Nebivolol

Use caution with history of severe anaphylaxis to a variety of allergens; patients taking beta-blockers may become more sensitive to repeated challenges. Treatment of anaphylaxis (eg, epinephrine) in patients taking beta-blockers may be ineffective or promote undesirable effects. Disease-related concerns:

In general, patients with bronchospastic disease should not receive beta-blockers; for patients with bronchospastic disease who do not respond to or cannot tolerate other therapies, initial low doses of beta1-selective nebivolol may be employed and used cautiously with close monitoring. Ensure patient has an inhaled beta2-agonist immediately available.

Use with caution in patients with diabetes mellitus; may potentiate hypoglycemia and/or mask signs and symptoms.

Note: Nebivolol has not been shown to reduce morbidity or mortality in the general HF population; only beta-blockers proven to reduce mortality (ie, bisoprolol, carvedilol, or extended-release metoprolol succinate) should be used in the treatment of heart failure. Use with caution in patients with compensated HF and monitor for a worsening of the condition. If condition worsens, consider temporary discontinuation or dosage reduction of nebivolol. Patients should be stabilized on HF regimen prior to initiation of beta-blocker. Beta-blocker therapy should be initiated at very low doses with gradual and very careful titration. Adjustment of other medications (ACE inhibitors and/or diuretics) may be required.

Use with caution in patients with hepatic impairment; dosage adjustment required with moderate impairment (Child-Pugh class B). Use is contraindicated in patients with Child-Pugh class C hepatic impairment.

Use with caution in patients with myasthenia gravis.

Can precipitate or aggravate symptoms of arterial insufficiency in patients with PVD and Raynaud's disease. Use with caution and monitor for progression of arterial obstruction.

Adequate alpha-blockade is required prior to use of any beta-blocker.

Beta-blocker use has been associated with induction or exacerbation of psoriasis, but cause and effect have not been firmly established.

Use with caution in patients with a history of psychiatric illness; may cause or exacerbate CNS depression.

Use with caution in patients with renal impairment; dosage adjustment required with severe renal impairment (CrCl • Thyroid disease: May mask signs of hyperthyroidism (eg, tachycardia). If thyrotoxicosis is suspected, carefully manage and monitor; abrupt withdrawal may exacerbate symptoms of hyperthyroidism or precipitate thyroid storm. Concurrent drug therapy issues:

Potentially significant interactions may exist, requiring dose or frequency adjustment, additional monitoring, and/or selection of alternative therapy. Consult drug interactions database for more detailed information. Special populations:

Bradycardia may be observed more frequently in elderly patients (>65 years of age); dosage reductions may be necessary. Other warnings/precautions:

Beta-blocker therapy should not be withdrawn abruptly (particularly in patients with coronary artery disease), but gradually tapered over 1-2 weeks to avoid acute tachycardia, hypertension, and/or ischemia. Severe exacerbation of angina, ventricular arrhythmias, and myocardial infarction (MI) have been reported following abrupt withdrawal of beta-blocker therapy. Temporary but prompt resumption of beta-blocker therapy may be indicated with worsening of angina or acute coronary insufficiency.

Chronic beta-blocker therapy should not be routinely withdrawn prior to major surgery.