Saturday, February 23, 2008

Bystolic and stress

All stressed out and nowhere to run, no one to punch out. I was at a meeting yesterday, one of the most stressful meetings I've ever attended. My heart was pounding, I'm sure my face was red, and I had no recourse but to listen politely to the proceedings. If ever there was a stress test for my aging heart, that hour-long ordeal was it.

My forty-something year old patient lives a perpetual stress test. Caught in a years long legal battle with a former business colleague, he lives his life in a never-ending nervous fit. His heart pounds along at a resting heart rate above 110, his blood pressure is high, but the worst symptom, the one that brought him in 2 weeks ago, is how very, very hot he feels. He can scarcely stand indoor heating; his secretary suffers the open office windows while his wife piles on the covers in their breezy bedroom.

I have seriously entertained the notion that this poor fellow has an adrenal tumor, so intense are his symptoms. While waiting for his first round of tests to come back, I wondered if we might give him, his secretary, and his wife a break with beta blockers.

Originally developed for blood pressure troubles, beta blockers have since been tapped to control abnormal heart rhythms, protect heart muscle after a heart attack, and to combat performance anxiety. They work by competitively blocking cellular receptors for beta-sympathetic adrenal hormones such as norepinephrine which set off the 'fight or flight' response. As such, they can slow down the pulse and blood pressure response to stress. The problem with earlier versions of beta-blockers is that they blocked both beta-1 receptors responsible for cardiovascular changes and beta-2 receptors which, among other things, relax smooth muscle and dilate the airways (so you can get more oxygen to run away from lions, tigers, and meetings, oh my).

As my patient also has asthma in addition to more stress than any human should have, I needed a beta-1 selective agent that would not contribute to an asthmatic constriction of his airways. Lucky for us, the sales rep from Forest Pharmaceuticals had just left a big supply of Bystolic (generic name nebivolol) in our drug closet. I gave him a bottle and hoped that there would be no unexpected beta-2 blockade.

Here's the phone message I received 2 days later:

Said the pill you gave him works wonders. His heart rate went from 160 to 78, no more body heat, has not been using his inhaler, and his BP has gone down. He also has been working all day.

Now that is a wonder drug! I wonder why I didn't take one before the meeting from hell.

28 comments:

JeanMac said...

Yeah, one for you and one for him - you are def. hero to those who live near him!

Mauigirl said...

Wow, great prescribing there! I know what you mean about that meeting; I was once in a contentious meeting between local political officials and our park conservancy and, without going into details, I felt the same level of aggravation you did.

sunflower said...

I also have asthma and high blood pressure. the dr. just gave me samples of bystolic. I am afraid to take it as I have had two bad experiences with blood pressure meds. I wound up in the er because of amiloride and methyldopa. After reading your story I decided I will take the medicine tomorrow. I hope it doesn't aggrivate my asthma.

femail doc said...

Sunflower: I've never prescribed amiloride, and goodness, methyldopa is an old one, haven't used that in years. The only trouble I've had with bystolic is that it can cause fatigue initially; I've discovered that it's better to start with a low dose, even breaking the 5 mg. pill in half (or using the 2.5 mg pill). Hope it works for you!

Anonymous said...

I've had serious problems with the last 4 prescriptions of HB meds in past year, but just received samples for Bystolic. I have tried for the past 2 days, and so far so good! Enjoy your blog, thank you for your honest assessment of Bystolic!

femail doc said...

Anon: Hope Bystolic continues useful for you! Thanks for your comments.

Anonymous said...

I also use Bystolic. I've found Bystolic is great for heart rate control and OK for blood pressure. As far as anxiety or stress, beta blockers such as Metoprolol and Betaxolol (also beta1 blockers) are far superior. Betaxolol and Propranol have been studied for Psychiatric issues. Perhaps the way they cross the blood brain barrier is somewaht different. The only problem with these beta blockers is more fatigue and strange dreams. Bystolic avoids the fatigue, weird dreams and shortness of breath. The jury is still out for blood lipids, glucose increases and weight gain.

Anonymous said...

I forgot to mention in my previous post, this is an excellent site. Very informative.

P.S. In all fairness to Bystolic regarding stress and anxiety in comparison to Metoprolol or Propranol, I take only 5mg. a day, perhaps at higher doses Bystolic is just as effective as the other beta blockers, maybe better.

Anonymous said...

I found this blog most interesting and informative. I have anxiety/panic attacks with some mild associated depression and have been given Lexapro by my Pdoc for all of the above.

Lexapro has "cured" what little depression I had but had made my anxiety worse; especially the early morning panic attacks that occur upon awakening.

I was given Prednisone a few months back and for Purpura and the panic attacks developed after that. They are an every morning event as of this date.

I read online about docs giving Propranolol (sp) to patients who had bad side effects from Prednisone but I can't get my own down to prescribe even a low dose.

I'm very healthy, take no other meds but the Lexapro and some Trazodone (for sleep after the Prednisone) and I discovered this blog after researching beta blockers.

I've read tons of info online about beta blockers for such purposes as anxiety/panic attacks' off-label uses but even with a healthy heart and no health problems my doc won't let me try any. He wants me to take benzodiazepines and I don't want to take an addictive mediction.

My husband was given a beta blocker by our doctor for hand tremors which were the side effect of another medication and he took them for several years till the second med was stopped. The doc had no problem giving beta blocker to my husband and "I" am healthier than he is. Neither one of us has high BP.

Anyone have anything to add/offer?

Anonymous said...

Was put on 10mg which I feel is to high. My problem is high heart rate. Cutting it down to 5mg myself.
This am very dizzy from it and Pulse is 60.

femail doc said...

Hi Anon with panic attacks,
I love beta blockers for panic attacks. Perhaps your doctor is unfamiliar with this application, but I've used them often with patients to control anxiety and panic.

Hi Anon on 10 mg Bystolic,
I can't imagine staying awake much less moving on 10 mg. of Bystolic. I always start people on 1/2 of a 5 mg pill, then work up to a whole one if needed. Very sedating, especially at first.

Anonymous said...

Cutting back to 1/2 of a 5mg.
10mg makes me very dizzy, plus:
tired feeling;
nausea, stomach pain;
diarrhea;
Given for control of high heart rate, not BP.
Thanks

josiane said...

i have problem wthith blood pressure and anxetie attack my docteur try so many blood pressure medication.so now hi but me on bystolic 5 mg but i will only take half,because i am so scare to take medication hi also give me ativan,the reason hi give me the bystolic because papittation and my rate and blood pressure was higth,now i take this for three days and i feel better hi am not so anxiueuse and my blood pressue when down but i still scare i long i have to be on this medecine.sincerely josiane

Newly Anxious said...

I was also placed on 2.5 mg of Bystolic today for a combination of hypertension and anxiety. I'm probably reading too much into it, but the Bystolic web site says not to take if your heart beat is irregular and skips beats. Why is it then prescribed for irregular heart beats caused by anxiety? It also warns not to stop abruptly and to wean off of it. Is this not the case for 2.5 mg? Or are there even lower possible doses?

My China Stem Cell Adventure said...

Hi Doc, you mentioned that Bystolic can cause fatigue initially. Does this eventually go away? My doc put me on 2.5 mg of Bystolic to help control my epinephrone, which he says is out of control. I took one pill today and it made me feel very weak and fatigued. Should this abate?

Thanks,

Mike

femail doc said...

Hi Newly Anxious--The irregular heartbeats of anxiety are often not irregular, they just feel that way. At any rate, if they are irregular, they are generally a kind of early beat that will not be affected by a beta-blocker. I should think you could just stop 2.5 mg. without tapering further--but check with your doctor on that.

Mike-- The fatigue of Bystolic may or may not abate. I tell my patients to take it at night. If 2.5 continues to make you tired, ask your doctor about breaking the pill in half or even fourths. If you continue to be tired by day--and some of my patients never get past this side effect--it may be time to start a different medication.
Judy P.

junior said...

hi im taking norvasc 10mg and my doc wants me to try bystolic 10mg not only for blood pressure but for my anxiety. My question is can i just completely stop norvasc and start bystolic or do i have to ween myself of of norvasc first. i also have asthma but hasnt bothered me for two years(thank goodness). Im sorta afraid to take meds, it even took me a while before i could norvasc. thank you for your input.

Anonymous said...

Did the initial patient has a tumor of some kind? I've had the same problems as your patient. My doc had me get a cat scan to see if I had a tumor on my adrenal gland. The test showed no rumors thank God. I still suffer from the similar symptoms and just live with them. I have been diagnosed with hypothyroidism and i'm on synthroid. Any ideas?

Pete said...

I just started on Bystolic 2.5 a day. Also taking Amlodipine, 2.5 a day. Do they mix OK? My pulse has slowed down since starting the Bystolic. On my exercise bike I cannot get my pulse above 110 bpm. Before the new meds, my pulse would sometimes rapidly increase on the bike to dangerous numbers. Also, I would have a rapid pulse and an increase in BP when under stress. Most days before the meds, my pulse and BP were normal, but for a month I have been having trouble with a sudden rapid pulse. The doc wants me to try the Bystolic for 30 days to see if my pulse stabilizes during stress and during exercise. I also started using a Resperate device.

Anonymous said...

My cardiologist recently said it appears I have a bit of "exercise induced hypertension". BP is fine at rest but to high while exercising - I am a semi-serious runner. I have been taking 2.5 of the Bystolic every morning with no side effects other than I when I run it seems to be much harder than pre-Bystolic. I assume there is an impact due to the lowering of the heart rate.

Anonymous said...

I started taking bystolic about 6 months ago due to huge amount of stress I was under. I was having panic attacks and then my BP was all over the place so the docs assumed it was high BP however, I never had it before. I was on several BP meds and my BP was so low I couldn't function and the regular BP meds made me sick. Went to a Cardio doc explained the situation and they figured I was having panic attacks which was increasing my BP. Cardio doc wasn't sure I actually needed a BP med at all. They started with 5mg and it was too much went to 2.5mg which seemed to work ok. Now that alot of the stress has been eliminated I'm wondering if I really do need this drug. My ankles and feet are swelling. Had a sonogram of my arteries in my legs and they are saying I have arterial insufficiency. I read up on bystolic and one of the things says it slows down the arterial pressure. Now I'm wondering if its the drug doing that since I never had any problems before. I also wore a heart monitor for 21 days to eliminate any heart ailment which I have none. I've gained 15 lbs since taking it and feel extremely tired and fatigued most of the time. I have started taking B12 which has helped with the fatigue. My BP is nearly perfect vs the 140 it was running which is borderline. I'm wondering what to do at this point. My head always feel foggy like and I feel slowed down compared to what I was. I was an active 54 yr old when all this started. I feel zombie like. The doc wants to try another BP med but I'm almost scared to try it since 6 others have made me so sick I couldn't function. They were all the lowest doses possible.
My question is if I was to stop taking it do you have to ween off of it? I take the lowest dose possible. Any suggestions?

Mark said...

I was on atenolol 25mg for about 5 years. Felt very stable on it and had a very stable BP.

Tried different doses of Bystolic with varied effects.

2.5mg kept me calm, but didn't provide effective BP reduction throughout the day.

5mg seemed to keep me calm, and provide effective BP control, as long as I was resting for at least 10 minutes. If I was moving around before PB was taken, which is often the case with a doctor's visit, my BP would be slightly elevated.

10 mg worked best for BP, but I occasionally felt anxious on this dose, and I noticed a hard time with memory. Some short- and long-term memory loss.

I was diagnosed with a bicuspid aortic valve about 2 years ago.

So my cardiologist put me on ATACAND 4mg in addition to the beta blocker.

My biggest concern is when I am resting and/or sleeping. I become hypotensive and/or bradycardic often with the duel therapy.

Anonymous said...

Hi! My name is Victoria, I'm 27 and i have the same symptoms as your patient, i feel very very hot all the time, specially in my head but no high blood pressure, only some palpitations... at the beginning started occasionally in my feet, hands or head; but now is constant and almost all over my body.
Sometimes I have anxiety/panic attacks, the more recurrent are the early morning panic attacks that occur upon awakening.

My doctor gave me Nebivolol (here in my country is Temerit)half of the 5 mg. pill every 24 hrs

Today i'm going to take a blood analysis for Cortisol, and another thyroid profile.

I just wonder what's the reason of this hot feeling? and what should i expect from the beta blockers?

Anonymous said...

I have been taking 100 to 150 mg of metoprolol every day--It had been working reasonably well for a couple of years, until a week ago--not sure about the trigger, because I have had significant stress on and off for years. My bp is triggered by eating, laying down, talking a lot, which, unfortunately, I do for a living. Recently, my face is getting flushed, and I feel pressure in my head and face. A new cardiologist wants me to take Bystolic, 5 mg, in the evening, but I can continue to take Metoprolol in the morning and early afternoon. I am afraid of new medication, since I have had medication reactions, and am afraid the Bystolic may work even less well the Metoprolol.

Any thoughts?

denverdoc said...

Anon: There are other conditions besides stress and BP that can cause flushing. I trust you are being checked for these so ask your doctor about this, especially if the Bystolic makes no difference.

I don't see a downside to trying Bystolic, though I'd urge you to start with 1/2 or less of the 5 mg tablet (the tablet breaks very easily but not evenly) to check out side effects. My experience has been that some people find it makes them very tired; this is not necessarily a bad thing at bedtime, but it may carry over into unpleasant daytime drowsiness. This side effect improves over time.

caspian Lundgren said...

I have been taking Bystolic 10 mg every morning for the past three to four years for hypertension without bothersome side effects. The medication maintained my blood pressure pretty well even during a death of a close family member.

Anonymous said...

Hi. Can you tell me if Bystolic can help me with facial blushing from nervousness? I asked to be put on propanolol but my Dr. wanted me to try this.

AnxiousAboutMed said...

Hello Doc,

I have history of mild blood pressure. For few years I took water pills. They were helping so my doctor started Valsartan/HCTZ 80mg-12.5mg two months ago. recently I mentioned to my doctor about palpitations (i also have history of MVP), he put me on additional dose of bystolic 2.5mg. My question is : is there any side effect from this combined therapy? Can this therapy be given for long term? Will it reduce my BP too much down?

Another question : Can a high BP can cause high eye pressure which can lead to Glaucoma?s My eye doctor recently mentioned that my optic nerve have some changes (it looks bigger) , so he took pictures and asked me to follow up in three months.


Thanks you