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Nadolol and Bendroflumethiazide (Tablet)

Source:http://www4.wiwiss.fu-berlin.de/dailymed/resource/drugs/3599

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Nadolol and Bendroflumethiazide (Tablet)
dailymed-instance:dosage
DOSAGE MUST BE INDIVIDUALIZED . NADOLOL AND BENDROFLUMETHIAZIDE TABLETS MAY BE ADMINISTERED WITHOUT REGARD TO MEALS. Bendroflumethiazide is usually given at a dose of 5 mg daily. The usual initial dose of nadolol is 40 mg once daily whether used alone or in combination with a diuretic. Bendroflumethiazide in nadolol and bendroflumethiazide Tablets is 30 percent more bioavailable than that of 5 mg bendroflumethiazide tablets. Conversion from 5 mg bendroflumethiazide tablets to nadolol and bendroflumethiazide tablets represents a 30 percent increase in dose of bendroflumethiazide. The initial dose of nadolol and bendroflumethiazide tablets may therefore be the 40 mg/5 mg tablet once daily. When the antihypertensive response is not satisfactory, the dose may be increased by administering the 80 mg/5 mg tablet once daily. When necessary, another antihypertensive agent may be added gradually beginning with 50 percent of the usual recommended starting dose to avoid an excessive fall in blood pressure.<br/>Dosage Adjustment in Renal Failure: Absorbed nadolol is excreted principally by the kidneys and, although nonrenal elimination does occur, dosage adjustments are necessary in patients with renal impairment. The following dose intervals are recommended:
dailymed-instance:descripti...
Nadolol and Bendroflumethiazide Tablets for oral administration combines two antihypertensive agents: nadolol, a nonselective beta-adrenergic blocking agent, and bendroflumethiazide, a thiazide diuretic-antihypertensive. Each tablet contains 40 mg or 80 mg nadolol combined with 5 mg bendroflumethiazide. Inactive ingredients: croscarmellose sodium, hypromellose (type 2910), lactose monohydrate, magnesium stearate, mannitol, microcrystalline cellulose, pregelatinized starch and talc.<br/>Nadolol: Nadolol is a white crystalline powder. It is freely soluble in ethanol, soluble in hydrochloric acid, slightly soluble in water and in chloroform, and very slightly soluble in sodium hydroxide. Nadolol is designated chemically as 1-(tert-butylamino)-3-{(5,6,7,8-tetrahydro- cis -6,7-dihydroxy-1-naphthyl)oxy}-2-propanol. Structural formula:<br/>Bendroflumethiazide: Bendroflumethiazide is a white crystalline powder. It is soluble in alcohol and in sodium hydroxide, and insoluble in hydrochloric acid, water, and chloroform. Bendroflumethiazide is designated chemically as 3-benzyl-3,4-dihydro-6-(trifluoromethyl)-2H-1,2,4-benzothiadiazine-7-sulfonamide 1,1-dioxide. Structural formula:
dailymed-instance:clinicalP...
Nadolol: Nadolol is a nonselective beta-adrenergic receptor blocking agent. Clinical pharmacology studies have demonstrated beta-blocking activity by showing (1) reduction in heart rate and cardiac output at rest and on exercise, (2) reduction of systolic and diastolic blood pressure at rest and on exercise, (3) inhibition of isoproterenol-induced tachycardia, and (4) reduction of reflex orthostatic tachycardia. Nadolol specifically competes with beta-adrenergic receptor agonists for available beta receptor sites; it inhibits both the betareceptors located chiefly in cardiac muscle and the betareceptors located chiefly in the bronchial and vascular musculature, inhibiting the chronotropic, inotropic, and vasodilator responses to beta-adrenergic stimulation proportionately. Nadolol has no intrinsic sympathomimetic activity and, unlike some other beta-adrenergic blocking agents, nadolol has little direct myocardial depressant activity and does not have an anesthetic-like membrane-stabilizing action. Animal and human studies show that nadolol slows the sinus rate and depresses AV conduction. In dogs, only minimal amounts of nadolol were detected in the brain relative to amounts in blood and other organs and tissues. Nadolol has low lipophilicity as determined by octanol/water partition coefficient, a characteristic of certain beta-blocking agents that has been correlated with the limited extent to which these agents cross the blood-brain barrier, their low concentration in the brain, and low incidence of CNS-related side effects. In controlled clinical studies, nadolol at doses of 40 to 320 mg/day has been shown to decrease both standing and supine blood pressure, the effect persisting for approximately 24 hours after dosing. The mechanism of the antihypertensive effects of beta-adrenergic receptor blocking agents has not been established; however, factors that may be involved include (1) competitive antagonism of catecholamines at peripheral (non-CNS) adrenergic neuron sites (especially cardiac) leading to decreased cardiac output, (2) a central effect leading to reduced tonic-sympathetic nerve outflow to the periphery, and (3) suppression of renin secretion by blockade of the beta-adrenergic receptors responsible for renin release from the kidneys. While cardiac output and arterial pressure are reduced by nadolol therapy, renal hemodynamics are stable, with preservation of renal blood flow and glomerular filtration rate. By blocking catecholamine-induced increases in heart rate, velocity and extent of myocardial contraction, and blood pressure, nadolol generally reduces the oxygen requirements of the heart at any given level of effort, making it useful for many patients in the long-term management of angina pectoris. On the other hand, nadolol can increase oxygen requirements by increasing left ventricular fiber length and end diastolic pressure, particularly in patients with heart failure. Although beta-adrenergic receptor blockade is useful in treatment of angina and hypertension, there are also situations in which sympathetic stimulation is vital. For example, in patients with severely damaged hearts, adequate ventricular function may depend on sympathetic drive. Beta-adrenergic blockade may worsen AV block by preventing the necessary facilitating effects of sympathetic activity on conduction. Beta-adrenergic blockade results in passive bronchial constriction by interfering with endogenous adrenergic bronchodilator activity in patients subject to bronchospasm and may also interfere with exogenous bronchodilators in such patients. Absorption of nadolol after oral dosing is variable, averaging about 30 percent. Peak serum concentrations of nadolol usually occur in three to four hours after oral administration and the presence of food in the gastrointestinal tract does not affect the rate or extent of nadolol absorption. Approximately 30 percent of the nadolol present in serum is reversibly bound to plasma protein. Unlike many other beta-adrenergic blocking agents, nadolol is not metabolized by the liver and is excreted unchanged, principally by the kidneys. The half-life of therapeutic doses of nadolol is about 20 to 24 hours, permitting once-daily dosage. Because nadolol is excreted predominantly in the urine, its half-life increases in renal failure . Steady state serum concentrations of nadolol are attained in six to nine days with once-daily dosage in persons with normal renal function. Because of variable absorption and different individual responsiveness, the proper dosage must be determined by titration. Exacerbation of angina and, in some cases, myocardial infarction and ventricular dysrhythmias have been reported after abrupt discontinuation of therapy with beta-adrenergic blocking agents in patients with coronary artery disease. Abrupt withdrawal of these agents in patients without coronary artery disease has resulted in transient symptoms, including tremulousness, sweating, palpitation, headache, and malaise. Several mechanisms have been proposed to explain these phenomena, among them increased sensitivity to catecholamines because of increased numbers of beta receptors.<br/>Bendroflumethiazide: The mechanism of action of bendroflumethiazide results in an interference with the renal tubular mechanism of electrolyte reabsorption. At maximal therapeutic dosage all thiazides are approximately equal in their diuretic potency. Thiazides increase excretion of sodium and chloride in approximately equivalent amounts. Natriuresis causes a secondary loss of potassium and bicarbonate. The mechanism of the antihypertensive effect of thiazides is unknown. Thiazides do not affect normal blood pressure. Onset of action of thiazides occurs in two hours and the peak effect at about four hours. Duration of action persists for approximately six to 12 hours. Thiazides are eliminated rapidly by the kidney.
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dailymed-instance:supply
Nadolol and bendroflumethiazide tablets, 40 mg/5 mg, contain 40 mg nadolol combined with 5 mg bendroflumethiazide, and are white to off-white, round, bi-convex tablets debossed with "G" bisect "531" on one side and plain on the other. Bottles of 100 . . . . . . . . . . . . . .NDC 0115-5311-01 Bottles of 500 . . . . . . . . . . . . . .NDC 0115-5311-02 Nadolol and bendroflumethiazide tablets, 80 mg/5 mg, contain 80 mg nadolol combined with 5 mg bendroflumethiazide, and are white to off-white, round, bi-convex tablets debossed with "G" bisect "532" on one side and plain on the other. Bottles of 100 . . . . . . . . . . . . . .NDC 0115-5322-01 Bottles of 500 . . . . . . . . . . . . . .NDC 0115-5322-02 Store at 20��to 25��C (68��to 77��F) [see USP Controlled Room Temperature].
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Exacerbation of Ischemic Heart Disease Following Abrupt Withdrawal: Hypersensitivity to catecholamines has been observed in patients withdrawn from beta-blocker therapy; exacerbation of angina and, in some cases, myocardial infarction have occurred after abrupt discontinuation of such therapy. When discontinuing chronically administered nadolol, particularly in patients with ischemic heart disease, the dosage should be gradually reduced over a period of one to two weeks and the patient should be carefully monitored. If angina markedly worsens or acute coronary insufficiency develops, nadolol administration should be reinstituted promptly, at least temporarily, and other measures appropriate for the management of unstable angina should be taken. Patients should be warned against interruption or discontinuation of therapy without thephysician's advice. Because coronary artery disease is common and may be unrecognized, it may be prudent not to discontinue nadolol therapy abruptly even in patients treated only for hypertension.
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dailymed-instance:overdosag...
In the event of overdosage, nadolol may cause excessive bradycardia, cardiac failure, hypotension, or bronchospasm. In addition to the expected diuresis, overdosage of bendroflumethiazide may produce varying degrees of lethargy which may progress to coma with minimal depression of respiration and cardiovascular function and without significant serum electrolyte changes or dehydration. The mechanism of thiazide-induced CNS depression is unknown. Gastrointestinal irritation may occur. Transitory increase in BUN has been reported, and serum electrolyte changes may occur, especially in patients with impaired renal function.<br/>Treatment: Nadolol can be removed from the general circulation by hemodialysis. In determining the duration of corrective therapy, note must be taken of the long duration of the effect of nadolol. In addition to gastric lavage, the following measures should be employed, as appropriate.<br/>Excessive Bradycardia: Administer atropine (0.25 to 1.0 mg). If there is no response to vagal blockade, administer isoproterenol cautiously.<br/>Cardiac Failure: Administer a digitalis glycoside and diuretic. It has been reported that glucagon may also be useful in this situation.<br/>Hypotension: Administer vasopressors, e.g., epinephrine or levarterenol. (There is evidence that epinephrine may be the drug of choice.)<br/>Bronchospasm: Administer a beta-stimulating agent and/or a theophylline derivative.<br/>Stupor or Coma: Supportive therapy as warranted.<br/>Gastrointestinal Effects: Symptomatic treatment as needed.<br/>BUN and/or Serum Electrolyte Abnormalities: Institute supportive measures as required to maintain hydration, electrolyte balance, respiration, and cardiovascular and renal function.
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Nadolol and Bendroflumethiazide
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Nadolol and Bendroflumethiazide (Tablet)
dailymed-instance:adverseRe...
Nadolol: Most adverse effects have been mild and transient and have rarely required withdrawal of therapy. Cardiovascular-Bradycardia with heart rates of less than 60 beats per minute occurs commonly, and heart rates below 40 beats per minute and/or symptomatic bradycardia were seen in about 2 of 100 patients. Symptoms of peripheral vascular insufficiency, usually of the Raynaud type, have occurred in approximately 2 of 100 patients. Cardiac failure, hypotension, and rhythm/conduction disturbances have each occurred in about 1 of 100 patients. Single instances of first degree and third degree heart block have been reported; intensification of AV block is a known effect of beta-blockers . Central Nervous System-Dizziness or fatigue has been reported in approximately 2 of 100 patients; paresthesias, sedation, and change in behavior have each been reported in approximately 6 of 1000 patients. Respiratory-Bronchospasm has been reported in approximately 1 of 1000 patients . Gastrointestinal-Nausea, diarrhea, abdominal discomfort, constipation, vomiting, indigestion, anorexia, bloating, and flatulence have been reported in 1 to 5 of 1000 patients. Miscellaneous-Each of the following has been reported in 1 to 5 of 1000 patients: rash; pruritus; headache; dry mouth, eyes, or skin; impotence or decreased libido; facial swelling; weight gain; slurred speech; cough; nasal stuffiness; sweating; tinnitus; blurred vision. Reversible alopecia has been reported infrequently. The following adverse reactions have been reported in patients taking nadolol and/or other beta-adrenergic blocking agents, but no causal relationship to nadolol has been established. Central Nervous System-Reversible mental depression progressing to catatonia; visual disturbances; hallucinations; an acute reversible syndrome characterized by disorientation for time and place, short-term memory loss, emotional lability with slightly clouded sensorium, and decreased performance on neuropsychometrics. Gastrointestinal-Mesenteric arterial thrombosis; ischemic colitis; elevated liver enzymes. Hematologic-Agranulocytosis; thrombocytopenic or nonthrombocytopenic purpura. Allergic-Fever combined with aching and sore throat; laryngospasm; respiratory distress. Miscellaneous-Pemphigoid rash; hypertensive reaction in patients with pheochromocytoma; sleep disturbances; Peyronie's disease. The oculomucocutaneous syndrome associated with the beta-blocker practolol has not been reported with nadolol.<br/>Bendroflumethiazide: Gastrointestinal-Nausea, vomiting, cramping and anorexia are not uncommon; diarrhea, constipation, gastric irritation, abdominal bloating, jaundice (intrahepatic cholestatic jaundice), hepatitis, and sialadenitis occasionally occur; and pancreatitis has been reported. Central Nervous System-Dizziness, vertigo, paresthesia, headache, and xanthopsia occasionally occur. Hematologic-Leukopenia, agranulocytosis, thrombocytopenia, hemolytic anemia, and aplastic anemia have been reported. Dermatologic-Hypersensitivity-Purpura, exfoliative dermatitis, pruritus, ecchymosis, urticaria, necrotizing angiitis (vasculitis, cutaneous vasculitis), respiratory distress including pneumonitis, fever, and anaphylactic reactions occasionally occur; photosensitivity and rash have been reported. Cardiovascular-Orthostatic hypotension may occur and may be potentiated by coadministration with certain other drugs (e.g., alcohol, barbiturates, narcotics, other antihypertensive medications, etc.; see PRECAUTIONS, Drug Interactions). Other-Muscle spasm, weakness, or restlessness is not uncommon; hyperglycemia, glycosuria, metabolic acidosis in diabetic patients, hyperuricemia, allergic glomerulonephritis, and transient blurred vision occasionally occur. Whenever adverse reactions are moderate or severe, thiazide dosage should be reduced or therapy withdrawn.
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Nadolol and Bendroflumethiazide