Cardioselective β1-blocker (with NO release) Pregnancy: Should not be used during pregnancy unless clearly necessary - beta-adrenoceptor blockers reduce placental perfusion (associated with growth retardation, intrauterine death, abortion or early labour) and may cause fetal/neonatal hypoglycaemia and bradycardia, generally expected within the first 3 days. If treatment is considered necessary, monitor uteroplacental blood flow and fetal growth and monitor the newborn closely. Mothers receiving nebivolol should not breast-feed (eMC 4.6).

Nebivolol

Brand names: Nebilet

Nebivolol is a highly beta-1-selective beta-blocker with additional nitric-oxide-mediated vasodilation, used for hypertension and as an adjunct for stable mild-to-moderate heart failure in older patients.

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: Hypertension: 5 mg daily

Route: Oral (tablets may be taken with meals)

Frequency: Once daily, preferably at the same time of day

Max: Chronic heart failure: maximum recommended dose 10 mg once daily (the SPC states no separate maximum for hypertension beyond the 5 mg daily dose)

eMC SPC 4.2 (Nebivolol 1.25 mg Tablets). HYPERTENSION: the blood-pressure-lowering effect becomes evident after 1-2 weeks; occasionally the optimal effect is reached only after 4 weeks. Beta-blockers can be used alone or with other antihypertensives; to date an additional antihypertensive effect has been observed only when nebivolol is combined with hydrochlorothiazide 12.5-25 mg. ELDERLY (over 65 years, hypertension): recommended starting dose 2.5 mg daily, increased if needed to 5 mg daily; limited experience above 75 years so exercise caution and monitor closely. CHRONIC HEART FAILURE (CHF): patients must have stable CHF without acute failure during the past six weeks, and any diuretic / digoxin / ACE inhibitor / angiotensin II antagonist therapy should have been stabilised during the two weeks prior to initiation. Uptitrate at 1-2 weekly intervals according to tolerability: 1.25 mg, then 2.5 mg once daily, then 5 mg once daily, then 10 mg once daily (maximum recommended dose 10 mg once daily). Initiation and every dose increase should be done under the supervision of an experienced physician over a period of at least 2 hours to confirm that blood pressure, heart rate, conduction and heart-failure status remain stable. If heart failure worsens or the drug is not tolerated during titration, first reduce the nebivolol dose, or stop it immediately if necessary (severe hypotension, worsening heart failure with acute pulmonary oedema, cardiogenic shock, symptomatic bradycardia or AV block). CHF treatment is generally long term and should not be stopped abruptly (risk of transitory worsening of heart failure); if discontinuation is necessary the dose should be gradually decreased, divided into halves weekly. In CHF no dose adjustment is required in mild to moderate renal insufficiency, and none is required for the elderly, because uptitration to the maximum tolerated dose is individually adjusted. HEPATIC IMPAIRMENT: data are limited, therefore use is contraindicated. PAEDIATRIC: efficacy and safety in children and adolescents aged below 18 years have not been established and no data are available, therefore use in children and adolescents is not recommended - no paediatric dose is stated; refer to a children's formulary. SPC 4.4 also advises that if the pulse rate drops below 50-55 bpm at rest and/or symptoms suggestive of bradycardia occur the dosage should be reduced, and that in ischaemic heart disease treatment should be discontinued gradually over 1-2 weeks.

Dose adjustments

Renal

Hypertension: in renal insufficiency the recommended starting dose is 2.5 mg daily, increased to 5 mg daily if needed. Chronic heart failure: no dose adjustment required in mild to moderate renal insufficiency since uptitration to the maximum tolerated dose is individually adjusted; there is no experience in severe renal insufficiency (serum creatinine >= 250 micromol/L) and use is not recommended in these patients (eMC 4.2).

Dose auto-extracted from UK Summary of Product Characteristics (SPC) via the eMC; US FDA prescribing information (openFDA / DailyMed) — cross-check; US labelling may differ from UK — not yet clinician-verified. Always confirm against the product SmPC and your local formulary before prescribing.

US labelling (FDA)

Reference — US labelling, may differ from UK

Can be taken with and without food. Individualize to the needs of the patient and monitor during up-titration. ( 2 ) Hypertension: Most patients start at 5 mg once daily. Dose can be increased at 2-week intervals up to 40 mg. ( 2.1 ) 2.1 Hypertension The dose of nebivolol tablets must be individualized to the needs of the patient. For most patients, the recommended starting dose is 5 mg once daily, with or without food, as monotherapy or in combination with other agents. For patients requiring further reduction in blood pressure, the dose can be increased at 2-week intervals up to 40 mg. A more frequent dosing regimen is unlikely to be beneficial. Renal Impairment In patients with severe …

Source: US FDA prescribing information (openFDA / DailyMed), label dated 2024-10-31. Accessed 2026-06-12. US dosing and indications can differ from UK practice — use UK sources for prescribing decisions.

Contraindications

Hypersensitivity to the active substance or to any of the excipients
Liver insufficiency or liver function impairment
Acute heart failure, cardiogenic shock or episodes of heart failure decompensation requiring i.v. inotropic therapy
Sick sinus syndrome, including sino-atrial block
Second and third degree heart block (without a pacemaker)
History of bronchospasm and bronchial asthma
Untreated phaeochromocytoma
Metabolic acidosis
Bradycardia (heart rate < 60 bpm prior to start of therapy)
Hypotension (systolic blood pressure < 90 mmHg)
Severe peripheral circulatory disturbances

Side effects

Common (hypertension): headache, dizziness, paraesthesia
Bradycardia, heart failure, slowed AV conduction / AV block (in the CHF trial bradycardia and dizziness each occurred in approximately 11% of patients)
Hypotension and postural hypotension; (increase of) intermittent claudication
Dyspnoea (common); bronchospasm (very rare)
Constipation, nausea, diarrhoea (common); dyspepsia, flatulence, vomiting (uncommon)
Tiredness and oedema (common); impotence, impaired vision, nightmares, depression, syncope (uncommon); angioneurotic oedema, hypersensitivity, psoriasis aggravated, urticaria (very rare / not known)

Interactions

Calcium channel antagonists of the verapamil and diltiazem type - combination generally not recommended (SPC 4.4, cross-referring to 4.5)
Class I antiarrhythmic drugs - combination generally not recommended (SPC 4.4)
Centrally acting antihypertensive drugs - combination generally not recommended (SPC 4.4)
Sulfonylureas - beta-blockers could further increase the risk of severe hypoglycaemia; advise careful blood glucose monitoring (SPC 4.4)
Anaesthetics that cause myocardial depression - caution; if beta blockade is interrupted in preparation for surgery, discontinue at least 24 hours beforehand (vagal reactions can be countered with intravenous atropine) (SPC 4.4)
CYP2D6 inhibitors (quinidine, propafenone, fluoxetine, paroxetine) may increase nebivolol levels - use caution (US label 7.1)
Digitalis glycosides - both digitalis and beta-blockers slow AV conduction and decrease heart rate; concomitant use can increase the risk of bradycardia (US label 7.3)
Catecholamine-depleting drugs (reserpine, guanethidine) and clonidine - excessive reduction of sympathetic activity; discontinue nebivolol for several days before the gradual tapering of clonidine (US label 7.2)
NOTE: eMC 4.5 was not captured in this bundle - the entries above come from eMC 4.4 and, where marked, from the US label 7. Clinician to review the full 4.5 before publication.

Clinical monograph

How it works

It selectively blocks beta-1 adrenoceptors, reducing heart rate, myocardial contractility and renin release; it also promotes endothelial nitric oxide release, producing peripheral vasodilation.

Prescribing in practice

Avoid in asthma and other reversible obstructive airways disease, and in marked bradycardia, second- or third-degree heart block, sick sinus syndrome and decompensated heart failure.
Do not stop abruptly, particularly in ischaemic heart disease, as this risks rebound angina or arrhythmia; withdraw gradually.
May mask the warning signs of hypoglycaemia, such as tachycardia, in patients with diabetes.

Monitoring

Monitor heart rate and blood pressure; in heart failure assess clinical status closely after initiation and dose changes, watching for fluid retention or worsening symptoms.

Counselling the patient

Do not stop the tablets suddenly without medical advice.
It may cause tiredness, headache or dizziness, especially when starting.
If you have diabetes, be aware it can hide the usual warning signs of a low blood sugar.

Evidence & guidelines

Guideline-recommended option for hypertension and for heart failure in older people (NICE NG136; NICE NG106).

Reference: NICE NG136/NG106; ESC; 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.

Calculators

Pathways