Class: beta-Adrenergic Blocking Agents
VA Class: CV100
Chemical Name: 1-(Indol-4-yloxy)-3-(isopropylamino)-2-propanol
Molecular Formula: C14H20N2O2
CAS Number: 13523-86-9
Uses for Pindolol
β-Blockers generally not preferred for initial management of hypertension, but may be considered in patients who have a compelling indication (e.g., prior MI, ischemic heart disease, heart failure) for their use or as add-on therapy in those who do not respond adequately to the preferred drug classes (ACE inhibitors, angiotensin II receptor antagonists, calcium-channel blockers, or thiazide diuretics).101 501 502 503 504 515 523 524 527
Black hypertensive patients generally tend to respond better to monotherapy with calcium-channel blockers or thiazide diuretics than to β-blockers. 85 89 90 500 501 504 However, diminished response to β-blockers is largely eliminated when administered concomitantly with a thiazide diuretic.500
Pindolol Dosage and Administration
Individualize dosage according to patient response and tolerance.1
If long-term therapy is discontinued, reduce dosage gradually over a period of about 1–2 weeks.1 (See Abrupt Withdrawal of Therapy under Cautions.)
BP Monitoring and Treatment Goals
When available, use evidence-based dosing information (i.e., dosages shown in randomized controlled trials to reduce complications of hypertension) to determine target dosages; target dosages usually can be achieved within 2–4 weeks but may take up to several months.501
Goal is to achieve and maintain optimal control of BP; individualize specific target BP based on consideration of multiple factors, including patient age and comorbidities, and currently available evidence from clinical studies.500 501
Initially, 5 mg twice daily, either alone or in combination with other antihypertensives.1 52 600 Increase dosage gradually by 10 mg daily at 3- to 4-week intervals as necessary up to 60 mg daily.1 The usual maintenance dosage range is 10–40 mg daily, given in 2 divided doses.2 11 15 500
If intolerable adverse effects occur, consider dosage reduction; if adverse effects worsen or fail to resolve, may need to discontinue and switch to another antihypertensive drug class.501
Maximum 60 mg daily.1
Dosage must be modified in response to the degree of hepatic impairment.1
Cautions for Pindolol
Bronchial asthma, heart block greater than first degree, cardiogenic shock, overt cardiac failure, or severe bradycardia.1
Avoid use in patients with decompensated CHF, may use cautiously in patients with well-compensated heart failure (e.g., those controlled with ACE inhibitors, cardiac glycosides, and/or diuretics).1
Adequate treatment (e.g., with a cardiac glycoside and/or diuretic) and close observation recommended if signs or symptoms of impending cardiac failure occur; if cardiac failure continues, discontinue therapy, gradually if possible.1
Abrupt Withdrawal of Therapy
Abrupt discontinuance of therapy is not recommended as it may exacerbate angina symptoms or precipitate MI in patients with CAD.1 Gradually decrease dosage over a period of about 1–2 weeks.1 Monitor patients carefully and advise to temporarily limit their physical activity.1 If exacerbation of angina occurs, reinstitute therapy promptly, and initiate appropriate measures for the management of unstable angina pectoris.1
Possible inhibition of bronchodilation produced by endogenous catecholamines.1
Generally should not be used in patients with bronchospastic disease, but may be used with caution in patients with nonallergic bronchospasm (e.g., chronic bronchitis, emphysema).1 (See Contraindications under Cautions.)
Possible risks associated with general anesthesia (e.g., severe hypotension, difficulty maintenaning heart beat) due to decreased ability of the heart to respond to reflex β-adrenergic stimuli.1 Use with caution in patients undergoing major surgery involving general anesthesia.1
Diabetes and Hypoglycemia
Use with caution in patients with diabetes mellitus receiving hypoglycemic drugs.1
Possible increased reactivity to repeated, accidental, diagnostic, or therapeutic challenges with a variety of allergens while taking β-blocking agents in patients with a history of anaphylactic reactions to a variety of allergens.1 Such patients may be unresponsive to usual doses of epinephrine.1
Safety and efficacy not established.1
Hepatic elimination; use with caution.1
Common Adverse Effects
Insomnia, dizziness, fatigue, nervousness, bizzare dreams or increased dreaming, weakness, paresthesia, edema, dyspnea, muscle pain, joint pain, chest pain, muscle cramps, nausea, abdominal discomfort, pruritus.1
Interactions for Pindolol
Pharmacokinetic interaction unlikely1
Possible decreases in serum digoxin concentrations 1
Monitor for signs of hypotension and bradycardia (e.g., vertigo, syncope, postural hypotension)1
Hypotensive agents (hydralazine, hydrochlorothiazide)
Possible increased hypotensive effects1
Adjust dosage carefully1
Concomitant use is contraindicated73
Pharmacokinetic interaction unlikely1
Effect on heart rate is seen within 3 hours.2
Hypotensive effect is usually seen within 1 week, but maximum therapeutic response may not be observed until 2 weeks or longer.1
Acute hemodynamic effects persist for 24 hours after administration.2
Distributed into milk.1
Plasma Protein Binding
In geriatric patients, plasma half-life is 7–15 hours.1
In patients with hepatic cirrhosis, half-life is 2.5–30 hours.1
At higher than therapeutically obtained plasma concentrations, the drug has membrane-stabilizing activity or a quinidine-like effect.4
Decreases stress- and exercise-stimulated heart rate.1 2 4 5 Has a lesser effect on resting heart rate (usually decreasing resting heart rate only by about 4–8 bpm or not at all),1 2 4 5 15 22 slowing of conduction in the AV node,4 and cardiac output,2 4 13 22 than do β-adrenergic blocking agents that do not possess intrinsic sympathomimetic activity (ISA).1 2 4 5 15 22
The precise mechanism of hypotensive effect has not been determined;1 the drug does not consistently affect cardiac output or renin release, and other mechanisms (e.g., decreased peripheral resistance) probably contribute to its hypotensive effect.1 15 16
May increase airway resistance,1 2 4 depending on the patient’s pretreatment sympathetic tone; patients with high pretreatment tone show a decrease in forced expiratory volume in 1 second (FEV1), whereas those with low pretreatment tone may show little, if any, change in FEV1.17
Advice to Patients
Importance of taking pindolol exactly as prescribed.1
Importance of not interrupting or discontinuing therapy without consulting clinician.1
Importance of immediately informing clinician at the first sign or symptom of impending cardiac failure (e.g., weight gain, increased shortness of breath) or if any difficulty in breathing occurs.1
In patients with heart failure, importance of informing clinician of signs or symptoms of exacerbation (e.g., weight gain, difficulty in breathing).1
Importance of patients informing anesthesiologist or dentist that they are receiving pindolol therapy prior to undergoing major surgery.1
Importance of informing clinicians of existing or contemplated concomitant therapy, including prescription and OTC drugs.1
Importance of women informing clinicians if they are or plan to become pregnant or plan to breast-feed.1
Importance of informing patients of other important precautionary information.1 (See Cautions.)
Excipients in commercially available drug preparations may have clinically important effects in some individuals; consult specific product labeling for details.
Please refer to the ASHP Drug Shortages Resource Center for information on shortages of one or more of these preparations.
* available from one or more manufacturer, distributor, and/or repackager by generic (nonproprietary) name
AHFS DI Essentials. © Copyright 2017, Selected Revisions February 13, 2015. American Society of Health-System Pharmacists, Inc., 7272 Wisconsin Avenue, Bethesda, Maryland 20814.
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