Back Pedaling on Beta Blockers (Atenolol, Metoprolol, Propranolol) for Hypertension

For decades, American physicians prescribed beta blockers as a primary treatment for high blood pressure. When we checked a few years ago, we discovered that 115 million prescriptions were dispensed for such medications annually. Assuming 30 tablets per prescription (a month’s supply), that totaled 3,450,000,000 pills. That’s over three billion pills! Now we are being told this might have been a big oops.

Guidelines on Beta Blockers:

Guidelines published in the Journal of the American Medical Association (JAMA, Dec. 18, 2013) for the treatment of hypertension relegated beta blockers to the back of the line. That’s because the evidence for their effectiveness in treating high blood pressure has been disappointing and there is even some suggestion of harm.

Drugs such as atenolol, bisoprolol, labetalol, metoprolol, nadolol,  and propranolol are prescribed for other conditions beside hypertension, though. Doctors have been using such medications for decades to treat irregular heart rhythms, angina, hypertrophic cardiomyopathy and even migraine headaches. But the overwhelming majority of the prescriptions that have been written for beta adrenergic blockers over the last 40 years were to lower blood pressure.

Breathing Problems and Brain Fog:

We recently received this message from a reader:

Q. My doctor prescribed atenolol for high blood pressure. Over the years I have experienced a lot of side effects: fatigue, brain fog, insomnia and nightmares as well as hair loss. My asthma has become a lot worse.

I thought these problems might just be due to hitting middle age. I am a 48-year-old African American woman and many of my Black friends were having the same troubles. Then I started asking questions and learned that about 80 percent of them were also taking atenolol.

I quit the medication and started feeling much better. Several of my friends are weaning off their pills, too. Is there anything we should know?

A. Physicians have been debating the role of beta blockers as first-line blood pressure medicines for years. An editorial in the journal Hypertension (Jan. 12, 2022) questions whether beta blockers such as atenolol are optimally effective for Black patients.

There are many treatments other than beta blockers that can help control hypertension. In our eGuide to Blood Pressure Solutions, we discuss both medications and non-drug approaches.

It’s Hard to Teach Old Docs New Tricks:

For over a decade cardiologists in the know have been encouraging their colleagues to back off beta blockers as first-line treatment for hypertension. One of the world’s most renowned hypertension experts, Franz Messerli, MD, and his colleagues wrote an article titled “Beta-Blockers in Hypertension–The Emperor Has No Clothes.”

Here was their conclusion:

“We systematically analyzed all available outcome studies and found no evidence that beta-blocker based therapy, despite lowering blood pressure, reduced the risk of heart attacks or strokes. Despite the inefficacy of beta-blockers, the incidence of adverse effects is substantial. In the MRC [Medical Research Council] study, for every heart attack or stroke prevented, three patients withdrew from atenolol because of impotence, and another seven withdrew because of fatigue. Thus the risk/benefit ratio of beta-blockers is characterized by lack of efficacy and multiple adverse effects.” F. H. Messerli et al., American Journal of Hypertension, Oct., 2003

Doctors ignored Dr. Messerli for a very long time. A study published in the Journal of the American Medical Association (JAMA, Oct. 3, 2012) demonstrated that beta blockers offered no meaningful benefit for high-risk heart patients (who had experienced heart attacks or were diagnosed with coronary artery disease). The researchers followed more than 44,000 such people for almost four years. At the end of the study, they had found no evidence that beta blockers prevented second heart attacks, strokes or death due to cardiovascular causes.

Are Beta Blockers Counterproductive for High BP?

Some data suggest that one of the most popular beta blockers, atenolol, might actually increase the risk of stroke compared to other kinds of blood pressure medications.

A Danish epidemiological study compared 14,644 patients taking beta blockers for hypertension with 40,676 people taking different kinds of blood pressure medicine. The researchers asked an important question. If these patients had to undergo noncardiac surgery for any reason, was there a difference in major adverse cardiovascular events (MACE)? Answer: people on beta blockers fared worse. Older people (those over 70) seemed especially susceptible to beta blocker-associated complications (Jorgensen et al, JAMA Internal Medicine, Dec. 2015).

Playing Catch Up:

The American medical establishment has been slow to realize that beta blockers should not be prescribed as first-line treatment for high blood pressure. Thank goodness we have finally caught up with European cardiologists. They issued guidelines about this many years ago.

We have discussed this and other medical misadventures in our book, Top Screwups Doctors Make and How to Avoid Them. If you would like to get a better understanding of the problems with such drugs and what better alternatives might be available you can check out our publications.

NEVER Stop These Drugs Suddenly!

No one must ever stop a beta blocker suddenly. Doing so could trigger chest pain, irregular heart rhythms or even a heart attack. We hope that the guidelines will not create withdrawal symptoms or complications for millions of patients who have been taking beta blockers for years or even decades.

Because there are no clear recommendations on how to phase off such drugs, doctors will need to be very cautious about this process.  No patient should ever discontinue a beta blocker without careful consultation with the prescriber.

Here are some side effects to be aware of regarding beta blockers and some stories from visitors to this website:

Beta Blocker Side Effects:

• Fatigue, tiredness, depression
, drowsiness
• Dizziness, lightheadedness
, vertigo
• Itchy skin rash
• Difficulty breathing, asthma
, wheezing
• Slow heart rate
, palpitations
• Cold hands or feet
, Raynaud’s syndrome, peripheral edema (swelling)
• Sensitivity to sunlight, sunburn
• Heart block (a problem with the rhythm)
• Blood disorders
• Memory problems, confusion
• Nightmares, insomnia, anxiety
• Digestive upset, diarrhea, nausea, constipation, flatulence
• Arthritis, joint pain

 Stories from Visitors to This Website:

A number of readers have had relevant experience with beta blocker medications.

ER developed a rash:

“One side effect of beta blockers was not mentioned. A few years ago, when I was taking a beta blocker, I developed a red, very itchy rash on my scalp. The first question the dermatologist asked was ‘Are you taking a beta blocker?’ It turned out to be psoriasis, and she had seen it before.

“The itching is terrible, and there is really nothing to do for it. I have tried all manner of things. Turmeric helped for a little while.”

S in Washington has advice on stopping:

“Seriously….DO NOT STOP TAKING METOPROLOL COLD TURKEY!

“You must wean off of it VERY GRADUALLY to lessen the effects. We did it 1/4 dose at a time for 2 weeks each step. There were still reactions at each stage; slightly elevated pulse, anxiety for no reason…but staying calm and deep breathing helps. It took about 2 months to get off completely and there were still mild spells for about another month.

“Unknown to most people is that beta blockers dampen your bodies response to adrenalin so your poor system has to re-learn how to handle it when you stop taking them. That’s what triggers the anxiety and rapid pulse.”

EAG has had trouble wth several beta adrenergic blocker side effects:

“I have been on metoprolol for years and before that it was Toprol. I have searched from doctor to doctor for reasons for all my problems: coughing, palpitations, fatigue, depression, dizziness, difficult breathing, cold feet and hands, light headedness, poor coordination, and many other problems. I have asked a number of doctors to change my high blood pressure medicine but they all seem to just laugh it off. Am I wrong in wanting to change?”

MB’s husband has vivid dreams that disturb her sleep:

“My husband was prescribed atenolol after a heart attack. I now sleep in a different bedroom because of his dreams. I’ve been punched and kicked because of his vivid dreams/nightmares to the point of bruises being left!

“It isn’t every night but at least 1-2 nights per week. We didn’t know what was causing them until we started investigating the side effects of his medications since it had really started just after he started atenolol.”

Martha is concerned about hair loss:

“Since being on beta blockers for two years my hair has gotten very thin. At first I attributed this to aging, but the hair loss is substantial. It never dawned on me it could be a side effect from metoprolol.”

Julie R offers advice from the perspective of a health care practitioner:

“I am a nurse practitioner and have often treated people with hypertension. Beta blockers (end in -lol) are NOT first line medications for hypertension unless you are taking them after a heart attack or because of another health condition (such as migraines). These guidelines for hypertension are brand new and will be soon published in the JNC-8.

“First line treatment is always lifestyle changes such as weight loss, exercise, smoking cessation, limited alcohol intake and decrease in added salt. Second line are medications for hypertension in the ACE (-pril), ARB (-sartan) and diuretic classes. If a provider gives you a beta blocker right out of the gate, you should be asking some questions.”

Learn More:

Share your own beta blocker story below. And should you wish to learn more about drugs (and non-drug approaches) for high blood pressure, check out our Guide to Blood Pressure Treatment. You may be surprised to learn that we predicted the end of beta blockers as first-line blood pressure medication more than seven years ago.