distilled from the UK SPC (or the US label where noted) but have not had a clinician sign-off. Confirm against the current SmPC before prescribing.

Adult dose

Dose: Loading 500 micrograms/kg/min for 1 minute, then maintenance 50 micrograms/kg/min for 4 minutes; titrate within 50-200 micrograms/kg/min

Route: Intravenous infusion (must be reconstituted/diluted before use)

Frequency: Continuous IV infusion, titrated to response

Max: 200 micrograms/kg/min (doses up to 300 micrograms/kg/min have been used; safety above 300 micrograms/kg/min not studied)

Supraventricular tachyarrhythmia: effective range 50-200 micrograms/kg/min. For inadequate response, repeat 500 micrograms/kg/min loading for 1 minute and step maintenance up (50, 100, 150, 200 micrograms/kg/min in 4-minute steps). As target heart rate/blood pressure is approached, omit the loading infusion and reduce the incremental maintenance dose to 25 micrograms/kg/min or lower. Perioperative tachycardia/hypertension: intraoperative bolus 80 mg over 15-30 seconds then 150 micrograms/kg/min infusion, titrate up to 300 micrograms/kg/min. Infusions longer than 24 hours not thoroughly evaluated. MUST NOT be administered without reconstitution/dilution - incorrect dilution may cause severe overdose or death. Paediatric (under 18 years): SPC paediatric posology was truncated in the source excerpt and not captured - verify dosing against a children's formulary.

Dose adjustments

Renal

Caution in renal insufficiency: the acid metabolite is renally excreted, with elimination half-life increased to about tenfold and considerably elevated plasma levels in renal disease.

Dose auto-extracted from UK Summary of Product Characteristics (SPC) via the eMC — not yet clinician-verified. Always confirm against the product SmPC and your local formulary before prescribing.

Contraindications

Hypersensitivity to the active substance
Severe sinus bradycardia (<50 bpm); sick sinus syndrome; severe AV-nodal conduction disorders (without pacemaker); 2nd or 3rd degree AV block
Cardiogenic shock; severe hypotension; decompensated heart failure
Concomitant or recent intravenous verapamil (must not be given within 48 hours of discontinuing verapamil)
Untreated phaeochromocytoma; pulmonary hypertension; acute asthmatic attack; metabolic acidosis

Side effects

Hypotension (most common, dose-related, can be severe)
Bradycardia (including severe bradycardia)
Atrioventricular block
Dizziness (associated with symptomatic hypotension)
Infusion/injection site reactions (including inflammation, induration, phlebitis)

Interactions

Intravenous verapamil - contraindicated; do not administer esmolol within 48 hours of discontinuing verapamil
Other drugs decreasing peripheral resistance, myocardial filling, contractility or impulse propagation - use with caution

Clinical monograph

How it works

It is a cardioselective beta-1 adrenoceptor antagonist that slows the sinus rate and AV nodal conduction; its rapid hydrolysis by red-cell esterases gives a very short half-life and quickly reversible effect.

Prescribing in practice

Because of its negative inotropic and chronotropic effects it can cause significant hypotension and bradycardia, and is contraindicated in severe bradycardia, high-grade heart block, decompensated heart failure and cardiogenic shock.
Its very short duration means effects resolve within minutes of stopping the infusion, which is an advantage if adverse effects occur but requires continuous titration.
Use with caution in asthma or bronchospastic disease and in diabetes, where it may mask signs of hypoglycaemia.

Monitoring

Administer with continuous ECG and blood-pressure monitoring and frequent infusion-site review, titrating to heart rate and blood-pressure response.

Counselling the patient

This is given as a closely monitored drip and acts and wears off very quickly.
Report dizziness or any infusion-site pain to the team.

Evidence & guidelines

Esmolol is a recognised option for acute rate control of supraventricular arrhythmias and perioperative haemodynamic control.

Reference: ESC AF Guidelines 2020; AHA Perioperative Beta-Blocker Guidelines; ESC Aortic Disease Guidelines 2014; MHRA SPC; 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).

Curated clinical cross-links plus same-class fallbacks.

Pathways